Book Review: Music Therapy and Pediatric Pain

by Peggy A. Farlow
Written during music therapy internship, Matheny School and Hospital, Peapack, NJ
September, 1999

In her book, Music Therapy and Pediatric Pain, (Loewy, J. V. (Ed.), 1997 Cherry Hill, NJ, Jeffrey Books) editor Joanne V. Loewy collected papers and articles written by music therapists, physicians, social workers, university professors and psychologists which dealt with music therapy and pediatric pain and combined these works into one publication. Each chapter in the book deals with a specific topic as it relates to the use of music therapy in alleviating pediatric pain. Topics covered focus on a mind-body approach using music therapy techniques and psychotherapeutic principles with traditional medical practices. The topics discussed in this book include:

1. Mind-body theory of resonance

2. Current myths and misconceptions regarding the undertreatment of pain in children

3. Developmental aspects of how the pain experience manifests in children of varying ages and diagnoses

4. Discussion of acute, chronic and procedural pain and clinical treatment strategies

5. Summary of pain and music therapy practices revealed through research over the past 20 years

6. Interviews with music therapists who have worked with children in pain and a discussion of both positive and negative countertransference effects

7. Toning and music-mediated imagery using entrainment techniques

8. Music therapy techniques to address fear and discomfort of procedural pain

9. Pain management techniques using the Music Vibration Table (MVT^tm)

10. Team-centered approach to manage physical and emotional pediatric pain

11. Music therapy techniques to manage pain of Sickle Cell anemia

12. Summary of book contents and future implications for music therapy and pain research

Four common themes that occurred throughout the book were; 1) the concern that children are frequently undertreated for pain, 2) the ability of music to give the child a feeling of being in control and of building a sense of empowerment and awareness in his/her own pain experience, 3) the need to develop specific treatment protocols that address the needs of the child and the child’s family, and 4) the importance of establishing a multidisciplinary team approach in treating pediatric pain. Goals given for the use of music therapy with pediatric patients include: to increase the hospitalized child’s physical activity; to decrease fear and anxiety; to decrease reliance on medication or parental support for pain relief; to reduce maladaptive pain behaviors; and to reduce pain. While this book dealt with many aspects of pain management in children, this review will focus on the music therapy techniques presented. Music therapy techniques described in the book which will be discussed in this review include: resonating; entrainment; integration; improvisation; Music Vibration Table (MVT^tm); and relaxation.

Resonating is a technique that strives to integrate a person’s mental, physical and emotional aspects as they relate to pain. When using this technique, the therapist works to empathize as fully as possible with the condition of the patient. The therapist and music act as a biofeedback system to enable the patient to become more aware of his or her own inner processes. The resonating technique uses a three-part approach, that includes: 1) using a conscious focusing activity to minimize pain-related sensory stimulation; 2) utilizing breathing and awareness of the body to facilitate relaxation; and 3) providing appropriate music to support the process of "letting go" of the pain. The goal of this approach is to help the person in pain establish as positive and pain free experience as possible, to encourage honest communication of feelings, and to provide a means for the person to effectively process pain on their own.

Entrainment is a technique used to change a person’s perception of pain by first matching the type and intensity of pain with appropriate music stimuli, then gradually changing the music stimuli and along with it the person’s perception of pain. A rhythmic entrainment technique has been used successively with infants by first establishing a rocking pattern that approximates the rate and level of the infant’s distress. Successive approximation techniques are then used to move the infant toward a more regulated and normal rate of motion by gradually decreasing the rate and tempo of rocking, patting and singing. Harmonic entrainment and imagery techniques have been used with older children by finding a tone and image which at first resonates with or even enhances the pain. Then, gradually altering the pitch and image by improvising or "toning around" the pain until the pain "moves" or disappears altogether.

Integration is a technique used to manage pain by helping the child become aware of his/her whole body. This is done by helping the child to focus on the breath, heart rate, emotional intention, and feelings of the pain itself. Music is used to foster this awareness by using harmonic, rhythmic and tonal aspects which support the child’s feelings and perceptions. This technique strives to empower the child to "take action" in understanding and controlling the pain. The child is encouraged to use verbalizations, singing and instrumental improvisations to find his/her own creative powers to give the pain a voice in order to understand it, know it and accept it. Symbolically transforming the pain is central to the success of this technique.

Improvisation is discussed in the book as being an effective technique to use with children experiencing procedural pain. Prior to the procedure, music improvisation can be used to relax, engage, focus or empower a child. The therapist may musically match the child’s crying sounds, statements or movement, directing them into a musical structure, thus creating a safe and manageable container for the child’s experience. As the child begins to become involved in the musical activity, he/she becomes present in the moment and regains a sense of control in a specific time and space. The therapist can then encourage the child to actively process the experience through improvising words to music creating such songs as "The Needle Song" or "The Ouchie Song." During and after the procedure, relaxation can be encouraged by blowing bubbles to visualize and "blow out" the pain. Improvisation using wind instruments can be used to encourage elongation of breath thus inducing a sense of relaxation. The use of improvisation is effective in creating meaningful individualized songs to support and express the child’s feelings while also helping them to re-frame the situation into one in which they can accept and understand. The goal of this technique is to minimize the child’s distress while maximizing his/her coping skills.

Music Vibration Table (MVT^tm) is a technique structured around music and music vibration to modify a person’s physical and psychological perception of pain. This approach combines the psycho-social effects of music listening with the physiological effects of fluctuating physical vibrations. The MVT^tm is constructed from a hospital stretcher and is designed to stimulate the body with controlled levels of vibrations derived from a music source also used for listening. This intervention uses the principle that therapeutic interventions can be made in advance of pain as well as in reaction to it. MVT^tm can be used with a patient before a surgical procedure to preempt central sensitization of nociceptive neurons while also helping to reduce psychological pain. It can also be used after surgery to promote relaxation, reduce pain and shorten recovery time.

Relaxation is a technique that focuses on decreasing anxiety that accompanies pain as well as reducing the pain symptoms directly. Relaxation techniques discussed in this book include 1) deep breathing, 2) guided imagery, 3) repetitive movement and 4) distraction. The first technique of deep rhythmic breathing promotes relaxation by slowing the respiration rate, improving circulation, reducing stress and tension and lessening pain. Singing, rapping and chanting are useful activities that encourage deep breathing. The second technique of guided imagery utilizes the child’s imagination and creative abilities to promote relaxation. One example given in the book as a pain management technique using imagery included suggestions for a guided body scan. This scan "can help the patient to locate the pain and then breathe through it or to imagine different sensations to help alleviate the pain: hot/cold, dry/moist, light/dark....Having patients consult their inner doctor to find out what they might need for themselves may be effective." (p.118). The third technique of repetitive movement promotes relaxation by inducing a comfortable, altered state of mind. Waving a scarf in time to the music, tilting an ocean drum back and forth, beating a drum to the beat, or gently rocking back and forth can lull the patient into a relaxed non-painful state of being. And the fourth technique of distraction uses fun music activities to lessen anxiety and promote relaxation. Activities using live, familiar music with unusual instruments can be effective in capturing and holding the child’s attention during painful procedures, such as needle punctures.

The music therapy techniques discussed in this review have proven to be beneficial in treating pediatric pain in the medical setting. However, like all medical treatments, no one technique will be effective for all children. Below is a list of some of the strengths and weaknesses of the music therapy techniques described in this paper.

Strengths

a. Entrainment is effective when offered immediately after a painful or anxiety-provoking medical procedure

b. With MVT^tm, the intensity and duration of the pain experience can readily correlate to the rhythm, pitch, and intensity used in the music listening source

c. Integration is effective in transforming anxiety related to procedural pain into a more pleasant experience and can help the child develop effective coping skills

d. Improvisation technique is very person-centered and offers the child a chance to take control over his/her pain

e. Relaxation techniques empower the patients to take control over their pain and may lessen their need for pain medications

f. Relaxation techniques can be used at home by the child and his/her family to help prevent repeated hospitalizations

Weaknesses

a. The resonating technique requires a high level of patient cooperation which may not be possible for patients with impaired cognitive abilities due to illness or medication

b. Entrainment requires much sensitivity and insight on the part of the therapist to be able to quickly pick up on verbal and physical cues of the patient and alter music interventions appropriately

c. Using improvisation techniques with children during painful procedures requires cooperation of the parents and the medical staff involved in child’s treatment in order to be effective

d. MVT^tm requires expensive equipment and uses pre-recorded music which does not offer the ability to change the intervention to match the moment

Joanne Loewy’s book presented a good overview of pain management issues with children. And while the focus of her book was on pediatric pain, the techniques discussed could be adapted and used with patients of all age groups in medical and rehabilitation settings. This book included good definitions and descriptions of the different types of pain, presented understandable explanations of ethical and moral issues related to pain management, and gave useful examples of music therapy techniques and music activities. I believe the biggest benefit I gained from reading Music Therapy and Pediatric Pain was that it offered excellent, research based justifications for using live music therapy activities in medical settings over pre-recorded music. The information contained in this book could be very beneficial for therapists trying to establish new employment opportunities in medical settings.

I believe the biggest benefit I gained from reading Music Therapy and Pediatric Pain was that it offered excellent, research based justifications for using live music therapy activities in medical settings over pre-recorded music. The information contained in this book could be very beneficial for therapists trying to establish new employment opportunities in medical settings.

Here is a list of important points dealing with this issue:

a. Compared life energy to a vibratory phenomenon which correlates to music and sound

b. Discussed importance of music selection that must be adapted to suit the patient’s needs in the moment

c. Stated stimulating, active music activities work best for occupying and directing the mind when dealing with physical pain.

d. Music and its inherent vibration can alter the psychological activation of nociceptive neurons which, in turn alter the physiological perception of pain.

e. Changes of rhythm that occur in the breathing of a child in pain are subtle and difficult to attend to using pre-recorded music. Shifts of dynamic phrasing and meter can only be achieved with live music activities.

f. Music and pain are processed along the same neural pathways. The stronger stimuli my diminish the intensity of the weaker. Music therapy involving active music making, rather than passive listening, may be more effective in treating pain.

g. Any technique that expands one’s sense of time can be used as an analgesic as the pain experience is dependent on the person’s perception of time.

h. The variety of levels available in music activities allows the child to participate in some way regardless of physical limitations.

i. Musical interaction between child and therapist becomes a purposeful and enjoyable activity rather than a task or distraction. As the therapist is able to pace and slow the child’s breathing patterns, a sense of relaxation is achieved and the level of stimulation is decreased.

j. Relationship between music therapist and patient represents a significant force in the healing process.

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