Music For Educators and Trainers

Effectiveness of Vibroacoustic Music for Pain and Symptom Management in Outpatient Chemotherapy Treatment

Vibroacoustic Music for Pain and Symptom Reduction in Chemotherapy
The goal of modern medicine is unquestionably to provide patients with life-saving and/or life-improving treatment of injury or illness. Current discoveries about mind-body connections reveal that the state of mind has a great deal of effect upon the success of medical treatment. Much of this research indicates that the ability to attain a state of relaxation aids the healing process (1, 2, 10). The initiation of this relaxation response is a goal in various holistic health methods, including Tai Chi, guided visualization and mental imaging, Yoga and music therapy. Vibroacoustic music (VAM), music that is designed to be felt through tactile stimulation as well as heard, has been noted as a highly effective method of eliciting the relaxation response and other emotional and physiologic changes beneficial in medical settings (3,5, 7, 11).

Vibroacoustic music is generally administered through speakers built into a mattress, pad, recliner, or table. The sound is heard via these speakers or may also be channeled through headphones. The listener feels the music in his or her body as well as hearing it through normal auditory processes. This vibration and the innate musical properties of anxiolytic (anxiety-reducing) music are able to assist listeners in reaching slower brainwave states (alph/theta and possibly delta) as well as being able to trigger physiologic states of relaxation demonstrated by various physical measures (4, 6, 8, 9). This particular method of stimulating the relaxation response may have great application in hospitals and other care facilities due to its ease of administration, non-invasiveness and overall pleasing effects.

The Ella Milbank Foshay Cancer Center implemented a vibroacoustic music program in the Winter of 2000 with the goal of reducing patient pain and symptoms resulting from cancer and cancer treatment. Results of this Foshay evaluation of 41 sessions revealed 61% to 74% decrease of pain and symptoms in cancer patients. The project focused on the use of vibroacoustic music (VAM) to elicit the relaxation response and assist in pain and symptom management. This project was based upon a program developed by Dr. George Patrick at the National Institute of Health (NIH). Results of a program evaluation at the NIH site demonstrated reduction in pain and symptoms for hospitalized patients by 47.36% to 60.97% with a combined reduction of 53.04% ("The Effects of Vibroacoustic Music on Symptom Reduction" IEEE Engineering in Medicine and Biology, March/April 1999).

Chris Brewer, affiliate and Arts Therapy Project Director of the Mind Body Institute of Jupiter Medical Center, developed and coordinated the program and study at the Foshay Cancer Center. Assistance with program development and structuring of study parameters was provided by Dr. Patrick, NIH. Additionally, statistical analysis of the compiled data from the Foshay program was provided by the NIH.

All outpatient chemotherapy and radiation therapy patients and cancer survivors were offered the opportunity to experience a VAM session as a tool for the reduction of pain and symptoms resulting from cancer and cancer treatment. No charge was made for the service and patients could have as many sessions as they desired. The vibroacoustic sessions were monitored for results during a 5-week program evaluation period. The program is ongoing and data continues to be gathered for continued evaluation.

Information about the Foshay vibroacoustic music program was offered to three cancer support groups and at a public open house. Chemotherapy and radiation therapy nursing staff were trained in the use of vibroacoustic music. Nurses introduced patients to the vibroacoustic music program and were primarily responsible for assisting patients during the sessions. Additionally, the Arts Therapy Project Director for the Mind Body Institute spent 6 hours per week administering the program and assisting patients with sessions.

Interested patients were scheduled for one-hour sessions that included a brief introduction to vibroacoustic music, a 30- to 40-minute music session and a 5- to 10-minute debriefing. An evaluative survey was administered pre- and post-session to each patient. The BETAR (Bio-Energetic Transduction Aided Relaxation) model of vibroacoustic table was used for the program. Anxiolytic music played for all first sessions was the TheraSound "Balance" recording specifically designed for vibroacoustic use. Additional sessions used either "Balance" or the TheraSound recording entitled "The Musical Body-Harmonizer." Headphones were available but not mandatory. The vibroacoustic sessions were provided in a room specifically designated for this program. Information about the National Institute of Health program evaluation on vibroacoustic music and a handout on relaxation techniques was available to patients.

METHODS

Sampling Procedure
The program evaluation yielded data from the use of the BETAR vibroacoustic table using anxiolytic music with 27 adult patients at the Ella Milbanks Foshay Cancer Center, a department of Jupiter Medical Center. Data was compiled from 41 of 45 observations. Four sessions were not used as data was incomplete in both pre- and post-evaluations. Subject ages ranged from 33 to 78 with an average age of 61 overall, 58 for females and 64 for males. Data for statistical analysis was taken from 23 of the 27 patients, 13 female and 10 male.

Patients represented a convenience sample of individuals volunteering for a vibroacoustic music session. Patients were recruited from 1) nurses referral in either the Chemotherapy or Radiation Therapy departments, and 2) patient response from information about the program via printed materials, word of mouth, or demonstration during a cancer-related support group meeting. The patients had various cancer diagnosis and were either in treatment at the time or were cancer survivors. One patient was a hospital volunteer experiencing back pain. Of the 45 sessions in the evaluation sampling, 18 were repeat sessions. Patients completed a range of one to seven sessions with an average of 1.7 sessions per patient. Four women and three men completed more than one session, representing 26% of all patients. As no attempt was made to develop a meaningful control group, this paper reports as a program evaluation rather than a comparative study.

Measurements and Variables
Data for this study was gathered from two patient self-report instruments provided by George Patrick of the National Institute of Health. These measurement tools were completed immediately before and after the vibroacoustic session. The tension/relaxation state of the patient was measured using the Poppin "Self-Report Rating Scale for Tension and Relaxation." This instrument lists seven statements regarding tension/relaxation state. Patients select the statement most accurately describing their state at that moment, both pre- and post-session. Twenty-two patients completed this rating scale in 39 of the session reports. This scale was used as a comparative value for the symptom intensity. A visual-analog scale was used to measure effects upon pain and symptoms.

RESULTS

Descriptive Findings
The patients' state of relaxation was measured using the seven-point Poppin Self-Report Rating Scale for Tension and Relaxation. With an N=39, the pre-rating was 5.23 (5 is described in the scale by the words "Feeling Some Tension in Some Parts of My Body") while the post-rating was 2.84 (3 is described as "Feeling More Relaxed than Usual). This represents a 34% reduction of tension during the vibroacoustic sesson, a statistically significant difference.

Patients reported several symptoms on the symptom intensity evaluation. They were: anxiety, pain, fatigue, nausea, headache, tension, anger/hostility and a category compiled as miscellaneous symptoms. No suggestion was made to patients about symptoms to consider in the evaluation. Anxiety, pain and fatigue were the symptoms listed most frequently in this evaluation.

The symptom intensity scale used was an anchored, unmarked scale of 100. An aggregation of all symptom data showed an average participant pre-session rating of symptom intensity of 62.505 (+ or -3) and a post-session rating of 22.206 (+or - 2). Data determined a 64% cumulative reduction of symptom intensity for all symptoms reported. The evaluation provided patients the opportunity to list and rate three symptoms. In an analysis of the three most frequently reported symptoms, the intensity of symptoms were reduced as follows: Anxiety (N = 36) was cumulatively listed as 68.500 (+ or - 4) in pre-ratings and 25.500 (+ or - 2) in post-ratings, representing a 62.8% reduction of anxiety. Pain symptoms (N = 23/20) were pre-rated as 52.783 (+ or - 4) with a concluding rating of 20.250 (+ or - 3) and an improvement in pain intensity of 61.6%. Fatigue symptoms (N = 12) were rated pre-session as 60.500 (+ or - 6) and rated post-session as 15.583 (+ or - 4) demonstrating a 74.3% reduction of fatigue symptoms. All results were performed as unpaired t-tests and were statistically significant at P< .0001.

Statistics were also determined for the other reported symptoms. These symptoms had sample sizes of four to seven and demonstrated between 47% and 89% reduction of intensity.

All statistics reported here for symptom intensity were analyzed by the National Institute of Health from the data compiled by Chris Brewer, Arts Therapy Project Director.

Table 1.
Symptom Intensity Change from a Vibroacoustic Music Session

Symptom (N)	Pre	SD	Post	SD	% Diff.	P
Anxiety (36)	68.500	21.814	25.500	12.923	62.8	.0001
Pain(23 pre,20 post)	52.783	19.797	20.250	15.660	61.6	.0001
Fatigue (12)	60.500	21.288	15.583	14.074	74.3	.0001

DISCUSSION

The program evaluation yielded descriptive data gathered immediately prior and post-VAM session. No attempt was made to use a meaningful control group or to design this as a comparative study. There was also no attempt to alter variables to isolate or determine critical elements for program success. Additionally, neither the Foshay or NIH programs evaluated long-term effects. Both measured pain and symptom reduction immediately following the VAM session. Future research on length of effect would be quite valuable as would studies investigating specific variables in VAM for pain and symptom reduction.

Results of the Foshay evaluation of 41 sessions revealed 61% to 74% decrease of pain and symptoms in cancer patients. The NIH program demonstrated 49% to 61% reduction from 267 patients. It is possible from these program evaluations to make conjecture that the use of vibroacoustic music is indeed, effective, for pain and symptom management in oncology and other hospital settings. Though the Foshay program was based upon the success and structure of the National Institute of Health VAM program, differences in program structure existed which are important to note.

The NIH program is based in a Recreation Therapy department of a medical center. On-staff recreation therapists assist patients in the VAM session and are available at all times to assist patients as their primary duty. The therapists facilitate the VAM session by providing an explanation of the process and procedure and also lead the patient through a brief guided relaxation to assist the patient in attaining the desired relaxation response. The music portion of the VAM experience is 25 minutes long and is followed by a short debriefing. A recreation therapist is with the patient for the entire length of the experience.

At the Foshay Cancer Center, no staff is available to facilitate VAM sessions in the manner available at the NIH. Nursing staff at Foshay, as in most hospital settings, feel pressured for time to perform their varied duties. The VAM program was therefore set up so that nursing staff could use the vibroacoustic music as a part of their nursing care in a manner that demanded as little time as possible. Therefore, the Foshay program evaluated the potential of using vibroacoustic music as a nursing care tool as much as it evaluated the ability of vibroacoustic music to manage patient pain and symptoms. It became clear during this program evaluation that it is viable for nursing staff to integrate the use of vibroacoustic music as a nursing care method under a program designed to accommodate the multi-tasking of most nursing positions. Foshay nurses voiced some initial concern about the amount of time the vibroacoustic music program would take to implement. However, the nurses were successful in being able to add the VAM sessions into their tight time schedule without unduly affecting their effectiveness in other duties. Several nurses shared personal stories of patients who were greatly aided from the VAM sessions and for whom the nurses felt highly pleased to have been able to help. In a post-study meeting and in surveys filled out by nursing staff, the nurses indicated that they felt the VAM sessions helped them to fulfill their role of carrying for patients' overall well-being. The implication of this discovery is the potential for this program to be duplicated in other hospital and care facilities that do not have recreation therapy departments or on-staff music therapists but whose role it is to provide extended nursing care services. It is important to note that all nurses facilitating VAM sessions in this program were trained in the use of vibroacoustic music. It is considered essential by the author that the facilitators of any form of therapy be trained in its use. As part of the nurses training at Foshay, the Arts Therapy Project Director spend six hours per week for five weeks facilitating the program, including troubleshooting any problems encountered by the nursing staff.

Issues of patient safety were also a consideration in this setting. Solutions for leaving patients alone during VAM sessions included the availability of an easily-accessed call button and the placement of the vibroacoustic equipment in close proximity to areas of high use where nurses have easy access for checking on patients. Nursing staff were made aware of situations in which patients might not be good candidates for VAM. These included patients whose condition required constant visual supervision, and patients with particular injuries or health issues: severe back problems which did not allow them to lay flat on the BETAR table, and certain head or neck injuries which might be adversely affected from the vibration.

The time constraints experienced by nurses also eliminated the possibility of having the nursing staff provide a pre-session guided relaxation exercise as is done at the NIH. Rather than attempt to add this task to the nurses busy schedule, the Foshay program was designed to compensate for the positive relaxation effect of the guided exercise by simply extending the amount of time patients spent experiencing the vibroacoustic music. The NIH program used 25 minutes of music whereas the Foshay program used 40 minutes for the first session when "Balance" was used (playing the 20-minute program twice) or 35 minutes for the "Musical Harmonizer" music session which was an option for patient use after the first session. It had been the observation of the Arts Therapy Project Director that deeper brain wave and relaxation states appeared to occur after 20 minutes on the BETAR. This observation was not scientifically tested. However, it was reasoned that by increasing the session to 35 or 40 minutes, patients had more opportunity to reach deeper levels of relaxation. The successful reduction of pain and symptoms in the Foshay program indicate that this strategy may indeed be effective. Again, no comparisons were made during this study but would be an important variable to research in the future.

The third and final difference in this program from the NIH program was the model of vibroacoustic table used. The NIH study used a Somatron recliner model designed for hospital use. The BETAR table was available for use at the Foshay Center. This is a flat table that also has differences from the Somatron in the distribution of sound delivery in the speaker system. Since both programs yielded significant reduction in pain and symptoms it could be assumed that there is no significant difference in effectiveness based upon the vibroacoustic equipment used. However, there could be merit in studying the two models to determine if any significant difference exists. One relevant item of note by the Foshay staff was their interest in experimenting with the use of a recliner system. Overall the nursing staff felt that a recliner had more practical application than did a flat table. Three points were important here: 1) the recliner position is usable by all patients, including those who might not be able to lay flat due to back problems, and 2) the recliner eliminates any concern about patients potentially rolling off of a flat table and 3) a recliner feels less "medical" and creates a mental attitude of greater comfort. It should also be stated that a recliner allows the patient to be in the trendallen position, that of having the knees slightly bent and elevated. There is some indication that this position may be beneficial in triggering the relaxation response. Further research would be necessary to determine the significance of this position.

CONCLUSION
Based upon the success of the Foshay and NIH program evaluations, it is clear that vibroacoustic music can indeed offer patients assistance in attaining a relaxed state and reducing pain and symptoms in medical situations. Additionally, the Foshay Cancer Center program offers a model for developing vibroacoustics as a nursing tool. Refinement of program design would be beneficial as would future research into specific aspects of the application of vibroacoustic music in pain and symptom management.

ACKNOWLEDGEMENTS
The author wishes to acknowledge the assistance of Dr. George Patrick and Mark Mattiko of the National Institute of Health for their advice, direction, and assistance in program development and statistical analysis. Appreciation is also extended to the fine nursing staff and administration at the Ella Milbank Foshay Cancer Center of Jupiter Medical Center for their willingness to experiment and participate in this program.

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