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Child Life & Music Therapy, Partners for Pain

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dave knott

on 20 August 2013

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Transcript of Child Life & Music Therapy, Partners for Pain

by David Knott, MT-BC
Why treat pain?

Human right, ethical duty (Walco, Cassidy, & Schechter, 1994), (Czarnecki, et al, 2011)

When untreated, can lead to other health challenges, increased perception of pain, disturbances to development, medical and social complications

Partners in addressing psychological and emotional factors in pediatric pain
thinking/associations/cultural factors/social supports

leads to perception of pain
Tissue damage detected in peripheral nerves send ascending (afferent) signals through dorsal horn of spine to thalamus and reticular formation in brain stem, then on to cerebral cortex

Once in the cortex, pain perception is influenced by memories, thoughts, emotions

Gate Control Theory (Wall & Melzack, 2008)
Pain signals pass through many “gates” traveling toward and away from the brain
Closing/restricting gates reduces perception of pain
Stress, mood and emotions influence pain perception - a gate Child Life targets

Types of pain

Acute Pain
Experienced due to inflammation, tissue damage (APS, 2001)

Associated with increased anxiety, avoidance, somatic symptoms, increased parent distress

BP may increase, HR may increase
Recurrent Pain
Pain that alternates with pain-free periods

Examples: HA, abdominal pain, irritable bowel syndrome, back pain, limb pain
Chronic Pain
Pain with no protective purpose, continues without usefulness

Now considered chronic if persisting >1mo

Examples: rheumatoid arthritic pain, complex regional pain syndrome, Crohn's disease, children with physical disabilities and neuropathic pain (Treede, et al, 2008)

“It is more important to know what sort of a person has a disease than to know what sort of disease a person has.”


Child Life &
Music Therapy
An overview of the experience of pain in hospitalized children is presented with suggestions for the application of music therapy to decrease perception of pain, improve coping skills and positively transform their experience.
Long term risks of under-treatment
Inadequate treatment creates limitations to development
increased risk of depression, isolation and despair
may predispose to lasting pain sensitivity

Chronic pain may influence long-term structural changes to central and peripheral nervous systems
(Schwartzman, Erwin, & Alexander, 2001)
Self-report, Behavior, Physiological
Multi-disciplinary team approach essential
Infants - FLACC (Face, Legs, Activity, Cry, Consolability) (Merkel, et al., 1996)
~Age 3 and older/capable of understanding: Wong-Baker FACES scale, Likert 1-10, Visual-Analogue

Consider Developmental factors & Caregiver input
"Pediatricians are encouraged to advocate for and facilitate the use of services offered through child life programs that can have a dramatic effect in improving psychological and physical comfort." (APS, 2001)

"Reviving and sustaining children's hope, while pursuing multi-pronged 3P treatment (psychological, physical and pharmacological) is central to successful chronic pain treatment." (Kuttner, 2010)
0-3m No apparent understanding of pain, but prototypical sensory and emotional perceptual awareness; memory for pain shortly after birth

3-6m Immediate pain response of infancy supplemented by increased emotional differentiation

6-18m Children develop clear fear of pain situations. Words to describe pain more reflexive (“ouch” “owie”) available at 14m. Somatic localization becomes evident

Developmental sequence of
how children understand pain
(Craig & Korol, 2008)
Up to 6yo Prelogical thinking characterized by concrete understanding, egocentrism, and transductive logic. Meaningful description of pain and pain language (“hurt”, “pain”)

7-10yo Concrete operational thinking characterized by child being able to distinguish self from environment. Beginning capacity for behavioral coping strategies (hypnosis, relaxation, guided imagery training)

11yo+ Formal logical thinking, characterized by abstract thinking and introspection. Increased use of cognitive coping skills
Music listening in 7-16yo’s reduced use of morphine in post op recovery following minor surgery (Nilsson, 2009).

Interactive MT sessions pre- and post- op for brain surgery patients lowered anxiety, perception of the hospitalization or procedure, relaxation, and stress, no stat. sign. for mood or pain (Walworth, 2008).

A within-subjects crossover design of 32 pediatric patients used musical entrainment to match and then shape the music in the direction of the child's perception of healing (Bradt, 2010).

A meta-analysis of 19 RCT's of ages 1 month to 18 years undergoing medical and dental procedures found significant reduction in pain and anxiety across represented studies, although methodological quality of studies was generally poor (Klassen, 2008).

A 2006 Cochrane review of 51 studies exploring use of music for reducing pain found reductions in pain and opioid use, but because these reductions were small, the clinical significance of using music to reduce pain is still unclear (Cepeda, et al., 2006).
Complementing treatment of pain
with music medicine (use of recorded music by hospital personnel) and music therapy (use of engagement interventions by trained therapists)

Music redirects attention away from painful stimulus
Modulates mood and emotions
Stimulates endogenous opioids, reduces cortisol
Shared neural processing with pain
Triggers unconscious memories of rhythm of mother’s heartbeat and melody of voice

Why does music affect pain perception?
Potential mechanisms:

1. Pain assessment made as standard care in every session.
2. Develop pain profiles that are uniquely responsive to music.
3. Support the work of staff serving our young patients experiencing pain.

Music therapy pain initiative
Efferent signals descend through the system modulating perceptions of pain leading to an individual's experience of pain
experience of pain
a brief survey of evidence supporting the application of music to positively impact the pain experience
Bush, G., Luu, P., & Posner, M. I. (2000). Cognitive and
emotional influences in anterior cingulate cortex. Trends in cognitive sciences, 4(6), 215-222.

Cepeda, M. S., Carr, D. B., Lau, J., & Alvarez, H. (2006). Music
for pain relief. Cochrane Database Syst Rev, 2(2).

Czarnecki, M. L., Turner, H. N., Collins, P. M., Doellman, D.,
Wrona, S., & Reynolds, J. (2011). Procedural pain management: A position statement with clinical practice recommendations. Pain Management Nursing, 12(2), 95-111.

Gosselin, N., Peretz, I., Johnsen, E., & Adolphs, R. (2007).
Amygdala damage impairs emotion recognition from music. Neuropsychologia, 45(2), 236-244.

Klassen, J. A., Liang, Y., Tjosvold, L., Klassen, T. P., & Hartling,
L. (2008). Music for pain and anxiety in children undergoing medical procedures: a systematic review of randomized controlled trials. Ambulatory Pediatrics, 8(2), 117-128.

Koelsch, S. (2010). Towards a neural basis of music-evoked
emotions. Trends in cognitive sciences, 14(3), 131-137.

Koelsch, S., Fritz, T., & Schlaug, G. (2008). Amygdala activity
can be modulated by unexpected chord functions during music listening. Neuroreport, 19(18), 1815-1819.

Kuttner, L. (2010). A child in pain: What health professionals
can do to help. Crown House Publishing.

Merkel, S. I., Voepel-Lewis, T., Shayevitz, J. R., & Malviya, S.
(1996). The FLACC: a behavioral scale for scoring postoperative pain in young children. Pediatric nursing, 23(3), 293-297.

Murphy, F. C., Nimmo-Smith, I. A. N., & Lawrence, A. D. (2003).
Functional neuroanatomy of emotions: a meta-analysis. Cognitive, Affective, & Behavioral Neuroscience, 3(3), 207-233.

Neugebauer, V., Li, W., Bird, G. C., & Han, J. S. (2004). The
amygdala and persistent pain. The Neuroscientist, 10(3), 221-234.

Nilsson, S., Kokinsky, E., Nilsson, U., Sidenvall, B., & Enskär, K.
(2009). School-aged children’s experiences of postoperative music medicine on pain, distress, and anxiety. Pediatric Anesthesia, 19(12), 1184-1190.

Price, D. & Barber J. (1987). A quantitative analysis of factors
that contribute to the efficacy of hypnotic analgesia. Journal of Abnormal Psychology, 96, 46-51.

Rainville, P., Carrier, B., Hofbauer, R. K., Bushnell, M. C., &
Duncan, G. H. (1999). Dissociation of sensory and affective dimensions of pain using hypnotic modulation. Pain, 82(2), 159-171.

Schwartzman, R. J., Erwin, K. L., & Alexander, G. M. (2009). The
natural history of complex regional pain syndrome. The Clinical journal of pain, 25(4), 273-280.

Thaut, M. (2005). Rhythm music and the brain: Scientific
foundations and clinical applications (Vol. 7). Routledge.

Treede, R. D., Jensen, T. S., Campbell, J. N., Cruccu, G.,
Dostrovsky, J. O., Griffin, J. W., Hansson, P., Hughes, R., Nurmikko, T. & Serra, J. (2008). Neuropathic pain redefinition and a grading system for clinical and research purposes. Neurology, 70(18), 1630-1635.

Wall, P., & Melzack, R. (2008). The Challenge of Pain (Penguin

Walco, G. A., Cassidy, R. C., & Schechter, N. L. (1994). Pain,
hurt, and harm: the ethics of pain control in infants and children. The New England journal of medicine.

Walworth, D., Rumana, C. S., Nguyen, J., & Jarred, J. (2007).
Effects of live music therapy sessions on quality of life indicators, medications administered and hospital length of stay for patients undergoing elective surgical procedures for brain. Journal of music therapy, 45(3), 349-359.

Windich-Biermeier, A., Sjoberg, I., Dale, J. C., Eshelman, D., &
Guzzetta, C. E. (2007). Effects of distraction on pain, fear, and distress during venous port access and venipuncture in children and adolescents with cancer. Journal of Pediatric Oncology Nursing, 24(1), 8-19.
Does music neuroscience offer evidence for the application of music therapy to mediate pain influenced by emotional states such as fear?
Neurologic music therapy is an advanced approach to both conducting research and guiding practice based on neuroscience evidence from musical perception and production studies. The Rational-Scientific Mediating Model (R-SMM) and the Transformational Design Model (TDM) (Thaut, 2005) provide clear and systematic approaches to designing research questions and conducting clinical work.

Rational-Scientific Mediating Model of Neurologic Music Therapy

Level 1 studies identify specific brain regions responsible for musical perception and production

The R-SMM uses a 4 stage model to guide inquiry.
Level 2 studies identify brain regions responsible for non-musical processing but that are shared with those responsible for musical perception and production.
Level 3 studies aim to demonstrate immediate effects of the influence of music on shared networks while
Level 4 studies are comprised of experimental trials designed to answer questions of efficacy.
By pursuing the R-SMM, a better understanding of mechanisms of action can be gained and treatment protocols can be designed that have a reduced risk of being based on type 1 errors.
Experimental (Price & Barber, 1987) and neuroimaging studies (Rainville, et al., 1999) suggest that it is the affective dimension of pain as processed in the anterior cingulate cortex (ACC) that is most associated with suffering and autonomic arousal. And Bush, Luu & Posner suggest that the ACC is involved in an attention circuit that regulates cognitive and emotional processing (2000).

A 2003 meta-analysis of 106 fMRI and PET studies sought to both clarify theories of emotional processing in the brain and, using statistical analysis, more clearly define neural systems responsible for processing of specific emotions. A unique neural circuit for fear was found and central to that system was the amygdala (Murphy, Nimmo-Smith & Lawrence, 2003). Additionally, the amygdala is considered to have a role in contributing to the emotionality and affective behavior of the pain experience (Neugebauer, 2004).
Music perception and processing is widely distributed throughout the cortex and lower structures within the central nervous system and is capable of influencing emotions via activation of limbic networks including the Anterior Cingulate Cortex (ACC) and the amygdala (Koelsch, 2010).
Further confirming the role of the amygdala in the emotional processing of fear from a musical stimulus, a more recent neuroimaging study used a test subject with bilateral damage restricted to the amygdala. The test subject and four matched control subjects were asked to rate the intensity of fear, peacefulness, happiness, and sadness in computer generated musical excerpts. The test subject appeared to have a selective impairment when rating scary and sad music and this result was reported to be congruent with previous findings with test subjects with similar damage to the amygdala (Gosselin, Peretz, Johnsen & Adolphs, 2007). Koelsch, Fritz and Schlaug showed modulation of the amygdala even by single chords when those chords were part of a non-syntactically correct, or “unexpected” chord sequences (2008). This suggests that, in addition to the shared processing of fear-inducing musical and non-musical stimuli, the amygdala may be involved in the ongoing evaluation of expectation and so assumes a broader role in generalized processing of musical emotions than previously thought.
RCT's exploring the role of music in modulating fear-mediated pain are non-existent, however one study is somewhat related. Fifty pediatric oncology patients from 5-18 years of age were randomly assigned to a standard care condition or a standard care plus their choice of a distraction technique as they endured a venipuncture. Among the distraction techniques available was use of a music table (table patient lay on with speakers installed so they could both hear and feel the music) and their choice among several available “age-appropriate, upbeat” selections. Participants pain and fear was self-reported, parents reported the participants’ fear and nurses reported participants’ fear and distress at three points in time: before, during and after the procedure. The results from this study indicated that nurse and parents’ reports of fear and distress were significantly less in the intervention group than the standard care group. Interestingly, a strong correlation was found between the participant’s report of pain and fear, possibly due to the interaction between cognitive and sensory aspects of the perception of pain. Unfortunately this study did not statistically distinguish the music table condition from any other of the distraction conditions. (Windich-Biermeier, et al., 2007).
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