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The Effects of Music on Pain

Perception of Stroke Patients
during Upper Extremity Joint

Article in Journal of music therapy February 2005

DOI: 10.1093/jmt/42.1.81 Source: PubMed


21 76

2 authors, including:

Soo Ji Kim
Ewha Womans University


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Journal of Music Therapy. XLII (1). 2005, 81-92
O 2005 by the Amedcan Music Therapy Association

The Effects of Music on Pain Perception

of Stroke Patients during Upper Extremity
Joint Exercises
Sou Ji Kim, MME, MT-BC
University of Kansas

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Iljoo Koh, MME, MT-BC
Private Practice, Seoul, Korea

The purpose of this study was to determine the effects of

music therapy on pain perception of stroke patients during
upper extremity joint exercises. Ten stroke patients (1 male
and 9 females) ranging in age from 61 to 73 participated in
the study. Music conditions used in the study consisted of:
(a) song, (b) karaoke accompaniment (same music to condi-
tion A except singers' voices), and (c) no music. Exercise
movements in this study included hand, wrist, and shoulder
joints. During the 8-week period music therapy sessions,
subjects repeated 3 conditions according to the randomized
orders and subjects rated their perceived pain on a scale im-
mediately after each condition. The General Linear Model
(GLM) Repeated Measures ANOVA revealed that there were
no significant differences in pain rating across the three
music conditions. However, positive affects and verbal re-
sponses, while performing upper extremity exercises with
both music and karaoke accompaniment music, were ob-
served using video observations.

Most western countries have managed to reduce the occurrence

and impact of stroke by successfully treating and preventing it and
its related diseases such as cardiac disorders and hypertension. On
the contrary, the n u m b e r of stroke victims in Korea has increased
over the past years mainly due to westernizing dietary habits, insuf-
ficient preventive measures fox the disease, and the rapid growth of
elderly population (Kim & Rim, 1992). In 2002, CVA was the sec-

Tile authors wish to thank the KwanakSenior Center in Seoul, Korea for its gen-
erous support of this research.
82 Journal of Music Therapy

ond major causes of death in Korea, and stroke was the most com-
m o n form of CVA (Korea National Statistical Office, 2002). Ac-
cording to a related study, Korean clinicians have found that of the
entire stroke patients, only 9% recovered without any residual
symptoms, 18% died several days after the stroke attack, and 73%
demonstrated hemiplegia, speech disorders, sensory disorders,
a n d / o r physical dysfunctions in hands and gait (Kiln & Hahn,

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1995). The researchers also emphasized the need of rehabilitation
on a daily basis in order to maximize their residual physical func-
tioning (Kim & Hahn, 1997). As revealed by man), clinicians, a ma-
jority of stroke patients show residual symptoms that interfere with
their daily activities; therefore it is crucial for the patients to con-
tinue with their rehabilitation.
In spite of the importance of rehabilitation, several symptoms of
stroke interfere with successful rehabilitation. Paralysis, the most
c o m m o n fallout of stroke, especially, was observed to cause depres-
sion, stress, and low self-esteem (Kang, 2001). Also, paralysis is re-
sponsible for spasticity, for which stroke patients experience a lim-
ited range of passive and active joint mobility, and difficulties with
daily functioning and balancing of the extremities.
According to Twist (1985), spasticity is the significant problem
because it causes pain on muscles and joints, and fi'equently leads to
difficulty and stiffness using the upper extremities. In fact, research
on stroke patients' physical functioning indicates that limited upper
extremity movements not only affect lower extremity movements
such as gait (Nashner & Forssberg, 1986) but also cause inefficient
movements of other body parts. The latter is observed in decreased
ability of body turning and ineffective control of body postures
(Hwang, 1998). Movements in upper extremities are associated with
other physical risks. Tang and Wollacott (1998) note that elderly
people use upper extremities more to keep balance than younger
people do. Considering that 24% of stroke patients fall during reha-
bilitation exercises, and most falls occur while walking or shifting
from sitting to standing, increased physical strength and joint move-
ment exercise are indeed crucial (Chun, Choi, & Chun, 1999).Judg-
ing from these outcomes, upper extremity exercises are significant in
supporting patients' physical balance and efficient movements.
The upper extremities in particular are closely related to daily
living skills such as getting dressed, bathing, and eating, and patients
are often distressed by difficulties with and limitations of their im-
VoL XLII, No. 1, Spring 2005 83

paired functioning. These activities of daily living are also focal

points o f rehabilitation for patients who start their program after
stroke attacks (Jeon, 1992). Unfortunately, repeated exercises have
a tendency to elicit negative thoughts and feelings in stroke pa-
tients, and the resulting frustration can make them perceive pain
more intensely. Pain, therefore, can be quite a discouraging factor
for stroke patients to avoid their daily rehabilitation exercises.

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A recent study pointed out that depression and pain from reha-
bilitation processes reduced stroke patients' self-esteem, and that
the lowered self-esteem decreased patients' participation in exer-
cises and motivation for treatment (Kang, 2001). Considering this,
it is clear that some types of emotional treatment interventions
should be introduced to stroke patients' rehabilitation programs in
o r d e r to counteract the effects of depression and pain. As a treat-
m e n t medium, music has been used as a source o f distraction in
pain management. Research in music therapy shows the effective-
ness of music as a distraction in various clinical settings. Music has
been used in pain m a n a g e m e n t during dental treatment for ado-
lescents and young adults (Gfeller, Logan, & Walkm, 1990), labor-
ing procedures for expecting mothers (Hanser, Larson, & O'Con-
nell, 1983), palliative care for terminally ill patients (Curtis, 1986),
medical treatment for pediatric patients (Malone, 1996), and pain
m a n a g e m e n t for a patient with chronic pain (Cohvell, 1997).
Given these positive effects of music in pain m a n a g e m e n t tasks,
stroke patients may benefit from using music during their physical
rehabilitation. Music, with its expectable and regular beats as well as
flexibility in tempi and styles, can help patients match their move-
ments to the rhythm of their music, and pace them for their physical
abilities. Several studies show that music has been used to increase
su-oke patients' physical functioning such as h a n d grasp strength
(Cofrancesco, 1985) and to facilitate gait training (Staum, 1983;
Thaut, Rice, & Mclntosh, 1997). When familiar and favored music is
used for patients during their exercises, physical rehabilitation can be
more tolerable and even enjoyable (Da~s, Gfellm, & Thaut, 1999).
In fact, music therapy has been found to encourage stroke patients
mad help them adhere to exercise programs (Johnson, Otto, & Clair,
2001). By comparing four music conditions, live, instxumental, vocal,
and no music, the researchers discovered positive effects of music
on physical exercise and also some encouraging responses from the
subjects regarding the use of music in their exercise program.
84 Journal of Music Therapy

Only one stud},, however, has specifically addressed the use of

music therapy with stroke patients for improving their u p p e r ex-
tremity functioning (Cofrancesco, 1985). In the stud},, the re-
searcher e x a m i n e d patients' hand functioning, using a dy-
n a m o m e t e r to assess their hand grasp strength. The subjects played
the piano, drmns, and rhythm instruments and reacted positively
during music therapy treatment sessions. Even though the research

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was c o n d u c t e d with only three subjects, the result indicates that
music therapy sessions helped reduce pain during physical exer-
cises designed to increase the patients' hand functioning.
T h e purpose of this study was to d e t e r m i n e the effects o f nmsic
therapy on pain perception of stroke patients during u p p e r ex-
tremity j o i n t exercises. T h r e e music conditions were introduced:
(a) song, (b) karaoke a c c o m p a n i m e n t (same music as Condition
A, except singers' voices), and (c) no music (silence).
O n e male and nine female individuals (N= 10) participated in
the study. Their age ranged fiom 61 to 73 with a mean of 67. Subjects
were diagnosed with stroke, on an average of 3 },ears prior to their
participation in the study. Eight of them had severe hemiplegia, and
two o f them had both mild hemiplegia and limited language skills.
in sum, all demonstrated difficulties using their u p p e r extremities
to varying degrees. They were members of a daycare center for se-
nior citizens in southwestern Seoul, South Korea, where they re-
ceived physical therapy, music therapy, and other types o f health
and recreation services on a weekly basis. The subjects showed
m e d i u m to m e d i u m h i g h levels of functiolaing on the Activities of
Daily Living evaluation designed and c o n d u c t e d by a team of a
nurse, a social worker, and a physical therapist, who were all em-
ployed at the centeL Although official data for their cognitive func-
tioning and connnunication skills were not available, all subjects
exhibited cognitive abilities and receptive language understanding
that are intact mad at an appropriate level for the participation.

Having c o n d u c t e d a weekly music therapy sessions with stroke
patients at the center for a few ),ears, the researchers felt a need for
a research project in developing a session protocol with the popu-
lation. Thus, they met with a physical therapist employed at the
VoL XLII, No. 1, Spring 2005 85

center for consultation. During the consultation, the following

were p o i n t e d out and discussed: (a) exercise regiments of stroke
patients at the center had focused on the rehabilitation of ambula-
tion and gross-motor functioning: (b) the majority of the patients
were o b s e r v e d to have improved or regained their a m b u l a t o r y
skills and some gross-motor functioning, yet they s e e m e d to lack
confidence in using their hands, wrists, and shoulders, showing a

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characteristic walking pattern of putting their hands oil their backs
to hide them; (c) one of" the patients had recently fell and injured
herself as walking with her hands hidden behind; (d) during post-
accident discussions with the center staff, the patient said she had
feelings of self-consciousness and shame whenever she had to show
her impaired hands, confessing her lack of confidence using them,
and (e) the walking pattern and emotional responses similar to
those o f the female patient were observed a m o n g most patients.
Therefore, it was concluded from the consultation that intensive tip-
per extremity exercises, focusing on the hand, wrist, and shoulder
joints, m i g h t help the patients build up confidence in using their
impaired hands a n d / o r arms. It was also concluded that the exer-
cises m i g h t facilitate the patients to feel m o r e c o m f o r t a b l e expos-
ing their affected u p p e r extremities in o t h e r people's company.
Using these inputs, the lead researcher designed a pool o f vari-
ous hand, wrist, arm, and shoulder movements, focusing on the
use o f b o t h hands and ~q'ist joints. T h e s e m o v e m e n t s were then
tried during 4 weekly pilot sessions as a part of movement-to-music
applications, in order to test their suitability for the study. While ex-
ercising, the subjects were videotaped, and they were interviewed
later for their responses to the exercise m o v e m e n t s . During the
analysis of the tapes and interview responses, particular attention
was paid to the easiness and simplicity of m o v e m e n t s , and to a
good flow f r o m one m o v e m e n t to the next. M o v e m e n t s that
seemed to be too difficult or reportedly cause pain were removed
from the pool. Appropriate n u m b e r s of repetition for each move-
m e n t were also discussed. As a result, five groups of u p p e r extrem-
ity exercise m o v e m e n t s were selected, and n u m b e r s for repetition
were d e t e r m i n e d (see Figure 1). The m o v e m e n t s involved a use of
both extremities even though the majority of the subjects showed
difficulty using their affected hand(s), wrist(s), a r m ( s ) , a n d / o r
shoulders. During the exercises, patients were strongly e n c o u r a g e d
to move their affected extremity as well ,as their unaffected one in
order to facilitate the movements.
86 Journal of Music Therapy

Movelnents Counts Repetitions

1. Hand grasp & release 4 8
2. Finger counting--bofla hands sinmltaneously l0 2
3. Hand supination & pronation 4 12
4. Hand clasp & stretching (in the listed order)
- - in & out 4
- - up & down 4
- - in & out 4
5. Shoulder rolls (in the listed order)

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- - forwards 2
- - backwards 2

Exercise movements, counts, and repetitions.

Music Selection
T h r e e kinds o f music were used for the study: (a) song, (b)
k a r a o k e a c c o m p a n i m e n t , and (c) n o music (silence). S o n g was op-
erationally d e f i n e d as music with lyrics, melody, a n d p o p instru-
m e n t a l acconapaniment. T h e operational definition o f karaoke ac-
c o m p a n i m e n t was nmsic with p o p i n s t r u m e n t a l a c c o l n p a n i m e n t
b u t with n o lyrics, n o melody, a n d singer's voices.
Given that the lnajority o f the subjects were in their 60s, p o p u l a r
K o r e a n music f r o m their y o u n g adult years were c o n s i d e r e d most
a p p r o p r i a t e in selecting specific music styles (Clair, 1996 ) in the
b e g i n n i n g o f the music-selecting process. However, in the course o f
the pilot sessions, it b e c a m e obvious that p r e f e r r e d music by the
subjects t e n d e d to c e n t e r a r o u n d the era o f 1980s a n d later. This
u n e x p e c t e d p r e f e r e n c e s e e m e d to be consistent with the re-
searchers' observations f r o m weekly music t h e r a p y sessions held at
the c e n t e r for the past few years. T h e r e could be several reasons for
this, o n e o f w h i c h is the fact that for the subjects, 1960s were the
time w h e n the), had suffered immensely f r o m the repercussions o f
Korean War a n d i m m e r s e d themselves in the nation-wide recon-
s u u c t i o n project. D u e to power o f music that can bring back m e m o -
ties a n d associations with certain life events, music f r o m this era
could have b e e n painflfl and disconcerting rather than enjoyable for
the subjects. O n the conu-ary 1980s were the period when the econ-
o m y o f the n a t i o n showed t r e m e n d o u s growth, a n d life quality o f
Vol. XLII, No. 1, Spring 2005 87

Titles (Rough translation) Styles Artists
1. Beat Four Adult pop Song, Dae-kwan
2. Flower Song Traditional Kim, Young-im
3. Guys & Gals These Days Adult pop Hyn, Suk
4. Puppy Love Adult pop Doe,-Mee
5. The Guy In a YellowShirt Adult pop Han, Myong-snk
6. Lady Samba Dance pop Seol, Woon-doe
7. Love In Mallipoe Aduh pop Park, Kyong-won

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8. I Don't Believe In Good-byes Adult pop Choo, Hyun-mee
Karaoke Accompaniment
Titles (Rough translation) Styles Artists
1. Love Is Not For Everyone Adult pop Tae,Jin-ah
2. Guys & Gals These Days Adult pop Hyun, Suk
3. Beat Four Adult pop Song, Dae-kwan
4. Are You Comin' Over? Adult pop Bae, II-ho
5. Fm Still Ill Love With Yon Adult pop Durian
6. The Excuse Raggae Kiln. Koen-moe
7. Sweetie Dance pop Sharp
8. Young-ja, My Darling Adult pop Hytm, Suk

Titles, styles, and artists of the 16 selected inusic pieces.

the m a j o r i t y o f K o r e a n s b e g a n to i m p r o v e . T h e r e f o r e , it is p o s s i b l e
that a r o u n d this time, the subjects b e c a m e m o r e f i n a n c i a l l y secure,
i n v e s t i n g m o r e t i m e a n d m o n e y into p u r s u i n g t h e i r l e i s u r e activi-
ties i n c l u d i n g music. In a d d i t i o n , K o r e a n t r a d i t i o n a l s o n g s with
w e s t e r n style a r r a n g e m e n t a n d m o r e r e c e n t p o p p i e c e s w e r e also
i n c l u d e d in t h e r e p e r t o i r e s i n c e t h e y w e r e p o p u l a r with o r fre-
q u e n t l y u s e d for t h e subjects d u r i n g t h e i r weekly music sessions.
F o r specific p i e c e s e l e c t i o n , f o u r c r i t e r i a w e r e e s t a b l i s h e d f o r
b o t h s o n g a n d k a r a o k e a c c o m p a n i m e n t c o n d i t i o n s : (a) d u p l e me-
ter; (b) m o d e r a t e t e m p o (M.M. J = 9 0 - 1 0 0 ) ; (c) c l e a r beat; a n d
(d) overall a p p r o p r i a t e n e s s f o r a n d r e c o g n i z a b i l i t y by e l d e r l y Ko-
r e a n p o p u l a t i o n . Twenty-five s o n g s a n d 25 k a r a o k e a c c o m p a n i -
m e n t s w e r e c h o s e n a c c o r d i n g to t h e c r i t e r i a . T h e n , e i g h t p i e c e s
were r a n d o m l y s e l e c t e d for e a c h category, r e s u l t i n g in a total o f 16
m u s i c p i e c e s to be u s e d in t h e study. Two r a n d o m l y c h o s e n songs
f r o m t h e e i g h t were also i n c l u d e d in t h e k a r a o k e a c c o m p a n i m e n t
g r o u p r e s u l t i n g in an o v e r l a p (see F i g u r e 2).
88 Journal of Music Therapy

0 1 2 3 4 5 6 7 8 9 10
Least Most
Painfid painful

~IC, U RE 3'
A rating scale for subjects' perceived pain.

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Each of the 16 pieces was r a n d o m l y n u m b e r e d according to its
c a t e g o r y and then r e c o r d e d o n t o a tape for 3 minutes. A total of
eight tapes were prepared, o n e for each week, with one song and
o n e karaoke a c c o m p a n i m e n t in each of them.

Due to the small n u m b e r o f subjects, all 10 of t h e m served as
t h e i r own controls. I n d e p e n d e n t variables were: (a) song, (b)
k a r a o k e a c c o m p a n i m e n t , a n d (c) no music (silence). Song was
o p e r a t i o n a l l y d e f i n e d as music with lyrics, melody, a n d p o p in-
s t r u m e n t a l accompaniment. T h e operational definition of karaoke
a c c o m p a n i m e n t was music with p o p instrumental a c c o m p a n i m e n t
but with no lyrics, melody, and singers' voices. A d e p e n d e n t vari-
able was the subjects' perceived pain d u r i n g the u p p e r extremity
exercises, rated on a scale.
A rating tool with 11 scales was designed so that the subjects could
m a r k their perceived pain sensation after each of the 3-minute ex-
ercise trials. On the scale, zero indicated 'the least painfid,' and 10
indicated 'the most painful' (see Figure 3).

T h e study was c o n d u c t e d in an activity r o o m at the center, the
s a m e time in the a f t e r n o o n , over an 8-week period. Each 20-
minute session was structured in the following order: (a) the sub-
jects sat on chairs in a senti circle, facing researchers; (b) the sub-
jects a n d r e s e a r c h e r s had a brief, casual conversation to set the
m o o d a n d build trust; (c) the subjects participated in the u p p e r
extremity exercise for a p p r o x i m a t e l y 3 minutes, with the lead re-
s e a r c h e r d e m o n s t r a t i n g m o v e m e n t s in f r o n t and the assistant
researcher c o u n t i n g out loud and video-taping the session; (d) the
subjects were instructed on how to mark, and they rated their per-
Vol. XLII, No. 1, Spring 2005 89

Weekly Session Nunlbers

Orders of conditions 1 2 3 4 5 6 7 8
1st exercise trial N S K N S S N S
2rid exercise trial K N S K N K S N
3rd exercise trial S K N S K N K K
S: Song. K: Karaoke Accolnpaniment. N: No music (silence).

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Floum.: 4-
Random orders of experimental conditions for eight weeks.

ceived pain on a scale ilnmediately after the exercise; (e) u p o n

marking, the researchers g a t h e r e d the rating sheets and wrote
each subject's n a m e on top of the c o r r e s p o n d i n g sheet; (g) pro-
cedures (c), (d), and (e) were r e p e a t e d for two m o r e trials, ac-
c o r d i n g to the r a n d o m i z e d o r d e r for the week; and (f) the re-
searchers t h a n k e d the subjects and c o n f i r m e d the following
week's session. During each session over the 8-week period, three
music conditions were randomly assigned for a series of three ex-
ercise trials (see Figure 4).
As for the purpose of videotaping, it was two-fold: (a) to gather
additional data for the subjects' overall responses and participation
during the exercises; and (b) to u n d e r s t a n d individual responses
that are noteworthy yet might not be reflected on the rating scales.
Data collected from video analysis were p l a n n e d for future uses so
that the researchers could develop session protocols for their prac-
tice with this population.

In o r d e r to c o m p a r e the effects of three music conditions on
perceived pain of the subjects, pain ratings of the participants were
analyzed using the General Linear Model (GLM) Repeated Mea-
sures Analysis of Variance. Due to the small n u m b e r of subjects and
the research design employed for the stud),, the statistical test was
d e e m e d most appropriate. It was conducted at a .05 level of signif-
icance. Maalysis revealed that there were no significant differences
in pain ratings across three music conditions, that is, song, karaoke
a c c o m p a n i m e n t , and no music (silence), F(2, 7) = 0.23, p = .05 (see
Table 1).
90 Journal of Music Therapy

GI_J~IRe49eatedMeasures Analysis of Variance
df Type I11KS MS Fvalue

Between subjects 2 22.575000 11.287500 0.23

Error 27 1349.575000 49.984259

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In this study, subjects with stroke rated their pain on a scale dur-
ing u p p e r extremity exercises, in o r d e r to find differences in their
pain p e r c e p t i o n across three different e x p e r i m e n t a l conditions.
T h e y were song, karaoke a c c o m p a n i m e n t , and no music (silence).
T h e results showed no significant differences across those condi-
Initially, the results from the statistical analysis were r a t h e r sur-
prising to the researchers since there were no significant differ-
ences across the three conditions including two that employed mu-
sic, that is, song and karaoke a c c o m p a n i m e n t . T h e researchers
expected to see at least one of the music conditions, be it song or
karaoke a c c o m p a n i m e n t , p r o d u c e a statistically significant de-
crease in the subjects' pain ratings. In that regard, several points
were reviewed as possible influences on the results, and thus they
deserve discussion.
First, the n u m b e r of subjects (N = 10) was too small. With a
larger n u m b e r o f stroke patients, the results could have been dif-
ferent. Second, subjects in this study have suffered fi'om stroke
m o r e than an average o f three years, and it seems c o m m o n that
pain sensations in chronic stroke patients b e c o m e somewhat dull
or less acute. Subsequently, it could have been challenging for the
subjects to rate their pain on a scale with as m a n y as 11 points
(from 0 to 10). T h e y might have missed subtle changes in perceiv-
ing pain sensations even though they were aware of the changes in
e x p e r i m e n t a l conditions. A rating scale with smaller number, for
e x a m p l e , f o u r or five, could have b e e n m o r e a p p r o p r i a t e for the
patients to m a r k the pain assuredly. Instead of rating scales, pic-
tures of faces representing pain c o n d i t i o n s - - ' f r o w n , ' 'neutral,' and
'smile,' or written explanations of perceived p a i n - - ' e x t r e m e l y
painful,' 'quite painfnl,' ' s o m e w h a t painful,' and ' n o t painful,'
could also have b e e n more accessible to the subjects.
VOI. XLII, No. 1, Spring 2005 91

Third, even t h o u g h the u p p e r extremity exercise movements

were designed with particular care and revised many times before
the beginning of the stud),, the subjects might have difficulties fol-
lowing them d u r i n g weekly study sessions. Normally, the subjects
participate in physical exercises and use various apparatuses in the
rehabilitation rooms at the day care center, but that e q u i p m e n t is
designed to put more emphasis on gross-motor ability, ambulation,

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and gait trainings. Therefore, engaging themselves in a somewhat
unfamiliar exercise regimen, focusing on the u p p e r extremities,
could have been d e m a n d i n g in and of itself. M t h o u g h some posi-
tive verbal responses and facial expressions emerged during musical
experimental conditions nearly every week, none of the three con-
ditions seemed to successfully hold the subjects' attention and to
produce significant decrease in their pain perception.
Finally, many positive verbal and nonverbal responses from the
subjects were observed fl'om video evaluation. It was found that the
participants made quite a few comments on songs and karaoke ac-
companiments during exercises, expressing their interests in them
and verbalizing the positive feelings they had from listening to
them. Perhaps the most important discovery from the video analy-
sis was the fact that the participants demonstrated strong motiva-
tion in continuing their u p p e r extremity exercises even after the
completion of the study. In addition, physical therapists at the cen-
ter initiated positive comments on the content and the progression
of the study sessions. Even though the statistical analysis did not re-
veal any significant differences in the participants' pain ratings
across three experimental conditions, subjects' increased motiva-
tion for rehabilitation and their positive mental association be-
tween music and exercise were, from a clinician's point of view,
more valuable outcome and also crucial indicators for their future
participation in music therapy.
Future research might include a larger n u m b e r of subjects and
different d e p e n d e n t variables, such as facial expressions or verbal
responses that might indicate the subjects' pain perception. In ad-
dition, it is r e c o m m e n d e d that researchers recruit stroke patients
who are in their initial stage of rehabilitation and are not familiar
with music therapy. These 'unexposed' individuals might show
more alert and therefore m o r e statistically significant responses
during different experimental conditions.
92 Journal of Music Therapy

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