C l i n i c a l T r i a l M u s i c : A n e w I n t e r g r a t e d M o d e l i n P h y s i o t h e r a p y FRANCES LE ROUX A B S T R A C T : Thirty su b je c ts with sp in a l p a in a t a p r iv a te p r a c tic e w ere ra n d o m ly s e le c te d a n d in te rview ed . A sh ortform M c G ill P ain Q u estion n aire w a s u sed to m easure p a in in tensity before a n d a fter treatm ent. The exp erim en ta l grou p re c e iv e d p h y sio th e r a p y a n d slo w tem po m usic, w h ile the con trol grou p re c e iv e d on ly p h ysio th era p y. The stu d y d e m o n stra te s the im p o rta n t role o f p s y c h o lo g y in the trea tm en t o f p a in a n d the va lu a b le use o f m usic as p a r t o f p h ysio th era p y. K E Y W O R D S: PHYSIOTHERAPY, PAIN, M U SIC , P S Y C H O L O G Y INTRODUCTION P ain is o ne o f the m o st ch alleng ing p ro blem s in p hysiotherapy. It is a c h a l len ge to th o se w ho seek m eans to h elp the patient, and it is a ch allen g e to th e patient w ho is tryin g to fin d so m eo n e to reliev e h is o r h er u n p le asan t sym ptom s. T he Intern ation al A sso ciatio n fo r the S tud y o f P ain (1968) d efin ed pain as an u n p le asan t sen so ry an d em otion al ex p e ri e n ce asso cia te d w ith actual o r potential tissu e dam ag e. It is a p erson al ex perience an d is c o m p o se d o f both p hy sical and p s y c h o lo g ic a l fa c to rs. A c c o rd in g to M elzack, W eisz an d S p rag u e (1963) the p ain e x p e rie n ce c o n sists o f three m a jo r p sy c h o lo g ica l d im en sio n s; sen so ry -d is c rim in a tiv e , m o tiv a tio n a l-a ffe c tiv e and c o g n itiv e -e v a lu a tiv e . T h e g ate c o n tro l m e ch a n ism has b een p ro p o sed to ex p lain the p ro cess o f p ain m o d u latio n an d is still the m o st satisfactory theory o f the pain m echanism . P ain can be m o d u lated at v ariou s levels o f the n eurax is inclu din g th e p erip h eral, d o rsal horn an d b ra in stem . T he p sy ch o lo g ica l ap pro ach es to m o d u late pain w ill take p lace in the co rti- co lim b ic area, by co g n itiv e strategies, b eh a v io u r m o d ificatio n an d p sy ch o th era py. A ll these levels are n eu ro p h y sio lo g i- cally an d n eu ro ch e m ically interrelated. A p s y c h o lo g ic a l a p p ro a c h s h o u ld b e a m a jo r co n sid eratio n in the treatm e n t o f a p ainful cond itio n. (A dam s, 1997). T he gate co ntro l theory also p ro vid es a co n cep tual fram e w o rk fo r the m u ltip le in flu en ces on the tran sm issio n (T) cells in the c en tral n ervo us sy stem (M elzack , Loeser, 1978). M u ltip le interaction s d eterm in e the n atu re o f the p attern w hich is g en e ra t ed by the tran sm issio n o f cells. In this w ay it is p la u sib le to p o stu la te th a t p atie n ts rece iv in g p h y sio th erap y w o uld b en e fit fro m intro du cing an o th er sensory C O R R E SPO N D EN C E M R S F H L E R O U X H ove-T o M e d ic a l C en tre 3 rd A venue, Fish H o ek , 7975 input. P ain red u ctio n is rep o rted by R id e r (1985) in a p ro ced u re inv olv ing m usic an d m u s c le re la x a tio n . W o lfe (19 78 ) rep o rted that m u sic p la y ed d uring pain re h a b ilita tio n s e s s io n s a p p e a re d to im p ro v e the p a tie n t’s level o f phy sical activ ity an d v erb al ex pression . S tudies by H a n se r an d O ’C o nn ell (1983) ind icated th a t m o th ers in lab o u r em itted fe w e r pain resp o n ses in the p re sen ce o f a specially d e sig n ed m u sic pro gram . G o o d (1995) ind icated th a t the an x iety levels o f p o st o p e ra tiv e p a tie n ts w e re s ig n ific a n tly low er if m u sic, p o sitiv e th in k in g , and relax atio n w ere co m b in ed . T h e re la tio n ship b etw een m u sic an d m e d icin e has b een reco g n ised an d in this rap idly d ev e l o ping field h as m any d iffere n t c o m p o nents. D u rin g the late p art o f this century, the Intern ation al S o ciety for M usic in M edicin e w as esta b lish e d an d the c o n n ectio n an d interp lay b etw een the m ind, b o d y an d s o c ia l e n v iro n m e n t o f th e p atien t w as identified. M usic affects all three p sych o lo gical d im en sio n s o f p ain. T h e m o tivatio nal- affectiv e d im ension , has the poten tial to c h an g e u n p le asan t em otion al asp ects like fe a r an d d epression . T h e sen so ry e v a lu a tion c o m p o n en t o f p ain is to re-co n c ep tu - alize the p ainfu l ex perience. T he patient can d issociate h im o r h e rse lf fro m the p a in b y c o n c e n tra tin g on th e m u sic. L argo tem p o m u sic, w h ich is o f a slow tem p o, 60 b eats per secon d, h as b een su c c e s sfu lly u se d b y M e irin g (1 9 8 6 ) to im p rov e the atten tio n span o f h y p eractiv e children. T h e p u rp o se o f this stu dy w as to attem p t to show that the ad d itio n o f m u sic to p h y sio th erap y w ill en h a n ce an d su p p ort the p sych o lo gical d im en sio n o f pain an d that tw o th erap ies u sed sim u ltan e o u s ly w ill b e m o re b en e fic ia l than one. METHOD T h irty su bjects (8 m e n an d 22 w om en) w ith sp inal pain w ere ran d o m ly selected to p articip ate in this study. E ach su bject w as in terv iew ed an d the p urpo se o f the stu dy w as ex p lain ed to th e m p rio r to c o m m e n ce m en t o f p hy siotherapy . A co n sen t fo rm w as sig ned in d icatin g th e ir w illin g n ess to p artic ip ate in the study. T h e av er age age w as 49 years. C h ild ren u n d er tw elv e w ere ex clud ed . R an d o m selection w as u sed to allocate th e su bjects to the e x p e rim e n ta l a n d c o n tro l g ro u p . T h e M cG ill (sh ort form ) P ain Q u e stio n n a ire - M P Q (M elzack , 1987) w as co m p le ted before an d after treatm e n t o n d ay o n e and four. S ub jects w ith an initial p ain in ten si ty lo w e r th a n 8, w ere ex clu d ed as w ell as tho se w ho to o k an alg esics b efo re tre a t m ent. T h o se w ith h earin g d iso rd ers, signs o f sen ility o r a secon d p a th o lo g y that co u ld c o n trib u te to p ain w ere also ex c lu d ed. T h e ex p e rim en tal g ro u p w as ex p o sed to re c o rd e d la rg o -te m p o m u sic w h ile rece iv in g phy siotherapy , w h ile the c o n trol g ro up o n ly receiv ed p hysiotherapy. S ub jects w ere ev alu a te d an d treated by the sam e p h y sio th e rap ist on a d aily basis, w h ile a secon d p h y sio th e ra p ist assisted w ith th e M PQ . MATERIALS P ain is n o t a sim p le sen so ry m odality, b u t a co m p le x m u lti-d im en sio n al ex p e ri ence. T h e M cG ill Q u e stio n n a ire w hich w as d e v e lo p e d b y M e lz a c k an d T org en son (1971) c o n sists o f d escrip tiv e, m o tiv atio n al - em o tio n al an d ev alu ativ e d im en sio n s o f p ain. A t the sam e tim e it p ro v id es a b asis fo r the ev alu a tio n o f pain. It has b een su ccessfu lly u sed by S ch o rr (1993). T h e M P Q tak es ab ou t 5 to 10 m in u tes to co m p lete, w h ich is tim e c o n su m in g in a b usy p ractice. T he re fo re it w as d ecid e d to use the sh o rt-fo rm M P Q w h ich w as d ev e lo p e d fo r u se in specific research setting s w h ere the p eriod a v a il ab le to o btain in fo rm atio n fro m p atie n ts is lim ited. R ead in g , E v e ritt an d S led m ere (1982) esta b lish e d the v alid ity an d re lia bility, r = 0 ,86 , w h ich in d icates its e v a lu ativ e potential. T h e ex p e rim en tal g ro u p w as ex p o sed to a re c o rd e d v ersio n o f slow tem po m u sic, av erag e 60 beats p e r m in u te in a 10 SA J o u r n a l o f Ph y sio t h e r a p y 1998 V o l 54 No 2 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) 4 /4 tim e, w h ich is largo tem p o m u sic. T he sam e m u sic w as used ev ery tim e. S om e o f the m u sic that w as used, w as B ach, JS - C o ncerto N o. 4 in G m in o r BW V, 2nd m o v e m en t (largo); C h op in , F F S on ata N o. 3 in B m in o r o p 58 (largo); V ivaldi, A - C o n ce rt in F m a jo r RV 286 (largo); and D v o rak , A - S ym ph on y N o. 9, N ew W orld (largo). C ertain p h y sio th e ra p e u tic m o d a lities like T E N S ; acu p un cture an d interferential th e rap y m ay have an im m ediate analgesic effec t on p ain and w ere th erefo re ex c lu d ed fro m the treatm e n t reg im e. Techniques o f ch o ice w ere m o b ilizatio n accord ing to the M aitland tech niq ue, u ltrasou nd , m a s sag e an d traction . T h e treatm e n t was aim e d at red u cin g the su b je c t’s pain. RESULTS T h irty p atie n ts w ere adm itted into this stu d y and 15 allocated to eith e r the c o n trol o r the ex p erim en tal group. O n ad m issio n there w ere no statistical d ifferen ces b etw een the tw o g roups. A fter the treatm e n t on d ay one the ex p erim en tal g ro u p h ad sig nifican tly less p ain than the c o n tro l g ro up (p= 0.002). O n d ay fo u r a sig n ifican t d ifference w as again o bserv ed a fte r treatm e n t (p= 0.032) In this stu dy a p v alu e o f <0.05 was c o n sid ered to be significant. T h e resu lts ind icated that m u sic h ad an im m ediate effect on p ain intensity. DISCUSSION T h e p a p e r d e s c rib e s an e v a lu a tiv e stu dy inv estig atin g the effect o f m usic d u rin g p h y s io th e ra p y o f a g ro u p o f p atie n ts w ho ex p erien ced spinal p ain. T he ex p erim en tal g ro u p sh ow ed sig nifican tly lo w e r pain inten sity after the treatm e n t on both d ays o f testing . In co ntrast the co n trol g ro up also sh ow ed a low er p ain inten sity after treatm ent, alth o u g h this w as n ot significant. P h y sio th erap y m o dalities do reliev e p ain , b u t w ith the addition o f m u sic a m o re effectiv e fo rm o f treatm ent to o k place. M an y stu dies o f m u sic in pain m a n ag em e n t h ave sh ow n an increase in p a in to le ra n c e a n d th re s h o ld (S torr, 1997). In this study, the first w h ere m u sic an d p h y sio th erap y w ere co m b in ed for pain relief, m u sic ap p e ared to have an en hancin g effect w h en in teg rated w ith o th e r m e th o d s o f tre a tm e n t. T h is stren gth ens the co ncept that therapeutic p ro ced ures in co m b in atio n are o fte n m o re effectiv e than the m ere ad ditive effects o f each. M usic as seen in the literature elic its psych o lo gical and co gn itiv e resp on ses an d cau ses relax atio n (M aslar, 1986). P h y sio th erap y is m ain ly a p h y sical treat m en t, w h ich influ ences the m o d u latio n o f p ain at the dorsal h o rn and p erip h eral le v e ls (u ltra s o u n d , m a n u a l th e ra p y an d m a nipu lation ). A cu p u n c tu re and T E N S are m o d u lated at the b ra in stem lev el, but th e y w ere n ot u sed in this research. T he ad d itio n o f m u sic b ro u g h t fo rth a corti- co lim b ic m o d u latio n and at the sam e tim e a fulfilm en t o f the p sy c h o lo g ica l n eed s o f the subjects. A s p sy c h o lo g ica l ap p ro ach es can be u sed to red u ce pain, it also fo l lo w s th a t p s y c h o lo g ic a l fa c to rs m a y en h a n ce an d m ain tain pain. P ain has an e m o tio n al an d sen so ry co m p o n en t, it is thus im p o rtan t d u rin g p h y sio th e rap y to tak e p sy ch o lo g ica l facto rs into c o n sid era tio n and to p ay attention to th e p a st e x p e rien ce, cu ltu re and social b ack g ro u n d o f patients. T h e em o tio n al co m p o n en t o f p ain is im p o rtan t an d can n o t be ignored. P ain is a h ig h ly p erso n al ex p e rie n ce , w h ich p atients often fin d difficu lt to talk about, b u t b y listenin g to sp ecific m usic, a fo rm o f cath arsis can tak e p la ce b ecau se o f the p erson al in v o lv em e n t w ith m usic. T h e use o f sp ecific p re scrip tiv e m u sic to reh abilitate p sy ch o lo g ica l an d p h y sio lo g ical d ysfu nctio n has sev eral advantages. In the p o litical clim a te o f so uth A frica, injuries an d p ain are o fte n associated w ith p o o r relation sh ips, d eg rad in g o f hum an v alue and fear. T h e em o tio n al co m p o n en t o f p ain is n o rm a lly o bv io us and m usic can h elp n o t only to red uce fe a r b u t also ag gressive feelin gs. It w ill b e ad visable on fu rth er rese arch to re-test su bjects after 10 d ays o f term in atio n o f treatm ent. M u sic sh ou ld p lay an im p o rtan t co m p o n e n t in m e d ical ed u c atio n , students sh ou ld h ave the o pp ortun ity to e x p e rie n ce m u sic o f variou s levels o f interv en tio n to assist them in se lf k no w ledg e. T his will lead to a d ra m atic rev o lu tio n fo r subjects w ith pain an d it w ill also help p h y sio th e r apists en terin g into the interd iscip lin ary v en tu re as they ex p a n d th e ir inv estig atio n o f m u sic and p sy ch o lo g y and p h y sio th e r apy. It sh ou ld lead to a m o re interd iscip li n ary research co nd ucted on an in tern a tion al level. CONCLUSION In this stu dy m u sic ap pears to help o v e rc o m e e m o tio n a l p ro b le m s d u rin g p h y sio th erap y o f p ain fu l spinal co n d i tions. T h e co m b in atio n o f m u sic therapy and p h y sio th e rap y ap pears to b e m o re effectiv e fo r pain inh ibition than p h y sio therapy alone. ACKNOWLEDGEMENTS T h e a u th o r w ish es to th a n k P ro f Jo an M ey e r as w ell as D r L L au b sc h er fro m th e D ep artm e n t o f P sy ch o lo g y o f the U n iv ersity o f the W estern C ap e fo r their assistan c e in this rese arch p roject. REFERENCES Adams N 1997 The Psychophysiology o f Low B ack Pain. New York: Churchill Livingstone: 5 0 - 5 4 Brown C J, Chen A C M , Dworkin S F 1989 Music in the control o f hum an pain. Journal o f M usic Therapy. 8: 47 - 60 Good M P L 1995 Comparison o f the effects o f relaxation and music on post-operative pain. Journal o f M usic Therapy 53: 1783 Hanser S B, O ’Connell A 1983 The effect of music on relaxation o f expectant mothers dur ing labour. Journal o f M usic Therapy 29: 50 - 58. International Association o f the Study o f Pain 1986 C lassification o f chronic pain: Descriptions o f chronic pain syndromes and definitions o f Pain. Pain Supplement 3: S217 - 221. M aslar P M 1986 The effect o f music on the reduction o f pain: A review o f the literature. The Arts in Psychotherapy 13: 215 - 219. Meiring D 1986 Die uitwerking van largo tempo m usiek op hiperaktiwiteit by kinders. Tesis Universiteit Pretoria: Suid Afrika: 62- 64. M elzack R 1987 The short-form M cGill Pain Questionnaire. Pain 30: 191 - 197 M elzack R, Loeser J D 1978 Phantom body pain in paraplegics: evidence for a central pat tern generating mechanism for pain. Pain 4: 195 - 210 Melzack R, Rorgerson W S 1971 On the lan guage o f pain. Anaesthesiology 34: 50 - 59 Melzack R, Weisz A Z, Sprague L T 1963 Strategies for controlling pain: Contributions o f auditory stim ulation and suggestion. Experim ental Neurology 8: 239 - 247 Reading A E, Everitt B S, Sledmere C M 1982 The McGill Pain Questionnaire. Journal o f Clinical Psychology 21: 339 - 349. Ic pain. Rider M 1985 Entertainment mechanisms are involved in pain reduction, muscle relaxation and m usic-m ediated im agery. Jo urn a l o f M usic Therapy 22(4): 48 - 56 Schorr J A 1993 M usic and pattern change in chronic pain. A d va n ced N ursing Science 15(4): 27 - 36 , Storr A 1997 M usic Therapy In H ealth and E ducation. . L ondon: Jessica K ingsley Publishers: 161 - 168. Wolfe D E 1978 Pain rehabilitation and music therapy. Journal o f M usic Therapy 15: 162 - 178 SA J o u r n a l o f Ph y sio t h e r a p y 1998 V o l 54 No 2 11 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )