Lars Heslet Professor ICU 4131 National University Hospital Rigshospitalet Copenhagen Denmark

1
Lars HesletProfessorICU 4131National
University Hospital RigshospitaletCopenhagen
Denmark
Music as Adjuvant Therapy in Pain Management
2
The Musical Brain
3
Music as medicine

• Ancient cultures
• Treatment of disease with music in ancient
  cultures in
• India, Greece and China, most extensively
  applied in
• Arab cultures healing centers with sound of
  string
• instruments and water.
• Modern times
• Scientists have documented that music affects
  our
• endocrine system, host defense, autonomous
• nerve system and counter regulation of
  stress.
• Music reduces anxiety and improves quality of
  sleep.
• The sense of hearing is unaffected by sleep
• sedation and anesthesia.

• If we consider music as a drug
• How is it administered?
• For how long?
• Duration of effect?

4
The Musical Brain
Same old song Music has played an important role
for millennia. Instruments similar to this bone
flute have been found at Neanderthal sites.
Abbott A. Neurobiology, maestro,please. Nature
200241612-14
5
The Musical Brain
Music can provoke an intense emotional response,
but how and why do our brains react so
dramatically to musical stimuli?
6
Music and the 3 parts of the CNS
7
Brains perception of tones is complex and
hemispheric specialized
8
Music Tones Melody
Music
Temporal synchronization between left hemisphere
and the rest of the brain, is greatest when
melody-like tone patterns are applied reflecting
perceptual inte-gration of local and global pitch
patterns in melody-like sequences
Patel A Balaban E. Temporal patterns of human
cortical activity reflect tone sequence
structure. Nature 200040480-84
9
Music as medicine - Introduction
10
Thorgaard P et al. Designed sound and music
environment in postanaesthesia care units--a
multicentre study of patients and staff.
Intensive Crit Care Nurs. 2005 Aug21(4)197-8.
A multicentre study in post anaesthesia care
units - patient and staff opinion of specially
designed music environment (DME)

• Methods
• 325 Patients and 91staff members opinion using a
  questionnaire-anonymously
• in the case of staff. Patients were not asked for
  permission to play music.
• Results
• Patients
• 83 found the DME pleasant or very pleasant,
• 6 found it unpleasant,
• 11 answered "no opinion".
• Staff
• Equally positive attitude towards DME
• The staff had a positive attitude regarding
  beneficial effect on
• working conditions and distress.
• Conclusion
• A strong correlation (Plt0.05) was found between a
  positive attitude towards DME and degree of
  relaxation and satisfaction with stay.

11
Thorgaard P et al. Designed sound and music
environment in postanaesthesia care units--a
multicentre study of patients and staff.
Intensive Crit Care Nurs. 2005 Aug21(4)197-8.
A multicentre study in post anaesthesia care
units (PACUs) patient and staff opinion of
designed music environment (DME),

• A strong correlation
• between a positive attitude
• towards DME degree of
• relaxation (Plt0.05)
• The staff had an equally
• positive attitude towards the
• DME

12
Purpose Effect of a specially designed music
environment on feeling and wellbeing of lightly
sedated patients in Cardiac Catheter Laboratory
undergoing invasive procedures. Method 193
patients randomly assigned to music group,
listened to music during the procedure (99) or to
a non-music group (94)Patients interviewed by
questionnaire. Result - Music group 91 of the
patients defined the sound environment as
pleasant - compared to 56 in the non-music
group. - Number of patients with 'no opinion'
on the sound environment lower in the music
group than in the non-music group (8 vs 42).
Music in the Card Lab - a controlled trial (I)
Thorgaard B et al. Specially selected music in
the cardiac laboratory-an important tool for
improvement of the wellbeing of patients. Eur J
Cardiovasc Nurs. 2004 321-6.
13
Music in the Card Lab - a controlled trial (II)
Thorgaard B et al. Specially selected music in
the cardiac laboratory-an important tool for
improvement of the wellbeing of patients. Eur J
Cardiovasc Nurs. 2004 321-6.
14
ConclusionSpecially designed music positive
effect on the wellbeing of patients and their
opinion on the sound environment during invasive
cardiac procedures. It is suggested specially
designed music should be a part of the sound
environment in the Cardiac Catheter Laboratory.
Music in the Card Lab - a controlled trial (III)
Thorgaard B et al. Specially selected music in
the cardiac laboratory-an important tool for
improvement of the wellbeing of patients. Eur J
Cardiovasc Nurs. 2004 321-6.
15
Music in therapy Pain therapy
16
Acute pain
17
Effect of music on acute pain A Metaanalysis (I)

• Objective
• To evaluate the effect of music on acute pain
  intensity, pain relief, and analgesic
  requirements.
• Selection criteria
• Only randomized controlled trials were included
  that evaluated the effect of music on any type of
  pain in children or adults.
• Trials that reported results of concurrent
  non-pharmacological were excluded

Cepeda MS et al. Music for pain relief (Review).
Cochrane Database of Systematic Reviews 2006,
Issue 2. Art. No. CD004843. DOI
10.1002/14651858.CD004843.pub2
18
Effect of music on acute pain A Meta analysis
(II)
0
-1
-2
1
2
Favours music
Favours control
Conclusion Music has a significant effect on (i)
Pain intensity, (ii) Type of music and a (iii)
Morphine sparing effect (plt 0.05)
Cepeda MS et al. Music for pain relief (Review).
Cochrane Database of Systematic Reviews 2006,
Issue 2. Art. No. CD004843. DOI
10.1002/14651858.CD004843.pub2
19
Chronic non-malignant pain
20
Effect of music on chronic nonmalignant pain (I)

• Chronic non-malignant pain (CNMP) persists in
  spite of traditional interventions.
• Most CNMP patients have moderate effect of
  conventional analgesics and frequent adverse
  effects and affective psychological disorders
  with loss of personal power.
• Previous most studies of music intervention have
  focused on decreasing pain and anxiety related to
  acute pain postoperative and procedural pain.
• However, the effect of music on power, pain,
  depression, and disability in working age adults
  with chronic non-malignant pain has not been
  investigated.

Sandra L. Siedliecki SL Good M. Effect of music
on power, pain, depression and Disability
Journal of Advanced Nursing 200654(5)553562.
21
Effect of music on chronic nonmalignant pain (II)

• Method
• Randomized controlled clinical trial in chronic
  non-malignant pain randomly
• assigned to researcher-provided music,
  subject-preferred music or
• control group. Pain, depression, disability and
  power measured with NRS.
• Results
• The music groups had more power and less pain,
  depression and disability than the control group.
  
• No statistically significant differences between
  the two music interventions.
• The model predicting both a direct and indirect
  effect for music was supported.
• Conclusion
• Nurses can teach patients how to use music to
  enhance the effects of
• analgesics, decrease pain, depression and
  disability, and promote feelings of
• power

Music used for 1 hour a day for seven consecutive
days
Sandra L. Siedliecki SL Good M. Effect of music
on power, pain, depression and Disability
Journal of Advanced Nursing 200654(5)553562.
22
Effect of music on chronic nonmalignant pain (III)

• Statistical analysis

ANOVA p 0.002
P lt 0.001
Pain
Power
Disability
Depression
Music Selfpref.
Music Standard
Control no music
NS
p 0.048
Sandra L. Siedliecki SL Good M. Effect of music
on power, pain, depression and Disability
Journal of Advanced Nursing 200654(5)553562.
23
Music in stress and host defense
24
Music and immune defense (I)

• Objective
• To study the effect of music on the immune
  defense and metastatic cancer in rats exposed to
  sound stress (noise)
• Injected with sarcoma cells.
• Number of metastases evaluated after 8 days
• Music counteracted the effect of noise stress on
  the immune system and cancer metastases.
• Music reduced the number of metastases even in
  unstressed animals

Núñez et al. Music Immunity and Cancer. Life
sciences 2002711047-57
25
Music and immune defense (II)
Núñez et al. Music Immunity and Cancer. Life
sciences 2002711047-57
26
Music and immune defense (III)
Núñez et al. Music Immunity and Cancer. Life
sciences 2002711047-57
27
Music and immune defense (IV)
Núñez et al. Music Immunity and Cancer. Life
sciences 2002711047-57
28
Music and immune defense (V)

• Music counteracted the negative stress effect on
  the immune defense, by increasing the number of
  killer cells (CD 16)? and reducing the cortisol
  level.
• Stress in itself increased number of metastases.
  Music, however, reduced number of metastases in
  the animals exposed to stress.
• Music even reduced number of metastases in
  unstressed animals

Núñez et al. Music Immunity and Cancer. Life
sciences 2002711047-57
29
Conclusion Music as medicine
30
Conclusion (I)

• Music processing in the brain is complex
  involves several CNS centers.
• Music has a harmonizing effect on the mind, e.g.
  as a daily musical break or musical meditation
  and further dampens the worrying ambient noise of
  daily hospital activity with alarms and
  irrelevant conversation
• Music coordinates the function of the neocortex
  and integrates the 2 hemispheres (corpus
  callosum) affects the emotional brain.
• Music has a number of specific biological effects
  in disease and in health

31
Conclusion (II)

• Reduces sensation of both acute, procedural and
  chronic pain.
• Has a de-stressing effect both in acute and in
  chronic stress anxiety reducing effect
• Has a positive effect on immune defense the
  effect is mostly documented in animal studies.
• Systematic use of special designed music acts as
  drugs but without adverse effects and
• Music may be used as an adjuvant therapeutic
  measure in concert with analgesics sedatives and
  anxiolytics
• The effect of music has probably only a short and
  temporal effect but considering its price, and
  lack of adverse effects an important effect
• The type of medical music, however, is probably
  important

32
Music for the eye
www.musicahumana.com
33
MUSICA HUMANA
The scientific organization Musica Humana was
founded in Denmark in 1998 by a team of professor
Lars Heslet, Assistant professor Per Thorgaard
the Composer Niels Eje Objective To create a
Designed Music program and further to biomusical
science documentation designed music-environment
www.musicahumana.dk
34
Music and designed sound environement
35
The Sound sources used

• Loudspeakers in the ceiling
• Earphones
• Ordinary Stereo-equipment
• Audio pillows

36
Music in therapy other effects
37
Stress og Music
Music has anti-stress effects
After Molina PE. Opioids and opiates analgesia
with cardiovascular, haemodynamic and
immune implications in critical illness. Journal
of Internal Medicine 2006 259 138154.
38
Stress induced by white noise
Music and immune defense (II)
39

• Kronisk stress og musik
• Musik påvirker signalstofferne i hjernen.
• Alzheimerpatienter ? musikeffekten øget mængde
  melatonin ? afslappet og rolig sindstilstand.
  Melatonin er det hormon der signalerer søvn.
• Forhøjet binyrebarkhormon Cortisol ses ved
  kronisk stress. Musik har en påvirkning af
  kronisk stress bedømt ved Cortisolmålinger i
  spyt.
• Stress ? betydende stigning i Cortisol indholdet
  i spyt allerede indenfor 15 minutter. Musik
  medførte det en betydelig reduktion i Cortisol
  koncentrationen.
• Musik reducerer stress, angst og får BT og puls
  til at falde i forbindelse med kirurgi i
  lokalbedøvelse.
• Ved en lodtrækningsundersøgelse med musik og
  ikke-musik under bedøvelse blev blodtryksmønstret
  undersøgt. Efter bedøvelsen mindst stigning i
  hjertefrekvens og blodtryk i musikgruppen
  sammenlignet med ikke musikgruppen.

40

• Den musikalske hjerne
• The brain prosesses music at several levels. The
  biomusical science has focused on teh interplay
  between music and the brain the socalled musical
  brain.
• A slow paced rythm in classical music ? changes
  the electropencephalographic waves to alpha
  theta level
• Nyere undersøgelser musikalske stimuli øger
  aktiviteten i den nye hjerne (neocortex) knyttet
  til indlæring og koordination og styrke
  forbindelsen mellem de to hjernehalvdele.
• Undersøgelser tyder på at musik kan styrke evnen
  til at løse opgaver som stiller krav til højere
  mentale funktioner.

41

• Music in the ICU
• Patients listening to music induces wellbeing,
  relaxation, reduced anxiety and stress.
• Nurses are affected by music patients music
  sessions i relation to a modified behavior with
  conversation with a lower voice.
• Ambient noise with e.g. alarms is stressing
• Music played via loudspeakers in the ceiling
  applied to the ambient noise improves the sound
  environment

Unpublished personal observations in the ICU 2007
42
Music and reduction of anxiety in breast cancer
patients waiting a randomized trial

• 20 patients in 2 groups (music vs no music)
• 20-minute music-based intervention in a
  preoperative
• holding area before performing the biopsy
• Measurements blood pressure, heart rate and
• respiratory rate (RR)
• Self completion of Standardized Stress
  Questionnaire
• Result
• Stress Questionnaire and RR lower in the
  music-group
• (plt 0.05)
• State trait Anxiety Inventory (STAI)

Haun et al. Effect of music on anxiety of women
awaiting breast biopsy. Behav Med 200127127-32
43
Effect of music for mood disturbances in
hematopoietic stem cell transplantation (HSCT)

• A controlled trial of 69 patients undergoing
  autologous HSCT
• Randomized to Music or no intervention
• Results
• Level of mood was improved dramatically already
  after the 1rst musical session
• The positive effect continued every day during
  the hospital admittance period.
• Results were found to be both clinical important
  and statistical significant (plt0.01)

Cassileth et al. Music therapy for mood
disturbance during hospitalization for
autologous stem cell transplantation. Cancer
2003 982723-9.
44
Oplevelse af lydmiljøetPatienter under opvågning
efter operation
45
HjertepatienterØnsker du musik ? vs. Synes du
om lydmiljøet ?