<%BANNER%>

Effects of Listening to Music as an Intervention for Pain and Anxiety in Bone Marrow Transplant Patients


PAGE 1

EFFECTS OF LISTENING TO MUSIC AS AN INTERVENTION FOR PAIN AND ANXIETY IN BONE MARROW TRANSPLANT PATIENTS By DAVID OTIENO AKOMBO A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2006

PAGE 2

Copyright 2006 by David Otieno Akombo

PAGE 3

This dissertation is dedica ted to two special people; Barbara Achando and Andrea Alali.

PAGE 4

iv ACKNOWLEDGMENTS I wish to thank Dr. John Graham-Pole, Dr. Russell Robinson, and Dr. Paul Richards for their inspirati on and encouragement. I also would like to thank Dr. John Wingard, director of the Bone Marrow Transpla nt 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 th eir help, especially in recruiting patients for my study. Many thanks also go to Dr. Jose ph Riley III for his constant help in the protocol. 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 as sisted and encouraged me in various ways during my course of studies. I am especially grateful to Jill SonkeHenderson, 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 th e School of Music. I am particularly thankful to Trent Weller, St even Bingham, Don Devit o, 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

PAGE 5

v many stylistic suggestions and substantiv e challenges to help me improve my presentation and clarify my arguments. Finally, this dissertation w ould 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 member s, I alone remain responsible for the content of this dissertation, including a ny errors or omissions which may unwittingly remain.

PAGE 6

vi TABLE OF CONTENTS page ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES.............................................................................................................ix LIST OF ABBREVIATIONS..............................................................................................x ABSTRACT....................................................................................................................... xi CHAPTER 1 INTRODUCTION........................................................................................................1 The Problem of the Study.............................................................................................3 Research Hypotheses....................................................................................................4 Limitations.................................................................................................................... 5 Definition of Terms......................................................................................................6 Significance of the Problem........................................................................................11 Implications of the Study to Music Education...........................................................16 2 REVIEW OF THE LITERATURE............................................................................20 Introduction.................................................................................................................20 Philosophical Rationales.............................................................................................20 Rationales...................................................................................................................21 Pythagoras (c. 560 c. 480 B.C.)........................................................................21 Plato (427 B.C. 347 B.C.).................................................................................21 Arthur Schopenhauer (1788 1860)....................................................................22 Ren Descartes (1596 1650).............................................................................22 Baruch Spinoza (1632 1677).............................................................................23 Summary and Implications of the Present Study................................................23 Theoretical Rationales................................................................................................25 Gate Control Theory............................................................................................25 Specificity theories..............................................................................................29 Pattern theories....................................................................................................30 Nociception versus pain theories.........................................................................30 Implications of Gate Control Theory for the Present Study.......................................30 Research......................................................................................................................3 0 Clinical Effects of Music............................................................................................31 Phenomenological Approaches..................................................................................32

PAGE 7

vii 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 Music on Anxiety................................................................................50 Effects of Music on Pain.....................................................................................59 Musical Preferences of Patients...........................................................................60 Type of Music......................................................................................................62 Music as a Form of Distraction...........................................................................65 Summary and Implications for the Present Study...............................................68 3 METHODOLOGY AND PROCEDURES.................................................................70 Research Design.........................................................................................................71 Subjects....................................................................................................................... 72 Procedures...................................................................................................................75 Modified Hartsock Music Preference Questionnaire..........................................79 Visual Analogue Scale........................................................................................79 Data Collection...........................................................................................................81 Sampling.....................................................................................................................83 Instruments.................................................................................................................84 Physiological Parameters............................................................................................84 Visual Analogue Scale (VAS)....................................................................................85 Psychological Parameters...........................................................................................86 State-Trait Anxiety Inventory.....................................................................................87 Scoring and Norms.....................................................................................................88 Reliability Procedures.................................................................................................89 Validity....................................................................................................................... 89 Audio Recording.........................................................................................................90 Statistical Procedures..................................................................................................90 Interpretation of Data..................................................................................................91 Data Management.......................................................................................................93 4 RESULTS...................................................................................................................94 Introduction.................................................................................................................94 Sample 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 In tervention on Heart Rate........................................................101 Effect of the Music Interv ention on Respiratory Rate..............................................103 Research Hypothesis.................................................................................................104 Summary of Results..........................................................................................107

PAGE 8

viii 5 DISCUSSION AND RECOMMENDATIONS.......................................................109 Findings....................................................................................................................109 Hypothesis 1......................................................................................................112 Hypothesis 2......................................................................................................113 Hypothesis 3......................................................................................................114 Hypothesis 4......................................................................................................115 Hypothesis 5......................................................................................................116 Issues......................................................................................................................... 116 Implications for Future Research..............................................................................119 Implications for Future Clinical Practice..........................................................119 Implications for Music Education.....................................................................120 Implications for Theory.....................................................................................121 Limitations................................................................................................................122 Sample......................................................................................................................124 Conclusions...............................................................................................................125 APPENDIX 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 MUSICAL SELECTIONS.......................................................................................133 G CONSEN T FORM....................................................................................................139 H COVER LETTER TO SUBJECTS..........................................................................149 I COVER LETTER TO PARENTS............................................................................151 J INSTITUTIONAL REVIEW BOARD LETTER....................................................153 K POST-INTERVENTION QUESTIONNAIRE........................................................154 LIST OF REFERENCES.................................................................................................155 BIOGRAPHICAL SKETCH...........................................................................................178

PAGE 9

ix LIST OF TABLES Table page 1-1 Proportions of Bone Marrow Transp lants by Disease at Shands at UF...................13 3-1 Data Collection Process...........................................................................................82 4-1 Reasons for Admission.............................................................................................95 4-2 Musical preferences..................................................................................................96 4-3 Mean Pain Readings from Visual Analogue Scale at Timed Intervals during Music Intervention...................................................................................................96 4-4 Visual Analogue Scale Scores Betw een Time 1 (T1) and Time 5 (T5)...................97 4-5 Mean Scores for the state portion of the State Trait Anxi ety Index (STAI) at Timed Intervals During Music Intervention.............................................................98 4-6 State Portion of the State Trait Anxi ety Index (STAI) Scores Between Time 1 (T1) and Time 5 (T5)...............................................................................................99 4-7 Mean scores for the Systolic Blood Pr essure (SBP) at Timed Intervals During 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 Intervention............................................................................................................103 4-12 Respiratory Rate (RR) Scores Be tween Time 1 (T1) and Time 5 (T5).................103 4-13 Mean Score on the Likert Scale fo r Those Preferring Music of a Longer Duration and those who felt pleasant.....................................................................105 4-14 Responses to the Questionnaire..............................................................................106

PAGE 10

x 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 DHEA Dehydroepiandrosterone EMG Electromyogram ESWL Extracorporeal shock wave lithotripsy GI Guided imagery without music GIM Guided imagery with music HR Heart rate ICU Intensive Care Unit IDEA Individuals w ith Disabilities Act IRB Institutional Review Board RR Respiratory rate SI Self-generated imagery without music SIM Self-generated imagery with music SPSS Statistical Packag e for Social Sciences STAI State-Trait Anxiety Inventory VAS Visual Analogue Scale

PAGE 11

xi Abstract of Dissertation Pres ented 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 By David Otieno Akombo December 2006 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, subjec ts served as their own controls. Data were collected in a series starting from pre-in tervention, during music intervention, and then post-musical intervention. Data were analyzed to test the hypoth esis that, following music listening, BMT patients have a greater decrease in self-reported pain, anxiet y, blood pressure, heart rate, and respiratory rate compared to baselin e reports. Subjects pain perception was measured by a numeric rating scale, the Vi sual 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 differe nce in the subjects pain and anxiety scores following the musical sessions.

PAGE 12

xii It is well recognized that pain and anxiety affect the autonomic nervous system (ANS) activity and balance. The interac tion among feeling states, immunity, and autonomic function has been demonstrated by a number of studies. These studies show that pain perception and anxiety stimulate sy mpathetic activity, increase cortisol ratio, and suppress the immune system. These studies also demonstrate that positive emotional states created by music enhance parasy mpathetic activity, in crease physiological coherence, reduce the cortis ol ratio, and boost immunity. Recent research has examined the physio logical 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 (DHE A), coherence in the ANS, reduce cortisol, improve autonomic balance, and faci litating the entrai nment of physiological systems. The goal of this research is to extend th is approach to the patient population aged 7 years and older who are receiving BMT. Th e study, conducted at Shands Hospital at the University of Florida, examined the whether or not music can potentiate the immunoenhancing effects of positive pain a nd anxiety states. Such interventions may yield significant health benefits in healthy individuals as well as BMT patients who exhibit both immunosuppression and autonomic imbalance.

PAGE 13

1 CHAPTER 1 INTRODUCTION Listening to music has made me feel better. When you played Beethovens Fifth Symphony I felt as though someone was scra tching the cancer cells out of my body, commented a 51-one-year old bone marrow transplant patient after music intervention. Little research exists on music intervention on pain and anxiety in bone marrow transplant patients. Music intervention is defi ned as the use of mu sic to influence the patients physical, mental, or emotional states before, during, or after medical treatment (Bruscia, 1989, p. 87). Despite th e lack of research validati ng music intervention on pain and anxiety, efforts are ongoing to devel op 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, dimini shing the amount of anesthetic patients need before surgery, reducing the amount of tim e patients need to be in the hospital after surgery, speeding the healing process, increa sing 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 (Bo ttomly, 1998; Cleeland et al., 1994). Cancerrelated pain and anxiety have been reduced effectively through mu sic listening (Bailey, 1983; Beck, 1991; Cook, 1986; Zimmerman, Po zehl, Duncan, & Schmitz, 1989). The management of such pain and anxiety is a sp ecial challenge for all health care personnel. Music appears to be particularly effectiv e in the treatment of cancer-related pain (Kerkvliet, 1990). It is well r ecognized that pain and anxiety can affect the activity and

PAGE 14

2 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 dige stive and sweat glands, and the activity of certain endocrine organs, are controlled by a major compone nt 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 intenti ons of the person. The autonomic nervous system is not subject to ones will--that is, it is in a sense autonomous. (p. 1686) Interaction among emotional states, immun ity, and autonomic function have been demonstrated by a number of studies, which showed that noxious stimuli, such as physiological and psychological sympathetic ac tivity, increase cort isol levels. These stimuli also can alter the immune system, while positive emotional states can enhance parasympathetic activity, increase physiologi cal coherence, reduce th e cortisol ratio, and boost immunity. Recent research has examined the physiol ogical and psychological effects of music on both healthy and unhealthy populations, espe cially those experiencing anxiety and pain. Bone marrow transplant patients have a greater decrease in selfreported pain, anxiety, blood pressure, heart rate, and respiratory rate co mpared to baseline values (Sahler, Hunter, & Liesveld, 2003). In the present research, attention is focu sed 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 certai n rhythmic patterns, tone textures, chord progressions, and harmonic resonance help reduce anxiety, diminish the experience of pain, and enhance the benefits of stress ma nagement interventions (McCraty, 1999). Used regularly, music therapy has also been f ound to reduce cortisol levels, improve the

PAGE 15

3 autonomic balance, and increase dehydr oepiandrosterone (DHEA) levels. Dehydroepiandrosterone is a st eroid hormone made by the adre nal glands that acts on the body and is converted into testosterone a nd 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 st udy was conducted at Shands Ho spital at the University of Florida (Shands at UF). The investigation examined whether or not music can be designed to potentiate the immunoenhancing eff ects of positive psychol ogical states. This study investigated whether or not the use of music, an inexpensive and non-invasive method, could be used to enhance the mana gement of pain and anxiety. The data, combined with the existing literature, were ex amined 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 c oherence. These interventions may yield significant benefits to healthy individuals, such as schoolchild ren, as well as to a variety of clinical conditions in which immu nosuppression and autonomic imbalance are observed. The Problem of the Study According to Stewart (2005), bone marrow tr ansplants are a relatively new medical procedure now used to treat diseases once thought incurable. Si nce 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 an d ovarian cancer. A bone marrow transplant is used to tr eat 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 c ontains stem cells that produce the body's blood

PAGE 16

4 cells. These blood cells include 1) white blood cells (leukocytes), wh ich fight infection; 2) red blood cells (erythrocytes), which car ry oxygen to and remove waste products from organs and tissues; and 3) pl atelets, which enable the bl ood 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 ad ministered drugs that kill al l 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 physio logical distress whenever they are experiencing the treatment (Spintge, 1989). As the cancerous cells grow and expand in the bone marrow, they cause pain and anxi ety as they destroy normal bone tissue. Despite opioid medication, mode rate to severe anxiety a nd pain have been reported during bone marrow transplants. Th e 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 anxiet y symptoms because music can make patients feel much more confident about dealing with their pain (V oss, 2005). Pain is a psychophysiological entity and therefore requires to be treated via a multi-disciplinary therapeutic approach (R ogers, 1995; Schorr, 1993). Research Hypotheses The following five hypotheses are examined in this study: 1. Bone marrow transplant patients have lo wer levels of self-reported pain as compared to the baseline measurements while listening to preferred music. 2. Bone marrow transplant patients have lowe r levels of state anxiety levels as compared to the baseline measurements while listening to preferred music. 3. Bone marrow transplant patients have lo wer systolic blood pressure (SBP) as compared to the baseline measurements while listening to preferred music.

PAGE 17

5 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 lowe r levels of respiratory rate (RR) as compared to the baseline measurements while listening to preferred music. Limitations The subjects in this stud y include only those patien ts diagnosed with acute leukemia, chronic leukemia, lymphoma, a nd 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 cel ls, 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 analgesi cs 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 manageme nt, but instead offered suggestions on the most effective musical stimuli for pain and anxiety interventions in patients undergoing BMTs. In this study, the research er provided only a few exampl es of musical styles that could be used in pain and anxiety inte rvention modalities in BMT patients. Due to sampling specifications, the generali zability of this research may be limited. For instance, only those patients who are unde rgoing 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 th is age. Since listening to music is an

PAGE 18

6 independent variable in this study, those subj ects with hearing diffi culties were excluded from the study. Study sessions were initiate d after 24 hours of base line recorded indices and four hours after analgesics were admi nistered to decrease the probability of measuring dependent variables prior to the peak drug concentrati ons. Patients undergoing BMTs are routinely administered strong an ti-anxiety drugs. Many of the patients were also taking medications which affect their hear t rate and blood pressure. It is not known what effect, if any, these medi cations 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 im mature white blood cells (referred to as lymphoblasts ) in the bone marrow. It is a hematol ogical 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 older. Acute myelogenous leukemia (AML), also known as acute myeloid leukemia: This is a cancer of the myel oid 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 t ypes of blood cells, a process called differentiation. If differentiation does not occu r, myeloblasts accumulate and overtake the number of healthy blood cells spreading into the bloodstrea m and other vital organs. The lack of healthy blood cells resu lts in symptoms such as an emia and abnormal bruising. Myeloid leukemias are characterized as "acute or "chronic," based on how quickly they progress if not treated. Patients with chr onic myelogenous leukemia (CML) often show

PAGE 19

7 no symptoms, and the disease can remain dorma nt for years before transforming into a crisis, which is markedly similar to AML. Analogue: This is compound that is struct urally similar to another compound. Anxiolytic: This is a medication used to reduce anxiety, tension, or agitation. Anxiolytic music: This is sedative music cons idered to be slow (60~80 beats/minute), melodic, and instrumental (withou t 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, radi ation, and certain drugs. Cortisol: This is a major adrenal glucocorti coid. It stimulates conversion of proteins to carbohydrates, raises blood sugar le vels, and promotes glycogen storage in the liver. 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 ar e due to a characteristic chromosomal translocation termed the Philadelphia chromosome It is traditionally treated with chemotherapy, interferon, and bone marrow tr ansplantation, but a specific inhibitor (imatinib mesylate) has radica lly changed its management. Complementary and Alternative Medicine (CAM): This is a group of diverse medical and health care systems, practices, a nd products that are not presently considered to be part of conventional medicine.

PAGE 20

8 Dehydroepiandrosterone (DHEA): This is a steroid hormone made by the adrenal gland that acts on the body much like testoste rone, and it is converted into testosterone and estrogen. Dicrotism : This is a condition in which the pul se is felt as two beats per single heartbeat. Distraction: This is a condition where concentr ation 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 extraversi on, psychoticism and neuroticism as advanced by Hans Eysenck wh ich 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 orig inate in a particular lymph node and later spreads to the spleen, liver, and bone marrow. It occurs mos tly in individuals between the ages of 15 and 35 years. It is characterized by progressi ve, 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 ag e, spiritualism, yoga, massage therapy, imagery, music and dance among others.

PAGE 21

9 Leukemia: This is an acute or chronic di sease 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 leuc ocytes in the tissues of the body with or without a corresponding increase in those in the circulat ing blood. It is classified according to the type of leukocyte most prominently involved. Lymphoma: This is a general term for various neoplastic di seases of the lymphoid tissue. 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, whic h 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 orga ns. 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, cognitiv e, 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 improvise d music; creating song lyrics, melodies, harmonies, and orchestrations; moving to mu sic; and listening actively to music to facilitate imagery and teach specific relaxation skills. Nociceptor: These are receptors which are sensiti ve to painful mechanical stimuli, extreme heat or cold, and chemical stimuli. All nociceptors are free nerve endings.

PAGE 22

10 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 lym phomas are grouped together and called non-Hodgkin's lymphomas. Lymphomas account fo r 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 viable infant. Opioids: Originally, these were agents that caused somnolence or induced sleep. However, presently the term refers to any de rivative, natural or synthetic, of opium or morphine or any substance that has simila r effects. Narcotics have potent analgesic effects associated with significant changes in mood and behavior, and with the potential for dependence and tolerance fo llowing repeated administration. Pethidine: This is a drug used to trea t 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 appreh ension, and heightened autonomic nervous system activity. State Trait Anxiety Inventory (STAI): This is a self-repor t inventory established by Charles Spielberg (1976) to assess anxi ety. The STAI is designed to differentiate between the temporary condition of "state anxiety" and the more general and longstanding quality of "trait anxiety" in adults. It consists of two categories with 20 items in each category. One category measures how respo ndents feel "right now "state anxiety" and the other measures how one normally feels "trait anxiety."

PAGE 23

11 Themes : Abstract constructs, which research ers identify before, during, and after data collection. Unmet Analgesic Needs Questionnaire: This is a tool designed for cancer patients designed by Zhukovsky (1994) to measure preval ence and intensity of pain, and identify characteristics associated with unmet anal gesic needs and dissatisfaction with pain control. Visual Analogue Scale (VAS): This is a measurement instrument that measures the amount of pain that a patient feels ra nging across a continuu m 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 spect rum (e.g., no pain" and "the worst possible pain"). 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 attempte d 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 ha s 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 phy sical, mental, and emotional illness. This practice is manifested through musical contex ts by the dissemination of music as a product of human behavior. The practice in cludes 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

PAGE 24

12 upon the human body has been one of the most cont roversial topics in the field of holistic and complementary therapies in health science. Peck (2002) observed: Medications possess the notor ious quality of being doubl e-edged swords. This is true of modern synthesized pharmaceutical s. 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 b ecome popular during the past several decades. Music is considered to be a medium which eases a nxiety, reduces pain pe rception, and increases pain thresholds. Although music therapy is an established alli ed health profession and is used with increasing frequency in the treatment of those with illnesses, a lack of empirical research literature exists supporting the us e of music in the mitigation of pain and anxiety. In addition, many of these studi es are insufficient, and their findings are therefore often contradictory. I konomidou and Rehnstrm (2004) noted: Most studies in the literature have not been carried out according to standard principles for randomization or controlle d circumstances, and statistical methods have been poorly documented, thus advocat es 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 re searcher examined how patients felt about themselves, what benefits they derived from listening to music, and whether or not these experiences carried meaning for them be yond the act of listening to music. Study participants were recruited from Shands Hosp ital at the University of Florida (Shands at UF), a community health care hospital servi ng 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

PAGE 25

13 fluctuated between 8% and 20% of all cancer patients. Table 1-1 shows the breakdown of these patients by disease duri ng the past five years. Table 1-1. Proportions of Bone Marrow Transplants by Disease at Shands at UF from 1999 to 2004 Diagnosis Percentage Acute leukemia 25% Lymphoma 25% Myeloma 25% Bone marrow failure state 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 musi c with post-operative surg ery, dentistry, spinal cord injuries, pediatric treatments, and ch ronic pain (Browning, 2000). Additionally, in this study the researcher examined how careg ivers 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 orde r 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 defined pain 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 ph enomenon 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 in terpretations of pai n. Internal processes, such as increased anxiety, and external forces can influen ce 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

PAGE 26

14 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: A n unpleasant sensory and emotional experience associated with act ual or potential tissue damage or described in terms of such damage (para. 11). While th e phenomenon of pain itself is so elusive, both scientists and allopathic healers have a myriad cons tructs 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 an cient practice is still in use today in some societies. However, during the past decad e, 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 fo r 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 musi c for health and how it was used in ancient times is a fascinating field of study. It has nonethele ss received lim ited attention. With the exception of anecdotes about Pythagor ass 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 b een dismissed in the recent past. Music has often been deliberately perceived as incons equential to the development of modern science. Fortunately, some scholars are beginni ng to address this fi eld of inquiry. Many current scholars are discovering that music can be cathartic for some patients. Gilchrist

PAGE 27

15 (2002), a London-based physician, has written ab out the power of music to bring about healing. He observed, I am a very conventiona l doctor, but I do like to use other sources for emotional problems where c onventional 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 patients pain? 2. What effect does listening to musi c have on a patients anxieties? 3. What effect does listening to music ha ve on a patients blood pressure (BP)? 4. What effect does listening to music have on a patients heart rate (HR)? 5. What effect does listening to music have on a patients resp iratory 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 gr oup of hospitalized pers ons. 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 increasi ng 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 le ss 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.

PAGE 28

16 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 rese arch in the field of music and healing. In addition, these few available st udies report insignificant resu lts from music intervention, hence additional research is needed (M ok & Wong, 2005). The subject of music and healing has a high profile in public awareness be cause of a series of scientific discoveries in sound and imagery therapy. This study provi ded possible interpreta tions of the data, based on the self-reported pain ratings f ound on a Visual Analogue Scale (VAS) and a calculated anxiety rating de rived 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 em otionally debilitating. Physical problems, such as headaches resulting from anxi ety, 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; Richte r, 1984; Zimny & Weidenfeller, 1962) and increase attentiveness (Wagner, 1975). A wide range of emotional, stress-relate d problems, such as teenage suicide, teenage pregnancies, delinquency, violence in school, physical and sexual abuse of children, and drug trafficking among youth ar e 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

PAGE 29

17 reported cases of seriously emotionally distur bed schoolchildren due to anxiety in the last 10 years (Zill, 1993). Giles (1996) observed th at 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 (Goodl and, 1984). Many students in today's classes are suffering from chronic stre ss 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 trav eling 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 ma ny 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 clas sroom, and it is this group that could be helped by music (p. 11). Recently, su ch long-lasting, stress-related behaviors have been described as personality disord ers and conduct disorders, serious conditions that should be given the same attention by sc hool authorities as othe r debilitating physical and emotional problems (Rizzo & Zabel, 1988). In using music to heal schoolchil dren, Giles (1996) observed: Given the body of evidence for music's pow er 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:

PAGE 30

18 How often have we seen students who were on the brink of failure in school lift their self-esteem through mu sic, and "find their way?" How many times have we seen little sad faces light up to the stra ins 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. G iles (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 a nd anxiety, children can be uplifted and given hope through music (Wagner, 1975). The effects of music on anxiet y within the school system can also be examined in the context of other subjects. When refe rring 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 anxi ous, and this anxiety interferes with their learning. Furner and Be rman (2006) observed: When anxiety is reduced, students can beco me more successful at math, and be better equipped to be successful in a world that is highly technologically and mathematically oriented. (para. 21) In todays world, we see strife and anxi ety everywhere (Giles, 1996). American schools, faced with violence and crime, ar e looking for hope and new direction. Giles (1996), observing that children in school car ry these anxieties fr om class, stated: It is no wonder that so many are at risk for emotional problems, physically debilitating conditions, and failu re in school. There is no be tter time to bring music into the schools as a he aling 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 liv es. Giles (1996) pointed out that we must recognize and be more aware of the poten tial good in music to heal and produce

PAGE 31

19 emotional health. It is imperative to study the psychological effect s of music to alter negative emotions, such as anger, rage, and depression, to feelings of contentment or happiness. This research supports the idea th at music can help students anxiety. Giles (1996) observed: Few music teachers have made a serious effo rt to study the specific attributes of music for healing, with the deliberate inten tion 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 musi c 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 hea lthy students, represents a new direction in using music to promote health in schools. Al salam 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 musi c activities. When this new dimension is added to the curriculum, students are involve d in music activities that can ultimately reduce the stress in their lives and replace them with new self-esteem (Giles, 1996).

PAGE 32

20 CHAPTER 2 REVIEW OF THE LITERATURE Introduction In this chapter, the philo sophical rationales that suppor t this work are examined. Relevant theories are presented, followed by se lected literature on the efficacy of music intervention on the physiology of pa tients and healthy populations. Philosophical Rationales Pain can be an isolating event in the hu man experience. Whenever I am in pain, I feel isolated from the society. This isolati on brings me anxieties. When I am in pain and listen to music, I feel connected to th e 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 modern era, the Greek philosophers are credited with the ideology of the cathartic na ture of music. The subject of music and healing, especi ally 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 ey ewitness accounts of individual music healers. The anecdotes reproduce evidence verbatim, as recorded in treatises of healing rituals.

PAGE 33

21 Rationales Pythagoras (c. 560 c. 480 B.C.) Pythagoras, who is sometimes regarded as the Father of Psychotherapeutics, championed the discipline of nature in thera py. His philosophy was enshrined in the fact that psychics and physics were inseparably mi ngled into a regimen of life. Pythagoras conducted perhaps the worlds first physics e xperiment. By playing strings of different lengths, Pythagoras discovered that sound vibrations natura lly occur in a sequence of whole tones or notes that repeat in a patte rn 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 Aristo tle believed in the un ity of the soul and body through the medium of scientific investigation. Plato (427 B.C. 347 B.C.) Plato believed that music occupied the l eading position among the arts, where he saw an analogy between the movement of the soul and musical progressions ( ). While synthesizing Platos ideals on the sign ificance 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 Platos treatises, Laws Republic Gorgias Philebus, and the Temaeus In Temaus Plato described the numerical (vibrationalmusical) creation of the physical universe and the soul, which animates it. Plato called his students to act ivate the ancient shrines and sacred temples of the earth with sacred song, thereby employing perpetual choi rs as if to imitate the harmonies of the

PAGE 34

22 Heavenly Choir. Plato observed that "music is a prime factor in transformation . for music is medicine of the soul" (Sch ullian & Schoen, 1948 quoting Plato, p. 57) Arthur Schopenhauer (1788 1860) The effects of music on the mind are sim ilar 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 so mething 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, transcendi ng all the others in metaphysical significance making, Wagner and Ma hler regard their writings on music as being the profoundest that there are (M agee, 1998, p. 144). Schopenhauer's philosophy was the biggest non-musical influence on the life of Richard Wagne r (1813-1883). It was due to Schopenhauers metaphysical philosophy of loving-kindness or caritas (' ) which Wagner discovered in 1854 that he deve loped his intuition re garding 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 th e voice of the metaphysical will. When music, suitable to any scene, action, even t, or environment, is played, it seems to disclose to us its most secret meaning (Schopenhauer, 1958). Ren Descartes (1596 1650) Debates on the mind and body as a composite whole are evidenced in the writings of these ancient philosophers and through late r ones as well. According to Descartes' famous dualist theory, human beings are co mposed of physical bodies and immaterial

PAGE 35

23 minds. Descartes (1694) divided music into three basic component parts: 1) the mathematical-physical aspect of sound; 2) th e 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 autono mous, 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 gr eat 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 br ing about such str onger emotions; hence music can be useful in thes e 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 (Conservato ire). The idea was that music, through harmony, had the power to develop positive emotions, er adicate animosity, and promote wellness (Arveiller, 1980; Lecourt, 1992). For these r easons, the masses were educated through music, and music was considered bene ficial for those who were sick. In Europe, the first students of the Pari s 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

PAGE 36

24 psychiatry, which was developed by the work of Dr. Philippe Pinel (Bynum, Porter, & Shepherd, 1985). Music therapy had, in esse nce, 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 relationa l model. Musical societies, such as the Orpheons (choral groups and brass bands), developed throughout France (with national and international exhibitions). The groups shar ed the conviction that music education for the masses and workers would transform societ y and make people feel better (Arveiller, 1980; Lecourt, 1992). This music would also tr ansform 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 orga nized musical events in hospitals while offering musi c education courses for patients in the hospital (Arveiller, 1980; Lecourt, 1992). Music has long been used to produce ther apeutic 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

PAGE 37

25 United States, led by John Dewey (1859-1952) began a new revolution in philosophy. They first confounded the scientific pro cess of arriving at information. For the pragmatists, the five-step scientific process was the source of ultimate reality. Instead of relying on tradition, belief, re ligion, and myth about music a nd 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 w hy such concepts exist or for what purpose. Assuming that science acts with pe rfect wisdom and does nothing in vain, Dewey argued that every step of the scientif ic process is crafted for its proper function. These ideas led scientists to th eories of pain and anxiety. Theoretical Rationales Pain is the most common reason people s eek 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 approach es to treat pain, such as: 1) pain medication; 2) imagery; 3) deep breathing; and 4) mu sic. Theories of pain have evolved from foundations created by ancient ph ilosophers who considered pain to be an emotion. Aristotle (384 BCE 7, 322 BCE) th e Greek scientist a nd philosopher called it a passion of the soul. The concept then pr ogressed through time, culminating into the pain theories of the 18th and 19th century psychologists. Gate Control Theory The Gate Control Theory of Pain wa s first proposed by Ronald Melzack and Patrick Wall (1965). They suggested that th ere is a "gating system" in the central nervous system (in the spinal cord where the ne rves come in from an injury) that opens to let pain messages through to the brain and cl oses to block them. Melzack and Wall were

PAGE 38

26 governed by theories of evolutionary psychol ogy 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 w ith the recognition of an entity's own body-called the kinesthetic sense Melzack and Wall suggested th at the gate inhibits or facilitates passage rather than completely openi ng or closing, so it opens more or restricts the passage of pain signal s. Pain is in the brain according to Melzack and Wall (1965), and only there. According to the Gate Control Th eory 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 be lief that psychological as well as physical factors guide the brain's interpretation of pa inful sensations and the subsequent response. These emotions and attention open and shut the gate. Although th e 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 nonpharmacological 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 natu re 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 sp inal cord acts like a gate to increase or decrease neural impulses from peripheral nerv es 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

PAGE 39

27 and serotonin, and descending influences from th e brain. A pain response is activated when the number of impulses passing through th e 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 su mmation) and over a period of time (temporal summation), the pain message is amplified and carried to the spinal cord via afferent nerves. However, before nerve impulses can ascend to the brain, a porti on of them must go through the densely packed, diffusely in terconnected nerve fibers called the substantia gelatinosa. This region is found on both sides and throughout the length of the spinal cord within the dorsal horns. Between this transmissi on, from sensory neurons to ascending spinal cord neurons, that impulse pattern can be modified. Some fibers continue to the thalamus, and ot hers penetrate the reticular formation in the lower part of the brain, then go to other sensory portions of the brain. Other fi bers are carried along pathways to the limbic system (Bonica, 1977; Melzack & Wall, 1983). The substantia gelatinosa play a role in the inhibi tion and activation of neural impulses. Injury produces signals that are tr ansmitted from small diameter fibers to the dorsal horns, which may activate the substantia gelatinosa in the spinal cord. This activation then opens th e gate in order to transmit the message further to the brain as indicated in the schematic representati on of the theory (see Figure 2-1).

PAGE 40

28 Figure 2-1. Schematic representation of the Gate Control Theory. On the other hand, large diam eter fibers may exert an inhibitory influence on the cells in the substantia gelatinosa which result in inhibiti on and closure of the gate, preventing the continued transmission of the impulse to the br ain. The reticular formation and the limbic system also exert a powerful inhibitory control over information projected by the substantia 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 individuals perception and res ponse to pain. Va rious psychological pr ocesses, such as past experience, cultural learning, the m eaning of the situation, individual pain Sensation Auditory stimulation Music stimulation Distraction Music listening The Gate Cerebral Cortex Pain fibres Spinal cord Descending inhibitin g s y stem Closes the gate Opens the gate (Adapted from Carr and Mann 2000) Pain Fibers

PAGE 41

29 threshold, attention, and emo tions, influence pain perception and re sponse via action on the spinal gating sy stem (Melzack & Wall, 1965, 1983). The focus or attention an individual gives to the painful experience may increase the intensity of the painful experience. Several research ers have found distraction of attention--by means of auditory inputs--effective in decreasing pain (Gardne r & Licklider, 1959; Melzack, Weisz, & Sprague, 1963). However, Melzac k 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 postoperative pain. Subjects were able to use auditory stimulati on 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 diffi cult or virtually impossible (p. 72). As spinal activity is initiated through th e spinal pathways, the sympathetic nervous system is also activated. The sympathetic nervous system res ponse commonly referred to as a "fight, fright or flight" response, cont ributes to the emotiona l response of the pain experience (Cooper, 1990; Me lzack & Wall, 1983). Ja nig (1990) proposed that tachycardia, hypertensio n, tachypnea, and diaphoresis do no t result direct ly from pain, but instead are manifestations of the anxiety response. Specificity theories Specificity theories consider pain as an independent sensatio n with specialized peripheral sensory receptors (nociceptors), which respond to damage and send signals along pathways (nerve fibers) in the nervous sy stem to target centers in the brain. These brain centers process the si gnals to produce the experien ce of pain (Kent & Molony, 2001).

PAGE 42

30 Pattern theories Pattern theories consider that periphera l sensory receptors, which respond to touch, warmth, and other damaging and non-damaging stimuli, give rise to painful or nonpainful 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 stimul us, whereas pain is an experience, that is the product of the pa rts of the brain responsible for mental processing of the noxious stimulus. According to Kent and Molo ny (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 Wa ll (1990) observed that this method, we believe, holds promise as an effective tool for the pain control (p. 30). Research Patients who have undergone bone marrow tr ansplant report less pain and anxiety after listening to music. Perhaps most intr uding is that the therapy may also shorten the time for the new marrow to start producing blood cells (Leingang, 2003, para.1). This chapter presents previous research in areas related to the cu rrent study topic. It includes past research on the efficacy of music intervention on the physiology and psychology of both patient s and healthy populations.

PAGE 43

31 Clinical Effects of Music Music therapy is defined as a systema tic process of intervention wherein the therapist helps the client to achieve bette r 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 mu sic in health care settings is the improvement in a patient's physiological and psychological status th rough the processing of music. In bone marrow transplant patients, the goal of music interv ention 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 perf ormed a meta-analysis of 30 medical and dental studies using music interventio n. The average effect size--across all 55 physiological, behavioral, and psychologi cal dependent variab les analyzed--was 0.98, indicating that the groups r eceiving music intervention sc ored almost one standard deviation better than the cont rol 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 (Col lins & Kuck, 1991; O'Sullivan, 1991). Cook (1981) advocated the use of mu sic as an intervention for patients exposed to altered sensory environments, including increased, decreased, or distorted stimuli. Cook hypothesized that in such situ ation, listening to music can normalize stimulation of the

PAGE 44

32 reticular activating system, and it can decr ease unpleasant stimulations. When people listen to music, they process it through their reticular activating system, and they respond individually to its pitch, te mpo, rhythm, and volume. Listening to music alters the prominence of environmental noise and serves as a coping resource. Phenomenological Approaches Neither the sound nor musical notation of the music used for healing in ancient civilizations remains. Apart from sparse writ ten records, the only in formation provided is from ancient inscriptions of musical inst ruments or music-healing ceremony paintings unearthed by archeologists. Until the mid19th 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. Sin ce these sources are cl early non-scientific, scholars have disregarded all the efficacies therein with regard to health care. In order to understand the rationale for th is study, it is important to examine the practice of using music for healing through th ese ancient cultural traditions. Even though ancient approaches to the st udy of music and healing are purely anecdotal, this chapter examines the literature, which defines the ch aracteristics 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 show s profiles of usage of music in healing among traditional societies in pre-coloni al 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 literatu re reviewed herein nonetheless provides a background on the role of music in hea ling with reference to pain from both physiological and psychological standpoints.

PAGE 45

33 For much of the history of mankind, mu sic 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). Musi c and healing, as disciplines of inquiry, have their origins in ancient civilizations, such as Mesopotam ian, Egyptian, Hindu, and Chinese. In Egypt, the use of music in healing was discove red at Kahum by Petrie in 1889, and the archeological eviden ce 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, scient ist, 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 musi cal powers. At the very heart of Greek civilization, music was divine. Demigods, such as Apollo, Am phion, and Orpheus, c onjured up notes of sonic energy into a revered purifier of body, soul, and mind (Grout & Palisca, 1996). Davis (1999) addressed the historical perspe ctives 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 musi cal 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

PAGE 46

34 important of the mythic musicians in anci ent Greek culture was Orpheus, whose music reportedly had the power to cause inanimat e 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 of Diseases, Atlee (1804) recommended the use of music in the treatm ent of diseases. Atlee argued that music healing offered a unique, and occasionally in stantaneous, 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 patients brain from immediate temporal distractions, thereby libe rating 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 spirit s. For example, the specific timbre of the instruments--together with th e sound intensity--has variable effects on a patient. Certain kinds of music are more e ffective during certain times of the day. When music is performed, the patient not only interprets it wi thin culturally defined norms, but also sees into the future in order to reveal th e 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 cha nges are measured by overt behavior, while physiological change is measured by standard ized medical criteria. In comparing the

PAGE 47

35 direct use of music in therapy and guided imagery, researchers (Marina, 1991; Moreno, 1995) concur that music assists patients in tr aveling 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 refe rence to the concept of holistic healing because the epistemological thought of the anci ent civilizations being referenced--such as long-standing health care pr actices from East Africa to Southeast Asiacreates the ancient holistic approaches upon which all healing was based (Sommer, 1996). Holistic healing is viewed to consist of multiple biol ogical, 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 musi c 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 Shamans tr avels to the spirit world to establish those connections that will be a benefit to the patient (p. 331). Even though Morenos 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 ma ny 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 disc ipline that consider s the impact of music in ritual

PAGE 48

36 performances upon the measured progress of the patient-participant with psychophysiological problems of a known etiology. Moreno also connected cultural music-ma king 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 patien t within the cultural context. According to Moreno, the supernatural healing that is ac hieved by way of communication between the spirit and the patient is due to music. He c ontended 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 stat e, allowing the healer to fly to the sky to encounter the spirits. This metaphysical eff ect of healing using music continues to challenge many scientists (Mullings, 1984). Cons equently, this idea has led many of them to give credence to the thought that the us es of music in ther apy may precipitate epistemological issues of the placebo e ffect (Engel, Guess, Kleinman, & Kusek, 2002; Mullings, 1984). Hart (1999) observed that the placebo response represents the mysterious self-healing forces generate d 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 benef it 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 us ed in controlled studies to determine the efficacy of medicinal substances (Achterberg, Dossey, Gordon, Hegedus, Herrmann & Nelson, 2006). The connection between the effica cies of music healing to the placebo effect has been discussed (Engel, Guess, Kleinman, & Kusek, 2002). Observations have

PAGE 49

37 also been made to support th e fact that placebos still fl ourish 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 c onditions clearly need to be met if musicbased 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 tr ue of the Taita, a Bant u-speaking tribe of Kenya. Morenos sentiments are that belief and tr ust in the powers of the supernatural are catalyzed with music, and therefore music a nd 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; Mu llings, 1984; Benenzon, 1997) seem to point to music as the most fundamental phe nomena in healing. In many parts of the non-Western world, a healer initia tes the healing process. The music healer, usually performs the healing process using se veral stages. Kovach (1985) identified four stages. The first stage is the preparatory stage in which the subjects, the audience, and the Sh aman 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, us ually by the Shaman and preferably in the Shamans home, both the clients immediat e family members and the community are invited to the healing ceremony. The second stag e is the actualization of the spir it helpers in which the medium of music, bells, and cost umes 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 establ ished Taita traditions. The third stage is the

PAGE 50

38 trance state, where, with the help of the Shaman, the patients 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 s oul then returns to earth anew. The fourth stage is the termination of the ritual wher e 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 concep ts 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 s uperior powers that bri ng healing and comfort through music. The Taita are a small ethni c group of people w ho live in a coastal province of Kenya, close to the Tanzanian bo rder to the east of Mt. Kilimanjaro. The Taitas legend of creation is imbued with supe rnatural powers, and it is attributed to musical powers. According to Taita cosmol ogy, their country was cr eated on regular and irregular musical rhythms, which are manife sted 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 importa nt role when healing was needed. It has been noted that in all cultures and at al l times, healers knew the positive effects of music. Even though the specific role and appli cation 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

PAGE 51

39 the Taita of Kenya for instance, is an area in stilled with esoteric beliefs. Another reason is that the cultural notions of the etiology of diseases are st ill 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 cosmol ogy also associates the origin of all diseases with the evil pepo or pepo 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 he aling 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 manage d by removing its cause or, failing that, by administration of analgesia (p. 137) In adding credence to the tr aditional and cultural beliefs Cornelius (1990) observed that sound is used to reach outwards toward s the deities. In tu rn, it is through the vibratory matrix which sound provides that the deities themselves descend from the spiritual abode to participate in the worl d 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 f unction of dance in Nigeria, Harper concluded

PAGE 52

40 that the main purpose of dance was to app ease the supernatural powers, solicit divine protection, and give thanks to the gu ardian spirits of the community. From a biomedical standpoint, Graham-Pol e (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 (Frieds on 1998) observed that the sounds of the garaya (a two-stringed plucked lute) and buta (a gourd rattle) call th e divine horsemen of the sacred city of Jangare to descend into the heads of borii thereby healing the people they have made sick. However, the foregoing phenomenological practices of using music to cure diseases have not gone without some challe nges. Even though hist orical debates on the efficacy of music as a healing device are no t the focus of this study, a few instances are worth mentioning. Early 19th century American s used herbal remedies to deal with common discomforts, such as colds or cons tipation. These remedies came to be called snake oil (Carol, 2000). Snake oil was orig inally 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 th e legitimacy of music as a healing agent, branding it merely as brainwashing tech nique (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 obs erved that these changes promoted the disruption of old behavior patterns and facilitated th e promotion of new ones.

PAGE 53

41 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 holis tic healing traditions while communicating with the gods. Klwer (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). Klwer also noted: The drum is connected with the Shamanisti c practices and ritual s 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 ir regular rhythm which blocks th e vital physical energy flow. Cottrell also referred to current medical rese arch, which has shown that stress is a cause of 98% of diseases, such as heart attacks, strokes, a nd immune system breakdowns. Recent biofeedback studies (Echenhofer, 1987; Harner, 1990; Spintge & Droh, 1992; Turow, 2005) show that drumming along with ones own heartbeat alters brainwave patterns and dramatical ly reduces stress. Rhythm is the element of music that dis tinguishes 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.

PAGE 54

42 Among the Taita, a regular and balanced mete r is regarded as a sign of good health. Even during improvisation, performers are expe cted to render an exact replica of a standardized musical practice. Such myt hologies can relay regul ar and replicated rhythms to heal the person in an immedi ate 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 th e 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 e xorcise 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 ultim ate 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 regard ing the condition of a patient in a trance following a session of musical healing. C onvulsions 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 diso rder). This disorder is synonymous with the term kuchima na pepo that means to run with the spirit, as opposed to rolling with the spirit ( kugaragara na pepo ) (Erdtsieck, 1997). Fugue or "flight," involves presumed forgetting. It al so 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 ne w location. They may give themselves a new

PAGE 55

43 name or even choose a new group of friends. Once patients are brought back to their original surroundings, they will usually reme mber 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 drumme r 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 subcon scious 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 bri ngs out the speech in the sufferer, which then indicates to the presiding witchdoctor mganga which spirit must be dealt with. Specific instruments play distinctive rhyt hms 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 orang jahat Larco (1997) observed that illn ess is a cultural c onstruct, and, in the context of the prevailing norms, the cultures perceptions fo r diagnosis and cure are efficacious. In the midst of all the foregoing mythological patt erns, both the Taita and the Balinese believe

PAGE 56

44 strongly in the effects of music, which compel the white, or beneficial, gods to descend to Earth to provide healing. For this reason, mu sic is evidently ubiquitous in the healing ceremonies of the Taita who use folk mu sic and a healing drum ensemble, or ngoma. It is also evident among some Balinese who use fo lk music with a healing ensemble, or gamelan gong beri, or the 20th century gong kebyar Jilek (1999) equated the therapeutic effectiveness of indigenous tr eatment methods with the curr ent Western therapies (Jilek, 1984). In his research on the social role of mu sic 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 expectatio ns, 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 st ressed 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 pr oposed that music be used as preventive treatment in health care. Browne himself favor ed "the fine Adagio and Allegro Parts in Italian Operas" (p. 38). He concluded his 125-page essay with a lengthy discussion of

PAGE 57

45 various diseases and how patient s respond to musical stimuli. Musica Medicina sets the stage for scientific inquiry into the disc ipline 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 individuals satisfaction or ha ppiness with life in domains he or she considers important (Bergner, 1989). Modern-day researchers are intrigued a bout 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 stat e of the person who is ill or dying. In all cases, the therapist is trying to make the patien ts future, in some sense different from the present. Browne (1729) deve loped nine cogent theories about music and medicine: Success in music does not depend on the pr oficiency 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 ha ve 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 Brownes treatises on th e use of music as medicine has brought a phenomenon change in the subject. Brownes contribution was followed closely by two of his medical students: Benj amin Rush, who is regarded as the father of American

PAGE 58

46 psychiatry and Samuel Matthews, whose publications Music in Medicine (1808) and On the Effect of Music in Curi ng and Palliating Diseases (1806) contributed immensely to the field of music and medicine. Brownes theories led to th e development of scientific approaches to music and healing in the Western world. The implementa tions of these theories were seen in Victorian England in the 1890s when the Soci ety of St. Cecilia began to employ London musicians to give concerts in London hosp itals (Davis, 1989). Anec dotes and traces of some quasi-scientific approaches to the fiel d of music and healing in the United States occur where music was performed for hospita lized 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 (C AM) would help match the standardized scientific interventions. During this Age of Enlightenment, to borrow the ideas of Magner (1992), social and medical reformers were insp ired by the belief that it was possible to improve the human condition through the applica tion of aesthetics. The idea that listening to music could cure illnesse s reached its peak with the invention of the phonograph in 1877. The new invention provided music to grea ter numbers of hospitalized patients as the cost of delivering this service beca me economically feasib le (Taylor, 1981). At the turn of the 20th century, scientists began to develop music therapy programs in hospitals, by carrying out systematic stud ies 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

PAGE 59

47 as adjunct therapy (Schullian & Schoen, 1948). Patient s 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 scientif ic models. Such experiments were conducted in many regions of the world including Japan, Britai n, Australia, and the United States. Music continues to have a place in contem porary healing. Regarding his work with an autistic child, Alvin (1991) stated: I hoped that in time, music could reach his subconscious and bri ng out his feelings of aggression, fear or anger so that it could relieve his anxieties and tensions, provide a non-threatening e nvironment in which he could express himself freely and find his identity; help him to deve lop his perceptual awareness and motor control. (p. 32) Research carried out by Neher (1961) s uggested that repetitive African drum patterns might promote an altered state of consciousness leading to healthful results (Mullings, 1984). In fact, African music has be en credited with affecting musical heart rate rhythmicity (HRR), which is a specific kind of heart rate va riability (HRV). The heart rate variability corresponds to the predom inance and cyclicity of (binary) patterns in a series of respiratory rate inte rval differences (Bettermann, 2002). Music and Anxiety in the 20th Century Ladies and Gentlemen, my respect ed and beloved music friends! Musica 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 psyc hoanalytic points of view. Anxiety is a biologically mediated respons e to stress or change (May, 1977). Anxiety has been additionally defined as the apprehension cu ed by a threat to some value that the

PAGE 60

48 individual holds essential to his existence as a person. Its special ch aracteristics are the feelings of uncertainty and he lplessness in the face of danger (May, 1977; Selye, 1977). Anxiety is a common phenomenon occurri ng in hospitalized patients, a condition nurses deal with on a daily basis (Shul dham, Cunningham, Hisc ock, & Luscombe, 1995). Anxiety has been used as a nursing diagnos is, defined as a process that includes constructs of stress and perceived threat resulting in states of anxiety that are transitory in nature (Carpenito, 1993). Sp ielberger, Gorusch, Lushene, Vagg, and Jacobs (1983) described a state of anxiety, as characte rized by subjective feelings of tension, apprehension, nervousness, and worry, and al so by the activation or arousal of the autonomic nervous system. Selye (1977) defined anxiety as r eactions to stress. A year later, Cannon (1978) defined anxiety as irritation of the entire organism and an activation of instinctive defense mechanisms. He calle d these mechanisms "alarm re actions" which were identified in many clinical studies. Thes e pathophysiological reactions, which have also been referred to as psychovegetative reactions, can caus e the patient more suff ering (Bodley, 1974; Birbaumer, 1977). These reactio ns can also make medical treatment more difficult and reduce resistance in the organism (Gedda & Rizzi, 1962; Williams & Jones, 1968; Wilson, 1969). Wolpe (1958) defined anxiety as a set of emotional predispositions attributed to a special kind of circumstance (p. 4). Accordi ng 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,

PAGE 61

49 Kirkpatrick, 1985; Lane & Wilkins, 1994); 2) the benefits of music for relaxation and stress management (Davis, 1992); 3) the app lication 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 anxi ety among students. Hammer ( 1996) studied the relationship between music therapy and part icipants perceived stress level. The participants were engaged in a music therapy sessions that included relaxation techniques and guided imagery. The State Trait Anxiety Inventory (S TAI) was administered before and after the music therapy session. In the experimental gr oup, 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 Vi nk, in his work, Rueger (1991) described a variety of musical recipes to cure an equally impressive vari ety of disorders. By closely examining his laboratory, it is obvio us 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 musi c 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:

PAGE 62

50 Rethinking the application of music th erapy has required the development of methodology that is observable and meas urable, and can be applied to many different treatment settings. (p. xxx) Effects of Music on Anxiety Patients undergoing a bone marrow transp lant often experience anxiety in anticipation of events that are unfamiliar, uncomfortable or have undesirable results. Numerous studies have researched the effect s of music on anxiety levels in different types of subjects. Music is an easily administered, nonthrea tening, 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 illn ess, 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 sympatheti c nervous system, as manifested by an increased heart rate (HR), blood pressure, respiratory rate (RR), and neurohumoral responses, possibly leading to a destructiv e 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 prognosi s if they experienced anxiety prior to and during transplantation (Illescas-Rico, Amaya-Ayala, Jimenez-Lopez, CaballeroMendez, & 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 StateTrait Anxiety Inventory (STAI) scores or test anxi ety scores were noted between groups

PAGE 63

51 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 testi ng in either the experimental or control group. However, the standard deviation of the experiment al group decreased, wh ich might reflect a statistically nonsignificant trend toward synchronization between the pulse and the musical beat. Four different studies assessed the eff ects 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 gr oups: 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 be fore 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 th e groups, but pooled data revealed significant differences over a period of time. Bolwerk (1990) compared the effect s of listening to relaxing music ( n = 20) to a control group ( n = 20) of myocardial infarctio n patients who scored as being anxious on the STAI at the baseline. Baselin e differences in anxiety scores between music and control groups were statistically non significant. Post-interventio n, however, the music group's STAI scores were significantly lower ( p < 0.007) compared to the control group. The decrease in the music groups preand pos t-intervention anxiety scores was also

PAGE 64

52 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 in fluenced 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 preto 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; a nd 3) control (uninterrupted re st). 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, Hospit al 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; theref ore, 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), a nd respiratory rate (RR) in 40 myocardial infarction patients. The experi mental group listened to 25 mi nutes of relaxing classical music, whereas the control group received 25 minut es of uninterrupted rest. A statistically significant decrease in STAI scores postintervention 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 group.

PAGE 65

53 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 mu sic intervention, musicvideo intervention, or scheduled rest groups. Su bjects received their assigned intervention for 30 minutes once daily on post-operative days 2 and 3. Pa tients were in either intensive care or progressive care unit settings. No significan t 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 measur ed 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 se lf-selected music played from the preoperative to the post-operative period on state anxiety. A significant decrease in STAI scores occurred in the experiment al group compared to the control group. The p 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 preand post-intervention STAI scores, HR, BP, and RR. The experimental group listened to sedative music for 20 minutes in th e holding area, result ing in significantly decreased STAI scores ( p = 0.005) and RR ( p = 0.002) post-interven tion. Decreases in systolic blood pressure (SBP) were ma rginally statistically significant ( p = 0.055) in the

PAGE 66

54 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 tre nd toward decreased anxiety with the use of music in the surgical setting. Collectively, research supports the us efulness of music in decreasing anxiety. Recent studies (Campbell, 1997; Panksepp, 1995; Sloboda & Juslin, 2001; Tse, et al. 2005) have shown that music lowers a pa tient's blood pressure, basal metabolism, and respiration rates, and it increases the pr oduction of endorphins that reduce pain. Endorphins are the bodys natu ral 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 scientif ic rationale in the 20 century supports the use of music to increase the production of endorphins and reduce pain and anxiety in patients. Musics ability to alter pain and emotional states has long been known experientially, and more recently this ab ility has been scientifically documented. Studies continue to show the effect s 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 lo w-, moderate-, and high-intensity exercise. Repeated-measures ANOVA revealed increased respiratory frequency (RF) during fast music, as compar ed to the no music and sedative music conditions ( p < 0.01).

PAGE 67

55 In an investigation on music and labor pain, Geden, Lower, Beattie, and Beck (1989) carried out two studies to examine th e 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 we re 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 repor t lower pain ratings and cardiovascular responses than subjects listening to rock mu sic, self-selected music, or a dissertation (placebo-attention) as compared to subjects in a no-treatment control group. Significant group effects were found. Subject s 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 contro l. Again, significant group effects were obtained for heart rate and systolic and diastolic bl ood pressures. Statistical analysis showed significantly lower pain per ception in the music group comp ared to the control group. This finding is important for health care professionals; music may be an effective treatment for women who have troub le coping with pain sensation. In another study on the effect of music on st ress 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 an esthesia. They also studied listening to music and therapeutic su ggestions, and found a pos itive effect on post-operative recovery

PAGE 68

56 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 eff ects on state anxiety, Rohner and Miller (1980) observed that music in various institut ions and other research settings has the potential to reduce anxiety in high-anxiety su bjects. 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 ST AI questionnaire was administered in a counterbalanced fashion prior to and followi ng the music (or no music) treatment. State anxiety (S-Anxiety) refers to the subjective and tran sitory feeling of tension, nervousness, and worries and may be characterized by activat ion of the autonomous nervous system, at a given moment (Fountoulakis, Papa dopoulou, Kleanthous, Papadopoulou, Bizeli, Nimatoudis, et al., 2006). Results proved to be statistically nonsignificant. In addition, a trend of sedative music having some anxi ety-reducing effects upon high state anxiety subjects was noted. In an attempt to respond to the issue of wh ether 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 st udy explored the possible beneficial effects of singing on a patients well-being during a singing lesson. Eight amateur musicians were included, consisting of two ma les and six females between the ages of 28 and 53 years, and eight professional singers co nsisting 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-

PAGE 69

57 energetic, and tense-relaxed--w ere scored before and after the lesson. In addition, a semistructured interview was performed. Heart rate va riability analyses showed significant changes over a period of time in the two groups for total power and lowand high-frequency power. Power increased during singing in the professiona ls, but no changes occurred in the amateurs. A power increase during singing in the professionals indicates an ability to retain more "heartbrain connection," that is, more cardiophysiological fitness for singers. In another st udy on anxiety, Yilmaz, Ozcan, Basar, Basar, Batisla m and Ferhat (2003) carried out a study to determine if music decreases anxiety and pr ovides 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 surg ery, and one means of helping reduce anxiety in patients is to incorporate music in the surgical holding ar ea. 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 w ho 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 pref erred the musical intervention since they experienced less anxiety. Researchers at the Bryan Memorial Hospita l in Lincoln, Nebraska, investigated the influence of music therapy on the mood and a nxiety 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,

PAGE 70

58 participated in the study. Data relating to anxiety and mood were obtained through blood pressure and heart rate using Spielberge r'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 th e "music therapy" group after the second intervention. Significant main effects were al so observed over a period of time for heart rate, systolic and di astolic blood pressures in the musi c therapy group, which indicated a generalized physiologic relaxation response. Reduced anxiety and improved mood were indicated in all three groups, and the rese archers noted that all the interventions demonstrated generalized relaxation (Barnas on et al., 1995). To support the use of music in patients undergoing open-h eart surgery, Voss (2005) noted: Health care providers shoul d feel confident in using music for post-operative openheart patients and should try it with ot her patients to decrease anxiety and pain. From a clinical perspective, sedative music is low risk, and it is therefore recommended in addition to pain medicati on 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 sett ing for ambulatory patients. In the Day Surgery Unit of St. Marys Hospital in Mequon, Wisconsin, the au thors investigated 42 ambulatory surgery patients assigned to either an experimental group, which received music therapy along with the standard pre-operative instructi ons, or a control group, which received the standard pre-operative instruction alone. Th e results revealed that patients in the experimental group showed signi ficantly lower heart rates compared to those in the control group. The experimental group al so showed greater improvements in blood pressure and respiration rate. The research ers concluded that music therapy offers demonstrable benefits for ambulatory surger y patients and recommended that patients be

PAGE 71

59 offered music as an effective option to help alleviate post-operati ve anxiety (Augustin & Hains, 1996). Effects of Music on Pain The arts are quintessentially holistic in th eir 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 populati on 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 pers istent pain, that is, pain associated with cancer, migraine or tension headaches, chest pain, pain from diab etes with neuropathy, arthritis, fibromyalgia, neuralgias, neck a nd back disorders, facial pain disorders, functional or organic bowel disorders, or pelvic disorders (Gallagher, 1999). Various types of music have been investigat ed 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 ta ctile thresholds, wh ereas 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 experiment al groups: 1) headphones with self-selected music; 2) headphones with no mu sic; and 3) no headphones. Analysis of variance

PAGE 72

60 (ANOVA) yielded no significant differences in pain levels among grou ps, 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 one-month post-surgery. Good (1995) compar ed the individual and combin ed effects of jaw relaxation and music in a control group on pain levels of 84 abdo minal surgery patients during their first post-operative ambulation. S ubjects were randomized into groups and instructed in the interventions pre-operatively using an audiotape. After the analysis of the taped interventions for 2 postoperative da ys, 89% of experimental subjects reported that music had helped them redu ce 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 sp ecific 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 qua lities of the music may cause different physical and psychol ogical responses (Gardner, 1990). Music therapists and music healer s sometimes believe that th eir own favorite music is universally liked and therapeu tic 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 wou nded Hungarian soldiers would recover quickly if made to listen to music of their cultural background; in this

PAGE 73

61 case, Hungarian dances such as Johannes Brahmss 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 cultur al awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desi re are all needed in this endeavor. Music appropriate for stress reduction ha s 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 cr itical care units should theoretically substitute pleasing, meaningful sounds for loud, unfamiliar sounds, thus resulting in decreas ed 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 patients 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 tra its, 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 intr overts. On the other hand, music with low stimulative value, as preferred by intr overts, may be a source of stress for extraverts. (p. 234) Musical preferences and thei r effect on different individuals have been debated during the past decade. Knowledge of musical preferences is enormously significant in the selection of music for th erapeutic work (Kopacz, 2005). Research into personalitydependent musical preferences has a long history, but little research has been conducted

PAGE 74

62 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, an d 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 Furnha m, 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 inte resting to see how th is theory might be applied to patients who are in pain or experiencing anxiety, and how these factors affect thei r musical preferences. With this consideration in mind, the research er decided to underscore the importance of a narrower dimension of pain perception and its us efulness 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 expressi vely organized sounds composed of some key elements: rhythm, pitch, harmony, a nd 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 rhythm ic 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).

PAGE 75

63 The ideal music should be calming. The cal ming 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 ve ry important. The music must be well balanced and somewhat stable in terms of harmony, rhythm, instrumentation, melodic elements, tempo, and timbre. Ov erly dissonant intervals or harmonic progressions should not be sust ained during long periods of time, and the music that exhibits tensions within t onality needs to be resolved (Spintge, 1989). Podolsky (1934) observed Good music and good health are intimat ely associated with each other (p. 200). In this study, the pre-recorded audio musi c used was based on pieces selected by the subjects. Favorite music wa s 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 de finite melodic structur e and generally little dynamic variation. This kind of music fits Spintges (1989) definition of anxiolytic music. According to Spintge, music is anxiol ytic if it has an eff ect on the cardiovascular system, respiratory system, endocrine syst em, metabolism, motor system, exocrine secretion and excretion, reception and perception. Examples of this music would include Beethovens Adagio from Piano Sonata #8 ( Pathetique ) and Glucks 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 Sousas marches produced an accentuation of dicrotism a condition in which the pulse is felt as two b eats per single heartbeat. Sedative music is considered to be slow and between 60 a nd 80 beats a minute. It should also have a

PAGE 76

64 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 a ccording to duration, instrumentation, dynamics, and interpretation. It is impor tant that there are no extremes in rhythm, melody, or dynamics and that instrumental rather than vocal music be chosen. 2. Patients should make their own selections. 3. The effects of individual pieces and comb inations of pieces should be tested and verified in ongoing clinical stud ies so that new trends and new technologies can also be considered. 4. Recordings should be of high quality, yet technicall y simple and reliable (laser-CD-disc preferable). The type of music an individu al listens to tends to infl uence his respons e to therapy (Spintge, 1989). Podolsky (1934) discussed in detail an earlier 1918 st udy of the effects of three rapid music se lections on the heart rate and blood pressure. Pati ents 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, E llis and Brighouse ( 1952) measured the heart rate and respiration of 36 students who were randomly selected from a group of colleg e 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

PAGE 77

65 greater decrease in anxiety occurred as reflect ed by exam scores in subjects who listened to sedative music, compared to thos e who listened to stimulative music. Kaempf and Amodei (1989) studied the e ffects of sedative music therapy on the anxiety of 33 surgical patien ts in the operating room holding area. The experimental group received 20 minutes of se dative music therapy via a ta pe recorder placed on a nearby bedside stand, while th e control group received no music therapy. Both groups showed reductions in blood pr essure and heart rate after th e 20-minute period. However, the music group had greater redu ctions in respira tion than the contro l group had. Summers et al. (1990) found that when 45 co llege students listened to fast rhythms, their heart rates increased. Ho wever, slower rhythms of 60 be ats per minute resulted in lower heart rates a nd blood pressures. Music as a Form of Distraction Drever (1952) defined distraction as a condition where concen tration of attention is disturbed, difficult, or virtually impossible, as caused by irrele vant stimuli. Distraction is regarded as a major influencing factor in th e 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, expe ctations, and attentiondistraction levels. This is consistent with the Gate Control Theory of pain. Locsin (1981) observed that attention switching might not always be easil y achieved but may be learned and used to aid in pain control. Pleasant music played repetitively may enhance distraction. In the early 18th century, Fr ench 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 orchestr al accompaniment was also found to distract the patient's attention and that would result in his feeling less pain, thereby decreasing his

PAGE 78

66 suffering resulting from the crude dental pr actices 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 distra ction or stimulus can elicit changes in the lower synapses of the sensory pathways, and th is is influenced by the significance of the stimulus and past experiences (Hernand ez-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 dyna mic control of the brain (Melzack et al., 1963). 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 in crease in the tolerance duration of pain compared to the control condition without aud itory stimulation. Wh en intense auditory stimulation--without explicit s uggestions--was given to redu ce the subjects pain, the auditory stimulation was found to have an in significant 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 sugge stion), could act on input patterns evoked by noxious stimuli during their transmission. Locsin (1981) conducted a study of 24 obstetr ic patients to determine the effects of music therapy on post-operative pain. The women received 30-minut e sessions of music therapy every 2 hours during the first 48 hours po st-operatively. Heart rates of the music

PAGE 79

67 therapy group were significantly lower at 48 hours but not at 24 hours post-operatively, compared to the control group. Analysis s howed that blood pressu re 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 ra tes at 24 or 48 hours in the two groups. Post-operative patients, w ho listened to music th erapy during the first 48 hours post-operatively, used less pain medicat ion 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-opera tive patients during the first two postoperative days (Locsin). In a study of 17 a dult post-operative pa tients, Moss (1988) found that patients musical preferences seemed to influence whether or not music therapy was soothing. Patients reported that the music they selected he lped them relax by providing a distraction from external noises. Updike (1990) suggested th at a reduction of pain can result from a physical and/or an emotional etiology. Pain may either be di verted via the concentr ation 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 systol ic blood pressure and mean arterial pressure were found when co mparing 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 res ponses before and after the music therapy. Analysis of patients' moods indicated a shift toward a more desirable state of well-being.

PAGE 80

68 Music therapy was found to re duce anxiety, depression, and pain experience. Listening to music is a useful technique for distraction a nd 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 neurophys iological 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 therefor e be reduced by inhibiting the psychological feedback of noxious stimuli from the areas of surgical injury. Hernandez-Peons study supports the idea that music not only serves as a distraction, but if the type of music is considered pleasurable, it may also bloc k the transmission of other sensations. Studies and observations discussed in this chapter have thus fa r revealed that both ritual and scientific practices themselves produce therapeutic, psychological results through altered states of consciousness. Even though historical debate s 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 researcher s on this particular argument of the influence of musical stimuli were Mu llings (1984) and Sargant (1973) whose controversial views on the efficacy of the cathar tic nature of music act ed as a catalyst for subsequent research. In Sargants views, it was violent dancing, which by brining on perspiration, effected the cure. Mullings a nd Sargant observed that the new and healthier behavior patterns facilitated following th e musical stimuli brought desired change. Summary and Implications for the Present Study A review of the music therapy literature de lineates at least th ree broad domains of functioning where music therapy has successfu lly been utilized in the treatment of

PAGE 81

69 emotionally disturbed childre n: 1) affect regulation; 2) communication; and 3) social/behavioral dysfunction. Assessment a nd intervention in each of these domains require strong grounding in developmental th eory, which is a key component in the training of music therapists. In the middl e of the 20th century, music therapy was identified as an intervention to treat imp airments 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 we ll suited to help improve communication deficits and stimul ate nonverbal communicat ion in children. Numerous positive outcomes in improving social functioning, social awareness, and cooperation (Werbner, 1966) and decreasi ng 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 exhibiti ng significant levels of anxieties (U.S. Department of Education, 2001). As a benef it 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. xx) Perron and Schonwetter (2001) observed th at patients do not always receive sufficient relief from opioids. They also not ed that opioids may have undesirable side effects, hence using intervention su ch as music would be appropriate.

PAGE 82

70 CHAPTER 3 METHODOLOGY AND PROCEDURES This chapter is divided into six sections In the first section, the 15 subjects included in the study are discussed. The s econd section describes the procedures and setting used during the study. The third secti on discusses the data collection process and the instruments used. The fourth section in cludes the reliability procedures. The fifth section presents the instruments that were us ed. 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 empi rical method accepted by positivists, according to Wheeler (1995), tests theories through proced ures for scientific objectivity, including careful observation of behavior, the isolat ion 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 Descar tes, 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 goe s on inside the observer. (p. 11) The following discussion presents a met hodology 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 observa tions. This chapter also presents a

PAGE 83

71 discussion on the methodology based on data co llected ethnographically, with a limited amount of controlled experimental work. In this chapter, the researcher presents the procedures under which the re search study was conducted. Research Design This research study used a repe ated-measures design. In a within-subjects design, each particip ant provides more than one re sponse (Becker, 1999). In this repeated-measures design, the participant re sponded both before the treatment and after the treatment. This according to Becker (1999), is a typical wi thin-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 "repeat ed 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, repeatedmeasures 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 respir atory rate. Each of the subject s 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)

PAGE 84

72 Upon commencement of the first session, subj ects enrolled in the study were given the opportunity to choose the type of music th ey would prefer to listen to during the study. The researcher used the Modified Ha rtsock 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 met hod 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 assump tions of the t-test are not met, then other statistical tests should be considered (Becker, 1999). The assumptions are: Assumption 1 (independence) is not met b ecause I get more than one score from each person: Therefore we used the pair ed 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 supportiv e indicators for within -subject factors, for example, SBP, HR, and RR levels brought about by different music, as determined by subjects musical preferences. The research er achieved this by comparing the mean differences as within-subject factors variables. Subjects In order to investigate th e effects of listening to music on pain and anxiety, 15 eligible patients (subjects) aged 7 and older from the Bone Marrow Transplant Unit at

PAGE 85

73 Shands Hospital at UF participated in the study. Participants were interviewed individually either in a clinic or in a privat e room within the BMT area. Four health care professionals with medical or doctoral degr ees assisted in conducting the structured, semi-structured, and unstructured interviews. In this particular research the issue of language barrier did not arise si nce all the subjects spoke E nglish as their native language or mother tongue. Pregnant subjects were excluded from th e study. Participants were interviewed individually in a clinic or in a private r oom within the BMT area. Four health care professionals with medical, doctoral, or nur sing degrees assisted in conducting the semistructured interviews, assessing pain, state anxiety, and record ing of the three vital signs selected: blood pressure, resp iratory rate, and heart rate. The health care personnel also assisted in arranging meetings with the pati ents during the post-intervention period. The subjects were required to be able to co mmunicate in English because the research instruments, such as the STAI scale, were designed in English. Patients excluded from the research included those who: are incubate d; have a hearing deficit; are unable to speak and read English; require artificial pacing which would pr eclude assessment of heart rate; are unable to give informed cons ent; those not oriented to time, place, or person; and have complications. Once the protocol was begun, patients we re withdrawn from the study if: they developed any complications; they requested th at the intervention be terminated; and if they were interrupted during the time for th e music intervention by medical or nursing care activities. If the patients were administ ered analgesic medicati on, efforts were made

PAGE 86

74 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 participat e in the study, a signed consent form was obtained from the subject and from the parent if the su bject was between the age of 7 and 18. Following the IRB approval, the subjects we re recruited from patients requiring a bone marrow transplant. After their admission in to 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 collecti on 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 co llected information regarding the diagnosis of the subjects based on th e available medical data. The information included for example, neurologic status, leuke mia, 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, ex amined the physiological parameters, which included the vital signs. This was done a da y before the musical intervention. Other points of interest included the sociocultural and psychospiritual conc erns of the patients

PAGE 87

75 toward music. The researcher engaged the patient s 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 addi ng 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 ps ychological concepts ; interpreting or explaining the spiritual through psychologi cal concepts; valida ting the spiritual through the alleged science of psychol ogy; integrating the spiritual with psychology . the spiritualizing of psychology. (para. 3) Other aspects that were discussed in the que stionnaire included the level of musical knowledge, such as formal and non-formal music education. In this context, the researcher noted every patients music li stening experience prior to the music intervention. Procedures Qualitative data analysis is a search for general statements about relationships between categories of data (M arshall & Rossman, 1994), and no single right way exists to analyze the data in a qualita tive study (Leedy & Ormond, 2001) The researcher used the data collection tool (see Appendix D) to prov ide the framework for the data analysis. In this study, the researcher began with a larg e body of information and through inductive reasoning (from particular to general), sort ed and categorized the data, and gradually condensed the data to a small set of abstra ct, underlying themes (Creswell, 1998; Leedy & Ormond, 2001). An analytical search for wh at Creswell called pat terned regularities in the data was conducted. The researcher ex amined how listening to self-selected music affected the following variable s: self-reported pain, anxiet y, blood pressure, heart rate, and respiratory rate.

PAGE 88

76 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 pa tterns; and testing the emergent hypotheses against the data (Marshall & Rossman, 1994). Using researcher-constructed t ypologies to locate naturally occurring variations in this researchers observations the salient, grounded categor ies of meaning held by the participants (Marshall & Rossman, 1994) were identified. The resear cher also created several categories, base d 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 explan ations that were the most plausible (Marshall & Rossman 1994). The researcher used the Statistical Pack age for Social Sciences (SPSS base 11.5 for Windows, 2002, SPSS Inc., Chicago, IL) for da ta management, analysis, and graphical presentation of results. The data were entere d as text into MS Word using codes. The degree of the coding was based on three factor s offered by Neuman (2000): the research questions, the richness of the data, and this studys research purposes. The researcher marked, labeled, and sorted the data in order to find relationships be tween music and pain indices, music and anxiety indices, music a nd BP indices, music and RP indices, and

PAGE 89

77 music and RR indices. Similarities or dissim ilar trends, themes, and behavior were examined. As new ideas, concepts, and themes emerged, the researcher recoded the data. After the initial coding process and locati ng themes and assigning the initial codes or labels to condense the larg e set of data into categories, the researcher then conducted axial coding. Axial coding is a technique th at facilitates building connections within categories, that is, between categorie s 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 se parately, the resear cher used the SPSS computer software program to index, code/label and extract themes. The researcher then summarized the data and incorporated res pondent quotations to support the data. The summary was then cross-referenced with unfolding themes, differences in the respondents points of views, what they sa id, 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 s ubject (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

PAGE 90

78 require the patients to choose from the provi ded 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 appropriate ly. 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 th en liaised with the health care personnel in the BMT Unit, such as the nurse s and physicians on duty; to make sure the patient was in his room at an appropriate ti me following the infusion or to learn if the patient had undergone any other pharmacol ogical 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 th eir self-evaluation. The researcher also addressed the concept of comfort or the con cept of having no pain in order to help the patients understand the VAS numeri cal scale. Points of interest included presence of pain, pain intensity, age of patient, language, condi tion, and a cognitively rate their pain using the VAS pain rating scale, for example, to 10. Other points of in terest included their anxiety at that particular moment. This was measured us ing 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 discus sion of the patient's musical preferences selected from choice, (i.e., Baroque, Country and Western, Cl assical, Gospel/Religious, Rock/Disco, Movie Soundtracks, Romantic, Jazz/Blues, other) (see Appendix E).

PAGE 91

79 Modified Hartsock Music Preference Questionnaire Modified Hartsock Music Pr eference Questionnaire wa s first developed in 1982 by Jane Hartsock. The questionnaire was to determ ine if listening to favorite music affects the levels of anxiety in the listener (Hartsoc k, 1982). Since then it has been used to assess the usefulness of music in improving the qual ity of life for patients (Gerdner, 2000). The questionnaire first consiste d of short questions where the respondent selected the appropriate answers from the gi ven choices regarding his favo rite 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 questionnair e was also used to obtain personal data (Hartsock, 1982). Findings from the Modified Hartsock Music Preference Questionnaire (see Appendix E) guided the selecti on of individualized music. The researcher discussed and dispelled misconceptions about pain a nd anxiety management, respectively. The researcher then explained to the patients the purpose of music in tervention, which is, using the arts as Complementary and Alte rnative Medicine (C AM) to support the controlled analgesia, and also to edu cate them about the use of nonpharmacologic methods (e.g., relaxation with music). The re searcher discussed pot ential outcomes of pain and discomfort interventions using mu sic. The researcher discontinued using a subject from the study if the patient b ecame uncomfortable with the study. The researcher arranged for parents of pediat ric patients to be present during music intervention. Visual Analogue Scale Approximately one minute prior to the musi c, heart rate and blood pressure were recorded from a monitor at th e nurses station. The data we re obtained from an arterial

PAGE 92

80 line, which was already in place, using a Hewlett-Packard monitor. The equipment was connected with a Transpac II Sorenson trans ducer in the first f acility and from a previously inserted arterial line, using a Hewlett-Packard monitor with a Baxter transducer, in the second facili ty. 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 Questionn aire. 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 through that represented the patients level of perceived pain intensity. The VAS line was de signed in such a way that means no pain at all and means the worst pain possible. Each subject was then advised that the musi c is believed to help reduce pain. Next, the self-selected music was played using a portable CD player for the patients for 30minutes. 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-selecte d, each musical selection was matched by other selections that consis ted of relatively uniform rhyt hm 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 its elf without the influence of a verbal message. The musical selections we re classified as follows: Baroque Country and Western Classical Gospel/Religious

PAGE 93

81 Rock/Disco Movie Soundtracks Romantic Jazz/Blues Other Data Collection Data collected during the study included : subjects biographical information; subjects self-report of pain; anxiety measur es; blood pressure; hear t rate; respiratory rate; music preference; and s ubjects general comments rela ted to the intervention. All this information was recorded by the researcher on the data collection sheet (see Appendix D). If patients expressed a willingness to pa rticipate 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 standa rd assessments of anxiety each time before, during, and after the musical intervention. Vital signs: Vital signs of all the subject s were recorded each time before, during, and after the musi cal intervention. Satisfaction: All subjects completed standa rd patient satisfaction assessments at the end of the research afte r each musical intervention

PAGE 94

82 Table 3-1. Data Collection Process T1 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 in tervention (+45 minutes) The day before intervention (24 hours T1), pain and anxiety scores were collected from each subject in the study sample. This in itial recording was aimed at assessing the consistency of the pain, anxiety, and the vi tal signs prior to music intervention. The second reading (T2) just before the music intervention, however, ac ted as the baseline reading. The recording was also taken immedi ately before the musical intervention. After every 15 minutes, more readings were taken and recorded on a sheet (see Appendix D). After 30 minutes, the investig ator then entered the room and discontinued playing the music. Subjects were asked to rate th eir pain using the numeric VAS from the postintervention pain score. After 45 minutes, the researcher asked the patient to rate his pain for the last time. This concluded the intervie w 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 da ta collection sheet. Subjects were allowed to make other music se lections if they pr eferred another music style during subsequent sessions. Patients were asked whether or not the mu sic was of some support during their stay in the BMT Unit, and the degree of this suppor t, as measured on an attitudinal scale. Patients were also asked if they would have pr eferred not to listen to music. At the end of

PAGE 95

83 the music intervention, patients were asked to indicate whether or not they would have preferred to listen to music a nd the reasons for this preference. Patients participation in this study was entirely voluntary. Uncontrolle d 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 utili zed in the Bone Marrow Transplant Unit included the patients cultural and religi ous background, which provided a personalized approach. In all instan ces, the patients musical preferen ces were of primary importance. Sampling The researcher used the convenien ce sampling (also known as accidental sampling). Convenience sampling approach that makes no preten se of identifying a representative subset of a popul ation, but rather, it takes peop le who are readily available (Leedy & Ormond 2001). This sampling method is also referred to as a nonprobability sampling technique, commonly used in explor atory 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 wa s--how alike or different its members are with respect to the characteristics of the re search interest (Leedy & Ormond. The use of the purposive convenience sa mpling 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, th is research may be most applicable to the

PAGE 96

84 BMT setting. But this BMT Unit is a setting with people who are in dire pain and filled with anxiety, hence, understanding their mu sical preferences is of great importance. As illustrated (see Appendix D) the first data collection day (T1) was 24 hours preintervention--a day for interaction. Patients we re visited by the Primary Investigator (PI) and trained assistants. The data collectors ad ministered the two se lf-report scales: the Visual Analogue Scale (VAS) for pain and th e 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 fl eeting emotional state. The inst rument 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 pe riod of 30 minutes. Pain and anxiety were measured after the first 15 minutes (T3), imme diately after the inte rvention (T4), and 45 minutes post-intervention (T5). Instruments The instruments used in this study m easured two groups of variables: 1) physiological parameters; and 2) psychological parameters. Physiological Parameters A bedside monitor was used to collect sy stolic blood pressu re, heart rate, and respiratory rate. Data were co llected at baseline before the bone marrow transplant, 24 hours before music intervention, immediately before the intervention, 15 minutes during intervention, 30 minutes at th e end of the intervention, a nd 45 minutes post-intervention.

PAGE 97

85 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). Gould (2001) described the VAS as a horizontal line, 100 mm in length, and anchored by word descriptors at each e nd, as illustrated (see Appendix B). The descriptors range from 0 ( no pain ) to ( 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 appear s to be continuous; therefore, his pain does not take discrete jumps. The feelings are categorized as no pain, mild pain, moderate pain and severe pain Many other ways exist in whic h 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 represen ts his perception of his current state. The VAS, a pain rating scal e (see Appendix B), was used to assess the patients perception of pain intensity. The VAS has been found to be superior to categorical scales in differentiating between precise changes in de grees of pain. It is therefore more useful in studies pertaining to analge sic 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 of pethidine a drug used to deal with moderate to severe pa in. Researchers conducted another study of 1,497

PAGE 98

86 patients with various diagnoses, comparing th e 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 (Littm an 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 th e 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 re quired in interpreting persona l pain intensity (Kremer, Atkinson, & Ignelzi, 1981; McGuire, 1988). Th e VAS is considered easy to administer and score, but may be confusing to some patie nts who have difficulty visualizing pain as a straight line (Kremer et al., 1981; McGuire, 1988). Psychological Parameters 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 a nxiety and help patients according to their needs. MacArthur & MacArt hur (2006) have stated: Among many instruments to asse ss 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 citati ons in the last thre e decades. Thus, it is the standard in the field. (para. 8) The STAI consists of a 20-item questionna ire with questions about how the patient is feeling (see Appendix C). Data were co llected at baseline before the bone marrow transplant, 24 hours before music interven tion, immediately before the intervention, 15

PAGE 99

87 minutes during intervention, 30 minutes at th e end of the intervention, and 45 minutes post-intervention. The instrument that was used to obtain bl ood 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 pressu re and heart rate read ings in the second facility was a Hewlett-Packard m onitor 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 pre ssure (Hewlett-Packard, 1988). Both the Transpac II Sorenson transducer and the Baxter transducer had elec tronic 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 pressure(s) 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-st ate portion (STAI-s) (Spielberger et al., 1983). The STAI-s m easures 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

PAGE 100

88 feel "right now, at this moment," rated on a ( not at all ) to ( very much so ) scale. The STAI takes approximately 5 to10 minutes to complete. An overall score is derived by coding positive statements (e.g., I feel 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 re ported reliability (Cronbach's alpha) ranging from .83 to .92 (Spielberger et al .). Cronbach's alpha is an i ndex of reliability associated with the variation accounted for by the true score of the underlying construct (Cronbach, 1951). A sample item states, I feel at ease ." The State-Trait Anxiety Inventory (STAI) was initially conceptualized as a research instrument for the study of anxiety. It is a self-report assessmen t 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, c onsciously 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 interp retation: 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 standa rd (T) scores are available fo r 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, ma le neuropsychiatric patients, male medical

PAGE 101

89 patients, and male prison inmates. In this st udy, the participants were asked to rate their overall sense of control over pain using th e numeric rating scale with options ranging from ( no pain at all ) to ( worst pain possible ) (Kwekkeboom, 2003). Reliability Procedures The STAI scale has been demonstrated to be reliable and valid and has been used with cancer patients. Kwekkeboom (2003) obser ved that this nume rical rating scale measure of pain has been used successfully in recent research by ot her investigators (p. 435). In addition, the stability of the STAI scales was assessed on male and female samples of high school and college students fo r test-retest in tervals, ranging from one hour to 104 days. The magnitude of the reliabil ity coefficients decrea sed as a function of interval length. For the Trai t-anxiety scale, the coeffici ents ranged from .65 to .86, whereas the range for the Stateanxiety scale was .16 to .62. This low level of stability for the State-anxiety scale is exp ected since responses to the it ems on this scale are thought to reflect the influence of whatever transient situational factors exist at the time of testing (Spielberger et al., 1983). Validity The VAS scale has been eval uated in terms of validity and responsiveness. In general, the scaling method seems to be va lid and responsive (Bo lton & Wilkinson, 1998; Vickers, 1999; Wewers & Lowe, 1990). Co rrelations are presented in the manual between this scale and other measures of trait-anxiety: the Taylor Manifest Anxiety Scale, the IPAT Anxiety Scale, and the Mu ltiple Affect Adjective Check List. These correlations are .80,. 75, and .52, respec tively (Spielberger et al., 1983).

PAGE 102

90 Audio Recording Audio recordings are an essential form of data for music and healing research due to their excellent time resolution. With the audio equipment available today, obtaining good quality recordings do not present seri ous difficulties. Although audio player machines do not cause much of a problem in the bone marrow transplant unit, the number and placement of these machines require ca reful consideration. Therefore, portable players were used in the rooms only during mu sic sessions. Existing recordings are quite useful for investigating the e ffects of music on health, and th is effect was applied in the pain and anxiety phenomena (Standley, 1986). Statistical Procedures Although the reduction in pain and anxiety indices following music intervention do not necessarily prove the efficacy of music in these conditions, the effects can be suspected only if they reduce every time thos e musical stimuli are applied and all data analyzed. At the heart of qualitative and qua litative data analysis is the task of discovering themes. The first step of analysis therefore, is to look for themes. Themes are abstract -often uncertain -constructs, which researchers identi fy before, during, and even after data collection. Them e identification is one of th e most fundamental tasks in qualitative research. One such theme may incl ude the musical preferences of the patients under pain and anxiety. Caution is generally demanded because analyses are a complex, dynamic process, not a fixed state. A single observation is not sufficient to identify the effects of certain types of music on patients. Time series data are required, that is a series of observation data or measurements of the respective behaviors over a period of time. These data can then be analyzed in order to detect the presence of themes. For instance, the mere

PAGE 103

91 demonstration of a covariance of two variable s is not sufficient to prove the efficacy of music in the alleviation of pain and anxiet y. In order to identify these themes, it is necessary to examine and re view the literature. Ryan and Bernard (2003) stated: Richer literatures produce more themes. They come from the char acteristics of the phenomena being studied. And they come from already-agreed-upon professional definitions, from local common-sense constructs, and from researchers values, theoretical orientation, and personal experience with the subject matter. (p. 88) Interpretation of Data As previously suggested, the empirical and/ or experimental res earch can flow out of and serve to illuminate the interpretation of qualitative data. Serious consideration of music and healing in the field of heal th care research, supported by a myriad development of methodologies, coul d potentially lead to a signif icant shift in the focus of music and healing. In fact, as empirical and experimental approaches continue to be integrated with ethnographic approaches, the disc ipline will gain credence. The ways in which qualitative and empirical methods continue to be integrated between substantially different research contexts are particularly important. However, each of these approaches should feed into the other; in other words, qualitative methods should direct empirical research because empirical research offers in tuitions as to which phenomena seem to be especially important in specific artistic cont exts since empirical research can generate questions for qualitative methods (Ryan & Bernard, 2003). The analysis of the data from the post-in tervention questionnaire (see Appendix K) was done with the use of the St atistical Package for the Soci al Sciences (SPSS) software. This software includes a spreadsheet-type da ta entry window, statisti cal capabilities, and graphics. The software feat ures are modules for statisti cal data analysis, including descriptive statistics such as plots, frequenc ies, charts, and lists. The software package

PAGE 104

92 also includes sophisticated inferential and mu ltivariate statistical procedures, such as analysis of variance (ANOVA), f actor analysis, cluster anal ysis, and categorical data analysis. The SPSS package is particularly well suited to survey research, but by no means is it limited to just this topic of exploration. Descriptive statistics were used to describe the groups' characteristics. Nonparametric tests were used. A paired sample t-test was used to determine whether or not the differences were statistically significant for all dependent variables between groups at each time period (baseline, 15, 30, and 45 minutes). For physiological variables, the independent t-test was used to test for any statistically significant differences between the groups for each dependent vari able at five time points. Multiple comparisons were performed using a paired sample t-test to compare each pair (baseline vs. 15 minutes, baseline vs. 30 minutes, and base line vs. 45 minutes). The leve l of significance was set at .05. The researcher concluded the data analys is when the critical categories were defined and the relationships among them established (Marshall & Rossman 1994). At this point, the researcher no longer found si gnificant variability between the paired recordings of pain, anxiety, and vital signs. With the use of the qualitative methods of in-depth interv iews, participant observation, field notes, and use of the que stionnaire data, the researcher used a triangulation of methodologies that tested the findings. This research design was valuable for ensuring that the researcher captured the necessary data needed for addressing the research objectives and unders tanding the personal te stimonies, beliefs,

PAGE 105

93 and behaviors plus the social, cultural, and environmental aspects affecting the quality of life of the patients receiving BMT. Data Management The data collected, generally known as pr otected health information (PHI), was stored in locked filing cabinets or in co mputers with security passwords. Only the researchers and health care pe rsonnel had the legal right to re view these research records because the data were protected to the extent the law stipulates. University of Florida officials, the hospital and the clinical staff involved in this resear ch, and the Institutional Review Board (IRB) also had access to this PHI.

PAGE 106

94 CHAPTER 4 RESULTS Introduction The purpose of this study was to determin e the effect of musi c on patients pain, anxiety, blood pressure, heart ra te, and respiratory rate during their stay in the BMT Unit. This chapter presents the research findings of the study in three broa d categories. First, a description of the sample ch aracteristics is presented. Second, the hypotheses posed in Chapter 1 are addressed. Third, de scriptive findings are presented. Sample Characteristics Data from 15 patients were studied. Their reasons for admission which were comparable within the subjects formed a core of their demographic characteristics. These are represented in Table 4-1. The total sa mple was composed of 60.0% males and 40.0% females, with a mean age of 47.60 (range, 18 to 72 years). Further descriptions of the types of cancer and the length of time each su bject had been in the BMT Unit were also collected as part of the dem ographic data (see Appendix A). Initially, a total of 20 patients agreed to participate in the st udy. However, three subjects withdrew from the study for being t oo sick while two subjects were younger than 7 years old. The final sample consisted of 15 individuals who were between the ages of 7 and 72 years. The majority of the subject s were male (n = 15; 40%). There were differences among subjects with regard to th eir musical preferences. About 26% of the clients (4) chose each of the following: count ry, baroque, and classical music while only 13% (2) chose jazz. Only 6% (1) chose hip hop (see Table 4-2). One individual asked for

PAGE 107

95 gospel music, but picked country music as the second choice. Another patient also requested that Peter Gabriels rock tune All That You Cant Leave Behind be changed since it elicited disturbing memories. Trial 1 occurred 24 hours before the music intervention. Trial 2 occurred just before the music intervention at Time 2, while trial 3 was performed 15 minutes after the music in tervention had started (Time 3). The next trial was at the end the of the music interven tion (T4) while the fina l trial was 45 minutes following the termination of the musical intervention (T5). Patients cancer types varied; but acute le ukemia patients were the most common (46.7%). Most of the subjects (80%) had experi enced pain for at leas t six months but less than three years. Combinations of two to f our pain medications were being used most often on a regular basis. Table 4-1. Reasons for Admission Diagnosis No. of patients Percent Valid Percent Cumulative Percent Acute leukemia 7 46.7 46.7 46.7 Lymphoma 3 20.0 20.0 66.7 Myeloma 2 13.3 13.3 80.0 Other cancers 2 13.3 13.3 93.3 Bone marrow failure states 1 6.7 6.7 100.0 Total 15 100.0 100.0 Musical Preferences Questionnaire Hartsock Music Preference Analysis. The musical preferences were determined from the responses given to the modified Ha rtsock Music Preferen ce Questionnaire (see Appendix D). The purpose of this questionnaire was to determine what type of music the BMT client preferred. These data are presen ted in Table 4-2. The majority (53.40%) of the subjects selected classical, country and western, and other popular music.

PAGE 108

96 Table 4-2. Musical preferences Type Frequency Percent Valid Percent Cumulative percent classical 4 26.7 26.7 26.7 country 4 26.7 26.7 53.3 jazz 2 13.3 13.3 66.7 hip hop 1 6.7 6.7 73.3 other 4 26.7 26.7 100.0 Total 15 100.0 100.0 Effect of the Music Intervention on Pain To analyze the difference in pain intens ity reduction between ba selines values and the trials, an independent t-test was used to examine relationships between sample variables and the change in pain intensity. Hypothesis 1 Itemized subject VAS scores ar e presented in Appendix G. The results support Hypothesis 1: The VAS was us ed to determine this variable, with a possible range score of 0 to 10 cm. An i ndependent t-test was employed to compare pretest-posttest measures for each subject be tween trials. The effect of music was evaluated by a timed interaction, which asse ssed differences between the baseline and subsequent trial readings with the music intervention. As shown in Table 4-3, there was a general downward trend in the mean VAS index. The results showed a significant change in VAS scores (see Table 4-4). Table 4-3. Mean Pain Readings from Visu al Analogue Scale at Timed Intervals during Music Intervention N Minimum Maximum Mean Standard Deviation pain 24 hr pre-intervention 15 0.00 10.00 4.4000 3.35517 pain immediately before 15 0.00 9.00 3.0000 2.95200 pain at 15 min. During 15 0.00 7.00 2.0667 2.63131 pain at 30 min. at End 15 0.00 4.00 1.4000 1.72378 pain at 45 min. Postintervention 15 0.00 2.00 0.7333 0.88372 Valid N (listwise) 15

PAGE 109

97 Table 4-4. Visual Analogue Scale Scores Between Time 1 (T1) and Time 5 (T5) The mean VAS score at the baseline was 4.4 (SD = 3.35) for Time 1. The mean VAS score for Time 2 was 3.0 (SD = 2.95). The mean VAS score for Time 3 was 2.07 (SD = 2.63). Time 4 gave a mean VAS score of 1.40 (SD = 1.72), while the mean VAS score for Time 5 was 0.73 (SD = 0.88) (see Ta ble 4-2). An indepe ndent t-test was conducted on all the VAS trials. The independe nt t-test comparing the VAS readings at Time 2 baseline and Time 3 showed statis tical difference, t = 2.51 with p = 0.025, at a 95% confidence interval (see Ta ble 4-4). Significant relations hips were observed between actual VAS scores between th e baseline and Time 4, t = 3.36 with p = 0.005 at a 95% Paired Differences t df Sig. (2tailed) Mean Std Deviation Std. Error of the Mean 95% Confidence Interval of the Difference Lower Upper T1-T2 stai 24 hr preintervention stai immediately before 1.4000 1.50238 .38791 .56801 2.23199 3.609 14 .003 T2-T3 pain immediately before pain 15 min. During 0.9333 1.43759 0.37118 0.1372 1.7294 2.514 14 .025 T2-T4 pain immediately before pain 30 min. at End 1.6000 1.84391 0.47610 0.5789 2.6211 3.361 14 .005 T2-T5 pain immediately before pain 45 min. Postintervention 2.2667 2.31352 0.59735 0.9855 3.5479 3.795 14 .002

PAGE 110

98 confidence interval (see Table 4-4). Significant relationships were also observed between baseline and Time 5, t = 3.79 with p = 0.002. at a 95% confidence interval. Effect of Music Intervention on Anxiety Hypothesis 2. The researcher compared patients anxiety levels obtained before and after the music interven tion using independent t-test Hypothesis 2 stated: Bone marrow transplant patients have lower levels of state anxiety levels as compared to the baseline measurements while listening to preferred music. This hypothesis was evaluated using an independent t-test. The STAI score was defined as below the baseline mean of 48.20. A high STAI score was defined as at or above the baseline mean of 48.20. Table 4-5 prov ides a comparison of the average of the dependent state anxiety variable over a pe riod of time. Hypothesis 2 was supported. A significant difference in the state anxiety variables occurred over a period of time. Table 4-5. Mean Scores for the state portion of the State Trait A nxiety Index (STAI) at Timed Intervals During Music Intervention N Minimum Maximum Mean Standard Deviation STAI 24 hr. pre-intervention 15 33.00 59.00 49.0667 6.86052 STAI immediately before 15 41.00 60.00 51.6667 5.17779 STAI at 15 min. During 15 42.00 58.00 49.0667 4.28397 STAI at 30 min. at End 15 40.00 55.00 47.4667 4.24040 STAI at 45 min. Postintervention 15 38.00 52.00 45.2000 4.81367 Valid N (listwise) 15 The mean STAI scores at the baseline was 49.07 (SD = 6.86) for Time 2. The mean STAI score for Time 3 was 49.06 (SD = 4.28). The mean STAI score for Time 4 was 47.46 (SD = 4.24). Time 5 gave a mean STAI score of 45.20 (SD = 4.81) as shown in Table 4-6.

PAGE 111

99 Table 4-6. State Portion of the State Trait Anxiety Index (STAI) Scores Between Time 1 (T1) and Time 5 (T5) Paired Differences t df Sig. (2tailed) Mean Standard Deviation Standard Error of the Mean 95% Confidence Interval of the Difference Lower Upper T1-T2 STAI 24 hr preintervention STAI immediately before -2.60000 6.98774 1.80423 -6.46968 1.26968 -1.441 14 .172 T2-T3 STAI immediately before STAI 15 min. During 2.6000 4.38830 1.13305 0.1698 5.0302 2.295 14 .038 T2-T4 STAI immediately before STAI 30 min. at End 4.2000 4.58569 1.18402 1.6605 6.7395 3.547 14 .003 T2-T5 STAI immediately before STAI 45 min. Postintervention 6.4667 6.61024 1.70676 2.8060 10.1273 3.789 14 .002 An independent t-test was conducted on a ll the STAI trials. The results were significant, t = 2.30 with p = 0.038, at a 95% confidence interval (see Table 4-6). Significant relationships were observed between actual STAI r eadings scores between the baseline and Time 4, t =3.55 with p = 0.003, at a 95% confidence interval (see Table 46). Significant relationships were also observed between baseline and Time 5, t =3.79 with p = 0.002 (see Table 4-6). Effect of Music Intervention on Systolic Blood Pressure (SBP) Hypothesis 3. Hypothesis 3 stated: Bone marro w transplant patients have lower systolic blood pressure (SBP) as compared to the baseline measurements while listening to preferred music. The t -test statistics on blood pressure i ndicated that a d ecrease in the

PAGE 112

100 indices of blood pressure compared to the ba seline, which supports the assumption of the functional importance of music in the health of patients. The effect of music was evaluated by a change in time and by the interaction between group and time. As shown in Table 4-7, the mean systolic blood pressure (in mmHg) during Time 2 was 61.07 (SD =13.29) for Time 1. During the music intervention, the means varied considerably. The changes indicated 66.86 (SD = 13.34) for Time 2. The mean SBP during Time 3 was 63.60 (SD = 10.56), and the SBP for Time 4 was 60.07 (SD = 10.54). The mean systolic blood pressure increas ed from 61.07 to 66.87 mmHg in Time 2 but reduced to 63.60 mmHg in Time 3. The SB P further decreased from 63.60 mmHg in Time 3 to 60.07 in Time 4, culminating to a minimum of 58.73 mmHg in Time 5 (p < 0.05, independent t-test). A t-test analysis found a significant difference in SBP over a period of time (F = 5.109, p = 0.014. Further an alyses found a significant difference in SBP between the baseline and during the musi c intervention between Time 3 and Time 5 (p = 0.024) and during Time 3 and Time 5 (p = 0.01). Using the t-test, the study showed no significant change in systol ic blood pressure within patie nts during Time 2 and Time 3 (see Table 4-8). However, significant relati onships were observed between Time 2 and Time 5, t = 4.02 with a p = 0.001 at a 95% confidence interval (see Table 4-8). Table 4-7. Mean scores for the Systolic Bl ood Pressure (SBP) at Timed Intervals During Music Intervention N Minimum Maximum Mean Standard Deviation SBP 24 hr. pre-intervention 15 40.00 82.00 61.0667 13.29053 SBP immediately before 15 42.00 89.00 66.8667 13.33560 SBP at 15 min. During 15 46.00 85.00 63.6000 10.56139 SBP at 30 min. at End 15 43.00 83.00 60.0667 10.54559 SBP at 45 min. post intervention 15 40.00 87.00 58.7333 10.74022 Valid N (listwise) 15

PAGE 113

101 Table 4-8. Systolic Blood Pre ssure (SBP) Scores Between Time 1 (T1) and Time 5 (T5) Paired Differences t df Sig. (2tailed) Mean Standard Deviation Standard Error of the Mean 95% Confidence Interval of the Difference Lower Upper T1-T2 bp 24 hr preintervention bp immediately before -5.80000 11.63247 3.00349 -12.24185 .64185 -1.931 14 .074 T2-T3 sbp immediately before bp 15 min. During 3.2667 6.56252 1.69444 -0.3675 6.9009 1.928 14 .074 T2-T4 bp immediately before bp 30 min. at End 6.8000 5.41427 1.39796 3.8017 9.7983 4.864 14 .000 T2-T5 bp immediately before bp 45 min Postintervention 8.1333 7.83642 2.02336 3.7937 12.4730 4.020 14 .001 Effect of the Music Intervention on Heart Rate Hypothesis 4. The independent t-test was employed to examine the hypothesis that following music intervention, BMT patients have a significant decr ease in heart rate compared to the baseline heart rate. Analysis supported a significant change in the heart rate within subjects at the 0.05 level of significance. The me an heart rate significantly decreased. The mean HR (in beats per minute) during the baseline was 88.47 (SD = 18.43). During the music intervention, HR was 91.60 (SD = 19.42) during Time 2. The mean HR for Time 3 during intervention was 82.27 (SD = 17.43), and that for Time 4 was 78.80 (SD = 17.36). Time 5 intervention rating was 76.8 (SD = 16.92). Using the t-test, significant relationships were observed between baseline (T2) and Time 3, t = 2.51 with a

PAGE 114

102 p = 0.025 at a 95% confidence interval (See Ta ble 4-10). A significant relationship was also observed between baseline and Ti me 4, t = 3.64 with a p = 0.003 at a 95% confidence interval (See Table 4-10). Table 4-9. Mean scores for the Heart Rate (HR) at Timed Intervals during the music intervention N Minimum Maximum Mean Standard Deviation HR 24 hr preintervention 15 59.00 128.00 88.4667 18.43857 HR immediately before 15 68.00 130.00 91.6000 19.42311 HR at 15 min. During 15 59.00 126.00 82.2667 17.42521 HR at 30 min. at End 15 55.00 121.00 78.8000 17.36252 HR at 45 min. Postintervention 15 55.00 120.00 76.8667 16.92364 Valid N (listwise) 15 Table 4-10. Heart Rate (HR) Scores Between Time 1 (T1) and Time 5 (T5) Paired Differences t df Sig. (2tailed) Mean Standard Deviation Standard Error of the Mean 95% Confidence Interval of the Difference Lower Upper T1-T2 HR 24 hr preintervention HR immediately before -3.13333 15.33375 3.95916 -11.62488 5.35821 -.791 14 .442 T2-T3 HR immediately before HR 15 min. During 9.3333 14.38584 3.71441 1.3667 17.2999 2.513 14 .025 T2-T4 HR immediately before HR 30 min. at End 12.8000 13.62875 3.51893 5.2526 20.3474 3.637 14 .003 T2-T5 HR immediately before HR 45 min. Postintervention 14.7333 13.31737 3.43853 7.3584 22.1082 4.285 14 .001

PAGE 115

103 Effect of the Music Intervention on Respiratory Rate Hypothesis 5. To analyze the Respiratory Rate reduction between the baseline and the trials, a t-test was used to test whether or not listening to musi c affected respiratory rate. As shown in Table 4-11, the mean RR 24 hours pre-intervention was 20.4 (SD = 6.8 for Time 1 and 21.47 (SD = 5.42) for Time 2. During the music intervention, RR was 18.8 (SD = 4.59) for Time 3 and 17.47 (SD = 4.31) for Time 4. After 45 minutes following music intervention the mean RR wa s 16.67 (SD = 3.09) for Time 5. A t-test was used and found no significant change in RR between baseline and Time 4 and between baseline and Time 5 (see Table 4-12). However, further anal ysis using a t-test found a significant change in RR between baseline and Time 3 (p = 0.002). Table 4-11. Mean Scores for the Respiratory Rate (RR) at Timed Intervals During Music Intervention N Minimum Maximum Mean Standard Deviation RR 24 hr preintervention 15 16.00 44.00 20.4000 6.81175 RR immediately before 15 16.00 38.00 21.4667 5.42305 RR at 15 min. During 15 14.00 30.00 18.8000 4.58569 RR at 30 min. at End 15 12.00 30.00 17.4667 4.30725 RR at 45 min. Postintervention 15 12.00 26.00 16.6667 3.08607 Valid N (listwise) 15 Table 4-12. Respiratory Rate (RR) Scores Between Time 1 (T1) and Time 5 (T5) Paired Differences t df Sig. (2tailed) Mean Standard Deviation Standard Error of the Mean 95% Confidence Interval of the Difference Lower Upper T1-T2 RR 24 hr preintervention RR immediately before -1.06667 3.45309 .89158 -2.97892 .84559 -1.196 14 .251

PAGE 116

104 Table 4-12. Continued Paired Differences t df Sig. (2tailed) Mean Standard Deviation Standard Error of the Mean 95% Confidence Interval of the Difference Lower Upper T2-T3 RR immediately before RR 15 min. During 2.6667 2.69037 0.69465 1.1768 4.1565 3.839 14 .002 T2-T4 RR immediately before RR 30 min. at End 4.0000 2.92770 0.75593 2.3787 5.6213 5.292 14 .000 T2-T5 RR immediately before RR 45 min. Post intervention 4.8000 3.52947 0.91130 2.8454 6.7546 5.267 14 .000 Research Hypothesis Hypothesis 1 was statistically supported by this study: Clie nts undergoing BMT report a greater reduction in pain intensity after listening to their preferred music. A t-test was used to analyze differences in pre-and post-VAS scores. The results indicated that a significant difference existed in the pre-post VAS intensity scores between Time 1 and Time 5, as measured by a visual analogue scale (VAS). Table 4-4 depicts the mean difference in VAS scores in pre-post VAS intensity scores (r = 0.71). The music significantly decreased the VAS scores. Item ized VAS scores are presented (see Appendix L). Other parameters of interest include the analyses of the relationships among the following variables: age, gender, r ace, length of time in program, type of cancer, type of music, and the differences in VAS scores. Hypothesis 2 was statistically supported by this study: Listening to music can significantly reduce cancer pain intensity in clients receiving BMT. Further

PAGE 117

105 recommendations for future research and di scussion regarding to this study's significance to nursing practice and education are presented in Chapter 5. The follow-up questionnaire Likert-type sc ale item on enjoyment of the music was used to measure satisfaction with the music in tervention. Using the Likert scale, the mean satisfaction score for those who would prefer music throughout their stay in the hospital was 8 (SD = 0.41). Table 4-13. Mean Score on the Likert Scal e for Those Preferring Music of a Longer Duration and those who felt pleasant N Minimum Maximum Mean Standard Deviation preferring music 24 hrs 15 1.00 10.00 8.000 4.1404 Feeling pleasant 15 10.00 10.00 10.00 00.00 Valid N (listwise) 15 Hypothesis 3 was statistically supported by this study: List ening to music, subjects would have lower BP. The overall satisfacti on index was assessed on a 10-point Likerttype scale item in the follow-up questionnaire. This assessment was evaluated using the Likert scale of 0 to 10 where is dont like it at all and is like music extremely The mean overall music satisfaction score for subjects was 8. (SD = 4.14). A descriptive data analysis was performed on all data obtained from the Likert-type scale items in the follow-up questionnaire. Th e scale ranged from 1 to 10 (see Appendix K). Two open-ended questions we re asked regarding what might have interfered with the subject's concentration or enjoyment of music during the musical intervention. The identified interferences are summarized in A ppendix K. The types of interferences that the subjects found most annoyi ng were either noise generated by the staff or environmental/equipment noise.

PAGE 118

106 The majority of subjects reported that the music intervention experience was positive. Regardless of their musical prefer ences, all subjects (100.0%) answered Yes to the item in the follow-up questionnaire of Would you have liked to listen to music for a longer period of time inst ead of just 30 minutes? Yes or No. All the patients said they had a pleasant experience as indicated in Table 4-13. On the follow-up questionnaire, the subjects actually reported that they felt th e music was relaxing, and they would have liked to have listened to music longer and mo re often. In addition, when asked after the musical intervention had ceased whether or not they had any comments regarding the music intervention, the majority of respondents reported that listening to music especially while in their hospital beds was a positive experience. Thirteen of 15 subjects made positive comments. The themes of these comments included: the subjects enjoyed the music; they found it relaxing; and they would suggest the us e of music for all patients. Specific comments are given in Table 4-14. Table 4-14. Responses to the Questionnaire Pain can be an isolating event in the hu man experience. Whenever I am in pain, I feel isolated from the society. This isolat ion brings with it certain anxieties. When I am in pain and listen to music, I feel c onnected to the society. Music helps me in this way. When I listened to Beethovens 5th Symphony I felt as though someone was scratching the cancer cells out of my back. I enjoyed listening to the music. When I was listening to the music I felt more relaxed. I would have liked to listen to music longer. I would have liked to listen to music more often. Data were obtained from subjects to assess a subjective re port concerning two questions. All the subjects we re asked what they thought of the music. Each one of the

PAGE 119

107 subjects who completed the study reported that the music helped to decrease their pain. All the subjects (100%) recommended music for those receiving BMT, and two added that it was necessary that the patient enjoy mu sic. Thirteen subjects (65%) said that the music distracted them from th eir pain. One patient stated he completely forgot about his pain during the music sessions. One subject decl ared that the music blocked out the other noises in the ICU and replaced them with plea sant sounds. Five subjects commented that the music was either soothing or relaxing. One subject remarked that he usually preferred faster music but liked the relaxing music in th is particular situation. Thirteen subjects (65%) reported that the music was a pleasant experience. Two subjects said they fell asleep during the music. One of those who fell asleep stated that music helped decrease his pain while he was asleep. Two subject s (13.3%) reported the same comment: that they would have enjoyed the music more if they had not "felt so badly all over." Summary of Results This chapter presented the data obtained during the study. Background characteristic data about the subjects, including demographic information and background information, were presented. Result s of the data analyses were presented hypothesis by hypothesis. The last section of th is chapter discussed the data analyses of the additional research questions. Statistically significant decreases in pai n, anxiety, BP, HR, and RR occurred during the music intervention when compared to base line levels in these BMT subjects. Pain and anxiety levels signifi cantly decreased during the music in tervention periods compared to the baseline period. The majority of subjects concurred that the music intervention was enjoyable and that music helped them feel more relaxed. The tendency toward relaxation was further supported by the downward tr end in blood pressure, heart rate, and

PAGE 120

108 respiratory rate, and the fact that 55% of the time subjects fell asleep during the music intervention period. According to the subjective reports, all the subjects in the group benefited from listening to music. Based on the analysis of this research, music was significantly effective in reducing pain, as reported on th e VAS and via subjective comments. Music was also significantly effective in decreasi ng systolic blood pressure during Trial 1, but music produced no significant change during Trial 2. Trials took place prior to peak drug concentr ations. Medications that could affect a change in blood pressure, heart rate, or le vel of self-reported pain were recorded. Medications that were administered included morphine sulfate, oxycodone, prochlorperazine, digoxin, met oprolol, and nitroglycerin. The peak concentration is important in differentiating between the medi cation effect and the music effect on blood pressure, heart rate, and pain measured on a VAS. If the music listening occurred during the time when medication levels were rising, th at is, the time prior to peak concentration, the researcher could not determine whether or not a d ecrease in pain, systolic blood pressure, or heart rate resulted from the mu sic or the medication. However, if the music was introduced after the peak concentrati on of a medication, and the patient had a decrease in self-reported pai n, blood pressure, or heart rate, it is possible that the music was effective in producing the decrease in pain.

PAGE 121

109 CHAPTER 5 DISCUSSION AND RECOMMENDATIONS I would have liked to listen to music mo re often. commented an eighteen year old BMT patient after music intervention. The purpose of this research was to determ ine the effect of music listening with positive suggestion on BMT patients self-reported pain, anxiety, blood pressure, heart rate, and respiratory rate. The five hypothese s were based on the premise that observed reduction in pain, anxiety, and vital signs, such as blood pressure, heart rate, and respiratory rate, results from listening to music (Bolwerk, 1990; Guzzctta, 1989; Zimmerman et al., 1988). This chapter presen ts a discussion of th e research findings relative to the five proposed hypotheses. Comparison is then made of the research findings to results of similar studies. Implications and recommendations are also included in this chapter. Findings According to the Gate Control Theory of pain, an individual's pain perception may be altered by refocusing the subject's attenti on from pain to some other experience that is more pleasing. This is a kind of sensory exci tation which stimulates closure of the gate, resulting in interruption of the neurotransmission of the pain signal (Siegele, 1974). In this study, music was offered to the subjects as an auditory dist raction from pain. Previous studies in the area of pain management have established a positive relationship between the use of music and pain intensity reduction, as measured by both subjective and physiologic indicators (Bolwe rk, 1990; Gardner et al., I961; Guzzetta,

PAGE 122

110 1989). Other parameters of interest that have been studied include subjective variables such as mood and anxiety levels, as determined by questionnaire and interview responses (Beck, 1988, 1991; Bolwerk, 1990; Guzzetta, 1989; Munro & Mount, 1978; Updike & Charles, 1987). Physiologic vari ables that have been studied include autonomic responses to pain (e.g., blood pre ssure, heart rate, respiratory rate, and peripheral temperature (Beck, 1991; Curtis, 1986; Guzzetta, 1989; Lavine, Buchsbaum, & Poncy, 1976; Locsin, 1981; Melzack et al., 1963; Updike & Charles, 1987). Music is not always useful to patients wh en it comes to helping their subjective and physiologic indicators. The subject who re quested that Peter Gabriels rock tune All That You Cant Leave Behind be changed due to its referent nature to bad memories for the subject is a case in point. The fact that this music selection did not help the patient, this conception suggests the importance of philos ophical ideology on emotion and meaning in music as debated by recent scholars. To indicate his construction of emotion and meaning in music, Meyer (1956) defined and co ntrasted classic positions in philosophical aesthetics and proposed what he called the referentialists approach By this he meant that emotions and meaning in music are associated with extramusical world of concepts such as actions, emotional states, and ch aracter (Meyer, 1956). From this account occluding Meyers philosophical standpoint, not all studies ha ve established a positive relationship between anxiety and pain reduc tion and the use of music listening (Beck, 1991; Curtis, 1986; Zimmerman et al., 1988). Th ese inconsistent re sults regarding the therapeutic benefits of music on pain a nd anxiety reduction led the researcher to undertake this study. The fi ve research hypotheses within this study were: 1. Bone marrow transplant patients have lo wer levels of self-reported pain as compared to the baseline measurements while listening to preferred music.

PAGE 123

111 2. Bone marrow transplant patients have lowe r levels of state anxiety levels as compared to the baseline measurements while listening to preferred music. 3. Bone marrow transplant patients have lo wer 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 lowe r levels of respiratory rate (RR) as compared to the baseline measurements while listening to preferred music. The results of this study supported these five hypotheses. By analyzing the data from the STAI questionnaire, it appeared th at the State-Trait Anxiety levels of the subjects were significantly di fferent (analysis of the mean difference made using the ttest). These results are consistent with t hose of several scholars (Beck, 1991; Curtis, 1986; Davis-Rollans & Cunni ngham, 1987; Gardner & Licklider, 1959; Guzzetta, 1989; Lavine et al., 1976; Locsin, 1981; Melzack et al. 1963; Updike & Charles, 1987) who also found significant reduction in pain intensity and anxiety le vels after the use of music. As in the present study, these researchers co mpared baseline measurements with trial measurements. However, differences in popul ation samples, lengt h of time using the music interventions, and differences in outco me variables studied (e.g., use of control groups) make comparisons somewhat difficult. Because the BMT patients in this study r eceived pharmacologic treatment for pain and anxiety, comparisons with studies by B eck (1991) and Zimmerman et al., (1988) are more appropriate. These resear chers studied pain intensity levels in cancer patients using VAS pain scales before and after the use of music. Their conclusions supported music listening as an effective pain-i ntensity reducing intervention.

PAGE 124

112 Overall, the present study showed a signi ficant reduction in pain intensity after music intervention (see Table 4-4). This resu lt is consistent with reports by Bolwerk (1990), Guzzctta (1989), and Zimmerman et al. (1988). The results of this study are also consistent with a study on the effect of music on anxiety among cardiac patients (Bolwerk, 1990) which demonstrated that mu sic listening significantly lowered anxiety levels within the music group when compared to a control group. Hypothesis 1 The results of this study supported H ypothesis 1: Following music listening sessions, BMT patients would have a greater decrease in self-reported pain and anxiety compared to the baseline levels. The level of self-reported pain decreased significantly during Time 2 and Time 3. Each one of the subjects gave a self-report that music decreased his pain. Moreover, 75% of those who listened to musi c during the intervention said it distracted them from their pain. In addition, One hundred percent of the patients said the music was a pleasant experience. This study, like that of Melz ack et al. (1963) demonstrates that pain levels may be decreased by music listening. Th ese results of the study are al so consistent with Updike (1990), who found that patients with various di agnoses in an ICU had a decrease in pain perception after listening to anxi olytic and sedative music. The inference can be made from this rese arch and previous studies is that music listening affects a significant decrease in se lf-reported pain among the sample population studied. When given an opportunity to e xpress additional feelings about the music listening sessions, subjects in this research and in Locsin's (1981) research stated that music helped to distract them from their pain. Therefore follow ing music listening, BMT

PAGE 125

113 patients have a greater decrea se in self-reported pain compared to the baseline reported pain. Hypothesis 2 Results of the study also supported Hypot hesis 2: Following music listening, BMT patients would have a greater decrease in anxi ety compared to baseline anxiety reading. The results of this study sugge st that music listening signifi cantly diminished the State portion of the anxiety, especia lly between baseline and 45 mi nutes postintervention (see Table 4-6. In contrast, an increase in a nxiety occurred between Session 1 and Session 2 (see Table 4-5). The reasons for this increase may point to psychological just as much as physiological phenomena since scholars have observed that when transplant nears, anxiety and worries usually incr ease leading to problems with sleep, irritability or low mood (Bottomly, 1998; Cleeland et al., 1994). Th e results of this study, however, were consistent with the findings of other research ers who have reported a significant decrease in patients anxiety (Hanser & Thompson, 1994) Similarly, subjects in the ICU had a significant decrease in state portion of anxiety after listen ing to music (Rohner & Miller, 1980). The results of this research are also consistent with that done in school environments where it was found that music ha d a decrease in test taking anxiety among undergraduate nursing students (Summers et al., 1990) The results of this research like that of Summers et al., (1990) supported Hypothesis 2 that Bone marrow transplant patients have lower levels of state anxi ety levels as compared to the baseline measurements while listeni ng to preferred music.

PAGE 126

114 Hypothesis 3 Results of the study also supported Hypothe sis 3: Bone marrow transplant patients have lower systolic blood pressure (SBP) as compared to the baseline measurements while listening to preferred music. Fo llowing music sessions, BMT patients had a significant decrease in blood pressure compared to the baseline blood pressure. The results of this study suggest that music liste ning had a significant influence on systolic blood pressure between Session 2 and Session 5 (see Table 4-8). In contrast, there was no decrease in systolic blood pressure in between Session 2 and Se ssion 3 (see Table 48). Unexpectedly, a significant increase in systolic blood pressu re occurred between Session 1 and Session 2 (see Table 4-7). This ca n be attributed to the fact that the measures were taken in the morning when the cortisol levels are normally high as compared to the evening (Mores, Martire, Pi stritto, Volpe, Menini, Folli et al., 1994). Blood pressure is a physiologi cal indicator of anxiety a nd therefore when anxiety increases, the blood pressure may also increase (Bailey, 1983; Beck, 1991; Cook, 1986; Zimmerman, Pozehl, Duncan, & Schmitz, 1989). Results of this study were consistent with the findings of Zimmerman et al., (1988) whose studies reported a signifi cant decrease in systolic bl ood pressure following music listening compared to baseline measurements of systolic blood pre ssure. This study is also consistent with that of Updike (1990) who also found a significant decrease in systolic blood pressure of patie nts after listening to music of their choice. Consequently, this research and other studies support H ypothesis 3 that music listening may have a decrease in systolic blood pr essure among a sample population.

PAGE 127

115 Hypothesis 4 Results of the study supported Hypothe sis 4: Following music listening, BMT patients would have a greater decrease in hear t rate compared to their baseline heart rate indices. Even though heart rate did not change significantly between Session 1 and Session 2 (see Table 4-10), there was a consistent decrease in heart rate in the subsequent sessions as compared to base line (see Tables 4-16 and 4-17). These data supported the results of other researcher s (Zimmerman et al., 1988; Summers et al., 1990) whose research found that patients li stening to music with slow tempos of between 60 and 70 beats per minute had a significan t decrease in heart rate. There is no linear relationship between music listening and the reduction in pain and anxiety indices as observed in the study. The reason for this is that results of this and other earlier studies are inc onclusive. The absence of isomorphic or linear causal relationship between music list ening and heart rate suggest the need for more controls. Perhaps increasing the frequency of music listening sessions may have resulted in a significant decrease in heart rate. It should be noted at this point that the researcher attempted to control for the effect of medi cations that affect self-reported pain, blood pressure, and heart rate. Since this wa s a sample of convenience and hence, randomization of patients was not employed thereby decreasing the probability that patients received an even di stribution of medications. Ther efore there is likelihood that distribution of medication might have influenced the depe ndent variables. Although the researcher took into consideration the peak time of medication admi nistered on patients and gave music intervention after peak drug effects, additional research with more rigorous control for the effect s of medications is needed.

PAGE 128

116 Hypothesis 5 Results of the study also supported Hypot hesis 5: Following music listening, BMT patients would have a greater decrease in re spiratory rate (RR) compared to baseline respiratory rate. The results of this study s uggest that music listen ing had a significant influence on respiratory rate, especially between baseline (T2) and 15 minutes (T3) following music intervention (see Table 4-12). In contrast, an increase in RR occurred between Session 1 and Session 2 (see Table 411). A plausible explanation for this is perhaps that high RR is a physiological indicat or of high anxiety and hence when anxiety reduces, the RR also reduces (Anderson, C oyle, & Haythornwaite, 1992). Issues The significant decrease in noise annoyance during th e three music intervention periods compared to baseline was expecte d. Music eliminates noise annoyance. No previous research had evalua ted the effect of music inte rvention on noise annoyance in the BMT patient population. However, the previous success of music intervention in the reduction of pain and anxiety has been repor ted in the research of several scholars (Bolwerk, 1990; Moss, 1988; Standle y, 1986; Whipple & Glynn, 1992; White, 1992). The research suggested that the music in tervention could serve as a positive coping resource for the subjects such as the ones in this study. Thus, music intervention may decrease the subject's pain and anxiety wh en the intervention is in tandem with the cognition of environmental noise annoyance. Heart rate and blood pressure variable s demonstrated a downward trend from baseline levels during music intervention peri ods. Even though these findings had been anticipated, the decrease in HR and SBP during the music intervention most likely reflects decreased stimulation of the sympat hetic central nervous system (CNS). This

PAGE 129

117 decrease is secondary to obs ervable decrease in pain and anxiety during the music intervention. This observation therefore supports the conceptu al framework of this study. The results of the study gene rally showed that a reduc tion in pain and anxiety, including some measures of the physiologic variables, such as systolic blood pressure, heart rate, and respiratory rate were statistically significant during the music intervention periods compared to baseline levels. Howeve r, the amount of decrease was too small to neither alter clinical management of the subjects pain and anxiety nor substitute for medication. However, it is notew orthy that during 15 data co llection periods (55% of the time), subjects fell asleep during the music intervention, whereas no subjects fell asleep during the baseline data colle ction periods. So even though c linical management of the subjects was not altered by the significant decreases in HR and some BP variables, the subjects experienced less pain and anxi ety and became psychologically more relaxed. This was evidenced by the subjects falling asleep during the musi c intervention. When cancer patients experience pain and anxiet y, they usually have difficulties sleeping (Engstrom, Strohl, Rose & Stefanek, 1999). Another possibility is that in this sample the STAI may not be a valid measure of a subject's anxiety. Theoretically, the STAI asse sses a person's anxiety at that very moment (Spielberger, 1976). However, historically the STAI is a psychometrically a reliable instrument for assessment of state anxiet y (Spielberger, 1976). Since pain has been regarded as radically solipsistic and inhe rently subjective (Kau fman-Osborn, 2002) and culturally determined (Bates, Rankin-Hill, & Sanchez-Ayendez, 1997), render the VAS scale simply inexplicable. Tacitly acknowledgi ng the subjectivism of pain assessment, Kaufman-Osborn observed:

PAGE 130

118 Because pain can neither be identified with nor located neatly within any determinate embodied site, it would seem to follow that it must be something that resides in the ethereal and invisible doma in of consciousness. Precisely because it is so located, anyones claim to be in pain is strictly speaking, incorrigible in the sense that it cannot meaningfully be denied by another. (p. 139) Additional use of other scales such as the McGill Pain Questionnaire and Unmet Analgesic Needs Questionnaire (Zhukovsky, Go rowski, Hausdorff, Napolitano & Lesser, 1995) would therefore provide more validity to the measurements of pain. Turk and Melzack (1992) observed: A number of cultural, economic, social, demographic, and environmental factors, along with the individuals pers onal history, situational fact ors, interpretation of the symptoms and resources, current psychologi cal state, as well as physical pathology, all contribute to the response to th e question How does it hurt? (p. xi) In this study, most subjects, regardless of pain levels, agr eed or strongly agreed, as indicated on the follow-up questionnaire, that they enjoyed the music intervention, that it was relaxing, that they would have liked to listen to the music longer and more often. Themes about the music intervention, whic h were identified by subjects during openended questioning, indicated that music list ening was enjoyable, relaxing, and that it should be used with all patients. In this study, reports on relaxation followi ng music intervention are similar to those found by previous researchers (Bolwerk, 1990; Elliot, 1994, White, 1992, Zimmerman et al., 1988). These researchers findings also demonstrated a trend toward decreased anxiety following listening to music through headphones in coronary care unit patients. Subjects also reported an improvement in their mood and attitude following the periods of music interventi on. Although not measured obj ectively, these findings are similar to those noted in previous res earch. Barnason et al. (1995) documented an improvement in mood.

PAGE 131

119 Based on the findings of this study, the re searcher supports offering patients a choice of musical selections when administ ering music intervention. The impact of the subject's personality traits was not considered in this research. It has been observed that multiple personal and environmental factor s have an impact on anxiety (Shuldham, Cunningham, Hiscock, & Luscombe, 1995). This impact can influence patients musical preferences. Implications for Future Research The results from this study have implic ations for nursing research as well as education. Each implication will be discusse d in this section. Music demonstrated a significant reduction in pain intensity. The difference between baseline and post-timed post-test sessions of pain intensity scores was significantly different. Results were supportive of the use of music as a distract ion, but generalizability was not obtained. A need therefore exists for continued rese arch to determine whether or not music listening is more effective in pain and anxi ety management for clients who are receiving a BMT. Since the researcher did not control fo r the previous pain and anxiety experiences with the use of music as a distraction strategy on pain, perhaps the past experience influenced the reduction of VAS scores found within the subjects. Future studies, which are related to the use of music listening as a distraction, should minimally include this information on all subjects since pain percep tion can be altered by th ese past experiences (Iadarola & Caudle, 1997). Implications for Future Clinical Practice This research, along with previous researc h, suggests that music listening can be used effectively as a modality for intervention due to its potential benefits to pain perception and anxiety management for both bone marrow transplant clients as well as

PAGE 132

120 school students. This intervention is generally low in cost and is readily available to clients. Any care giver or educator, with so me form of training in the use of music listening to alleviate symptoms of pain and anxiety, could offer this alternative pain and anxiety intervention. Clients should be encour aged to use music listening in a place where other pain and anxiety mitigating methods are likely to be minimal. In hospitals, offering music intervention as a coping resour ce significantly decrea sed pain, anxiety, and physiological variables, such as blood pr essure, heart rate, and respiratory rates. Follow-up questionnaire data supported the e fficacy of the music intervention in this sample of bone marrow transplant patients. Implications for Music Education The hypotheses that music listening is e ffective in reducing anxiety was supported by this research. The use of self-selected mu sic listening is therefore suggested as an additional anxiety-relieving measure for childre n in schools. This research shows that music can play a major role in help ing students lower their anxieties. If anxiety is relieved, phys ical problems such as headaches resulting from anxiety will be relieved. Ultimately, the students will be more comfortable and they may have less fear and stress. Also, a wi de range of emotional, stre ss-related problems, such as teenage suicide, teenage pr egnancies, delinquency, violen ce in school, physical and sexual abuse of children, and drug traffick ing among youth, may be alleviated (Zill, 1993). Music can help these students (Giles, 1996). Crimes committed by children, even murder, which are all linked to anxiety may be reduced by music listening (Giles, 1996). Strategies should be implemented in the sc hools to enable students to cope with their anxieties through music listening. Students self-selected music should be used, but care must be taken to help students select mu sic that does not have inappropriate lyrics.

PAGE 133

121 In fact, it is recommended th at selected music should be w ithout any lyrics (Browning, 2000; Spintge, 1989). Selecting a piece of music for its emotional affects, in order to promote emotionally healthy students, repres ents a new direction in using music to promote health in schools. If this new dimens ion is added to the curriculum, students will be involved in music activities that can ultimat ely reduce their stress levels and anxieties and replace them with new self-esteem (Giles, 1996). Chronic pain is prevalent among people and K-12 students are not exempt. The results of this research show that pa tients respond well to music intervention on pharmacological pain regimen. Therefore, schoo l children may also benefit form listening to music to help control their chronic pain. Wh en chronic pain is controlled, the quality of life is also improved and this improvement may lead to a better academic achievement for students. Anxiety is also prevalent am ong students. Music plays a major role in helping students lower their anxieties. Stress-related problems such as teenage suicide, teenage pregnancies, delinquency, violence in school, physical and sexual abuse of children which come mostly as a result of se rver anxiety, may be reduced using music as modality for intervention. Implications for Theory A limitation of this study is that changes in HR and BP in this sample of 15 BMT patients may have been due to factors othe r than music listening. The administration of medications, pain, fever, or anxiety may have caused physiologic changes. This effect was minimized in the research design by the fact that subjects served as their own control. Several potential threats occurred to the external validity of the findings in this study sample. Because of their involvement in the study, subjects may have experienced

PAGE 134

122 a Hawthorne effect, which altered their res ponses. The Hawthorne e ffect--a scientific presumption that evolved in the 1920s refe rred to behavior during the course of an experiment that could possibly be altered due to the subject s awareness of participating in the experiment (Jones, 1992). Also, the subj ects were asked about their levels of pain, which might have heightened their pain pe rception. Additionally, the subjects may have answered the follow-up questionnaire in the manner they believed the researcher wanted, resulting in a social desirability bias. Genera lizability of the findings is also limited since the study was done in one unit with a homogenous sample in terms of diagnosis and BMT transplantation. The curren t sample included only six wo men so generalizability to women is also limited. The music preferences questionnaire had cont ent validity, and one item was able to be tested for construct validi ty. However, reliability of the tool was not assessed. This questionnaire asse ssed different constructs, and therefore tests for internal consistency were inappropriate. Testing-retes ting was also not possible because subjects' musical preferences in the critical care un it experience may change over a period of time. Therefore, use of this questionnaire ma y have resulted in measurement error. Limitations One of the problems of the study was the length of time that participants were exposed to music. The participants listened to music only for a short period of time. In this experiment, the participants were expos ed to music for exactly 30 minutes. In much of the past research, however, participants were exposed to the music for longer periods of time (Hammer, 1996), and in some cases an entire day (Brennan & Charnetski, 2000; McCraty). The only reason for exposing the par ticipants to music for only a short period of time in this study was to increase the ex ternal validity of th e study. Patients in the BMT Unit often cannot listen to music all da y due to limited personnel and an intricate

PAGE 135

123 environment that does not allow for additional equipment in the room. With proper planning, however, they can be given music for short intervals of time during their stay in the hospital. Another problem posed in this study was th e use of the STAI. Some of the past research used more objective measurements, such as salivary recordings and nervous system activity (Brennan & Charnetski, 2000). Because the participants were administered the state portion of the STAI, se veral times, within a short period of time, their answers might have been influenced by their previous answers. The study results included some significant relationships be tween the sexes and how their anxieties fluctuate with music practice. The participants were expos ed to music only for a short time, therefore the results could indicate that participants must be subjected to music for a much longer time in order for music to signi ficantly affect their levels of pain and anxiety. Also, music therapy was not incorporated into this study. Music therapy, such as the guided imagery used in Hammers (1996) experiment or the positively induced emotional state used by McCrat y et al. (1998), comp els the participant to become actively involved in reducing his stress levels while actually play ing music (Hammer, 1996). This study could have implications for people who passively practice specific types of music intended to relieve stress for short periods of time. They may think that they are lowering their stress levels. Bone marrow transplant patients may need to listen to music throughout the day and incorporat e some type of music therapy, such as guided imagery, into their music experience. They may ga in the maximum potential of the possible benefits of music listening. Since music was pr acticed only for a short period of time, the

PAGE 136

124 relationship between music listening, pain, a nd anxiety would have to be strong for the results to be significant. A re lationship could exist, but it might be too weak to be demonstrated in this study. For future studies, researchers should e xpose BMT patients to music listening for a longer period of time so that the music coul d have a greater effect. Also, physiological measures, such as skin temperature, EEG, a nd neurohormone levels, should preferably be used if possible. These methods are more e xpensive, but they provi de more objective and reliable data. Studies have suggested that the use of music as a distraction therapy may effectively reduce pain (Beck, 1991; Curtis 1986; Landreth & Landreth, 1974; Munro & Mount, 1978). Future researchers may want to investigate the rela tionship between music therapy and other pain-related variables. For example, variables of interest may include pain patterns, coping styles, and comp arable dosages of pain medications. Finally, the use of music listening, as an intervention for pain and anxiety reduction, may be more effective when used in an environment with more diverse subjects in terms of race, gender, age, educat ional level, and socioeconomic status. At the very least, future investigators should take every precautionary measure to control for all other confounding variables and other distract ions during data colle ction periods. Perhaps conducting the study in a home environment or a hospice setting would offer more control over extraneous e nvironmental variables. Sample During data analysis, a larger sample si ze would allow further stratification of subjects according to age, gende r, educational level, and hist ory of pain and anxiety in the patients demographics. Si gnificant differences in de pendent physiologic variables

PAGE 137

125 might be seen between subjects with high, medi um, or low scores, compared to subjects with scores above or below the m ean, as used in the current study. A larger sample would also permit a study th at evaluates the imp act of prior formal music education on responses to a planned mu sic intervention. In schools, music majors tend to listen more vigilantly to music th an biology majors (Vanderark & Ely, 1992). Subjects with prior music education may exhibit a different response to a music intervention than subjects without music trai ning. Since musical education was not taken into account in this study, fu ture research should include this fundamental variable. A more diverse sample of subjects, in cluding different diagnoses, level of consciousness, and physical location of the st udy would increase the generalizabilily of the research findings to a broader patient population. Music interven tion might prove to be even more effective during very stressf ul moments for both students and patients, which would further examine this study's conceptual framework by testing Melzacks Gate Control Theory (Melzack & Wall, 1970). In addition, a larger sample would allow for further investigation of the findings according to the subject's age. Based on the fact that all subjects request ed a choice of music, it is important to investigate whether or not self-selected musi c would have similar or more beneficial results, as compared to music that the re searchers provide while disregarding patients preferences. Future studies s hould look specifically at which of the variables, such as pain, anxiety, or vital signs, such as blood pre ssure, heart rate and respiratory rate, might be affected, as compared to the baseline measures. Conclusions This chapter discussed the findings of th is study investigating the relationships between music listening, pain intensity, a nxiety levels, blood pre ssure, heart rate, and

PAGE 138

126 respiratory rate in a sample of 15 BMT patients. Conclusion s and potential study limitations were presented. Recommendations fo r research, practice, and education were offered. This study was done for the purpose of furt hering the study of music listening as a modality for intervention for pain and anxi ety. The results were supportive of five research hypotheses, and hence suggest a pos itive relationship between the use of music and pain reduction and anxiety among patie nts undergoing BMT. This research has demonstrated effectiveness in reducing pain and decreasing anxiet y. In addition, music has been used as a process to distract pe rsons from unpleasant sensations and empower them with the ability to heal from within. As nurses develop practice patterns that are evidence based, the use of music listening coul d become an integral nursing intervention (McCaffrey & Locsin, 2002). More research needs to be co nducted in the area of music styles and their effect on different behavioral conditi ons, such as hyperactivity, aggression, or withdrawal-individual differences not withstanding (Giles, 1999). From this research, it seems prudent for health care professionals to understand general pain theory in orde r to adequately assess, dia gnose, and treat clients who experience much pain and anxiety. The study al so highlights the need for the appropriate use of distraction therapy, including music listening. The study proposes that music listening be taught as an adj unctive pain management op tion. Music education programs should also offer current informati on concerning non-pharmacological anxiety management methods for schoolchildren. As a healing component, music is percei ved as a positive addition to the school curriculum (Giles, 1990; Sahr, 2000). Music as healing agent has alr eady been perceived

PAGE 139

127 by school administrators and music educators as an effective additi on for students total educational experience (Beczkala, 1997). Most schools suffer from financial constraints and as such, their priorities are highly co mpromised. In many school districts in the United States, music has often been often the fi rst subject to be eliminated or cut back when school districts face d financial constraints (Carlton & Weikart, 1994). It is unfortuna te that most schools cannot support music and healing pr ograms even though research shows that schools which infused music therapy in their curriculum have not only produced higher student grades but more positive teacher asse ssments of students as well (Amaral, 1991; Lathrop & Boyle, 1972). The use of music for healing in the school curriculum is now being acknowledged as essential in help ing students achieve better scores (Carlton & Weikart, 1994; Giles, 1990). Anxieties such as those caused by math have been healed with music. In a study by Madsen and Forsythe (1973), higher math scores were obtained by groups of students who listened to a contingent of anxi olytic music. In this study, students could earn time to listen to soothing music to heal anxiety leading them to provide correct responses to math problems. North, Hargreav es, and ONeill (2000) conclude that music is important because it allows adolescents em otions to be pacified. Music teachers need to be cognizant of this fact and do all they can to integrate music and healing in the school curriculum.

PAGE 140

128 APPENDIX A DEMOGRAPHIC INFORMATION SHEET The Effect of Listening to Music as an Intervention on Pain and Anxiety in BMT Patients DATA COLLECTION TOOL Name__________________________________________Date:________ -Age:_____ -Sex: -Male_________ -Female_______ -Race: -Black________ -White________ -Hispanic_____ -Other________ Reasons for Admission: -Acute leukemia_______ -Chronic leukemia_____ -Lymphoma_____________ -Myeloma______________ -Bone Marrow Failure States________ -Other cancers________ -Length of time in program ________days -Current medication (within the past 4 hours which may alter pain perception, anxiety, blood pressure, or pulse)

PAGE 141

129 APPENDIX B VISUAL ANALOGUE SCALE (VAS)

PAGE 142

130 APPENDIX C STATE TRAIT ANXIETY INVENTORY (STAI)

PAGE 143

131 APPENDIX D DATA COLLECTION SHEET T1_________ __ 24 hours preintervention (-24 h) T2________ Immediately before the intervention (0) T3_________ __ Midintervention 15 min. (+15 min.) T4_________ At the end of the intervention (+30 min.) T5________ After the intervention (+45 min.) VAS STAI BP HR RR

PAGE 144

132 APPENDIX E MODIFIED HARTSOCK MUSIC PR EFERENCE QUESTIONNAIRE The following questions are concerned with music likes All information will be kept confidential. There are no right or wrong answers. 1. The following is a list of different types of musi c. Please indicate your three (3) most favorite types of music with 1 being the most favorite choice. _____Baroque _____Country and Western _____Classical _____Gospel/Religious _____Rock/Disco _____Movie Soundtracks _____Romantic _____Jazz/Blues _____Other Please put a check ( ) beside your choice in the following questions. 2. What form does your favorite music take? Vocal Nonvocal Both Other (e.g., nature sounds) 3. What type of music makes you feel the most happy? Country and Western Classical Spiritual/Religious/Gospel Rock/Disco Blues/Jazz/Folk Movie so undtracks. Other None 4. Is there any particular artist/perf ormer you enjoy listening to most? 5. What type of music makes you feel the most sad? Country and Western Classical Spiritual/Religious/Gospel Rock/Disco Blues/Jazz/Folk Movie soundtracks Other None 6. Before your hospitalization, how important a role did music play in your life? 1. Very important 2. Moderately important 3. Slightly important 4. Not important

PAGE 145

133 APPENDIX F MUSICAL SELECTIONS Baroque Music Johann Sebastian Bach (1685-1750) French Suite No. 4 in E Flat Major BWV815 Allemande Antonio Vivaldi (1678-1741) The Four Seasons, RV.269, 315, 293, 297, Op.8, Nos.1-4 No.1. La Primavera (Spring) in E, RV.269, Op.8, No.1 1.Allegro; 2.Largo; 3.Allegro Violin Concerto in D, RV.208a, Op.7, No.11 Classical Music Ludwig Van Beethoven (1770-1827) Symphony No. 5: Allegro con brio Fr Elise Violin Romance No. 2 Moonlight Sonata: Adagio sostenuto Minuet Symphony No. 8 in F major: Allegretto scherzando Coriolan" Overture Piano Concerto No. 2: Adagio Symphony No. 5 in C minor: Allegro Egmont": Overture Sonata No. 14 Op. 27 No. 2 in C Sharp Minor Franz Schubert (1797-1828) Impromptu Op. 90 No. 3 in G Flat Major D. 899 Impromptu Op. 90 No. 4 in A Flat Major D. 935

PAGE 146

134 Frederic Chopin (1810-1849) 3 Nocturnes, Op.9 Nocturne in Bb-, Op.9, No.1 Nocturne in Eb, Op.9, No.2 Nocturne in B, Op.9, No.3 Piano Sonata No.3 in B Op.58 Robert Schumann (1800-1856) Kinderszenen Scenes from Childhood Op. 15 Von Fremden Landern Und Menschen (From Foreign Lands & People) Traumerei (Dreaming) Der Dichter Spricht (The Poet Speaks) Intermezzo Op. 118, No. 2 in A Major E'tude Op. 10 No. 6 in E Flat Minor Nocturne Op. 72, No. 1 in E Minor 'Posthumous' Consolation No. 3 in D Flat Major Claude Debussy (1862-1918) ClairDeLune (From Suite Bergamsque) Pop I Can Only Imagine by Mercy Me You Raise Me Up by Stacie Orrico Adore by Jaci Velasquez Flood by Jars Clay Never Give Up by Yolanda Adams Jazz Duke's Place (Ellington/Kat z/Roberts/Thiele) 5:03 I'm Just a Lucky So and So (David/Ellington) 3:09 Cottontail (Ellington) 3:42 Mood Indigo (Bigard/Ellington/Mills) 3:57 Do Nothin' Till You Hear from Me (Ellington/Russell) 2:38 Beautiful American (Ellington) 3:08 Black and Tan Fantasy (Ellington/Miley) 3:59 Drop Me off in Harlem (Ellington/Ellington) 3:49 Mooche (Ellington/Mills) 3:38 In a Mellow Tone (Ellington) 3:48 It Don't Mean a Thing (If It Ain' t Got... (Ellington/Mills) 3:58 Solitude (DeLange/Ell ington/Mills) 4:55 Don't Get Around Much Anymore (Ellington/Russell) 3:31 I'm Beginning to See the Light (E llington/George/Hodges/James) 3:37 Just Squeeze Me (Ellington/Gaines) 3:58 I Got It Bad (And That Ain't Good) (Ellington/Webster) 5:31 Azalea (Ellington) 5:02

PAGE 147

135 Artist: Kenny G Summertime The Look of Love What a Wonderful World Desafinado In a Sentimental Mood The Girl from Ipanema Stranger on The Shore Body and Soul Round Midnight Over the Rainbow Country Western American Soldier by Toby Keith In My Daughters Eyes by Martina McBride Sweet Southern Comfort by Buddy Jewell Perfect by Sarah Evans I Wish by Jo De Messina Remember When by Alan Jackson Drinkn Bone by Tracy Byrd Little Moments by Brad Preistley Texas Plates by Kellie Coffey Simple Life by Carolyn Dawn Johnson Paint Me a Birmingham by Tracy Lawrence Watch the Wind Blow by Tim McGraw Songs about Rain by Gary Allan My Last Name by Dierks Bentley I Cant Sleep by Clay Walker Artist: Johnny Cash 1. Walk the Line 2. I Still Miss Someone 3. The Legend of John Henry's Hammer 4. Don't Take Your Guns to Town 5. In the Jailhouse Now 6. Ring of Fire 7. Understand Your Man 8. The Ballad of Ira Hayes 9. Folsom Prison Blues 10. Daddy Sang Bass 11. A Boy Named Sue 12. Sunday Morning Coming Down 13. Flesh and Blood 14. Man in Black 15. One Piece at a Time 16. (Ghost) Riders in the Sky

PAGE 148

136 Artist: Faith Hill Someone Else's Dream Let's Go to Vegas It Matters to Me Bed of Roses A Man's Home Is His Castle You Can't Lose Me I Can't Do That Anymore A Room in My Heart You Will Be Mine Keep Walkin' On Artist: Toby Keith How Do You Like Me Now?! Country Comes to Town You Shouldn't Kiss Me Like This I'm Just Talkin' about Tonight I Wanna Talk about Me My List Courtesy of the Red, White and Blue (The Angry American) Who's Your Daddy? Beer for My Horses Stays in Mexico Mockingbird You Ain't Much Fun (Live) Should've Been a Cowboy (Live) Show Tunes/Soundtracks Disney World Movie Music The Beauty and the Beast Original Motion Picture Soundtrack Prologue Belle 3) Belle (Reprise) Gaston 5) Gaston (Reprise) Be Our Guest Something There The Mob Song Beauty and the Beast To the Fair West Wing The Beast Lets Belle Go 13) Battle on the Tower Transformation 15) Beauty and the Beast (Duet)

PAGE 149

137 Hank Williams Hey Good Lookin Jambalaya on the Bayou Move It on Over Long Gone Lonesome Blues Honky Tonk Blues Why Dont You Love me Honky Tonkin Lost Highway Lonesome whistle I Saw the Light Lovesick Blues Rock n Roll Aerosmith Train Kept a Rollin' Kings and Queens Sweet Emotion Dream On Mama Kin Three Mile Smile/Reefer Head Woman Lord of the Thighs Artist: U2 All That You Can't Leave Behind Zooropa Achtung Baby Rattle and Hum Hip Hop Artist: Bun B Inauguration, The Get Throwed (featuring Z-Ro/Pimp C/Young Jeezy/Jay-Z) I'm Fresh (featuring Mannie Fresh) Pushin (with Scarface) What I Represent (UGK) Hold U Down (featuring Trey Songz/Mike Jones/Baby) Git It (with Ying Yang Twins) Retaliation Is a Must (with Mddl Fngz) Late Night Creepin (with Skinhead Rob) Bun Draped Up (with Lil' KeKe) Trill Recognize Trill (with Ludacris) I'm Ballin (featuring Jazzy Pha) The Story I'm a "G" (featuring T.I.)

PAGE 150

138 Story, The Draped Up (H-Town Mix) (featuring The H-Town All Starz) Will Smith Girls Ain't Nothing But Trouble (1988 Extended Remix) (w/DJ Jazzy Jeff) Parents Just Don't Understand (w/DJ Jazzy Jeff) A Nightmare on My Street (w/DJ Jazzy Jeff) The Fresh Prince of Bel Air (w/DJ Jazzy Jeff) Summertime (w/ DJ Jazzy Jeff) Just Cruisin' (w/ DJ Jazzy Jeff) 1,000 Kisses Radio (feat. Jada) Men in Black Gettin' Jiggy Wit It Miami Freakin' It Will 2K (feat. K-Ci) Wild Wild West (feat. Dr u Hill & Kool Mo Dee) Nod Ya Head (The Remix) Funk Lionel Richie Hello Running with the Night Penny Lover Easy Dancing on the Ceiling Stuck on You Brick House Three Times a Lady All Night Long Say You, Say Me Angel Still Goodbye

PAGE 151

139 APPENDIX G CONSENT FORM IRB# 482-2005 If you are a parent, as you read the information in this Consent Form, you should put yourself in your child's place to decide whether or not to allow your child to take part in this study. Theref ore, for the rest of the form, the word "you" refers to your child. If you are a child, adolescent, or adult reading this form, the word "you" refers to you. You are being asked to take part in a re search study. This form provides you with information about the study and seeks your authorization for the collection, use and disclosure ofyour protected health information necessary for the study. The Principal Investigator (the person in ch arge of this research) or a representative of the Principal Investigator will also describe this study to you and answer all of your questions. Your participation is entirely voluntary. Before you d ecide whether or not to take part, read the information below and ask questions about anything you do not understand. If you choose I n f ormed Consent to Par ticipate in Research and Authorization f or Collection, Use, and Disclosure of Protected Health Information University of Florida Health Center Institutional Review Board APPROVED FOR USE

PAGE 152

140 not to participate in this study you will not be penalized or lose any benefits to which you would otherwise be entitled. 1. Name of Participant ("Study Subject") 2. Title of Research Study Effectiveness of Listening to Music as an Intervention on Pain and Anxiety in Bone Marrow Transplant Patients. 3. Principal Investigator and Telephone Number(s) David Otieno Akombo (352) 392-0223 ext. 306 Co-Principal Investigator John Graham-Pole (352) 392-5633 4. Source of Funding or Other Material Support University of Florida 5. What is the purpose of this research study? To assess the effects of recorded mu sic on pain and anxiety levels in bone marrow transplant patients. 6. What will be done if you take part in this research study? You are being asked to take part in this research stu dy because you are greater than age 7 years. Those pe rsons who are hospitalized for bone marrow transplant often exhibit some fo rm of anxiety and pain during their hospitalization. The purpose of this study is to as sess the effects of music on pain and anxiety levels in these patients. If you will ing and able to participate in the study, we will spend 30 minutes with y ou playing a CD or

PAGE 153

141 tape of you chosen music. We w ill ask you to complete a 20 -item questionnaire measuring your anxiety and a 100 mm scale to record your response before and after listening to the music. You are being asked to take part in this research study because you are greater than age 7 years, and are an inpatient undergoing bone marrow transplant. Those persons who are hosp italized for bone marrow transplant often exhibit some form of anxiety a nd pain during their hospitalization. The purpose of this study is to assess the effects of music on pain and anxiety levels in these patients. If you are w illing and able to participate in the study, we will record some backgr ound information about you and your diagnosis in our secure computer (pas sword-protected) da tabase. You will be given the opportunity to select your favorite musi c or type of music, and, a day or two later, we will spend 30 minutes with you playing a CD or tape of your chosen music. We will measur e the effect of this procedure by having you fill out a 20 item questionn aire and marking a special scale before, during, and after the music is played, for a total of 6 times over 2 days. Of the procedures outlined above, filling out the questionnaires and scales would be regarded as inves tigalional or experimental. If you have any questions now or at any time du ring the study, you may contact the Principal Investigat or listed in #3 of this form. 7. If you choose to partic ipate in this study, how long will you be expected to participate in the research? You will only be asked to partic ipate in this study on two days. 8. How many people are expected to participate in this research? We expect 40 people to participate in the study. 9. What are the possible discomforts and risks? We do not know of any discom forts or risks from this study. Througho ut the study, the investigators will notify you of any in formation that may become available and that might affect your decision to remain in the study. If you wish to discuss the information above or any discomforts you may experience, you may ask questions now or ca ll the Principal Investigator or contact person listed on the front page of this form.

PAGE 154

142 lOa. What are the possible benefits to you? Possible benefits for study subjects partic ipating are pain and anxiety reduction. By listening to their chosen music, we hope th at the subjects will therefore find this a benefit to their well being. We hope you will enjoy the music and will continue listening to prerecorded music on ta pe and CDs that will be provided. lOb. What are the possible benefits to others? By participating in this study you will be he lping us understand if music has any effect on pain and anxiety levels in hospitalized persons. This information will support the development of more extensive music progr ams to support patients in your situation and their caregivers, thus possibly impr oving the quality of life for these patients. 11. If you choose to take part in this research study, will it cost you anything? No. 12. Will you receive compensation for ta king part in this research study? No. 13. What if you are injured because of the study? If you experience an injury that is directly caused by this study, only professional medical care that you receive at the University of Florida Health Science Center will be provided without charge. However, hospital expenses will have to be paid by you or your insurance provider. No other compensation is offered. Please contact the Principal Investigator listed in Item 3 of this form if you experience an injury or have any questions about any discomforts that you experience while participating in this study. 14. What other options or trea tments are available if you do not want to be in this study? Patient may listen to the music that is pr ovided to other pati ents on the unit. 15a. Can you withdraw from this research study?

PAGE 155

143 You are free to withdraw your consent and to stop participating in this research study at any time. If you do w ithdraw your consent, there will be no penalty, and you will not lose a ny benefits you are entitled to. If you decide to withdraw your consent to participate in th is research study for any reason, you should contact David Otieno Akombo at (352) 3920223 ext. 306 or Dr. John Gr aham-Pole at (352) 392-5633. If you have any questions regarding y our rights as a research subject, you may phone the Institutional Review Board (IRB) office at (352) 8461494. 15b. If you withdraw, can information about you stil l be used and/or collected? If you withdraw, we will not use any of the information about you in the study. 15c. Can the Principal Investigator withdraw you from this research study? You may be withdrawn from the study wi thout your consen t for the following reasons: We reserve the right to exclude your data from the final analysis if more than 50% of your survey questionnaires are left blank. 16. If you agree to participate in this research study, the Principal Investigator will create, collect, and use private information about you and your health. Once this information is collected, how will it be kept secret (confidential) in order to protect your privacy? Information collected ab out you and your health ( called protected health information), will be stored in locked fili ng cabinets or in com puters with security passwords. Only certain people have the legal right to review these research records, and they will protect the secrecy (confidentiality) of these records as much as the law allows. These people in clude the researcher s for this study, certain University of Florida officials, the hospital or clinic (if any) involved in this research, and the Institutional Review Board (IRB; an IRB is a group of people who are responsible for looki ng after the rights and welfar e of people taking part in research). Otherwise your research records will not be released without your permission unless required by law or a court order. If you participate in this research study, the researchers will collect, use, and share your protected health information with ot hers. Items 17 to 26 below describe how this information will be co llected, used, and shared.

PAGE 156

144 17. If you agree to participate in this research study, what protected health information about you may be collected, used and shared with others? Your protected health information may be collected, used, and shared with others to determine if you can participate in the study, and then as part of your participation in the study. This informati on can be gathered from you or your past, current or future health records, from pr ocedures such as phys ical examinations, xrays, blood or urine tests or from other pr ocedures or tests. This information will be created by receiving study treatments or participating in study procedures, or from your study visits and telephone calls. More specifically, the following information may be collected, us ed, and shared with others: Demographics (age, gender, race, place of birth and geographic location where they live) Current Diagnosis and medica tion currently being taken If you agree to be in this research study, it is possible that some of the information collected might be copied into a limited data set" to be used for other research purposes. If so, the limited data set may only include information that does not directly identify you. Fo r example, the limited data set cannot include your name, address, telephone num ber, social security number, or any other photographs, numbers, codes, or so fo rth that link you to the information in the limited data set. If used, limited data sets have legal agreements to protect your identity and confidentiality and privacy. 18. For what study-related purpos es will your protected health information be collected, used and shared with others? Your protected health information may be collected, used, and shared with others to make sure you can participate in the research, through your participation in the research, and to evaluate the results of the research study. More specifically, your protected health informa tion may be collected, used, and shared with others for the following study-related purpose(s): to assess the effects of musi c on pain and anxiety levels in patients having a bone marrow transplant 19. Who will be allowed to collect, use, a nd share your protected health information? Your protected health inform ation may be collected, used, and shared with others by:

PAGE 157

145 the study Principal Investigators, Da vid Otieno Akombo and Dr. John GrahamPole the University of Florida Institutional Review Board Other professionals at the University of Florida 20. Once collected or used, who may your protected health information be shared with? Your protected health inform ation may be shared with: United States and foreign governmental agencies who are responsible for overseeing research, such as the Food and Dr ug Administration, the Department of Health and Human Services, and the Office of Human Research Protections Government agencies who are re sponsible for overseeing public health concerns such as the Centers for Disease Control an d Federal, State and local health departments. 21. If you agree to participate in this research, ho w long will your protected health information be used and shared with others? Forever. However, all information is co mbined and presented so that no single person can be identified. 22. Why are you being asked to allow th e collection, use and sharing of your protected health information? Under a new Federal Law, researchers cannot collect, use, or share with others any of your protected health information for research unl ess you allow them to by signing this consent and authorization. 23. Are you required to sign this co nsent and authorization and allow the researchers to collect, use and share with others your protected health information? No, and your refusal to sign will not affect your treatment payment, enrollment, or eligibility for any benefits out side this research study. However, you cannot

PAGE 158

146 participate in this resear ch unless you allow the co llection, use and sharing of your protected health information by signing this consent/authorization. 24. Can you review or copy your protected health information that has been collected, used or shared with others under this authorization? You have the right to review and copy your protected health information. However, you will not be a llowed to do so until after the study is finished. 25. Is there a risk that your protected he alth information could be given to others beyond your authorization? Yes. There is a risk that information received by authorized persons could be given to others beyond your author ization and not covered by the law. 26. Can you revoke (cancel) your authoriz ation for collection, use and sharing with others of your prot ected health information? Yes. You can revoke your authorization at any time before, during, or after your participation in the research. If you revoke, no new information will be collected about you. However, informati on that was already collected may still be used and shared with others if the researchers have relied on it to complete and protect the validity of the research. You can revoke your authorization by giving a written request with your signature on it to the Principal Investigator. 27. How will the researcher(s) benefi t from your being in this study? In general, presenting research results helps the career of a scientist. Therefore, the Principal Investigator ma y benefit if the results of this study are presented at scientific meeti ngs or in scientific journals. 28. Signatures As a representative of this study, I have explained to the participant the purpose, the procedures, the possible benefits, and the risk s of this research study; the alternatives to being in the study; and how the particip ant's protected health information will be collected used and shared: Signature of Person Obtaining Consent & Authorization Date

PAGE 159

147 Consenting Adults. You have been informed about this study's purpose, procedures, possible benefits, and risks; the alternatives to being in the study; and how your protected health information will be collected, used and shared. You will get a copy of this Form. You have been given the opportunity to ask questions before signing this form, and you have been told that you can ask other questions at any time. Adult Consenting for Self. By signing this form, you voluntarily agree to participate in this study and hereby au thorize the collection, use and sharing of your protected health information as described in sections 17-26 above. By signing this form, you are not waiving any of your legal rights. Signature of Adult Consenting & Authorizing for Self Date Parent/Adult Legally Re presenting the Subject. By signing this form, you voluntarily give your permission for the pe rson named below to participate in this study and hereby authorize the collection, use and sharing of protected health information for the person named below as described in sections 17-26 above. You are not waiving any legal rights for y ourself or the pers on you are legally representing. After your signature, please prin t your name and your relationship to the subject. Consent & Authorization Signature Date of Parent/Legal Representative Print: Name of Legal Representative of and Relationship to Participant: Participants Who Cannot Consent But Can Read and/or Understand about the Study. Although legally you cannot "consent" to be in this study, we need to know if you want to take part. If you decide to take part in this study, and your parent or the person legally responsible for you gives permission, you bot h need to sign. Your signing below means that you agree to take part (assent). The signature of your paren t/legal representative above means he or she gives permis sion (consent) for you to take part. Assent Signature of Participant Date David Otieno Akombo October 14,2005 Page Research records must be retain ed for 3 years after completion of the research; if the study involves medical treatment, it is recommended that the records be retained for 8 years.

PAGE 160

148 If VAMC patients will be included in this study, or if the study is to be conducted in part on VA premises or performed by a VA employee during VA-compensated time, review by the VA Subcommittee for Clinical Investigations is required. You are responsible for notifying all parties about the approval of this study, including your coInvestigators and Department Chair. If you have any questions, please telephone the IRB-01 office at (352) 846-1494. cc: IRB file / Pharmacy / VA Research Center / Clinical Research CenterAn Equal Opportunity Institution

PAGE 161

149 APPENDIX H COVER LETTER TO SUBJECTS 11/2/05 David O. Akombo, University of Florida School of Music, 130 Music Building, P.O. Box 117900, Gainesville, FL 32611-7900, Tel: (352) 392-0223 Ext. 306 Fax:(352)392-0461 dakombo@ufl.edu Dear Participant: I am a doctoral student at the University of Florida. As part of my graduation requirements for the doctoral degree, I am conducting a research the purpose of which is to determine the effectiveness of listening to music as an intervention on pain and anxiety in bone marrow transplant patients. I am asking you to participate in this interview because you are greater than age 7 years, and are an inpatient undergoing bone marrow transplant. Those persons who are hospitalized for bone marrow transplant often exhibit some form of anxiety and pain during their hospitalization. The purpose of this study is to assess the effects of music on pain and anxiety levels in these patients. If you are willing and able to participate in the study, you will be given the opportunity to select your favorite music or type of music, and, a day or two later, we will spend 30 minutes with you playing a CD or tape of your chosen music. We will measure the effect of this procedure by having you fill out a questionnaire and marking a special scale before, during, and after the music is played, for a total of 6 times over 2 days. There are no anticipated risks, compensation or other direct benefits to you as a participant in this survey. You are free to withdraw you r consent to participate and may discontinue your participation in th e survey at any time without consequence. If you have any questions about this survey, please contact my faculty supervisor, Dr. Timothy Brophy, at (352) 392-0223 x222 or me at (352) 392-0223 ext. 306. Questions or concerns about your rights as a research participant rights may be directed to the UFIRB office, University of Florida, Box 100173, Gainesville, FL 32610; ph (352) 846-1494. Please sign and return this copy of the letter in the enclosed envelope. A second copy is provided for your records. By signing this letter, you give me permission to report your responses anonymously in the dissertation to be submitted to the University of Florida Graduate School as part of my PhD degree requirements. David O. Akombo_____________________________________________________________

PAGE 162

150 I have read the request described above for my participation in the music, pain and anxiety research. I voluntarily agree to participate in the research and I have received a copy of this description. Signature of participant Date____________________________________________________

PAGE 163

151 APPENDIX I COVER LETTER TO PARENTS 04/02/2005 David O. Akombo, University of Florida School of Music, 130 Music Building, P.O. Box 117900, Gainesville, FL 32611-7900, Tel: (352) 392-0223 Ext. 306 Fax: (352) 392-0461 dakombo@ufl.edu Dear Parent: I am a doctoral student at the University of Florida. As part of my graduation requirements for the doctoral degree, I am conduc ting a research the purpose of which is to determine the effectiveness of listening to music as an intervention on pain and anxiety in bone marrow transplant patients. I am asking you consent to your childs participation in this interview because your child is greater than age 7 years, and is an inpatient undergoing bone marrow transplant. Those persons who are hospitalized for bone marrow tran splant often exhibit some form of anxiety and pain during their hospitalization. The purpose of this study is to assess the effects of music on pain and anxiety levels in these patients. If you consent to this study, and your child is able to participate in the study, the child will be given the opportunity to select his/her favorite music or type of music, and, a day or two later, we will spend 30 minutes with him/her playing a CD or tape of their chosen music. We will measure the effect of this procedure by having him/her fill out a questionnaire and marking a special scale before, during, and after the music is played, for a total of 6 times over 2 days. There are no anticipated risks, compensation or other direct benefits to your child as a participant in this survey. You are free to withdr aw your consent for your child to participate and may discontinue your participation in the survey at any time without consequence. If you have any questions about this survey please contact my faculty supervisor, Dr. Timothy Brophy, at (352) 392-0223 x222 or me at (352) 392-0223 ext. 306. Questions or concerns about your rights as a research particip ant rights may be directed to the UFIRB office, University of Florida, Box 100173, Gainesville, FL 32610; ph (352) 846-1494. Please sign and return this copy of the letter in the enclosed envelope. A second copy is provided for your records. By signing this letter, you give me permission to report your responses anonymously in the dissertation to be submitted to the University of Florida Graduate School as part of my PhD degree requirements. David O. Akombo ___________________________________________________

PAGE 164

152 I have read the request described above for my child s participation in the music, pain and anxiety research. I voluntarily consent to my childs par ticipation in the research and I have received a copy of this description. ____________________________ ___________ Signature of parent/guardian Date

PAGE 165

153 APPENDIX J INSTITUTIONAL REVIEW BOARD LETTER

PAGE 166

154 APPENDIX K POST-INTERVENTION QUESTIONNAIRE 1. Was there anything that interf ered with (or restricted th e enjoyment of) your listening? Yes No (please check the appropriate box) -If yes, please give details Responses given by BMT patients: I would have enjoyed more if the nurse didnt interfere. Please remove that music becau se it brings bad memories. This blood transfusion is worrying me. Please do not let anyone interrupt me when I am listening to music ______________________________________________________________________ 2. On a scale of 0-10 where 0 is no interf erence and 10 is extreme interference, how would you rate that interference? 0 1 2 3 4 5 6 7 8 9 10 3. Would you have liked to listen to music for a longer period of time instead of just 30 minutes? Yes No (please check the appropriate box)

PAGE 167

155 LIST OF REFERENCES Achterberg, J., Dossey, L., Gordon, J., Hege dus, C., Herrmann, M. & Nelson, R. (2006). Mind-Body Interventions. [O n-Line]. Available at file:///C:/Documents%20and%20Settings/d akombo/Desktop/Cross%20reference.ht m (Last accessed, May 29, 2006). Aigen, K. (1991). The roots of music therap y: Towards indigenous research paradigm. Dissertation Abstracts International, 52 (6), 1933A. (University Miscrofilms No. DEY91-34717). Alakbarov F. (2003). What doctors knew centuries ago. Azerbaijan International Vol.11 no. 3 Autumn. [On-Line]. Available at: http://www.azer.com/aiweb/categories/ magazine/ai113_folder/113_articles/113_m usic_therapy_farid.html (Last accessed, October 10, 2005). Aldridge, D. (1993). Artists as psychotherapists. Arts in Psychotherapy, 20 (3), 199-200. Allen, K., Golden, L. H., Izzo, J. L. Jr., Chi ng, M. I., Forrest, A., Niles, C. R., et al. (2001). Normalization of hypertensive respons es during ambulatory surgical stress by perioperative music Buffalo, NY: State University of New York at Buffalo and Kaleida Health System. Alsalam, N. & Rogers, G. (1991). The condition of education Washington, DC: National Center for Education Statistics: U.S. Dept. of Education, Office of Educational Research and Improvement, Educational Resources Information Center. Alvin, J. (1991). Music therapy London: Stainer & Bell. Anderson, D.E., Coyle, K., Haythornwaite J.A., (1992). Ambulatory monitoring of respiration: inhibitory breathi ng in the natural environment. Psychophysiology 29 (5), 551. Arveiller J. (1980). Des musicothrapies Issy-les-Moulineaux, France: L.A.P. Atlee, E. (1804). An inaugural essay on the influence of music in the cure of diseases Philadelphia, PA: B. Graves. Augustin, P., & Hains, A. (1996). Effect of music on ambulatory surgery patients postoperative anxiety. Association of Operating Room Nurses, 63 (4), 750.

PAGE 168

156 Bailey, L. M. (1983). The effects of liv e music versus tape-recorded music on hospitalized cancer patients. Music Therapy, 3 (1), 17-28. Baines, S. (2000). A consumer-directed and partnered community mental health music therapy program: Program development and evaluation. Canadian Journal of Music Therapy 7 (1), 51-70. Bally, K., Campbell, D., Chesnick, K., & Tranme r, J. (2003). Effects of patient-controlled music therapy during coronary angiography. Critical Care Nurse, 23 (2), 50-58 Barnason, S., Zimmerman, L., & Nieveen, J. ( 1995). The effects of music interventions on anxiety in the patient after corona ry artery bypass grafting. Lincoln, NE: Heart Lung, 24 (2), 124-32. Bates M.S., Rankin-Hill, L., & Sanchez-Ayendez, M. (1997) The Effects of the cultural context of health care on tr eatment of and response to chronic pain and Illness. Social Science and Medicine, 45 (9), 1433-1447. Beck, S. L. (1988). The effect of the ther apeutic use of music on cancer-related pain. Dissertation Abstracts International. 4J.U2-B), 5526. (University Microfilms No. 8825878). Beck, S. L. (1991). The therapeutic us e of music for cancer-related pain. Oncology Nursing Forum. 18 1327-1337. Becker, L. (1999). Repeated-measures desi gns: Within-subjects factor. [On-Line]. Available at http://web.uccs.edu/lbec ker/SPSS/glm_1withn.htm#top (Last accessed, April 2, 2006). Beczkala, M. J. (1997). The perceptions of secondary adm inistrators regarding the role of the fine arts curriculum in the total education experience (Doctoral dissertation, Saint Louis University). Dissertation Ab stracts Internationa l, 58 (08), 2889A. Benenzon, R. (1997). Music therapy theory and manual: Contributions to the knowledge of nonverbal contexts Springfield, IL: Charles C. Thomas. Berger, D. S. (1999). Toward the Zen of performance: Music improvisation therapy for the development of self-confidence in the performer St. Louis, MO: MOB Music, Inc. Bergner M. (1989). Quality of life, h ealth status, and clinical research. Medical Care, 27 148-156. Besmer, F. E. (1983). Horses, Musicians & gods: The Hausa Cult of possession-trance South Hardley, MA: Bergin & Garvey Publishers. Bettermann, H. (2002). Effects of speech therap y with poetry on heart rate rythmicity and cardiorespiratory coordination. International Journal of Cardiology, 84 77-88.

PAGE 169

157 Birbaumer, N. (1977). Zum problem der psychosomatik. In Birbaumer (Ed.), Psychophysiologie der angst. Mnchen, Germany: Ur ban & Schwarzenberg. Bodley, P. (1974). Preoperative an xiety: A quantitative analysis. Neurosurgery and Psychiatry 34 230-239. Bolton, J., & Wilkinson, R. C. (1998). Respons iveness of pain scales: A comparison of three pain intensity measures in chiropractic patients. Journal of Manipulative and Physiological Therapeut ics, 21 (1), 1-7. Bolwerk, C. (1990). Effects of relaxing musi c on state anxiety in myocardial infarction patients. Critical Care Nursing Quarterly, 13 63-72. Bonica, J. (1977). Introduction to symposium on pain. Archives of Surgery, 112 749-760. Bottomly, A. (1998). Anxiety and the adult cancer patient. European Journal of Cancer Care, 7, 217-224. Bowler, C. A. (1990). Effects of relaxing musi c on state anxiety in myocardial infarction patients. Critical Care Nursing Quarterly, 13 63-72. Braun, J. (2002). Music in ancient Israel/Pales tine:Archaeological, written, and comparative sources (Trans. Douglas Scott). Grand Rapids, MI: William B. Eerdmans Publishing Co. Brennan, F. B., & Charnetski, C.J. (2000). Stress and immune system function in a newspapers newsroom. Psychological Reports, 87 218-222. Brophy, B. (1986, October 27). Children Under Stress. U.S. News and World Report 5863. Brophy, T. (2000). Assessing the developing child musician: A guide for general music Teachers Chicago, IL: GIA Publications. Browne, R. (1729). Medicina musica: Or, a mechanical essay upon the effects of singing, musick, and dancing on human bodiesTo whic h is annexd, a new essay on the nature and cure of the spleen and vapours London: John Cooke and J. and J. Knapton. Browning, C. A. (2000). Music therapy in childbirth: Research in practice. Music Therapy Perspectives, 19 (2), 74. Brownley, K. A., McMurray, R .G., Hac kney, A. C. (1995). Effects of music on physiological and affective responses to gr aded treadmill exerci se in trained and untrained runners. Chapel Hill, NC: International Journal of Psychophysiology, 19 (3),193-201.

PAGE 170

158 Bruscia, K. E. (1989). Defining music therapy Spring City, PA: Spring House Books. Burt, S. (2003). September 1, 1939 Revisited: Or, poetry, politics, a nd the idea of the public. American Literary History, 15 (3), 533-559. Bynum, F., Porter, R., & Shepherd, M. (1985) Introduction to the Anatomy of Madness. Essays in the History of Psychiatry, 1 1-24. Carlton, E. B. and Weikart, P. S. (1994). Foundations in elementary education: Music Ypsilanti, MI: High/Scope Press. Carr, E., & Mann, M. (2000) Pain: Creative approaches to effective management London: Macmillan Press. Campbell, D. (1997). Mozart Effect: Tappi ng the power of music to heal the body, strengthen the mind, and unlock the creative spirit New York, NY: Morrow/Avon. Campbell, M. (1982). Music th erapy students in concert. British Journal of Music Therapy, 13 (1), 8-15. Campbell, W., & Heller, J. (1980). An orient ation for considering models of musical behavior. In D. Hodges (Ed.), Handbook of music psychology (pp. 29-36). Lawrence K.S.: National Association for Music Therapy. Cannon, W. B. (1978). Wut, hunger, angst und schmerz Mnchen, Germany: Urban & Scharzenberg. Carol, L. (2000). Medical milestones of the last millennium. Food and Drug Administration, 34 (2), 8-13. Carpenti, L. J. (1993). Nursing diagnosis: Application to clinical practice Philadelphia: J. B. Lippincott. Carr, E. & Mann, M. (2000). Pain: Creative approaches to effective management London: Macmillan Press. Chapman C. & Stillman, M. (1996). Pat hological pain. In L. Krueger (Ed.), Handbook of perception: Pain and touch (213-241). New York: Academic Press. Clark, M. (1970). The genius of Beethoven. In Sunrise Magazine Theosophical University Press. [On-Line]. Available at: http://www.theosophynw.org/theosnw/arts/ar-mclk4.htm (Last accessed, August 12, 2005) Cleeland, C. S., Gonin, R., Hatfield, A. K., Ed monson, J. H., Blum, R. H., Stewart, J. A., et al. (1994). Pain and its treatment in outpatients with metastatic cancer. New England Journal of Medicine, 330 592-696.

PAGE 171

159 Cobb, D., & Evans, J. (1981). The use of bi ofeedback techniques with school aged children exhibiting behavioral and/or learning problems. Journal of Abnormal Psychology, 9 251-261. Cohen, B. (2001). Use of aromatherapy and mu sic therapy to reduce anxiety and pain perception in dental hygiene. Access, 15 (6), 34-41. Collins, S. K., & Kuck, K. (1991). Music ther apy in the neonatal intensive care unit. Neonatal Network, 9 (6), 23-26. Cook, J. D. (1981). The therapeutic us e of music: a li terature review. Nursing Forum, 20 252-266. Cook, J. D. (1986). Music as an in tervention in the oncology setting. Cancer Nursing, 9 (1), 23-28. Cooke, R. M. (1969). The use of music in play therapy. Journal of Music Therapy, 6 6675. Cooper, S. A. (1990). Treating acute pain: Do's and don'ts, pros and cons. Journal of Endontics, 16 85-91. Cornelius, S. (1990). Encapsulating power : Meaning and taxonomy of musical instruments of Santeria in New York City. Selected Reports in Ethnomusicology, 8 125-142. Cottrell, A. (2001). Healing musical in struments. [On-Line]. Available at: http://www.healingmusic.org/Main/catalog/Drums.htm (Last accessed, February 15, 2004). Creswell, J. (1998). Qualitative inquiry and research design: Choosing among five traditions Thousand Oaks, CA: Sage. Cronbach, L. J. (1951). Coefficient alpha and the internal st ructure of tests. Psychometrika. 16 297-334. Curtis, S. L. (1986). The effect of music on pain relief and relaxa tion of the terminally ill. Journal of Music Therapy, 23 10-23. Darrow, A. A., Gibbons, A. C., & Heller, G. N. (1985). Music thera py past, present, and future. The American Music Teacher, September/October 18-20. Davis, C. (1992). The effects of music a nd basic relaxation instruction on pain and anxiety of women undergoing in-o ffice gynecological procedures. Journal of Music Therapy, 29 (4), 202-218.

PAGE 172

160 Davis, W. B. (1987). Music therapy in nineteenth century America. Journal of Music Therapy, 24 (2), 76-87. Davis, W. B. (1989). Music therapy in Vict orian England: Frederick Kill Hartford and the Guild of St. Cecilia. Music Therapy Perspectives, 7 17-22. Davis, W. B. (1999). An introduction to music therapy: Theory and practice Boston, MA: McGraw-Hill. Davis-Rollans, C., & Cunningham, S. G. (1987) Physiologic responses of coronary care patients to selected music. Heart Lung, 16 370-378. Descartes, R. (1694). The passions of the soul/Les passions de l'ame (S. H. Voss, Trans.). Indianapolis, IN: Hackett Pub. Co. Diaz de Chumachiero, C. L. (1990). Dynami c implications of opera training in psychotherapy. Arts in Psychotherapy, 17 (1), 19-28. Dios Chemial Company. (1950). Music therapy St. Louis, MO: The Company. Drever, J. (1952). A dictionary of psychology London: Hazel Watson & Viney Ltd. Echenhofer, F. G., & Coombs, M. M ( 1987). A brief review of research and controversies in EEG biof eedback and meditation. Journal of Transpersonal Psychology, 19 161-171. Eliade, M. (1962). The forge and the crucible Trans. Stephen Corrin. New York, NY: Harper & Row. Elliot, D. (1992). Rethinking music teacher education. Journal of Music Teachers Education Fall 1992 6-15. Elliot, D. (1994). The effects of music and muscle relaxation on patient anxiety in the coronary care unit. Heart & Lung, 23 27-35. Ellis, D. S., & Brighouse, G. (1952). Effects of music on respiration and heart rate. American Journal of Psychology, 65 (1), 39-47. Engel, L., Guess, H., Kleinman, A., & Kusek, J. (2002). The Science of placebo: Towards an interdisciplinary research Agenda London: BMJ Books. Engstrom C. A., Strohl, R. A., Rose, L., & St efanek, M. E. (1999). Sleep alterations in cancer patients. Cancer Nursing 22 (2), 143-8. Erdtsieck, J. (1997) Pepo as an inner healing force: Prac tices of a female spiritual healer in Tanzania Amsterdam: Royal Tropical Institute. Fenwick, A. M. (1971). From silence to speech : A case-study of a sc hizophrenic patient. British Journal of Music Therapy 1-6.

PAGE 173

161 Flanagan, K., & Jupp, P. C. (1996). Postmodernity, Sociology and Religion New York, NY: MacMillan Press. Fountoulakis, K. N., Papadopoulou, M., Klean thous, S., Papadopoulou, A., Bizeli, V., Nimatoudis, I., et al., (2006). Reliability and psychometric properties of the Greek translation of the State-Trait Anxiety Inventory form Y: Preliminary data. Annals of General Psychiatry, 5 (2). Friedson, S. (1998). Tumbuka healing. In R. M. Stone (Ed.), The Garland encyclopedia of world music New York, NY: Garland Publishers. Furner, J., & Berman, B. (2006). Confidence in their ability to do mathematics: The need to eradicate math anxiety so our future students can successfully compete in a hightech globally competitive world. [On-Line]. Available at: http://www.people.ex.ac.uk/PErnes t/pome18/furner_math_anxiety_2.htm (Last accessed, March, 21, 2006). Furnham, A., Trew, S., & Sneade, I. (1999). The distracting effects of vocal and instrumental music on the cognitive test pe rformance of introverts and extraverts. Personality and Individual Differences, 27 381-392. Gage, N. L. (1989). The paradigm wars and th eir aftermath: A historical sketch of research on teaching since 1989. Educational Researcher, 18 (7), 4-10. Gallagher, R. (1999). Primary care and pain medicine: A community solution to the public health problem of chronic pain. Medical Clinics of North America, 83 555583. Gardner, K. (1990). Sounding the inner landsca pe: Music as medicine Stonington, ME: Caduceus Publications. Gardner, W. J., & Licklider, J. C. (1959). Auditory analgesia in dental operations. The Journal of the American Dental Association, 59 1144-1149. Gedda, L., & Rizzi, R. (1962). Psychologische verfassung de s individuums vor und nach dem eingriff und der Anaesthesie. Anesthetist, 11 (12), 378-385. Geden, E. A., Lower, M., Beattie, S., & Beck, N. (1989). Effects of music and imagery on physiologic and self-report of analogued labor pain. Nursing Research, 38 (1), 37-41. Gerdner, L., A. (2000). Effects of individuali zed versus classical "relaxation" music on the frequency of agitation in elderly pers ons with Alzheimer's disease and related disorders. International Psychogeriatrics, 12 (1), 49-65.

PAGE 174

162 Gfeller, K. (2003). Therapeutic power of music. Currents, 4( 3). [On-Line]. Available at: http://www.uihealthcare.com/news/ currents/vol4issue3/o3music.html (Last accessed, November 18, 2004). Gilchrist, I. (2002). My music helps h ealing. London: BBC World Service. Sunday, 29 December. [On-Line]. Available at: http://news.bbc.co.uk/ 2/hi/health/2385315.stm (Last accessed, July 1, 2005). Giles, M. (1990). Music and stress reduction in school children at risk for conduct disorders. Update: Applications of re search in Music Education Spring-Summer, 11-13. Giles, M. (1996). The healing powers of music. [On-Line]. Available at: http://www.music.vt.edu/outreach /vmea/1990years/1994/no2/healing.html (Last accessed, March 31, 2006). Glass, G. V., & Hopkins, K. D. (1996). Statistical methods in education and psychology (3rd ed.). Boston, MA: Allyn & Bacon. Godwyn, J. (1991). The mystery of the seven vowels, in theory and practice York Beach, ME: Phanes Press. Good, M. (1995). A comparison of effects of jaw relaxation and music on postoperative pain. Nursing Research, 44 52-54. Good, M., Stanton-Hicks, Grass, J. A., Ande rson, G. C., Lai, H. L., Roykulcharoen, V., & Adler, P. A. (2001). Relaxation an d music to reduce postsurgical pain. Journal of Advanced Nursing, 33 (2), 208-215. Good, M., Picot, B., Salem, S., Chin, C., Picot, S., & Lane, D. (2000). Cultural differences in music chosen for pain relief. Journal of Holistic Nursing, 18 (3) 245260. Goodland, J. (1984). A place called school New York, NY: McGraw-Hill. Gould, D. (2001). Visual Analogue Scale (VAS). Journal of Clinical Nursing, 10 697706. Graham-Pole, J. (2000). Illness and the art of creativ e self-expression: Stories and exercises from the arts for those with chronic illness Oakland, CA: New Harbinger Publications. Graham-Pole, J. (2005). Society for the ar ts in healthcare. (2005). Dedicated to promoting the arts as an integral compone nt of healthcare. [Brochure]. Washington, DC: Society for the Arts in Healthcare.

PAGE 175

163 Grape, C., Sandgren, M., Hansson, L. O., Ericson, M. & Theorell T. (2003). Does singing promote well-being? An empiri cal study of professional and amateur singers during a singing lesson. Stockholm & Sweden. Integrative Physiological & Behavioral Science, 38 (l), 65-74. Grout, J. D., & Palisca, C. V. (1996). A History of Western music New York, NY: W. W. Norton & Company. Guzzetta, C. (1989). Effects of relaxation a nd music therapy on patients in a coronary care unit with presumptive acute myocardial infarction. Heart Lung 18 609-616. Hairstone, M. (1999). Music therapy in school settings: Current practice. Journal of Music Therapy, 36(4) Washington DC: National Association of Music Therapy. Hamilton, D. (1994). Traditions, preferences, an d posture in applied qualitative research. In N. K. Denzin, & Y. S. Lincoln (Eds.), Handbook of qualitative research (pp. 6069). Thousand Oaks, CA: Sage. Hammer, S. E. (1996). The effects of guide d imagery through music on state and trait anxiety. Journal of Music Therapy, 33 47-70. Hanser, S. B. T., & Thompson, L. W. (1994) Effects of a musi c therapy strategy on depressed older adults. Journal of Gerontology, 49 (6), 265-269. Harner, M. (1990). The way of the shaman San Francisco, CA: Harper Press. Harper, P. (1969). Dance in Nigeria. Ethnomusicology 9 (1), 280-295. Hart, C. (1999). The mysterious placebo effect. Modern Drug Discovery 2 (4) 30-40. Hartsock, J. W. (1982). The effects of music on levels of depression on orthopedic patients on prolonged bed rest Masters Thesis, Iowa City, Iowa: The University of Iowa. Hassed, C. (1998). Mind-Body Medicine in h ealth promotion: Science, practice and philosophy. [On-Line]. Available: http://www.rhpeo.org/ijhparticles/1998/10/index.htm (Last accessed, February 24, 2006). Heitz, L., Symrend, T., & Scamman, F. L. (1992). Effects of music therapy in the postanesthesia care uni t: A nursing intervention. Journal of Post Anesthesia Nursing 7 22-31. Heller, G. N. (1987). Idea, initiatives, and im plementations: Music therapy in America, 1789-1848. Journal of Music Therapy 24 (1), 35-46. Hernandez-Peon, R. (1960). Neurophysiological correlates of habituation and other manifestation of inhibition. Electoencephalography and Clinical Neurophysiology, 13 101-113

PAGE 176

164 Hernandez-Peon, R. Scherrer, H., Jouvet, M. (1956). Modification of electric activity in cochlear nucleus during atte ntion in unanesthetized cats. Science 123 (3191), 331-2. Hewlett-Packard Company. (1988). Technical information: HP 7B534C monitor/terminal (No. 5954-1884). Andover, MA: Hewlett-Packard. Hollander, L. (1988). Music in the creative process and the path of enlightenment. Music Therapy 7 (1), 8-14. Hollandsworth, J. (1990). The physio logy of psychological disorders: Schizophrenia, depression, anxiety, and substance abuse New York, NY: Plenum Press. Hong, M., Hussey, D., & Heng, M. (1998), Music therapy with severely emotionally disturbed children in a re sidential treatment setting. Music Therapy Perspectives, 16 (2), 61-66. Hussey, D., Layman, D. (2003). Music therapy with emo tionally disturbed children. Psychiatric Times, 20 (6), 37-41. Iadarola, M. J., Caudle, R. M. (1997). Good pain, bad pain. Science 278(5336), 239 240. Ikonomidou, E. & Rehnstrm, A. (2004). Effect of music on vital signs and postoperative pain. AORN Journal 80 (2): 269-274, 277-278. Illescas-Rico, R., Amaya-Ayala, F., Jimenez-Lopez, J. L., Caballero-Mendez, M. E., Gonzalez-Llaye, J. (2002). Increased in cidence of anxiety and depression during bone marrow transplantation. Archives of Medical Research, 33 (2), 144-147. Isern, B. (1964). Music in special education. Journal of Music Therapy, 4 135-142. Janig, W. (1990). The sympathetic nervous system in pain: Physiology and pathophysiology. In M. Stanton-Hicks (Ed.), Pain and the sympathetic nervous system (17-90). Boston: Kluwer Academic. Janzen, J. M. (1978). The comparative study of medical system as changing social systems in social science and medicine. Social Science and Medicine 12 (2B), 121129. Jilek, W. G. (1999). Modern civilizati on, westernization, and mental health. Transcultural Psychiatry Newsletter, 17 (1). [online resource] Available: http://www.mentalhealth.com/newslet/tp9901.html (Last accessed, January 25, 2006).

PAGE 177

165 Johnson, L., & Pugach, M. (1992). Continuing the dialogue: Embracing a more expansive understanding of collaborative relationshi ps. In W. Stainback, & S. Stainback, Controversial issues confronting spec ial education: Divergent perspectives (169183). Needham Heights, MA: Allyn & Bacon. Jones, S. R. (1992). Was there a Hawthorne effect? The American Journal of Sociology, 98 (3), 451-468. Josepha, M. (1964). The therapeutic values of instrumental performance for severely handicapped children. Journal of Music Therapy, 1 73-79. Kaempf, G., & Amodei, M. E. (1989) The effect of music on anxiety. AORN Journal, 50 112-118. Kapferer, B. (1983). A celebration of demons: Exorcism and the Aesthetics of healing in Sri Lanka Bloomington, IN.: Indiana University Press. Kaufman-Osborn, T. (2002). Silencing the voice of pain. In From noose to needle Ann Arbor, MI: University of Mi chigan Press, (p. 135-164). Keating, S., & Sechrist, K. (2001). The nursing shortage in Californi a: The public policy role of the California Strategic Planning Committee for Nursing. Online Journal of Issues in Nursing, 6 ,1. Kent, J., & Molony, V. (2001). How is pain pr oduced? In Guidelines for the Recognition of animal pain. Animal Welfare Res earch Group, [On-Line]. Available at: http://www.vet.ed.ac.uk/animalpain/Default.htm (Last accessed, January 15th, 2006). Kerkvliet, G. J. (1990). Music ther apy may help cont rol cancer pain. Journal of the National Cancer Institute, 82 350-352. Kibler, V. E., & Rider, M. S. (1983). Effect s of progressive muscle relaxation and music on stress as measured by fi nger temperature response. Journal of Clinical Psychology 39 (2), 213-215. Klwer, T. (1997). The joy of drumming: Drums & percussion instruments from around the world Diever, Holland: Binkl ey Kok Publications. Koestler, A. (1959). The sleepwalkers: A history of man's changing vision of the universe London: Hutchinson & Co. Kopacz, M. (2005). Personality and music prefer ences: The influence of personality traits on preferences regarding musical elements. Journal of Music Therapy, 42 (3), 216239. Kovach, A. M. (1985). Shamanism and guided imagery and music: A comparison. Journal of Music Therapy, 22 (3), 154.

PAGE 178

166 Kremer, E., Atkinson, J. H., & Ignelzi, R. J. (1981). Measurement of pain: Patient preference does not confound pain measurement. Pain, 10 241-248. Kwekkeboom, K. (2003). Music versus distract ion for procedural pain and anxiety in patients with cancer. Oncology Nursing Forum, 30 (3), 433-440. Landreth, J. E., & Landreth, H.F. (1974). E ffects of music on phys iological response. Journal of Research in Music Education, 22 4-12. Lane, D., & Wilkins, R. (1994). Music as medicine: Deforia Lane 's life of music, healing, and faith Grand Rapids, MI: Zondervan Publishing House. Lang, P. H. (1946). Music in Western civilization New York, NY: W. W. Norton & Co. Larco, L. (1997). Encounters with the Huacas: Ritual dialogue, music and healing in northern Peru. The World of Music, 39 (1), Lavine, R., Buchsbaum, M., & Poncy, M. (1976). Analgesia: Somatosensory e voked response and subjective pain rating. Psychophysiology, 32 140-148. LeCompte, M., & Schensul, J. (1999). Designing and conducting ethnographic research Walnut Creek, CA: Altamira Press. Lecourt, E. (1992). The functions of musi c therapy in France in the XIX and XX Centuries. The Arts in Psychotherapy, an International Journal. 19 (2) 123-126. Lee, O., Chung, Y., Chan, M., & Chan, W. (2005). Music and its effect on the physiological responses and anxiety leve ls of patients rece iving mechanical ventilation: A pilot study. Journal of Clinical Nursing, 14 609. Leedy, P., & Ormond, J. (2001). Practical research planning and design Upper Saddle River, NJ: Prentice-Hall. Leingang, M. (2003). Music fights cancer. Democrat and chronicle Rochester, NY: University of Rochester Press. Lincoln, Y. S., & Guba, E. G. (1985). Naturalistic inquiry Newbury Park, CA: Sage. Linden, S. (1997). A festival of light: A hi gh school healing ar ts event celebrating diversity of the school community. Arts in Psychotherapy 24 (3), 255-259. Lipowski, Z.J. (1977). Psychosomatic medicine in seventies. American Journal of Psychiatry 134 (3), 233-244 Lippman, M. E (1964). Musical thought in ancient Greece New York, NY: Columbia University Press.

PAGE 179

167 Littman, G. S., Walker, B. R., & Schneider, B. E. (1985). Reassessmant of verbal and visual analog ratings in analgesic studies. Clinical Pharmacological Therapy, 38 16-23. Locsin, R. (1981). The effect of music on the pain of selected pos toperative patients. Journal of Advanced Nursing, 6 1925. MacArthur, D., & MacArthur, C. (2006) Anxiety. In Research Network on Socioeconomic Status and Health [On-Line] Available at: http://www.macses.ucsf.edu/Research/Psy chosocial/notebook/anxiety.html#Definit ion (Last accessed, January 20, 2006). Machlis, J. (1963). The enjoyment of music New York: W. W. Norton & Company. Madsen, C. K., & Forsythe, J. L. (1973). The effect of contingent music listening on increases of mathematical responses. Journal of Research in Music Education, 21 176-181. Magee, B. (1998). The story of philosophy New York, NY: DK Publishing. Magill, L. (2001) The use of music therapy to address the suffering in advanced cancer pain. Journal of Palliative Care, 17 (3), 167-72. Magner, L. (1992). A history of medicine New York, NY: Mercel Dekker, Inc. Magni, G., Marchetti, M., Moreschi C., Me rskey, H., & Luchini, S. (1993). Chronic musculoskeletal pain and depressive symptoms in the National Health and Nutrition Examination: Epidemiologic follow-up study. Pain, 53 163-168. Marina, R. (1991). Healing sounds from the Malaysian forests: Temiar music and medicine Berkeley, CA: University of California Press. Marshall, C., & Rossman, G. (1994). Designing qualitative research Thousand Oaks, CA: Sage. Martin, D. (2003). How to be a successful student San Anselmo, CA: Donald Martin Press LLC. Martin, R. A. (2001). Humor, laughter, a nd physical health: Met hodological issues and research findings. Psychological Bulletin, 127 (4), 504-519. May, R. (1977). The meaning of anxiety New York, NY: Norton. McCaffrey, R. & Locsin, R. C. (2002). Musi c listening as a nurs ing intervention: a symphony of practice. Holistic nursing Practice, 16 (3), 70-77.

PAGE 180

168 McCraty, R. (1999). Music and the immune system. [On-Line]. Available at: http://www.chucksilverman.com/musicimmune.html (Last accessed, March 20, 2006). McCraty, R., Barrios-Choplin, B., Atkinson, M., Tomasino, D. (1998). The effects of different types of music on m ood, tension, and mental clarity. Alternative Therapies in Health and Medicine 4 (1), 75-84. McGuire, D. B. (1988). Measuring pa in. In M. Frank-Stromberg (Ed.), Instruments for Clinical Nursing Research (pp. 332-352). Norwalk, CT: Appleton and Lange. McMahon, T. (2006). The psychospiritual approach. [On-Line]. Available at: http://wayoflife.org/f bns/psychospiritual.htm (Last accessed, February 12, 2006). Melzack, R., & Wall, P. (1965). Pain mechanisms: A new theory. Science, 150 971-979. Melzack, R., & Wall, P. (1970). Evolution of pain theories. International Anesthesiology Clinics, 8 (1), 3-34. Melzack, R., & Wall, P. (1983). The challenge of pain New York, NY: Basic Books. Melzack, R., & Wall, P. (1997). Textbook of pain Edinburgh, UK: Churchill Livingstone. Melzack, R., Weisz, A. Z., & Sprague, L. T. (1963). Stratagems for controlling pain: Contributions of auditory stimulation and suggestion. Experimental Neurology, 8 239-247. Merskey, H., & Bogduk, N. (1994). Classifica tion of chronic pai n. Seattle, WA. [OnLine]. Available at: http://www.iasp-pain.org/terms-p.html#Pain (Last accessed, February 15, 2005). Meyer, L. B. (1956). Emotion and Meaning in Music. Chicago: Chicago University Press. Migneault, B., Girard, F., Al bert, C., Chouinard, P., Boudr eault, D., & Provencher, D. (2004). The effect of musi c on the neurohormonal stress response to surgery under general anesthesia. Montreal, Quebec, Canada: Anesthesia & Analgesia, 98 (2), 527-532. Miller, J. J. (1998). The contributions of Wa yne Rupenthal to the field of music therapy. Journal of Music Therapy, 35 (2), 105-118. Mok, E., Wong, KY (2003). Effects of music on patient anxiety. AORN Journal, 77 2, 396-410. Montello, L. (1989). Utilizing music therapy as a mode of treatment for the performance stress of professional musicians Doctoral dissertation, New York, NY: New York University.

PAGE 181

169 Montello, L., Coons, E., & Kantor, J. ( 1990). The use of group music therapy as a treatment for musical performance stress. Medical Problems in Performance Art, 5 49-57. Moreno, J. (1995). Ethnomusic therapy: An Interdisciplinary approach to music and healing. The Arts in Psychotherapy, 22 (4), 329-338. Mores, N., Martire, M., Pistritto, G., Volpe, A. R., Menini, E., Folli, G., et al., (1994). Platelet alpha 2-adrenoceptors and diurna l changes of platelet aggregability in hypertensive patients. Journal of Hypertension, 12 (8), 939-45. Morton, L., Kershner, J. R. & Seigel, L. (1990) The potential for therapeutic applications of music on problems related to memory and attention. Journal of Music Therapy, 27 (4), 195-208. Moss, V. A. (1988). Music and the surgical patient: The effect of music on anxiety. Association of Operating Room Nurses, 48 67-69. Mullings, L. (1984). Therapy, ideology, and social change: Mental healing in urban Ghana Berkeley, CA: Universi ty of California Press. Munro, S., & Mount, B. (1978). Musi c therapy in palliative care. Canadian Medical Association Journal, 119 1029-1034. National Institutes of Mental Health (2006). Working to improve mental health through biomedical research on mind, brain, a nd behavior. Washington, DC: NIH [OnLine] Available: http://www.nimh.nih.gov/healthin formation/anxietymenu.cfm (Last accessed, January 15, 2006). Neher, A. (1961). A physiological explanat ion of unusual behavior in ceremonies involving drums. Human Biology, 34 (2), 151-160. Neuman, W. L. (2000). Social research methods qualitative and quantitative approaches Boston, MA: Allyn and Bacon. Newman, F., & Holzman, L. (1997). The end of knowing London: Rutledge. Nketia, K., (1962). The problem of meaning in African music. Ethnomusicology Ann Arbor, MI: Society for Ethnomusicology. Noonan, P. (1999). Take two tunes and call me in the morning. USA Weekend North, A. C., Hargreaves, D. J., & O'Neill, S. A. (2000). The importance of music to adolescents. British Journal of Educational Psychology, 70 (2), 255-272. Oddy, N. (2001). Convergencies: Possibility for therapeutic interventi on in a large scale community performance. Canadian Journal of Music Therapy, 8 (1), 48-63.

PAGE 182

170 Opsopaus, J. (2004). Using ancient Greek music for care of the soul: H Mousik Therapeia .[On-Line] at http://www.cs.utk.edu/~mclennan/BA/MT.html (Last accessed, February 16, 2005). O'Regan, P. (1979). Music therapy w ith emotionally disturbed child. British Journal of Music Therapy, 10 13-18. OSullivan, R. J. (1991). A musical road to recovery: Music in intensive care. Intensive Care Nursing, 7, 160-163. Panksepp, J. (1995). The emotional sources of chills induced by music. Music Perception, 13 (2), 171-207. Peck, D. (2002). Or perish in the attempt: Wilderness medicine in the Lewis & Clark Expedition Helena, MT: Farcountry Press. Pellino, T., Gordon, D., Engelke, Z., Busse, K., Collins, M., Silver, C., et al. (2005). Use of nonpharmacologic interventions for pain and anxiety after to tal hip and total knee arthroplasty. Orthopaedic Nursing, 24(3), 182-190. Perettl, P., & Swenson. K. (1974). Effect s of music on anxiety as determined by physiological skin responses. Journal of Research In Music Education, 22 278283. Perron, V., & Schonwetter, R. (2001). Assessmen t and management of pain in palliative care patients. Cancer Control, 8 (1), 15-24. Pilot, D., & Hungler, B., (1995). Nursing research: Principles and methods Philadelphia, PA: Lippincott. Pinel, P. (1801). Trait mdico-philosophique sur lalination mentale Paris: Brosson J.A. Podolsky, E. (1934). Music and health. Canadian Medical Association Journal, 30 (2): 195. Pratt, R. R., & Jones, R. W. (1985). Music a nd medicine: A partnershi p in history. In R. Sprintge & R. Droh (Eds.), Music and medicine (pp. 377-388). New York: Springer Verlag. Price, D. D., Bush, F. M., Long, S., Hark ins, S. W. (1994). A comparison of pain measurement characteristics of mechanical visual analogue and simple numerical rating scales. Pain, 56 217-226. Priestley M., (1975) Music therapy in action London: Constable.

PAGE 183

171 Raphael, R. (1969). Richard Wagner Ulrich Weisstein (Ed.) New York, NY: Twayne Publishers, Inc. Regelson, W., & Kalimi, M. (1994). Dehydroepiandrosterone (DHEA)-the multifunctional steroid. Effects on the CNS, cell proliferation, metabolic and vascular, clinical and other e ffects. Mechanism of action. Annals of the New York Academy of Sciences, 719 564. Reinert, D. F. (2000). Spiritual experience religious orientation, and self-reported behavior. International Journal for th e Psychology of Religion, 10 (3), 173-180. Reville, S., Robinson, J., Rosen, M., & Hogg, I. (1976). Reliability of a linear analogue for evaluating pain. The Anesthesia, 11 1191-1198. Richter, N. C. (1984). The efficacy of relaxation training with children. Journal of Abnormal Child Psychology, 12 310-344. Rider, M. S., Floyd, J. W., & Kirkpatrick, J. (1985), The effect of music, therapy, and relaxation on adrenal corticosteroids and th e re-entrainment of circadian rhythms. Journal of Music Therapy, 22 (1), 46-58. Ristad, E. (1982). A soprano on her head Moab, UT: Real People Press. Rizzo, J., & Zabel, R. (1988). Educating children and adoles cents with behavioral disorders: An Integrative approach Needham Heights, MA: Allyn and Bacon. Rogers, L. (1995). Music for surgery. Advances: The Journal for Mind, Body, Health, 11 49-58. Rohner, S. J., & Miller, R. (1980). Degrees of familiar and affective music and their effects on state anxiety. Journal of Music Therapy, 17 2-15. Rorke, M. (1996). Music and the wounded of World War II. Journal of Music Therapy, 33 (3), 189-207. Rueger, Christoph (1991). Die musikalische hausapotheke Geneve/Kreuzlingen: Ariston Verlag. Rouget, G. (1985). Music and trance: A theory of relations between music and possession Chicago: The Universi ty of Chicago Press. Rupenthal, W. (1965). Scribbling in music therapy. Journal of Music Therapy, 2 (1), 810. Ryan, W., & Bernard, R. (2003). Techniques to identify themes in qualitative data. Field Methods, 15 (1), 85-109.

PAGE 184

172 Sahler, O., Hunter, B., & Lies veld, J. (2003). The effect of using music therapy with relaxation imagery in the management of patients undergoing bone marrow transplantation: A p ilot feasibility study. Alternative Therapies in Health and Medicine, 9 (6), 70-74. Sahr, H. (2000). Review of the perceptions of secondary administrators regarding the role of the fine arts curriculum in the total education experience. Bulletin of the Council for Research in Music Education, 146 70-73. Salmon, S. (1981). Music therapy with maladjusted children. British Journal of Music Therapy, 12 (3), 4-11. Sargant, W. (1973). The mind possessed New York, NY: Lippincott. Scarfelli, J. P. (1989). Music and self-management methods St. Louis, MO: MMB Music Inc. Schopenhauer, A. (1958). The world as will and representation Indian Hills, CO: Falcon's Wing Press. Schorr J. A. (1993). Music and pa ttern change in chronic pain. Advances in Nursing Science, 15 (4), 27-36. Schullian, D. M., & Schoen, M. (1948). Music and medicine New York, NY: H. Schuman. Schultz, T. (1977). Four policy papers on the implemen tation of Public Law 94-142, The Education for All Handicapped Children Act of 1975 Cambridge, MA: The Massachusetts education Policy Fellowship Program and the Harvard University Graduate School of Education. Selye, H. (1977). Stress. Reinbek, Germany: Rowholt. Siegele, D. S. (1974). The gate control theory. American Journal of Nursing, 74 498502. Shapiro, A. K. & Shapiro, E. (1972). The Powerful placebo: Fr om ancient priest to modern physician Baltimore, MD: Johns Hopkins University Press. Shuldham, C., Cunningham G., Hiscock M., & Luscombe P. (1995). Assessment of anxiety in hospital patients. Journal of Advanced Nursing, 22 87-93. Shultis, C. (1999). Music therapy for inpatie nt psychiatric care in the 1990s. In Psychiatric Times XVI Issue 2. [On-Line]. Available at: http://www.psychiatrictimes.com/p990246.html (Last accessed, August 13, 2005).

PAGE 185

173 Shultis, C., & O'Brien, A. (1995). Designing an d implementing the single session series. Paper presented at the Conference of th e National Associatio n for Music Therapy. November, 1995. Houston, TX. Sloboda, J. A. & Juslin, P. N. (2001). Psyc hological perspectives on music and emotion. In: Sloboda, J. A. & Juslin, P. N. (Eds.) Music and emotion: Theory and research New York, NY: Oxford University Press. Sloboda, J. A., & ONeill, S. A. (2001). Emo tions in everyday listening to music. In Partrik N. Juslin, & John Sloboda (Eds.) Music and emotion: Theory and research New York, NY: Oxford University Press. Smeltzer, S., & Bare, B. (1996). Brunner and Sudharths textbook of medical-surgical nursing Philadelphia, PA: Lippincott. Smith, C. A., & Morris, L. W. (1976). Eff ects of stimulative and sedative music on cognitive and emotional components of anxiety. Psychological Reports, 38 (3), 1187-1193. Snelbecker, G. E. (1974). Learning theory, instructional theory, and psychoeducational design New York: McGraw Hill. Sokka, T. (2003). Assessment of pain in patients with rheumatic disease. Best Practice & Research Clinical Rheumatology, 17 (30), 427-449. Sommer S. (1996). Mind-body medi cine and holistic approaches. Australian Family Physician 25 (8), 1233-44. Spielberger, C. (1976). The nature and measurement of anxiety Washington DC: Hemisphere Publishing. Spielberger, C., Gorusch, R. L., Lushene, R., Vagg, P. R., & Jacobs, G. A. (1983). Manual for the state-tr ait anxiety inventory Redwood City, CA: Consulting Psychologists Press. Spinoza, B. (1910). The ethics of Spinoza and treatise on the correction of the intellect London: Everyman Edition. Spintge, R. K. W. (1989). The emotional si tuation of the patient. In M. Lee (Ed.), Rehabilitation, music and human well-being St. Louis, MO: MMB Music Inc. Spintge, R. K. W. & Droh, R. (Eds.) (1989). Music medicine St. Louis, MO: MMB Music, Inc. Spintge, R. & Droh, R. (1987). Effects of anxi olytic music on plasma levels of stress hormones in different medical specialtie s. In R.R.Pratt (Ed.), The fourth international symposium on music: Reha bilitation and human well-being (pp. 88101). Lanham, MD: University Press of America.

PAGE 186

174 Sriwatanakul, K., Weis, O. F., Aloloza, J. L., Kelvie, W., Weintraub, M., & Lasagna, L. (1983). Analysis of narcotic analgesic usag e in the treatment of postoperative pain. Journal of American Medical Association, 250 926-929. Standley, J. M. (1986). Music research in medical/dental treatment: Metaanalysis and clinical applications. Journal of Music Therapy, 23 (2), 56-122. Stevens, R., & Phil R. (1983). Learning to c ope with school: A study of the effects of a coping skill training program with te st-vulnerable 7th-grade students. Springer Science and Business Media, 7 (2), 155-158. Stewart, K. S. (2005). Bone marrow transplant [Online Resource] (Eds. S. Martin, M. D. Tallman, & P. J. Stiff. Highland Park, IL : BMT Newsletter. [On-Line]. Available at: http://www.bmtinfonet.org/bm t/bmt.book/acknowledgements.html (Last accessed, July 27, 2005). Stige, B. (2000). The voice and warmth of a ce llo: Introduction to Juliet te Alvins article. Journal of Music Therapy, 9 (1), 46-49. Stige, B. (2001). History and heritage: An essay based on a reading and playing of Robbins & Robbins (Eds.). Healing Herita ge: Paul Nordoff E xploring the Tonal Language of Music. Voices: A World Forum for Music Therapy, 1 (2). [On-Line]. Available at: http://www.voices.no/mainissu es/voices1(2)stige.html (Last accessed, October 2, 2004). Stoudenmire, J. (1975), A comparison of musc le relaxation traini ng and music in the reduction of state and trait anxiety. Journal of Clinical Psychology, 31 (3), 490-492. Stouthard M. E., Hoogstraten, J., & Me llenbergh, G. J. (1995). A study on the convergent and discriminant validity of the Dental Anxiety Inventory. Behaviour Research And Therapy 33 589. Summers, S., Hoffman, J., Neff, J., Hanson, S ., & Pierce, K. (1990). The effects of 60 beats per minute music on test taki ng anxiety among nursing students. Journal of Nursing Education, 29 66-70. Taussig, M. (1987). Shamanism, colonialism, and the wild man Chicago: University of Chicago Press. Taylor, D. B. (1981). Music in gene ral hospital treatment from 1900 to 1950. Journal of Music Therapy, 18 (2), 62-73. Tong, W. (2003). The scientific method. [On-Line] Available: http://servercc.oakton.edu/~bi lltong/eas100/scientificmethod.htm (Last accessed, February 12, 2006).

PAGE 187

175 Trotter II, R., & Schensul, J. (1998). Methods in applied anthropology. In H. R. Bernard (Ed.), Handbook of methods in cultural anthropology (pp. 691 735). Walnut Creek, CA: AltaMira Press. Tse, M., Chan, M., & Benzie, I. (2005). Th e effect of music th erapy on postoperative pain, heart rate, systolic blood pressure and analgesic use following nasal surgery. In Journal of Pain & Palliative Care Pharmacotherapy, 19 (3), 21-28. Turk D. C., & Melzack, R. (1992). The meas urement of pain and the assessment of people experiencing pain. In: Dennis Turk & Ronald Melzack (Eds). Hand-book of Pain Assessment (pp 3). New York: Guilford Press. Turow, G. (2005). Auditory driving as a ritual technology: A review analysis Stanford, CA: Stanford University Press. Ueberweg, F. (1972). A History of philosophy, from Thales to the present time (2 Volumes). New York, NY: C. Scribner's Sons. Updike, P. (1990). Music therapy results for ICU patients. Dimensions of Critical Care Nursing, 9, 39-45. Updike, P., & Charles, D. M. (1987). Music Rx: Physiological and emotional responses to taped music programs of preoperati ve patients awaiti ng plastic surgery. Annals of Plastic Surgery 9 29-33. U.S. Department of Education (2001), 23rd Annual Report to Congress on the Implementation of the Individuals with Disabilities Educat ion Act. Washington, DC: U.S. Government Printing Office. Vanderark, S., & Ely, D. (1992). Biochemical and galvanic skin responses to music stimuli by college students in biology and music. Perceptual and Motor Skills, 74 1079-1090. Vickers, A. (1999). Comparison of an ordinal an d a continuous outcome measure of muscle soreness. International journal of technol ogy assessment in health care. 5 (4), 709-716. Vink, A. (2001). Music and emotion. Living apar t together: A relationship between music psychology and music therapy. Nordic Journal of Music Therapy, 10 (2), 144-158. Vinogradov, S. O., & Yalom, I. (1989). Concise guide to group psychotherapy Washington, DC: American Psyc hiatric Association Press. Voss, J. (2005). Music eases pain, anxiety after open-heart surgery. University of Nebraska Medical Center (Ed. V. Cerino). In Today UNMC [On-Line] Available at: http://app1.unmc.edu/nursing/t oday/2dy_20050105_music_heart_pain.htm (Last accessed, April 10, 2005).

PAGE 188

176 Wade, J. B., & Hart, R. P. (2002). Atten tion and the stages of pain processing. Pain Medicine, 3 (1), 30-38. Wagner, M. (1975). Effect of music and bi ofeedback on alpha br ainwave rhythms and attentiveness. Journal of Research in Music Education, 23 3-13. Walker, Q. (1997). Religion of Ancient Greece. [On-Line]. Available at: http://victorian.fortunec ity.com/palette/187/greece.html (Last accessed, February 15, 2004). Wasserman, N. (1972). Music therapy for the em otionally disturbed in a private hospital. Journal of Music Therapy, 9 (2), 99-104. Werbner, N. (1966). The practice of mu sic therapy with psychotic children. Journal of Music Therapy 3 (1), 25-31. Wertheim, N. (1997), Is there an anatomi cal localization for mu sical faculties? In Music and the brain: Studies in the neurology of music Springfield, IL: Charles C. Thomas. Wewers, M, & Lowe, N. (1990). A critical re view of visual analogue scales in the measurement of clinical phenomena. Research in Nursing & Health, 13 (4), 227236. Wheeler, B. L. (1983). A psychotherapeutic cl assification of music therapy practices: A continuum of procedures. Music Therapy Perspectives, 1 (2), 8-12. Wheeler, B. L. (1995). Music therapy research: Quantitative and qualitative perspectives Phoenixville, PA: Barcelona Publishers. Whipple, B., & Glynn, N. J. (1992). Quantificati on of the effects of listening to music as a noninvasive method of pain control: Sc holarly inquiry of nursing practice: An International Journal, 6, 43-58. White, J. M. (1992). Music ther apy: An intervention to reduc e anxiety in the myocardial infarction patient. Clinical Nurse Specialist, 6 58-63. Williams, J. G., & Jones, J. R. (1968). Psychological responses to anesthesia and operation. The Journal of the Americ an Medical Association, 203 (6), 415-417. Wilson, W. E. (1969). Preoperative anxi ety and Anesthesia: Their relation. Anesthesia Analgesia Current research, 48 (4), 605-611. Winter, M. J., Paskin, S., & Baker, T. ( 1994). Music reduces st ress and anxiety of patients in the surgical holding area. Journal of Post Anesthesia Nursing, 9 (6), 340343.

PAGE 189

177 Whipple, B., & Glynn, N. (1992). Quantification of the effects of listening to music as a non-invasive method of pain control. Scholarly Inquiry for Nursing Practice: An International Journal, 6 143-56. Wolpe, J. (1958). Psychotherapy by r eciprocal inhibition Stanford, CA: Stanford University Press. Yilmaz, E., Ozcan, S., Basar, M., Basar, H., Batislam, E., & Fe rhat, M. (2003). Music decreases anxiety and provides sedation in extracorporeal shoc k wave lithotripsy. Kirikkale: Department of Urology, Kirikkale, Turkey: University Medical Faculty. Urology, 61 (2), 282-286. Zhukovsky, D. S., Gorowski, E., Hausdorff, J., Napolitano, B., & Lesser, M. (1995). Unmet analgesic needs in cancer patients. Journal of Symptom and Pain Management 10 (2):113-9. Zill, N. (1993). The changing realities of family life. The Aspen Institute Quarterly, 5 125. Zimmerman, L. M., Pierson, M. A., & Marker J. (1988). Effects of music on patient anxiety in coronary care units. Heart & Lung, 17 560-566. Zimmerman, L., Pozehl, B., Duncan, K., & Schmitz, R. (1989). Effects of music in patients who had chronic cancer pain. Western Journal of Nursing Research, 11 298-309. Zimny, G., & Weidenfeller, E. (1962). Effects of music upon GSR of children. Child Development, 33 891-396.

PAGE 190

178 BIOGRAPHICAL SKETCH David Otieno Akombo received his PhD in Mu sic Education from the University of Florida. Prior to doing graduate studies, Ak ombo received his Bach elor of Education degree in music education from Kenyatta Univ ersity in Nairobi, a Master of Arts in Education degree from Point Loma Nazarene Un iversity in Californi a and a Master of Music in ethnomusicology degree from Bow ling Green State University in Ohio. Akombos interest in music and healing research led him to co-found Music Therapy International, a not-for-profit organiza tion that helps children to heal from posttraumatic stress disorder (PTSD) Akombo has also jointly worked with the University of Floridas Center for Arts in Healthcare Rese arch and Education to establish the Arts in Medicine program in Nairobi, Kenya. Located at Mater Hospital a nd funded by the State of Florida Center for Cultural Affairs, this is the first known Arts in Medicine program to be established in Africa. Akombo has taught music at Alliance High School in Nairobi, Kenya, Daystar University in Nairobi, Kenya, Africa Nazaren e University in Ongata Rongai, Kenya, and Bowling Green State University in Bo wling Green, Ohio. He has published one composition with Alfred Publishing (formerly Warner Bros. Publications) and authored a book titled "Music and Healing Across Cultu res published by Culicidae Press. Akombo is a member of the Music Educators Nationa l Conference, the Florida Music Educators Association, American Mu sic Therapy Association, Society for Ethnomusicology, Society for the Arts in Healthcare, and World Federation of Music Therapy.


Permanent Link: http://ufdc.ufl.edu/UFE0015752/00001

Material Information

Title: Effects of Listening to Music as an Intervention for Pain and Anxiety in Bone Marrow Transplant Patients
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0015752:00001

Permanent Link: http://ufdc.ufl.edu/UFE0015752/00001

Material Information

Title: Effects of Listening to Music as an Intervention for Pain and Anxiety in Bone Marrow Transplant Patients
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0015752:00001


This item has the following downloads:


Full Text












EFFECTS OF LISTENING TO MUSIC AS AN INTERVENTION FOR PAIN AND
ANXIETY IN BONE MARROW TRANSPLANT PATIENTS















By

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


2006





























Copyright 2006

by

David Otieno Akombo



























This dissertation is dedicated to two special people;

Barbara Achando and Andrea Alali.















ACKNOWLEDGMENTS

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

protocol.

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

remain.















TABLE OF CONTENTS

page

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

CHAPTER

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

APPENDIX

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


Table page

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
DHEA Dehydroepiandrosterone
EMG Electromyogram
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

By

David Otieno Akombo

December 2006

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

post-musical intervention.

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.














CHAPTER 1
INTRODUCTION

"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
intervention.

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

boost immunity.

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

observed.

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).

Research Hypotheses

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.

Limitations

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

older.

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

liver.

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

and estrogen.

Dicrotism: This is a condition in which the pulse is felt as two beats per single

heartbeat.

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

tissue.

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

viable infant.

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

system activity.

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

data collection.

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

control.

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

pain").

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
Diagnosis Percentage
Acute leukemia 25%
Lymphoma 25%
Myeloma 25%
Bone marrow failure 15%
state
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

(1996) observed:

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).














CHAPTER 2
REVIEW OF THE LITERATURE

Introduction

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.

Philosophical Rationales

"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

rituals.









Rationales

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, &

Shepherd, 1985).

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.

Theoretical Rationales

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

nerves.

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).

























Sensation
Auditory stimulation
Music stimulation


The Gate Opens the
Sgate


Pain Fibers


(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

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,

2001).









Pattern theories

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).

Research

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,
para. 1).

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.

Phenomenological Approaches

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,

1984).

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

(Bergner, 1989).

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

United States.

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;

Wilson, 1969).

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

musical beat.

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

group.









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

decreasing anxiety.

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 &

Hains, 1996).

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

one-month post-surgery.

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.

200).

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
chosen.

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
(laser-CD-disc preferable).

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.,

1963).

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.
xx)

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.














CHAPTER 3
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.

Research Design

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

are:

* 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.

Subjects

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

intervention.

Procedures

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

1994).

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

(Hartsock, 1982).

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

intervention.

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:

* Baroque
* Country and Western
* Classical
* Gospel/Religious









* Rock/Disco
* Movie Soundtracks
* Romantic
* Jazz/Blues
* Other
Data Collection

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

Appendix D).

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.

Sampling

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).

Instruments

The instruments used in this study measured two groups of variables: 1)

physiological parameters; and 2) psychological parameters.

Physiological 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).

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).

Psychological Parameters

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

post-intervention.

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