The efficacy of music listening and music therapy in the

management of pain

Student No. 200543055

University of Leeds
MMus Applied Psychology of Music
Case Studies (5931M)
 Table of Contents

Introduction ....................................................................................................................... 1

Chapter 1: What is pain? .................................................................................................. 2

Difficulties in understanding and researching pain ................................................... 2

Theories of pain perception ...................................................................................... 3

The psychological factors of pain ............................................................................. 5

The treatment of pain ............................................................................................... 6

Chapter 2: Music listening and pain ............................................................................. 10

Music and everyday well-being .............................................................................. 10

Music as a drug ...................................................................................................... 11

Music and the Gate Control theory ........................................................................ 12

What evidence is there to suggest that music listening strategies may be a useful
tool in pain management? ...................................................................................... 13

Chapter 3: Music therapy and pain ............................................................................... 20

What is music therapy? .......................................................................................... 20

Theoretical grounding for music therapy in pain management .............................. 21

What evidence is there to suggest that music therapy may be a useful tool in pain
management? ........................................................................................................ 22

Conclusion ...................................................................................................................... 30

References ....................................................................................................................... 31
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Introduction
Music is widely used to enhance well-being, reduce stress and distract from unpleasant

symptoms (Kemper & Danhauer, 2005). Despite a lack of research validating music

interventions as an effective means of reducing pain, ongoing efforts are being made to

develop and assess new evidence on the therapeutic nature of music and it's use in the

treatment of pain (Akombo, 2006, p. 1; for recent review see Cole & LoBiondo-Wood,

2014).

This paper outlines the context, theories and evidence surrounding the use of music to

reduce surgical, procedural, acute and chronic pain. Three broad research questions have

been formed in order to reach the overall aim of this research: to evaluate the efficacy of

music and music therapy in pain management. These research questions form the basis of

the three main sections of this research paper.

Research questions

1. What is pain?

2. To what extent can music be considered an analgesic and how have music listening

interventions been used to reduce pain?

3. How has music therapy been employed in pain management and does this provide

evidence for its successful use in the reduction of pain?

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What is Pain?
Pain continues to be one of the most challenging problems in medical care for all

individuals involved in its suffering, diagnosis, and treatment (Melzack & Wall, 1996, p. ix).

The last decade has seen growing acknowledgment of the challenge that pain poses to

health and well-being, and research reflects the increased concern to empower patients

with the knowledge and interventions needed for coping with pain (Mitchell & MacDonald,

2012).

The two main pain types are acute, a "combination of tissue damage, pain and anxiety",

and chronic, a "distinct medical entity" continuing for more than 12 weeks, or after the

time that healing from trauma has occurred (Melzack and Wall, 1996, p. 35-36; British Pain

Society, 2013). Categorisation is essential for diagnosis but obscures the complex nature

of pain; within these categories reside an endless number of pain experiences.

Difficulties in understanding and researching Pain

Subjectivity

Pain has a highly subjective nature and no two people have the same pain experience

(McGuire, 1984). Various individual differences and details surrounding the pain

experience contribute to this subjectivity (Melzack & Wall, 1996; Coghill, 2011).

Measuring pain

There is doubt as to whether common measures of pain such as questionnaires and rating

scales provide adequate information about the dimensions of pain (Giordano, Abramson &

Boswell, 2010). Whilst some scales have been shown to be more sensitive to intensity and

unpleasantness than others, self-rating scales rely on subjective interpretation, which

casts doubt on their validity (Duncan, Bushnell & Lavigne, 1989). Giordano, Abramson, &

Boswell (2010) suggest that objective measures from neurotechnology, such as

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neuroimaging, should be integrated into assessment, potentially resulting in faster, more

accurate diagnoses and more effective treatment.

Experimental pain and real-life experiences of pain

Experimental pain is the induction of pain to often healthy participants, who are fully aware

of the controlled nature of the study, in order to have their responses measured (Behrens

& Michlovitz, 2006, p. 13). Such procedures not only require ethical consideration but also

lack ecological validity. Whilst contributing to the understanding of pain's underlying

mechanisms and development of it's assessment and treatment, extrapolation of results

from these studies to real-life pain sufferers should be done with care (Birnie, Caes,

Wilson, Williams & Chambers, 2014).

The physiological mechanisms of pain

Many theories have attempted to explain the physiological mechanisms of pain but the

occurrence of seemingly inexplicable pain experiences, including incidences of severe

injury/illness without pain, pain disproportionate to severity of injury/illness, pain without

injury/ illness, and the presence of pain long after an injury/illness has been treated,

highlight the difficulties in understanding such mechanisms (Melzack & Wall, 1996, pp. 3-

10). In relation to the latter example, it is now known that peripheral and central events

related to injury/illness can trigger long-lasting changes in the spinal cord and brain that

lead to continued generation of afferent information through pain conducting systems, but

this remains a complex physiological issue requiring further research (Lynch & Watson,

2006, p. 11-12). These incidences cast doubt on theories of pain as an evolutionary

survival tool; pain appears to provide no use to the sufferer (Melzack & Wall, 1996, p. 7).

Theories of pain perception

Specificity theory proposes the presence of dedicated pathways with specific receptors

and sensory fibres for each somatosensory modality, including pain (Moayedi & Davis,
 4

2013). Painful and non-painful stimulus are, therefore, seen as being processed through

different pathways (Melzack & Wall, 1996). Discoveries such as the myelinated primary

afferent fibres, which respond only to mechanical noxious stimuli, provided evidence for

specialisation, but popularity of the theory waned with the development of the Gate Control

theory (Burgess & Perl 1967; Melzack & Wall, 1965).

Intensity theory, described most notably by Plato in the fourth Century BCE, defines pain

as a feeling that occurs when a stimulus is stronger than usual (Moayedi & Davis, 2013, p.

8). Unlike Specificity theory, it does not consider pain or other sensory experiences as

unique, but a result of the summation of repeated stimulation. Discovery of specialised

fibres, mentioned above, cast doubt on the validity of the theory.

A number of theories may be grouped under the term Pattern theory, but all share the

proposition that it is not specialised fibres or receptors, or intensity of stimulation that lead

to pain, but excessive peripheral stimulation that produces particular patterns of nerve

impulses which are interpreted centrally as pain (Melzack & Wall, 1996, p. 158). Fibre

endings are considered to be largely alike, meaning that pain is the result of intense

stimulation of non-specific receptors. Like Intensity theory, this theory fails to account for

physiological specialisation.

Gate-control theory, developed by Melzack and Wall (1965), proposes the existence of a

gating system at the dorsal horn of the spinal cord that controls pain transmission from the

periphery to the somatosensory cortices in the brain (Hassett & Gervitz, 2009, p. 393).

Pain perception begins with the stimulation of skin, leading to transmission of signals to

three regions in the spinal cord: substantia gelatinosa, dorsal column and transmission

cells. The substantia gelatinosa, in the dorsal horn, acts as the 'gate' to the spinal cord,

modulating transmission of sensory information from primary afferent neurons to

transmission cells in the spinal cord. The gating mechanism is controlled by activity in
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large fibre activity, which 'closes the gate', and small fibre activity, which opens it.

Potentially harmful (nociceptive) information reaches a threshold that exceeds the

inhibition elicited and the gate opens, activating pathways which lead to pain. Activity from

fibres originating in the brain and descending to the dorsal horn can also modulate this

mechanism, so pain is therefore controlled by both peripheral input and neural centers

(Melzack & Wall, 1965). Non-painful input closes the gates to painful input, explaining why

factors such as active coping and social support, may improve the experience of pain,

while others, for example depression and anxiety, may worsen the experience (Hasset &

Gervitz, 2009, p. 393). The theory bridges the gap between Pattern and Specificity

theories and remains the predominant theory of pain today (Moayedi & Davis, 2013, p. 9).

The psychological factors of pain

Every pain has psychological characteristics and there is increasing recognition of the

influence that these factors have on this perceptual experience (Buljan, 2009, p.129).

Emotional and behavioural factors are known to influence the development of persistent

pain problems and the outcome of treatments (Turk & Okifuji, 2002, p. 678; Linton & Shaw,

2011). Ashburn and Staats (1999) state that chronic pain, more than acute pain, affects

mood, personality, and social relationships, and the prevalence of depression and

heightened anxiety in chronic pain sufferers supports this claim (Sagheer, Khan & Sharif,

2013).

Several psychological factors may result from, and/or exacerbate the pain experience.

Negative mood and the more severe effects of depression have been shown to be a good

predictor of post-operative pain and pain over time (Wegener, Castillo, Haythornthwaite,

MacKenzie & Bosse, 2011; Gureje, Simon & Von Korff, 2001), also affecting well-being,

patients' presentation during physical examinations, and decreasing activity levels and the

drive to seek out pleasurable activities and social interaction (Haythornthwaite, 2009).
 6

Haythorntwaite (2009) refers to catastrophising, a "negative cognitive-affective response to

anticipated or actual pain", which can result in irrational negative forecasting of future

events and magnification of the threat and experience of noxious stimuli (Quartana et al.,

2009, pp. 745-747). It appears that treating pain may not be possible without a holistic,

integrative and interdisciplinary approach that attends to both the organic nature of

symptoms and the range of factors that modulate nociception and the pain experience

(Buljan, 2009, p.129; Turk & Okifuji, 2002, p. 679).

The treatment of pain

The treatment of pain is a high priority issue in medical settings, aiming to improve the

physical, emotional and social dimensions of patients' quality of life (The British Pain

Society, 2013). The list of treatments below is not comprehensive, but provides examples

of the diverse approaches taken within pain management.

Pharmacotherapy

The use of drugs in the treatment of pain is historically established (Melzack & Wall, 1996).

In a medical setting, the standard method of approach is as follows. Firstly, treatment with

a nonopioid analgesic such as a nonsteroidal anti-inflammatory (NSAID) is prescribed for

mild to moderate pain, reducing the production of prostaglandins, which promote the

inflammation of tissue necessary for healing, and the associated pain (Lynch & Watson,

2006, p. 12; Ricciotti & FitzGerald, 2011). If this is inadequate, an antidepressant with

analgesic qualities may be added, either modulating pain pathways from the brain stem to

the spinal cord, or blocking off sodium and calcium channels, both of which are important

in nociceptive signalling (Lynch & Watson, 2006, p. 17). Neuropathic pain may require

anticonvulsant analgesics, which depress abnormal neuronal discharges in the Central

Nervous System. If these steps are inadequate, an opioid analgesic may be required,

which works at sites in both the brain and spinal chord to reduce neuronal excitability and
 7

modulate the release of nociceptive neurotransmitters (Lynch & Watson, 2006, p. 12;

Bovill, 1997). When and how these drugs are used, particularly strong acting drugs such

as opioids, remains controversial (Davis, Walsh, Lagman & LeGrand, 2005).

Cognitive Behavioural Therapy (CBT)

CBT is widely used in the management of chronic pain, helping patients to work through

patterns of negative thoughts and develop more healthy and adaptive thoughts, emotions,

and actions (Lynch & Watson, 2006, p. 1868). In pain management, errors in thinking such

as catastrophising are challenged and replaced with more realistic and effective thoughts,

decreasing distress, self-defeating behaviour, and the impact and intensity of pain (Hassett

& Gevirtz, 2009, p. 3). CBT is based on the principles of operant conditioning, relying on

the presence or withdrawal of positive and negative reinforcement, and uses four basic

components: education (awareness and alteration of perceptions), skills acquisition (new

behaviours to help reduce pain, e.g. relaxation exercises) cognitive and behavioural

rehearsal (setting of goals and self-reward), and generalisation and maintenance

(application of skills in daily life) (Moore-Groarke, 2005). The approach supports the Gate

Control theory of pain, recognising the influence of cognitive and affective factors on pain

(Moore-Groarke, 2005).

Mindfulness

The last 20 years has seen a majority of pain management procedures based on coping

approaches, but a more recent wave has moved towards acceptance-based approaches,

with mindfulness as a key component (Cusens, Duggan, Thorne & Burch, 2012, p. 64).

Bishop et al. (2004) suggest a two-component model of mindfulness based on self-

regulation of attention on the immediate experience, allowing for increased recognition of

current mental events, and orientation toward experiences in the present with curiosity,

openness, and acceptance (p. 232-233). Gardner-Nix (2009) refers to the "poorly
 8

controlled" Western pain treatments, suggesting that treatments targeting higher cognitive

processing, of which mindfulness may be one, are more effective than targeting

sensations or attention to pain (p. 369-370). Mindfulness has found success in treatments

such as Mindful-Based Stress Reduction, which involves a range of activities including

meditation, movement, discussion and use of mindfulness in daily life (Kabat-Zinn, 1982;

Morone, Greco & Weiner. 2008; Gardner-Nix, 2009, p. 373-374). The main goal of

mindfulness is acceptance of situation and release from the struggle to return to pre-

morbid status (Gardner-Nix, 2009, p. 377). UK organisation Breathworks bases its

approach on Mindfulness Based Pain and Illness Management and made recent progress

towards integration with NHS services (Roberts, 2013).

Biofeedback

Biofeedback takes a 'mind-body', or 'bioenergetic' approach to pain (Weintraub, Mamtani &

Micozzi, 2008, vii). Like CBT, the therapy is based on operant learning theory. The primary

principle is that patients receive information about a particular physiological parameter,

and can learn to control this aspect of their response to pain or stress; this requires

awareness, self-regulation and positive reinforcement (e.g. sound or visual feedback). To

reduce pain caused by tension headache, for example, the patient is trained to decrease

tension levels and produce a general relaxation response (McGrady, 2008, p. 9). Surface

sensors placed on the head measure muscular activity, responding to changes in facial

expression and grinding teeth, helping patients to regulate response and decrease pain

(McGrady, 2008, p. 10). Biofeedback may be used alongside CBT to explore negative

thoughts that contribute to physiological changes during stressful and painful situations.

Complementary and alternative therapies

The NHS lists 6 complementary therapies most commonly used in the management of

pain: acupuncture, aromatherapy, chiropractic, homeopathy, massage, osteopathy and

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clinical hypnotherapy, although Biofeedback, described above, may also be considered

such a therapy (NHS, n.d.). Physiological effects of such treatments remain largely

scientifically untested. Studies have tended to use small sample sizes and a lack of

standardisation whilst idiosyncrasies in, for example, susceptibility to hypnosis, makes

their efficacy questionable (Wilkinson & Faleiro, 2007; Elkins, Jensen & Patteron, 2007;

Lichtenberg, Bachner-Melman, Ebstein & Crawford, 2004). Reasons for turning to

alternative or complimentary therapies may not be due to a lack of satisfaction with

mainstream medicine. Barnes, Powell-Griner, McFann and Nahin (2004) found that most

adults using complimentary therapies did so alongside conventional medicine either

because they thought it would help further, or simply "out of interest". Weintraub, Mamtani

and Micozzi (2008) suggest that these therapies may offer more than modern medicine,

which they claim is inadequate for most patients, concluding that an integrative approach

to conventional and complementary treatments may be most successful (p. xv).

The reality of pain management is that not all treatments suit all pain, or patients. As

Ashburn and Staats (1999) state, "pain is only one of many issues that must be

addressed", and any treatment plan should aim to address the numerous factors that

influence the pain experience (p. 1865).

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Music Listening and Pain

Music listening appears to offer a seemingly unique and universal way to relax, distract, or

even relieve a person in pain (Kemper & Danhauer, 2001). As Gabrielsson (2011) points

out, music itself may act as the "active agent, the 'therapist'", used as a self-administered

treatment to bring about positive change to an individuals' feelings of emotional and

physical well-being and health (p. 209).

Gabrielsson (2011) outlines several case studies of participants who describe music as

relieving or eliminating pain, including a woman distracted from back pain by Chopin's

Nocturne No. 1, and another whose mix-tape relieved labour pain better than any other

pain relief was able to (pp. 209-220). Such a strong influence of music over pain may be

difficult to comprehend, but there is much evidence to suggest music's ability to induce

great psychophysiological change, likened to transcendence, ecstasy and even contact

with divinity (Gabrielsson, p. 159 & 178; Penman & Becker, 2009). The cases described

support the use of music listening as an effective distraction from pain, in line with Melzack

and Wall's (1965) Gate Control theory, and highlight the importance that type of music,

dependent on individual differences, past experiences and associative memories, may

have on music's effective use in pain management. Numerous researchers have

investigated the role that familiarity and preference may have on music's ability to affect

therapeutic change (Mitchell & MacDonald, 2006; Garza-Villarreal, Brattico, Vase,

Ostergaard & Vuust, 2012).

Music and everyday well-being

Music may play an important part in the promotion of wellness (a positive attitude towards,

and active engagement in an individual's personal health environment) for individuals in

daily life (Krout, 2007, p. 134). Several researchers have found music to play an important

role in emotional and psychological regulation (Saarikallio & Erkkilä, 2007; Saarikallio,
 11

2011; Greasley & Lamont, 2011; Schäfer, Sedlmeier, Städtler & Huron, 2013).

Researchers have also investigated a direct link between music and emotional well-being.

Batt-Rawden and DeNora (2005) found that music may be used to promote health and

well-being, to connect with others, and to provide self-empowerment, whilst Laukka (2007)

looked specifically to the listening habits of the elderly, finding that listening strategies

were most strongly associated with functions related to affective well-being and concluding

that music may be as a resource to satisfy important psychological needs and promote

psychological well-being. Music appears to play a vital role in psychological well-being,

and so, considering the numerous psychological factors of pain, it is perhaps unsurprising

that individuals turn to music listening as a form of self-administered therapy, both as a

direct source of pain relief, and a means of empowerment, relaxation and comfort

(Mitchell, MacDonald, Knussen & Serpell, 2007; Batt-Rawden, DeNora & Ruud, 2009).

Music as a drug

Miles (1997) likens audio-analgesia (the use of sound, or more commonly music, to reduce

pain) to taking "aspirin through the ears" (p. 137), and many have noted the euphoric,

relaxing and pleasurable effects of music (Blood & Zatorre, 2001; Rickard, 2004). Doak

(2003) found that adolescents in treatment for substance abuse reported similar reasons

for using drugs and listening to music: relaxation, elevating mood, focussing themselves,

and escaping reality (p. 69), whilst qualitative research by Bull (2005) into everyday

listening habits found individuals referring to music as a drug (p. 348). Physiological effects

of music, including changes in heart rate, respiration, blood pressure, skin conductivity,

skin temperature, muscle tension, and neurological activity, are well-documented, (Blood &

Zatorre, 2001; Knight & Rickard, 2001; Bernardi et al., 2009), and have been studied in a

variety of clinical populations (Byers & Smythe, 1997; Hamel, 2001; Lee, Chung, Chan &

Chan, 2005).
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Biochemical responses to music have also been investigated. β-endorphins, associated

with both situative stress and pain thresholds have been found to be significantly reduced

by music listening (Sheps et al., 1995; Gerra et al., 1998), leading to reduced stress and

pain. However, personality traits may influence the inter-individual variability in this

response to music and thus, findings may not be universally generalisable (Gerra, et al.,

1998). Decreased levels of dopamine neurotransmission are associated with depression

and seasonal affective disorder (Sutoo & Akiyama, 2004). Dopamine production is

increased by feelings of reward from "novelty and newness", and music may provide such

a reward (Altenmüller & Schlaug, 2013). Salimpoor, Benovoy, Larcher, Dagher and

Zatorre (2011) found that intense pleasure in response to music can lead to dopamine

release, leading to positive effects on the psychological factors of pain, and Salimpoor et

al. (2011) suggest that this fact helps to explain why music is of such high value across

human society in general. Serotonin release, in contrast to the novelty associated with

dopamine release, is "commonly associated with feelings of satisfaction from expected

outcomes" (Altenmüller & Schlaug, 2012, p.16), plays a role in mood, and helps control

eating, sleeping, arousal, and pain regulation (Krout, 2007, p.137). Evers and Suhr (2000)

found that serotonin levels of participants were significantly higher when exposed to

pleasant music than unpleasant music, supporting evidence that music improves mood

and aids in pain regulation through the neurophysiological responses that it induces.

Music and the Gate Control theory

Melzack and Wall's (1965) Gate Control theory of pain provides important theoretical

grounding for the use of music in the treatment for pain. To reiterate, the fundamental

basis for the theory is the belief that psychological and physical factors guide the brain's

interpretation of, and response to, painful sensations (Akombo, 2006, p. 26). The physical

causes of pain may be identical but the perceptions of this pain can differ. The theory

suggests that individuals can have the ability to alter the pain experience beyond the use
 13

of pharmacological intervention, and that the attention an individual gives to a painful

experience may increase pain intensity. This means that distraction may be a key factor in

the reduction of pain, with important implications for the use of music listening and music

therapy interventions to relieve pain.

What evidence is there to suggest that music listening strategies may be a useful

tool in pain management?

It may be noted that some of the literature in this section, dealing specifically with music-

listening interventions, has titles referring to "music therapy"; this is due to the lack of

consensus on what constitutes music therapy for pain. Klassen, Liang, Tjosvold, Klassen

and Hartling (2008) consider music listening interventions without the involvement of a

therapist as "passive therapy" but others seem less committed to labelling music listening

as therapy. The American Music Therapy Association (AMTA) emphasise a "therapeutic

relationship" in music therapy, and so, studies that lack this therapeutic relationship are

discussed in this music listening section rather than the following chapter, which considers

active and live music therapy interventions.

Whilst literature provides evidence for the psychophysiological effects of music, questions

surrounding the role of music listening as a tool in the treatment of pain remain

unanswered. An early study by Melzack, Weisz and Sprague (1963) compared the effect

of loud music and a placebo (a humming described to participants as 'ultrasonic sound') on

the tolerance of slow- and fast-rising pain, and the effect of suggestion on pain perception.

Intense musical stimulation combined with strong suggestion that it abolishes pain was the

most effective means of increasing tolerance, although participant "control" over pain was

apparent only for slow-rising pain. As the authors state, most experimental pains rise

rapidly in intensity, differing from many clinical pains; this has important implications for

the validity of results gathered from experimental pain research (p. 246).
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Others have used experimental methods to consider the effects of different types of music

on pain, for example, pleasant and unpleasant music (Roy, Peretz & Rainville, 2008;

Silvestrini, Piguet, Cedraschi, & Zentner, 2011) and preferred and non-preferred music

(Hekmat & Hertel, 1993). Mitchell and MacDonald (2006) used experimental methods to

investigate the effects of white noise, relaxing researcher-chosen music, and preferred

participant chosen-music on pain perception. Whilst listening to preferred music,

participants tolerated the painful stimulus significantly longer than during the other

conditions, females rated the intensity of the pain as significantly lower, and both male and

female participants felt significantly more control. Research suggests that preference may

affect efficacy of music listening for pain relief, although gender differences may also

influence it's effects.

Acknowledgement that other forms of distraction, such as affective pictures, may be as

suitable for reducing pain as music has also been tested experimentally (De Wied &

Verbaten, 2001; De Tommaso et al., 2009). Mitchell, MacDonald and Brodie (2006) found

preferred music to significantly increase tolerance of cold pressor pain in comparison to a

cognitive task, and significantly increase perceived control in comparison to humour,

although ratings of pain intensity did not differ significantly. Further studies comparing the

effects of music and other distracting stimuli would ensure a better understanding of the

role that music may play in pain management.

Medical procedures and operative pain

Perhaps of greater importance are those studies that have examined the effects of music

listening on pain in medical settings. In the following studies, music is used predominantly

adjunctively, but occasionally in replacement of, standard pharmacological care.

Gardner, Licklider and Wesiz (1960) found that music was effective in reducing the pain of

90% of 5000 patients undergoing dental surgery. Since this original study, investigations
 15

surrounding what would soon become known as audio-analgesia increased dramatically

and some have successfully replicated findings (Roy et al., 2008; Anderson, Baron &

Logan 1991). A case study report by Bhagania and Agnihotry (2011) describes a tooth

extraction performed without anaesthesia and instead with self-chosen Indian devotional

music; no pain was reported by the patient and no pain-related behaviours were exhibited.

Others, however, have failed to replicate results. Aitken, Wilson, Coury and Moursi (2002)

found that audio distraction (either up-beat music or relaxing music) resulted in no

significant difference in anxiety, pain or uncooperative behaviour across experimental

conditions or a silent control condition during 45 paediatric restorative dental procedures

and Filcheck et al. (2005) found no significant differences in pain or disruptive behaviour in

children undergoing restorative dental procedures whilst either listening to self-chosen

music through headphones, or no music.

The successful use of music listening in the reduction of pain has been found during

numerous other medical procedures, including labour and childbirth (Phumdoung & Good,

2003), caesarean section surgery (Ebneshahidi & Mohseni, 2008), and minor surgeries

such as laceration repair (Menegazzi, Paris, Kersteen, Flynn & Trautman,1991), and

catheter placement (Jacobson, 1999; Zengin, Kabul, Sarcan, Doğan & Yildirimet, 2013).

Some have found successful use of preoperative music listening interventions for patients

of caesarean sections (Li & Dong, 2012) and plastic surgery (Updike, & Charles, 1987),

and postoperatively, following elective caesarean sections (Sen et al., 2010), intestinal

surgery (Good, Anderson, Ahn, Cong & Stanton-Hicks, 2005), hernia and varicose vein

surgery (Nilsson, Unosson & Rawal, 2005; Nilsson, Rawal, Enqvist & Unosson, 2003),

gynaecologic surgery (Good, Anderson, Stanton-Hicks, Grass & Makii, 2002), and heart

surgery (Voss et al., 2004). Use of perioperative music interventions have been employed

successfully with women undergoing mastectomy (Binns-Turner, Wilson, Pryor, Boyd, &

Prickett, 2011) and patients of laparoscopic cholecystectomy (Graversen & Sommer,

 16

2013), although in the latter case, pain was only significantly lower in the music group

(who heard soft music during and after surgery) than the control group (no music) on the

seventh day after surgery, despite measures of effects also being taken 1 hour, 3 hours

and1 day post-operatively. The successful use of self-selected music as pain treatment for

postoperative caesarean section patients is particularly important considering the

impairment that pharmacological analgesics may have on the initial bonding of mother and

child (Ebneshahidi & Mohseni, 2008).

Supporting experimental pain research outlined previously, Akombo (2006) found that

clients undergoing bone marrow transplants reported a significant reduction in pain

intensity after listening to 30 minutes of preferred music (based on Modified Hartsock

Music Preference Questionnaire: Hartsock,1982). Statistically significant decreases in

blood pressure, heart rate, and respiratory rate were also found, and qualitative data

indicated that participants found the music enjoyable and relaxing. Shabanloei, Golchin,

Esfahani, Dolatkhah and Rasoulian (2010) found music listening to be a successful means

of reducing pain and anxiety during bone marrow biopsy and aspiration, and Pothoulaki et

al. (2008) found similar results in a sample of 60 patients undergoing haemodialysis.

Ratings of anxiety were significantly lower for the intervention group than for the control

group (who listened to no music), and the control group experienced significantly higher

levels of pain intensity in the post-test phase.

Cancer and chronic conditions

Cancer and it's treatment may lead to long-lasting, severe pain, with pain being probably

the worst symptom experienced by cancer sufferers, bringing both physical and emotional

stress (Huang, Good & Zauszniewski, 2010). Diseases such as osteoarthritis and chronic

pain disorders cause recurring, or near constant pain, often with unknown or complex

causes and complicating psychological factors (Rosemann et al., 2006), and standard
 17

medical treatment may be difficult, inadequate or ineffective (Tronvik, Stovner, Helde,

Sand & Bovim, 2003).

Many researchers have considered music listening as a possible intervention for improving

quality of life for cancer patients and their experience of painful treatments (Zimmerman,

Pozehl, Duncan & Schmitz, 1989; Clark et al., 2006; Bulfone, Quattrin, Zanotti, Regattin, &

Brusaferro, 2009). Huang et al. (2010) used music to relieve pain in 126 cancer patients

(from oncology, palliative, respiratory and gastrointestinal units) in Taiwan. A 30 minute

sedative music listening intervention of either Taiwanese or American music resulted in

significantly less pain than that of a control group, who 'rested' for 30 minutes. The role of

choice, however limited, may have played some part in the success of the intervention.

During a follow-up interview, several participants mentioned that familiar songs would be

the most distracting or relaxing, perhaps reflecting the decision by most to listen to

Taiwanese music (p. 1360). In a study of 20 female breast and cervical cancer patients,

Kaliyaperumal and Subash (2010) found that mean levels of pain were significantly lower

in the experimental group, who received two 20 minute sessions of music listening a day

(classical music) over a three-day study period, than the control group. Positive effects of

music listening were apparent despite a lack of choice or preference.

Researchers have also considered the effect of music on chronic pains, and pain resulting

from chronic illness. Siedliecki and Good (2006) studied the use of preferred music and

'standard music' (a choice of relaxing instrumental music used in previous pain studies) on

levels of power, pain, depression and disability in 60 non-malignant chronic pain sufferers.

The preferred music group were asked to choose music to meet personal requirements,

for example, they were asked to choose energetic, rhythmic, familiar, instrumental or vocal

music to promote energy when feeling fatigued. Results showed a statistically significant

effect, resulting in more power, and less pain, depression, and disability in both music
 18

groups than the control group. No significant differences were found between the music

groups, contrasting with research that has found preference to influence efficacy of music

to reduce pain. However, the 'standard music' group were able to choose music from a

collection of tapes, maintaining some sense of control over environment, which has been

shown to play an important role in pain perception (Haythornthwaite, Menefee, Heinberg &

Clark, 1998; Mitchell & MacDonald, 2006). McCaffrey and Freeman (2003) document the

successful use of music to reduce pain caused by osteoarthritis. Participants either

listened to 20 minutes of researcher-chosen relaxing classical music (n=33), or sat quietly

for 20 minutes (n=33) over 14 days. The music group reported far less pain at post-test

than pre-test on all 3 days that measures were taken (days 1, 7 and 14), while the control

group reported about the same level of pain from pre-test to post-test. Music listening

resulted in steadily decreasing pain for the experimental group over the study, while the

control group remained at relatively the same level. Similar results in relation to pain in

dementia patients were found by Park (2010). 15 participants listened to self-chosen

preferred music for 30 minutes before peak agitation time for 2 days per week, followed by

no music for 2 weeks; the whole process was repeated once. Mean pain levels after music

listening were significantly lower than before listening, although pain levels were not

significantly lower during listening than before or afterwards. Lack of adequate measures

of painkillers during the study may have acted as a confounding variable, reducing the

validity of the study. Garza-Villarreal et al. (2014) found that patient chosen music,

screened by researchers to ensure a low number of beats per minute, reduced pain and

increased functional mobility in 21 fibromyalgia patients. Onieva-Zafra, Castro-Sánchez,

Matarán-Peñarrocha and Moreno-Lorenzo (2013) found similar results in a 4-week

longitudinal trial with 60 fibromyalgia patients, who were assigned to either a music

listening intervention group (listening to researcher-chosen classical and salsa music once

a day for 4 weeks) or a control group. The treatment group reported a significant reduction
 19

in pain and depression at week 4 compared with the control group, who reported no

differences in pain.

Music listening had been used to reduce pain in a number of clinical populations, but the

literature on this topic remains fragmented; studies cover a broad spectrum of clinical

conditions but make little attempt to replicate findings or build a comprehensive, accurately

documented picture of this complex research area (Mitchell et al., 2007).

 20

Music Therapy and Pain

What is music therapy?

Music as a form of therapy is historically established, but far from the speculative nature of

ancient theories surrounding music, body, mind and spirit, the last sixty years has seen

music therapy develop into a clinically applied form of professionally administered therapy

(Wigram, Pederson & Bond, 2002, p. 11 & 18). Music therapy aims to address both

physical and psychological factors of well-being, with obvious implications for it's use in

pain management (World Federation of Music Therapy, 2011). For example, music may

help to keep communication channels between patient, family, friends, therapist, and other

medical staff open, which seems vital considering the influence that psychosocial factors

have on the pain experience and the development of comorbid psychological disorders

(Ashburn & Staats, 1999, p. 1865; Turk & Okifuji, 2002, p. 678; Innes, 2005, p. 2).

Bailey (1986) writes that the goals of music therapy are to assist the patient in

"experiencing improved comfort and an improved sense of inner well-being" and "regaining

a sense of control and becoming actively involved in the management of his/her pain"

(p.25). Emphasis is on "the total pain experience" and the positive effects that music

therapy may have on anxiety, fear, depression, withdrawal, tension and other components

of pain (Bailey, 1986, p. 26). Music therapy is tailored to the patient, considering their

relationship with music, appropriateness of music to patient and mood, and their current

coping skills, allowing personal, satisfying and meaningful techniques to be developed for

use during pain experiences (Bailey, 1986, p. 26-27).

As mentioned previously, no clear line divides the literature on music listening and music

therapy in pain management, but Thaut and Wheeler's (2010) differentiation between

receptive and active music therapy is explanatory. Music listening is described as

receptive music therapy (like the "passive" music therapy described by Klassen et al.,
 21

2008) but it is also noted that music therapy requires verbal processing of feelings and

experiences (p. 820). The listening interventions discussed below are examples of

receptive music therapy due their use of interaction with a therapist.

Theoretical grounding for music therapy in pain management

As with music listening, the mechanisms of Melzack and Wall's (1965) Gate Control theory

of pain, alternatively referred to as the spinal mechanisms involved in the modulation of

pain, are often used to support the use of music therapy for pain relief (O'Callaghan 1996).

The basic principle remains: music is a source of distraction and a way to refocus attention

away from painful stimuli to something more pleasant, 'closing the gate' and inhibiting

transmission of pain signals. Other theories have, however, been used as a foundation for

it's use in pain management. Theoretical perspectives based on the psychological

relationship between music and pain (the ability for music to distract, reduce anxiety and

relax via the influence of psychological factors such as memories) the psychophysiological

theory (the role of distraction through cognitive coping strategies to reduce the amount of

attention available for processing painful stimuli) and the physiological effects of music are

also theoretically applicable, although distraction appears to be the fundamental factor for

three of the four main theoretical perspectives here (O'Callaghan, 1996).

Unless stated otherwise, and in accordance with the levels of intervention outlined by

(Bruscia, 1998), the studies discussed below use music therapy at an Augmentative level,

enhancing the efforts of other treatments and making supportive contributions to an overall

treatment plan (p. 90).

 22

What evidence is there to suggest that music therapy may be a useful tool in pain

management?

Although numerous music therapy models and interventions exist, limitations of this paper

only allow consideration of those that have been used explicitly as a tool in pain

management.

Live music and interactive music

In combination with therapeutic interaction, as in Walworth (2003), live music may

demonstrate the effectiveness of music to reduce stress and pain via distraction

(McGovern & Silverman, 2012). Madson and Silverman (2010) found significant decreases

in anxiety, pain, and nausea, and increases in relaxation levels in recovering adult

transplant patients after short (15-35 minutes) therapy sessions consisting of live patient-

preferred music and therapeutic social interaction; both patients and staff noted the

emotional benefits and enjoyment that the intervention brought (p. 228). Patient-preferred

live music was also used by Chaput-McGovern and Silverman (2012) in a study of 27

patients in a post-surgical oncology unit. The interventions lasted approximately 20

minutes, with a short intervention considered essential for patients prone to fatigue (p.

419). There were significant differences between pre- and post-test, and pre-test and

follow-up measures (taken 30-45 minutes after the post-test measures were taken),

indicating that live music listening was effective in improving dependent variables,

including pain levels. There was no significant difference between post- and follow-up

tests, suggesting that positive effects were lasting, although the lack of control group

means further research is needed to support such claims.

Live music therapy has also been used in the treatment of paediatric patients during

surgery. Barrera, Rykov and Doyle (2002) found that listening to chosen songs, singing,

song writing, improvising and playing instruments with patients and their family during
 23

stressful and potentially painful procedures (e.g. taking medication or dressing changes)

resulted in significant improvement in children’s feelings, including measures taken from a

simplified version of the faces pain scale, and behaviour (Bieri, Reeve, Champion,

Addicoat & Ziegler 1990). Caprilli, Anastasi, Grotto, Abeti and Messeri (2007) used

interactive music to treat pain and stress in children during venipuncture. 108 patients

either underwent the procedure while interacting with musicians in the presence of a

parent (with the aim being to create a relationship between therapist, child and parent), or

only with parent provided support. Distress was significantly lower in the music group than

the control group before, during, and after venipuncture (supporting Malone, 1986), and

pain was significantly lower than the control group following the procedure. The presence

and performance of musicians appeared to have a beneficial effect on distress and pain.

Over a three-month period, Krout (2001) used observation and subject self-reports of 80

critically ill patients receiving hospice care to consider the effects of active and passive live

music therapy on pain, comfort and relaxation. A number of techniques were used: music

listening for comfort and facilitating relaxation; live music with relaxation and imagery to aid

pain control; and use of song, discussion, and song-writing to provide opportunities to

reminiscence, express feelings and explore spiritually (p. 387). Interventions significantly

increased pain control, physical comfort, and relaxation, but a lack of clear explanation of

the therapeutic processes, the use of multiple combinations of therapeutic methods, and

the consequent lack of control over specific variables, are obvious limitations (p. 388).

Singing

Singing is used as part of many of the therapeutic procedures outlined in this chapter, but

it's individual therapeutic value should not be underestimated. Magill (2000) writes of the

natural association between the voice and nurturing, and the use of vocal techniques in

therapy to provide intimate contact and patient support. Lyrics may be used to meet
 24

particular emotional needs, and may be personalised to better engage the patient and

diminish feelings of isolation (Magill, 2000, p. 169). The therapeutic effects of singing have

been observed with various clinical populations, including sufferers of pulmonary

disorders, aphasia and other neurological disorders (Bonilha, Onofre, Vieira, Prado &

Martinezet, 2009; Schlaug, Marchina, & Norton, 2008; Wan, Rüber, Hohmann, & Schlaug,

2010), although few have considered the effects of singing alone on pain, using vocal-

based protocols, such as Song Adaptation and Therapeutic Singing, alongside other

therapeutic techniques (Prensner, Yowler, Smith, Steele & Fratianne, 2001; Barrera et al.,

2002).

Music-based imagery (MBI)

The most internationally renowned model of receptive music therapy is the Bonny Method

of Guided Imagery and Music (BMGIM) (Wigram, Pederson & Bonde, 2002, p. 155). GIM

is a process where imagery is evoked during music listening, which is sequenced to

support, generate and deepen experiences related to psychological and physiological

needs of patients, and to facilitate experiences of their life in imagery (Bonny, 1990). The

therapy is psychotherapeutic, aiming to help clients gain new insight into their world, needs

and life (Wigram, Pederson & Bond, 2002, p. 31). Early clinical use of GIM focused on

psychological disorders, trauma or anxiety (Hanks, 1985; Blake & Bishop, 1994; Maack,

2006), supported by experimental research into it's positive effects on mood and cortisol

levels (McKinney, Antoni, Kumar, Tims & McCabe, 1997), but evidence exists for it's

successful use in reducing pain and improving quality of life in hospice, cancer, and

rheumatoid arthritis patients (Rider, 1987; Skaggs, 1997; Burns, Harbuz, Hucklebridge &

Bunt, 2001; Bonde, 2004; Jacobi & Eisenberg, 1994).

Others have adopted musical imagery as a means for interactive and personalised music

making. Christenberry (1979) first proposed the use of music therapy in burns patients,
 25

and since then, a number of researchers have investigated the use of MBI protocols to

treat pain in burns victims. Fratianne et al. (2001) investigated the use of MBI and musical

alternate engagement (MAE) in assisting burn patients in managing pain and anxiety

during the debridement process. The intervention was used both before and after the

procedure. Patients provided references to images of relaxing and safe experiences,

which were used by the therapist to improvise song lyrics and were coached in rhythmic

deep breathing, used throughout the intervention; the music was slowed throughout, thus

slowing the speed of patients' breathing (entrainment). The MAE encouraged physically

engaging and participatory musical tasks during the procedure, ranging from active

listening to musical games (p. 50). The interventions significantly reduced patients’ pain

perceptions and objective measures of pain early in the debridement process, although

they seemed less effective during the most painful aspect of the procedure, supporting

other research that has found music to be less effective as the intensity of pain increases

(Whitehead-Pleaux, Zebrowski, Baryza & Sheridan, 2007). Tan, Yowler, Super and

Fratianne (2010) also used MBI and MAE during dressing changes in burn patients,

finding significant decreases in self-reported levels of pain and anxiety before, during, and

after dressing changes on music therapy days, compared to control days. Decreases in

objective measures of anxiety (muscle tension) during and after changes were also found,

along with evidence of positive effects on patients' coping mechanisms outside the

intervention (p. 52). Gutgsell et al. (2012) investigated the effects of single session music-

imagery interventions, aimed at accessing patients' "safe place" through the use of live

harp music, alongside therapist-led relaxation and muscle relaxation. (p. 825). In a sample

of palliative care patients, a significantly greater decrease in numeric rating-scale pain

scores, and mean changes in the Functional Pain Scale were seen in the music therapy

group compared to a control group. Used alongside relaxation techniques, music-imagery

proved helpful in reducing pain, but not all research has supported such findings. Albert
 26

(2001) investigated the effectiveness of guided imagery and music on physiological

(sensory) and psychological (affective) components of pain and anxiety in 84 patients

undergoing laceration repair. No significant effects on pain were found between the

therapy group and the control group, despite 81% of patients reporting that the intervention

was slightly to very beneficial, and 71% stating that they would use it again during

procedures. The evidence appears contradictory.

Music-assisted relaxation

Relaxation techniques are recognised as an important tool in the management of pain

(Syrjala, Donaldson, Davis, Kippes & Carr, 1995; Schaffer & Yucha, 2004; Smith, Levett,

Collins & Crowther, 2011). In light of music's ability to relax and reduce anxiety, it is

unsurprising that therapeutic protocols have developed surrounding this fact. Pfaff, Smith

and Gowan (1989) carried out a small-scale study of 6 paediatric cancer patients

undergoing bone marrow aspirations to consider the effects of music-assisted relaxation

on fear, pain, and behavioural distress. Results indicated strong trends for reduction in

anticipatory and experienced fear, experienced pain, and anticipatory behavioural distress.

A similar study by Sahler, Hunter and Liesveld (2003) used combined music therapy and

relaxation imagery on patients undergoing bone marrow transplantation. The experimental

group (N=23) received 45 minutes of therapy twice weekly from the day of enrolment to

discharge, whilst the control group (N=19) did not. Therapy involved movement to a beat,

playing along with music, imitation and improvisation, and a 20 minute period of music

assisted relaxation. Significant decreases in self-reported nausea and pain were found

between pre- and post-test measures, and time-to-engraftment (transplant 'acceptance')

was lower in the experimental group than the control group. These promising results were

found despite the limitation that interventions began, on average, 5 days after

transplantation, meaning that effectiveness in modulation of stress may have been

 27

reduced. Unfortunately, no comparisons of pain or nausea were made between the two

groups.

Vibroacoustic therapy (VA)

Whilst VA therapy is based more on sound technology than therapeutic processes of

patient-therapist interaction, Hooper (2002) concludes that VA therapy adheres to

Bruschia’s criteria that music therapy must have a systematic intervention, a therapeutic

relationship, and a musical experience, and is therefore music therapy. The therapy is

passive and involves the application of frequency pitches directly to the patient, allowing

vibrations to be felt through the body. (Prensner et al., 2001). Music/sound may be pulsed

and combined with relaxing music, and low frequencies are most strongly felt (Wigram,

Pederson & Bonde, 2002, p. 140; Boyd-Brewer and McCaffrey, 2004). VA therapy has

successfully been used to treat pain, muscular, pulmonary, and psychological conditions,

and general physical ailments, although results have rarely been replicated and are more

anecdotal than statistically supported (Wigram, Pederson & Bonde, 2002, p.140).

Chesky (1992) found that VA frequencies of 60 Hz to 600 Hz provided optimal pain relief

for rheumatoid arthritis, supported by the discovery that these frequencies are known to

stimulate Pacinian corpuscles, nerve endings that mediate pain sensations (Boyd-Brewer

and McCaffrey, 2004), whilst Lundeberg (1983) concluded that relief of pain was greater

when VA therapy was applied close to the site of pain. Burke and Thomas (1997) found

that VA therapy reduced pain during knee replacements and both Burke (1994) and

Walters (1996) found similar successful results in the pain management of gynaecological

surgery patients although Walters (1996) failed to measure pain specifically, noting only

the decrease in time spent in post-anaesthesia care. Patrick (1999) found that a pre-

session orientation with guided relaxation, and a VA session, resulted in a cumulative

reduction of pain and symptoms by 53% in 272 patients with various conditions (including
 28

cancer and heart, lung, and blood disorders), whilst Butler and Butler (1997) found that VA

therapy following cardiovascular surgery led to use of shorter-acting anaesthetics and a

decrease in sedative and pain medications, as well as significant decreases in average

ventilator-dependent time and time spent in Intensive Care.

Over 40 years after VA therapy was first developed (Punkanen & Ala-Ruona, 2012, p.

128), Boyd-Brewer and McCaffrey (2004) wrote that VA research is still in its infancy (p.

114). Recent studies have found VA therapy to be effective in various clinical settings,

influencing objective measures of blood pressure and pulse rate, subjective feelings of

health and comfort (Rüütel, 2002), and finding use in the treatment of neurophysiological

disorders (Bergström-Isacsson & Witt-Engerström, 2007; Bergström-Isacsson , 2011).

However, contemporary large-scale, well-designed, and carefully documented studies are

still needed to explain the specific benefits, and/or recommend treatment protocols of VA

therapy in pain reduction (Punkanen & Ala-Ruona, 2012, p. 131).

Comparisons of music therapy interventions

Thus far, Colwell, Edwards, Hernandez and Brees (2013) is the only study to compare the

efficacy of different music therapy interventions on pain. The impact of listening,

composition and Orff-based music therapy (active music making including speech, singing,

movement and instrument playing) on various measures, including pain, in 32 hospitalized

children was investigated (p. 251). Interventions lasted up to 45 minutes and were given

the theme, All About Me. The listening intervention used music, chosen from a set of CDs

loaded onto an iPod, with encouragement from the therapist to discuss musical choices. In

the composition condition, patients created an instrumental composition, a title and jacket

cover with a short description of why the music represented the theme. The Orff-based

therapy involved a rhythmic reading of the book Hooray for You! A Celebration of You-

ness (Richmond, 2004). Patients made choices about musical activities and answered
 29

questions about themselves, which were chanted in refrain. Each of the conditions showed

only a slight decrease in perceived pain from pre- to post-test, although significant

decreases from pre- to post-test were found when the conditions were combined; the

greatest decrease (1 on a 10-point scale) was evident in the listening condition. The small

sample may have been problematic and more extensive comparative studies are required.
 30

Conclusion

Interest in alternatives to pharmacological interventions for pain management has grown

substantially during the past two decades, and there is growing evidence that various

means of reducing pain through distraction, including use of electronic gaming, may be

effective (Magora, Cohen, Shochina & Dayan, 2006; Jameson, Trevena & Swain, 2011),

supporting Melzack and Wall's (1965) Gate Control theory of pain. Music may alter the

sensation of pain itself, and the emotional factors of pain, reflecting music's ability to affect

both psychologically and physiologically change in individuals (Mitchell et al., 2007;

Schäfer et al., 2013; Blood & Zatorre, 2001).

Music listening (Phumdoung & Good, 2003; Zengin, et al., 2013; Huang et al., 2010), and

music therapy (Sahler et al., 2003; Tan, et al., 2010; Prensner et al., 2001) have been

found to provide effective reduction of pain in a number of medical settings as low-cost

and adjunctive interventions (Kemper, 2005). However, methodological limitations in this

area of research are a concern (Bernatzky, Presch, Anderson& Panksepp, 2011). A meta-

analysis by Michel and Chesky (1995) pointed to a lack of randomisation, reliance on

indirect and unreliable measurement of pain, the presence of too many uncontrolled

variables, and low replicability due to a lack of specificity about musical stimuli (p. 49).

More recently, Rayen (2013) noted that a there is still no definitive conclusion about the

efficacy of music therapy in pain management due to the low quality and poor

standardisation of the research thus far. More detailed methodological considerations and

comparisons are required to establish which musical interventions may be most successful

in easing different types of pain, for various populations of pain sufferers. Further large-

scale research is necessary to progress towards a more comprehensive understanding of

the medical and palliative applications of music and music therapy.

Word count: 8, 363.

 31

References

Aitken, J. C., Wilson, S., Coury, D., & Moursi, A. M. (2002). The effect of music distraction
on pain, anxiety and behavior in pediatric dental patients. Pediatric dentistry, 24(2),
114-118.

Akombo, D. O. (2006). Effects of listening to music as an intervention for pain and anxiety

in bone marrow transplant patients (Doctoral dissertation, University of Florida).

Albert, R. E. (2001). The effect of guided imagery and music on pain and anxiety during
laceration repair (Doctoral dissertation, Case Western Reserve University, Ohio).

Altenmüller, E., & Schlaug, G. (2013). Neurologic music therapy: The beneficial effects of
music making on neurorehabilitation. Acoustical Science and Technology, 34(1), 5-
12.

American Music Therapy Association (2012). Definition and Quotes about Music Therapy.
Retrieved from http://www.musictherapy.org/about/quotes/

Anderson, R. A., Baron, R., & Logan, H. (1991). Distraction, Control, and Dental
Stress1. Journal of Applied Social Psychology, 21(2), 156-171.

Ashburn, M. A., & Staats, P. S. (1999). Management of chronic pain. The Lancet,
353(9167), 1865-1869.

Bailey, L. M. (1986). Music therapy in pain management. Journal of Pain and Symptom
Management 1(1), 25-28.

Barnes, P. M., Powell-Griner, E., McFann, K., & Nahin, R. L. (2004). Complementary and
alternative medicine use among adults: United States, 2002. Seminars in Integrative
Medicine 2(2), 54-71.

Barrera, M. E., Rykov, M. H., & Doyle, S. L. (2002). The effects of interactive music
therapy on hospitalized children with cancer: a pilot study. Psycho‐Oncology, 11(5),
379-388.

Batt-Rawden K. B., DeNora, T., Ruud, E. (2009). Music listening and empowerment in
health promotion: A study of the role and significance of music in everyday life of the
long-term ill. Nordic Journal of Music Therapy, 14(2),120-36.
 32

Batt-Rawden, K., & DeNora, T. (2005). Music and informal learning in everyday life. Music
Education Research, 7, 289-304.

Behrens, B. J., & Michlovitz, S. L. (2005). Tissue response to injury. In Physical agents:

theory and practice. Philadelphia: F. A. Davis.

Bergström-Isacsson, M. (2011). Music and vibroacoustic stimulation in people with Rett

syndrome: A neurophysiological study (Doctoral dissertation). Aalborg University,
Denmark.

Bergström-Isacsson, M., Julu, P. O., & Witt-Engerström, I. (2007). Autonomic responses to

music and vibroacoustic therapy in Rett Syndrome: A controlled within–subject
study. Nordic Journal of Music Therapy, 16(1), 42-59.

Bernardi, L., Porta, C., Casucci, G., Balsamo, R., Bernardi, N. F., Fogari, R., & Sleight, P.
(2009). Dynamic interactions between musical, cardiovascular, and cerebral
rhythms in humans. Circulation, 119(25), 3171-3180.

Bernatzky, G., Presch, M., Anderson, M., & Panksepp, J. (2011). Emotional foundations of
music as a non-pharmacological pain management tool in modern medicine.
Neuroscience & Biobehavioral Reviews, 35(9), 1989-1999.

Bhagania, M., & Agnihotry, A. (2011). Extraction of a Grossly Decayed Tooth Without
Local Anesthesia But With Audio Analgesia A Case Report. Music and
Medicine, 3(4), 280-282.

Bieri, D., Reeve, R. A., Champion, G. D., Addicoat, L., & Ziegler, J. B. (1990). The Faces
Pain Scale for the self-assessment of the severity of pain experienced by children:
development, initial validation, and preliminary investigation for ratio scale
properties. Pain, 41(2), 139-150.

Binns-Turner, P. G., Wilson, L. L., Pryor, E. R., Boyd, G. L., & Prickett, C. A. (2011).
Perioperative music and its effects on anxiety, hemodynamics, and pain in women
undergoing mastectomy. AANA journal, 79(4).

Birnie, K. A., Caes, L., Wilson, A. C., Williams, S. E., & Chambers, C. T. (2014). A practical
guide and perspectives on the use of experimental pain modalities with children and
adolescents. Pain Management, 4(2), 97-111.
 33

Bishop, S. R., Lau, M., Shapiro, S., Carlson, L., Anderson, N. D., Carmody, J., Segal, Z.,
Abbey, S., Speca, M., Velting, D., & Devins, G. (2004). Mindfulness: A proposed
operational definition. Clinical psychology: Science and practice, 11(3), 230-241.

Blake, R. L. & Bishop, S. R. (1994).The Bonny method of guided imagery and music (GIM)
in the treatment of post-traumatic stress disorder (PTSD) with adults in the
psychiatric setting. Music Therapy Perspectives, 12(2), 125-129.

Blood, A. J., & Zatorre, R. J. (2001). Intensely pleasurable responses to music correlate
with activity in brain regions implicated in reward and emotion. Proceedings of the
National Academy of Sciences, 98(20), 11818-11823.

Bonde, L. O. (2004). The Bonny Method of Guided Imagery and Music (BMGIM) with
cancer survivors: A psychosocial study with focus on the influence of BMGIM on
mood and quality of life. (Unpublished doctoral dissertation). Aalborg University,
Denmark

Bonilha, A. G., Onofre, F., Vieira, M. L., Prado, M. Y. A., & Martinez, J. A. B. (2009).
Effects of singing classes on pulmonary function and quality of life of COPD
patients. International Journal of Chronic Obstructive Pulmonary Disease, 15(4), 1-
8.

Bonny, H. (1990). Music and change. Journal of the New Zealand Society for Music
Therapy, 12(3), 5-10.

Bovill, J. G. (1997). Mechanisms of actions of opioids and non-steroidal anti-inflammatory

drugs. European Journal of Anaesthesiology, 14, 9-15.

Boyd-Brewer, C., & McCaffrey, R. (2004). Vibroacoustic sound therapy improves pain
management and more. Holistic nursing practice, 18(3), 111-118.

Bruscia, K. E. (1988). A survey of treatment procedures in improvisational music therapy.

Psychology of Music, 16(1), 10-24.

Bulfone, T., Quattrin, R., Zanotti, R., Regattin, L., & Brusaferro, S. (2009). Effectiveness of
music therapy for anxiety reduction in women with breast cancer in chemotherapy
treatment. Holistic nursing practice, 23(4), 238-242.
 34

Burgess, P. R., & Perl, E. R. (1967). Myelinated afferent fibres responding specifically to
noxious stimulation of the skin. Journal of Physiology, 190(3), 541-562.

Burke, M. (1994). The effects of physioacoustic interventions on pain management of post-

operative gynecological patients. (Unpublished Master's Thesis). University of North
Carolina at Chapel Hill, North Carolina.

Burke, M., & Thomas, K. (1997). Use of physioacoustic therapy to reduce pain during
physical therapy for total knee replacement patients over age 55. In T. Wigram and
C. Dileo (Eds.), Music Vibration and Health (99-106). New Jersey: Jeffrey Books.

Burns, S. J., Harbuz, M. S., Hucklebridge, F., & Bunt, L . (2001). A pilot study into the
therapeutic effects of music therapy at a cancer help centre. Alternative therapies in
health and medicine, 7(1), 48-56.

Butler, C. and Butler , C.J. (1997) Physioacoustic Therapy with Cardiac surgery patients.
In Wigram, T. and Dileo, C. (Eds.) Music Vibration and Health (197-204). New
Jersey: Jeffrey Books.

Byers, J. F., & Smyth, K. A. (1997). Effect of a music intervention on noise annoyance,
heart rate, and blood pressure in cardiac surgery patients.American Journal of
Critical Care, 6(3), 183-191.

Caprilli, S., Anastasi, F., Grotto, R. P. L., Abeti, M. S., & Messeri, A. (2007). Interactive
music as a treatment for pain and stress in children during venipuncture: a
randomized prospective study. Journal of Developmental & Behavioral
Pediatrics, 28(5), 399-403.

Cassileth, B., & Gubili, J. (2010). Complimentary Therapies for Pain Management. in A.
Kopf & N. B. Patel (Eds.), Guide to pain management in low-resource settings (pp.
59-64). International Association for the Study of Pain.

Chaput-McGovern, J., & Silverman, M. J. (2012). Effects of music therapy with patients on
a post-surgical oncology unit: A pilot study determining maintenance of immediate
gains. The Arts in Psychotherapy, 39(5), 417-422.

Chesky, K. S. (1992). The effects of music and music vibration using the MVTTM on the
relief of rheumatoid arthritis pain (Doctoral dissertation) University of North Texas,
North Texas.
 35

Christenberry, E. B. (1978). The use of music therapy with burn patients. Journal of Music
Therapy, 16(3), 138-148.

Clark, M., Isaacks-Downton, G., Wells, N., Redlin-Frazier, S., Eck, C., Hepworth, J. T., &
Chakravarthy, B. (2006). Use of preferred music to reduce emotional distress and
symptom activity during radiation therapy. Journal of Music Therapy, 43(3), 247-
265.

Coghill, R. (2011). Individual differences in the subjective experience of pain: New insights
into mechanisms and models. Headache, 50(9),1531-1535.

Cole, L. C. & LoBiondo-Wood, G. (2014). Music as an adjuvant therapy in control of pain

and symptoms in hospitalized adults: a systematic review. Pain Management
Nursing, 15(1), 406-25.

Colwell, C. M., Edwards, R., Hernandez, E., & Brees, K. (2013). Impact of music therapy
interventions (listening, composition, orff-based) on the physiological and
psychosocial behaviors of hospitalized children: a feasibility study. Journal of
Paediatric Nursing, 28(3), 249-257.

Cusens, B., Duggan, G. B., Thorne, K., & Burch, V. (2010). Evaluation of the breathworks
mindfulness‐based pain management programme: effects on well‐being and
multiple measures of mindfulness. Clinical psychology & psychotherapy, 17(1), 63-
78.

Davis, M. P., Walsh, D., Lagman, R., & LeGrand, S. B. (2005). Controversies in
pharmacotherapy of pain management. The Lancet Oncology, 6(9), 696-704.

De Tommaso, M., Calabrese, R., Vecchio, E., De Vito Francesco, V., Lancioni, G., &
Livrea, P. (2009). Effects of affective pictures on pain sensitivity and cortical
responses induced by laser stimuli in healthy subjects and migraine
patients. International Journal of Psychophysiology, 74(2), 139-148.

De Wied, M., & Verbaten, M. N. (2001). Affective pictures processing, attention, and pain
tolerance. Pain, 90(1), 163-172.

Doak, B. A. (2003). Relationships between adolescent psychiatric diagnoses, music

preferences, and drug preferences. Music Therapy Perspectives, 21(2), 69-76.
 36

Ebneshahidi, A., & Mohseni, M. (2008). The effect of patient-selected music on early
postoperative pain, anxiety, and hemodynamic profile in cesarean section surgery.
The Journal of Alternative and Complementary Medicine, 14(7), 827-831.

Elkins, G., Jensen, M. P., & Patterson, D. R. (2007). Hypnotherapy for the management of
chronic pain. Intl. Journal of Clinical and Experimental Hypnosis, 55(3), 275-287.

Evers, S., & Suhr, B. (2000). Changes of the neurotransmitter serotonin but not of
hormones during short time music perception. European archives of psychiatry and
clinical neuroscience, 250(3), 144-147.

Filcheck, H. A., Allen, K. D., Ogren, H., Darby, J. B., Holstein, B., & Hupp, S. (2005). The
use of choice-based distraction to decrease the distress of children at the
dentist. Child & family behavior therapy, 26(4), 59-68.

Fratianne, R. B., Prensner, J. D., Huston, M. J., Super, D. M., Yowler, C. J., & Standley, J.
M. (2001). The effect of music-based imagery and musical alternate engagement on
the burn debridement process. Journal of Burn Care & Research, 22(1), 47-53.

Gabrielsson A. (2011). Music as therapy. In Strong Experiences With Music (209-221).

Oxford: Oxford University Press.

Gardner, W. J., Licklider, J. C. R., & Weisz, A. Z. (1960). Suppression of pain by sound.
Science, 132(3418), 32-33.

Gardner-Nix, J. (2009). Mindfulness-based stress reduction for chronic pain management.

In Clinical handbook of mindfulness (pp. 369-381). New York: Springer.

Garza-Villarreal, E. A., Brattico, E., Vase, L., Ostergaard, L., & Vuust, P. (2012). Superior
analgesic effect of an active distraction versus pleasant unfamiliar sounds and
music: The influence of emotion and cognitive style. PLOS ONE 7(1), 1-8.

Garza-Villarreal, E. A., Wilson, A. D., Vase, L., Brattico, E., Barrios, F. A., Jensen, T. S.,
Juan Ignacio Romero-Romo, & Vuust, P. (2014). Music reduces pain and increases
functional mobility in fibromyalgia. Frontiers in Psychology, 5(90), 1-21.

Gerra, G., Zaimovic, A., Franchini, D., Palladino, M., Giucastro, G., Reali, N., Maestri, D.,
Caccavari, R., Delsignore, R., & Brambilla, F. (1998). Neuroendocrine responses of
healthy volunteers totechno-music': relationships with personality traits and
emotional state. International Journal of Psychophysiology, 28(1), 99-111.
 37

Giordano, J., Abramson, K., & Boswell, M. V. (2010). Pain assessment: subjectivity,
objectivity, and the use of neurotechnology. Part one: Practical and ethical
issues. Pain Physician, 13(4), 305-15.

Good, M., Anderson, G. C., Ahn, S., Cong, X., & Stanton‐Hicks, M. (2005). Relaxation and
music reduce pain following intestinal surgery. Research in nursing & health, 28(3),
240-251.

Good, M., Anderson, G. C., Stanton-Hicks, M., Grass, J. A., & Makii, M. (2002). Relaxation
and music reduce pain after gynecologic surgery. Pain Management Nursing, 3(2),
61-70.

Graversen, M., & Sommer, T. (2013). Perioperative music may reduce pain and fatigue in
patients undergoing laparoscopic cholecystectomy. Acta Anaesthesiologica
Scandinavica, 57(8), 1010-1016.

Gutgsell, K. J., Schluchter, M., Margevicius, S., DeGolia, P. A., McLaughlin, B., Harris, M.,
Mecklenburg J., & Wiencek, C. (2012). Music therapy reduces pain in palliative care
patients: A randomized controlled trial. Journal of Pain and Symptom Management,
45(5), 822-831.

Hamel, W. J. (2001). The effects of music intervention on anxiety in the patient waiting for
cardiac catheterization. Intensive and Critical Care Nursing, 17(5), 279-285.

Hanks, K. (1985). The therapeutic use of music and imagery. Unpublished manuscript.

Hartsock, J. W. (1982). The effects of music on levels of depression in orthopaedic

patients on prolonged bed rest (Doctoral dissertation). University of Iowa, Iowa.

Hassett, A. L., & Gevirtz, R. N. (2009). Nonpharmacologic treatment for fibromyalgia:

patient education, cognitive-behavioural therapy, relaxation techniques, and
complementary and alternative medicine. Rheumatic Disease Clinics of North
America, 35(2), 393-407.

Haythornthwaite, J. A., Menefee, L. A., Heinberg, L. J., & Clark, M. R. (1998). Pain coping
strategies predict perceived control over pain. Pain, 77(1), 33-39.

Hekmat, H. M., & Hertel, J. B. (1993). Pain attenuating effects of preferred versus non-
preferred music interventions. Psychology of Music, 21(2), 163-173.
 38

Hooper, J. (2002). Is VA therapy, music therapy. Music Therapy Today, 26, 1-24.

Huang, S. T., Good, M., & Zauszniewski, J. A. (2010). The effectiveness of music in
relieving pain in cancer patients: a randomized controlled trial. International journal
of nursing studies, 47(11), 1354-1362.

Innes, S. I. (2005). Psychosocial factors and their role in chronic pain: A brief review of
development and current status. Chiropractic & Osteopathy, 13(6), 1-5.

Jacobi, E., & Eisenberg, G. (1994). The efficacy of the Bonny Method of guided imagery
and music (GIM) as experiential therapy in the primary care of persons with
rheumatoid arthritis. Paper presented at the Association for Music and Imagery
Conference, Little Switzerland, North Carolina.

Jacobson, A. F. (1999). Intradermal normal saline solution, self-selected music, and

insertion difficulty effects on intravenous insertion pain. Heart & Lung: The Journal
of Acute and Critical Care, 28(2), 114-122.

Jameson, E., Trevena, J., & Swain, N. (2011). Electronic gaming as pain distraction. Pain
Research & Management: The Journal of the Canadian Pain Society, 16(1), 27.

Kabat-Zinn, J. (1982). An outpatient program in behavioral medicine for chronic pain

patients based on the practice of mindfulness meditation: Theoretical considerations
and preliminary results. General hospital psychiatry, 4(1), 33-47.

Kaliyaperumal & Subash (2010). Effect of music therapy for patients with cancer pain.
International Journal of Biological and Medical Research, 1(3), 79-81.

Kemper, K. J., & Danhauer, S. C. (2005). Music as therapy. Southern Medical Journal,
98(3), 282-288.

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.

Knight, W. E., & Rickard, N. S. (2001). Relaxing music prevents stress-induced increases
in subjective anxiety, systolic blood pressure, and heart rate in healthy males and
females. Journal of music therapy, 38(4), 254-272.
 39

Krout, R. E. (2001). The effects of single-session music therapy interventions on the

observed and self-reported levels of pain control, physical comfort, and relaxation of
hospice patients. American Journal of Hospice and Palliative Medicine, 18(6), 383-
390.

Krout, R. E. (2007). Music listening to facilitate relaxation and promote wellness:

Integrated aspects of our neurophysiological responses to music. The arts in
Psychotherapy, 34(2), 134-141.

Laukka, P. (2007). Uses of music and psychological well-being among the elderly. Journal
of Happiness Studies, 8(2), 215-241.

Lee, O. K. A., Chung, Y. F. L., Chan, M. F., & Chan, W. M. (2005). Music and its effect on
the physiological responses and anxiety levels of patients receiving mechanical
ventilation: a pilot study. Journal of Clinical Nursing, 14(5), 609-620.

Li, Y., & Dong, Y. (2012). Preoperative Music Intervention for Patients Undergoing
Cesarean Delivery. Obstetric Anesthesia Digest, 33(4), 221-222.

Lichtenberg, P., Bachner-Melman, R., Ebstein, R. P., & Crawford, H. J. (2004). Hypnotic
susceptibility: Multidimensional relationships with Cloninger’s Tridimensional
Personality Questionnaire, COMT polymorphisms, absorption, and attentional
characteristics. International Journal of Clinical and Experimental Hypnosis, 52(1),
47-72.

Linton, S. & Shaw, W. (2011). Impact of psychological factors in the experience of

pain. Physical therapy, 91(5), 700-711.

Lundeberg, T. C. (1983). Vibratory stimulation for the alleviation of chronic pain. Acta
physiologica Scandinavica. Supplementum, 523, 1-51.

Lynch, M. E. & Watson, C. P. N. (2006). The pharmacotherapy of chronic pain: A review,

Pain Research & Management: The Journal of the Canadian Pain Society, 11(1),
11-38.

Maack, C. (2006). The Bonny Method of Guided Imagery and Music (BMGIM) and its
Adaptations in Psychotherapy for Patients with Complex Posttraumatic Stress
Disorder. Proceeding from the Australasian Music & Imagery Conference, New
Zealand: Auckland.
 40

Madson, A. T., & Silverman, M. J. (2010). The effect of music therapy on relaxation,
anxiety, pain perception, and nausea in adult solid organ transplant patients.
Journal of Music Therapy, 47(3), 220-232.

Magill, L. (2000). The use of music therapy to address the suffering in advanced cancer
pain. Journal of palliative care, 17(3), 167-172.

Magora, F., Cohen, S., Shochina, M., & Dayan, E. (2006). Virtual reality immersion method
of distraction to control experimental ischemic pain. The Israel Medical
Association Journal, 8(4), 261.

Malone, A. B. (1996). The effects of live music on the distress of pediatric patients
receiving intravenous starts, venipunctures, injections, and heel sticks.Journal of
Music Therapy, 33(1), 19-33.

McCaffrey, R., & Freeman, E. (2003). Effect of music on chronic osteoarthritis pain in older
people. Journal of advanced nursing, 44(5), 517-524.

McGrady, A. (2008). 'Biofeedback'. In M. I. Weintraub, M. & R. Mamtani & M., Micozzi

(Eds.), Complementary and integrative medicine in pain management (pp. 5-27).
New York: Springer.

McGuire, D. B. (1984). The measurement of clinical pain. Nursing Research,33(3), 152-

156.

McKinney, C. H., Antoni, M. H., Kumar, M., Tims, F. C., & McCabe, P. M. (1997). Effects
of guided imagery and music (GIM) therapy on mood and cortisol in healthy adults.
Health Psychology, 16(4), 390-400.

Melzack, R., Weisz, A. Z., & Sprague, L. T. (1963). Stratagems for controlling pain:
contributions of auditory stimulation and suggestion. Experimental Neurology, 8(3),
239-247.

Melzack R., & Wall P. D. (1995). Pain mechanisms: A new theory. Science, 150(699), 971-
979.

Melzack, R., & Wall, P. D. (1996). The Challenge of Pain. London: Penguin.
 41

Menegazzi, J. J., Paris, P. M., Kersteen, C. H., Flynn, B., & Trautman, D. E. (1991). A
randomized, controlled trial of the use of music during laceration repair. Annals of
emergency medicine, 20(4), 348-350.

Michel D. E., & Chesky K. S. (1995). A survey of music therapists using music for pain
relief. Arts in Psychotherapy, 23(1), 49-51.

Miles, E. (1997). Tune your brain: Using music to manage your mind, body, and mood.
Lincoln, Nebraska: iUniverse.

Mitchell, L. A., & MacDonald R. (2006). An experimental investigation of the effects of

preferred and relaxing music listening on pain perception. Journal of Music Therapy,
43(4), 295-316.

Mitchell, L. A., & MacDonald, R. (2012). 'Music and pain: Evidence from experimental
perspectives'. In R. MacDonald, G. Kreutz, & L. Mitchell (Eds.), Music, Health and
Wellbeing (pp. 230-238). Oxford: Oxford University Press.

Mitchell, L. A., MacDonald, R. A., & Brodie, E. E. (2006). A comparison of the effects of
preferred music, arithmetic and humour on cold pressor pain. European Journal of
Pain, 10(4), 343-343.

Mitchell, L. A., MacDonald, R. A., Knussen, C., & Serpell, M. G. (2007). A survey
investigation of the effects of music listening on chronic pain. Psychology of Music,
35(1), 37-57.

Moayedi, M., & Davis, K. D. (2013). Theories of pain: From specificity to gate
control. Journal of neurophysiology, 109(1), 5-12.

Moore-Groarke, G. (2005). Cognitive behavioural therapy for chronic pain. Irish

Psychiatrist, 6(4), 1-2.

Morone, N. E., Greco, C. M., & Weiner, D. K. (2008). Mindfulness meditation for the
treatment of chronic low back pain in older adults: A randomized controlled pilot
study. Pain, 134(3), 310-319.

NHS. (n.d.). Complementary and alternative medicine (CAM). Retrieved from

http://www.nhscareers.nhs.uk/explore-by-career/wider-healthcare-team/careers-in-
the-wider-healthcare-team/clinical-support-staff/complementary-and-alternative-
medicine-(cam)/
 42

Nilsson, U., Rawal, N., Enqvist, B., & Unosson, M. (2003). Analgesia following music and
therapeutic suggestions in the PACU in ambulatory surgery; a randomized
controlled trial. Acta Anaesthesiologica Scandinavica, 47(3), 278-283.

Nilsson, U., Unosson, M., & Rawal, N. (2005). Stress reduction and analgesia in patients
exposed to calming music postoperatively: a randomized controlled trial. European
journal of anaesthesiology, 22(2), 96-102.

O’Callaghan, C. C. (1996). Pain, music creativity and music therapy in palliative

care. American Journal of Hospice and Palliative Medicine, 13(2), 43-49.

Onieva-Zafra, M. D., Castro-Sánchez, A. M., Matarán-Peñarrocha, G. A., & Moreno-

Lorenzo, C. (2013). Effect of music as nursing intervention for people diagnosed
with fibromyalgia. Pain Management Nursing, 14(2), 39-46.

Park, H. (2010). Effect of music on pain for home-dwelling persons with dementia. Pain
Management Nursing, 11(3), 141-147.

Patrick, G. (1999). The effects of vibroacoustic music on symptom reduction: Inducing the
Relaxation Response through Good Vibrations. Engineering in Medicine and
Biology Magazine, IEEE, 18(2), 97-100.

Penman, J., & Becker, J. (2009). Religious ecstatics," deep listeners," and musical
emotion. Empirical Musicology Review, 4(2), 49-70.

Pfaff, V. K., Smith, K. E., & Gowan, D. (1989). The effects of music-assisted relaxation on
the distress of paediatric cancer patients undergoing bone marrow
aspirations. Children's Health Care, 18(4), 232-236.

Phumdoung, S., & Good, M. (2003). Music reduces sensation and distress of labour
pain. Pain Management Nursing, 4(2), 54-61.

Pothoulaki, MacDonald, Flowers, Stamataki, Filiopoulos, Stamatiadis, & Stathakis (2008).

An investigation of the effects of music on anxiety and pain perception in patients
undergoing haemodialysis treatment. Journal of health psychology, 13(7), 912-920.

Prensner, J. D., Yowler, C. J., Smith, L. F., Steele, A. L., & Fratianne, R. B. (2001). Music
therapy for assistance with pain and anxiety management in burn treatment. Journal
of Burn Care & Research, 22(1), 83-88.
 43

Punkanen, M., & Ala-Ruona, E. (2012). Contemporary Vibroacoustic Therapy

Perspectives on Clinical Practice, Research, and Training. Music and Medicine,4(3),
128-135.

Quartana, P. J., Campbell, C. M., & Edwards, R. R. (2009). Pain catastrophizing: a critical
review. Expert Review of Neurotherapeutics, 9(5): 745-758.

Rayen, A. 'Octave’ analgesia. (2013). Pain News, 11(1), 27-29.

Ricciotti, E., & FitzGerald, G. A. (2011). Prostaglandins and inflammation. Arteriosclerosis,

Thrombosis, and Vascular Biology, 31(5), 986-1000.

Richmond, M. (2006). Hooray for You!: A celebration of you-ness. Minneapolis: Marianne

Richmond Studios, Inc.

Rickard, N. S. (2004). Intense emotional responses to music: A test of the physiological

arousal hypothesis. Psychology of Music, 32(4), 371-388.

Rider, M. S. (1987). Treating chronic disease and pain with music-mediated imagery. The
Arts in Psychotherapy, 14(2), 113-120.

Roberts, L. (2013). Breathworks Pilot in the NHS. Retrieved from http://www.breathworks-

mindfulness.org.uk/blog/entry/breathworks-pilot-in-the-nhs

Rosemann, T., Wensing, M., Joest, K., Backenstrass, M., Mahler, C., & Szecsenyi, J.
(2006). Problems and needs for improving primary care of osteoarthritis patients:
the views of patients, general practitioners and practice nurses. BMC
musculoskeletal disorders, 7(1), 48.

Roy, M., Peretz, I., & Rainville, P. (2008). Emotional valence contributes to music-induced
analgesia. Pain, 134(1), 140-147.

Rüütel, E. (2002). The psychophysiological effects of music and vibroacoustic stimulation.

Nordic Journal of Music Therapy, 11(1), 16-26.

Saarikallio, S., & Erkkilä, J. (2007). The role of music in adolescents' mood
regulation. Psychology of Music, 35(1), 88-109.

Saarikallio, S. (2011). Music as emotional self-regulation throughout adulthood.

Psychology of music, 39(3), 307-327.
 44

Sagheer, M. A., Khan, M. F., & Sharif, S. (2013). Association between chronic low back
pain, anxiety and depression in patients at a tertiary care centre. The Journal of the
Pakistan Medical Association, 63(6), 688-690.

Sahler, O. J., Hunter, B. C., & Liesveld, J. L. (2002). The effect of using music therapy with
relaxation imagery in the management of patients undergoing bone marrow
transplantation: a pilot feasibility study. Alternative therapies in health and
medicine, 9(6), 70-74.

Salimpoor, V. N., Benovoy, M., Larcher, K., Dagher, A., & Zatorre, R. J. (2011).
Anatomically distinct dopamine release during anticipation and experience of peak
emotion to music. Nature neuroscience, 14(2), 257-262.

Schäfer, T., Sedlmeier, P., Städtler, C., & Huron, D. (2013). The psychological functions of
music listening. Frontiers in psychology, 4(511), 1-33.

Schaffer, S. D., & Yucha, C. B. (2004). Relaxation & pain management: The relaxation
response can play a role in managing chronic and acute pain. The American
Journal of Nursing, 104(8), 75-82.

Schlaug, G., Marchina, S., & Norton, A. (2008). From singing to speaking: why singing
may lead to recovery of expressive language function in patients with Broca's
aphasia. Music perception, 25(4), 315-323.

Sen, H., Yanarateş, O., Sızlan, A., Kılıç, E., Ozkan, S., & Dağlı, G. (2010). The efficiency
and duration of the analgesic effects of musical therapy on postoperative pain. The
Journal of the Turkish Society of Algology, 22(4), 145-150.

Shabanloei, R., Golchin, M., Esfahani, A., Dolatkhah, R., & Rasoulian, M. (2010). Effects
of music therapy on pain and anxiety in patients undergoing bone marrow biopsy
and aspiration. AORN Journal, 91(6), 746-751.

Sheps, D. S., Ballenger, M. N., De Gent, G. E., Krittayaphong, R., Dittman, E., Maixner,
McCartney, W., Golden, R. N., Koch, G., & Light, K. C. (1995). Psychophysical
responses to a speech stressor: Correlation of plasma beta-endorphin levels at rest
and after psychological stress with thermally measured pain threshold in patients
with coronary artery disease. Journal of the American College of Cardiology, 25(7),
1499-1503.
 45

Siedliecki, S. L., & Good, M. (2006). Effect of music on power, pain, depression and
disability. Journal of advanced nursing, 54(5), 553-562.

Silvestrini, N., Piguet, V., Cedraschi, C., & Zentner, M. R. (2011). Music and auditory
distraction reduce pain emotional or attentional effects?. Music and Medicine, 3(4),
264-270.

Skaggs, R. (1997). The Bonny Method of Guided Imagery and Music in the treatment of
terminal illness: A private practice setting. Music Therapy Perspectives, 15(1), 39-
44.

Smith, C. A., Levett, K. M., Collins, C. T., & Crowther, C. A. (2011). Relaxation techniques
for pain management in labour. Cochrane Database Syst Rev, 12, 1-35.

Sutoo, D. & Akiyama, K. (2004). Music improves dopaminergic neurotransmission:

Demonstration based on the effect of music on blood pressure regulation. Brain
Research,1016(2), 255-562.

Syrjala, K. L., Donaldson, G. W., Davis, M. W., Kippes, M. E., & Carr, J. E. (1995).
Relaxation and imagery and cognitive-behavioural training reduce pain during
cancer treatment: a controlled clinical trial. Pain, 63(2), 189-198.

Tan, X., Yowler, C. J., Super, D. M., & Fratianne, R. B. (2010). The efficacy of music
therapy protocols for decreasing pain, anxiety, and muscle tension levels during
burn dressing changes: a prospective randomized crossover trial. Journal of Burn
Care & Research, 31(4), 590-597.

Thaut, M. H., & Wheeler, B. L. (2010). 'Music Therapy'. In P. N. Juslin & J. A. Sloboda
(Eds.), Handbook of music and emotion: Theory, research, applications (pp. 819-
848). Oxford University Press.

The British Pain Society (2013). Guidelines for Pain Management Programmes for adults.
Retrieved from http://www.britishpainsociety.org/book_pmp2013_main.pdf. London:
The British Pain Society.

Tronvik, E., Stovner, L. J., Helde, G., Sand, T., & Bovim, G. (2003). Prophylactic treatment
of migraine with an angiotensin II receptor blocker: a randomized controlled
trial. Journal of the American Medical Association, 289(1), 65-69.
 46

Turk, D. C., & Okifuji, A. (2002). Psychological factors in chronic pain: Evolution and
revolution. Journal of consulting and clinical psychology, 70(3), 678-690.

Updike, P. A., & Charles, D. M. (1987). Music Rx: physiological and emotional responses
to taped music programs of preoperative patients awaiting plastic surgery. Annals of
plastic surgery, 19(1), 29-33.

Voss, J. A., Good, M., Yates, B., Baun, M. M., Thompson, A., & Hertzog, M. (2004).
Sedative music reduces anxiety and pain during chair rest after open-heart
surgery. Pain, 112(1), 197-203.

Walters, C. L. (1996). The psychological and physiological effects of vibrotactile

stimulation, via a Somatron, on patients awaiting scheduled gynecological
surgery. Journal of Music Therapy, 33(4), 261-287.

Walworth, D. (2003). The effect of preferred music genre selection versus preferred song
selection on experimentally induced anxiety levels. Journal of Music Therapy, 40(1),
2-14.

Wan, C. Y., Rüber, T., Hohmann, A., & Schlaug, G. (2010). The therapeutic effects of
singing in neurological disorders. Music perception, 27(4), 287.

Wegener, S. T., Castillo, R. C., Haythornthwaite, J., MacKenzie, E. J., & Bosse, M. J.
(2011). Psychological distress mediates the effect of pain on function. Pain, 152(6),
1349-1357.

Weintraub, M., Mamtani R., & Micozzi M. (Eds.) (2008). Complementary and integrative
medicine in pain management. New York: Springer.

Whitehead-Pleaux, A. M., Zebrowski, N., Baryza, M. J., & Sheridan, R. L. (2007).

Exploring the effects of music therapy on paediatric pain: Phase 1. Journal of music
therapy, 44(3), 217-241.

Wigram, T., Pedersen, I. N., & Bonde, L. O. (2002). A comprehensive guide to music
therapy. London: Jessica Kingsley.

Wilkinson, J., & Faleiro, R. (2007). Acupuncture in pain management. Continuing

Education in Anaesthesia, Critical Care & Pain, 7(4), 135-138.
 47

World Federation of Music Therapy (2011). About WFMT: What is music therapy?
Retrieved from http://www.musictherapyworld.net/WFMT/About_WFMT.html

Zengin, S., Kabul, S., Al, B., Sarcan, E., Doğan, M., & Yildirim, C. (2013). Effects of music
therapy on pain and anxiety in patients undergoing port catheter placement
procedure. Complementary therapies in medicine, 21(6), 689-696.

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(3), 298-309.