• Pain

    Posted on August 14, 2014 by Debbie Benkovitz in Guest Blogs, Pain Management.

     

    Pain is inevitable in a hospital, but management of pain has come a long way and research proves that music therapy can help patients cope with the discomfort of their illnesses, traumas, and procedures. At Children’s Hospital of Pittsburgh of UPMC, we do many things to decrease and alleviate pain. Hospital staff members join forces to prevent pain, and as a member of the Pain Council, I have the opportunity to work with physicians, nurses, social workers, psychologists, pharmacists, anesthesiologists, and others to review “best practices” of pain prevention and management. Together, we discuss medications and other pain relieving techniques such as comfort positioning, use of child-friendly language, relaxation techniques, and music therapy. We have adopted two cartoon characters: Spike, a cute porcupine, and BooBoo, a Band-Aid with a face, arms, and legs, to remind staff and patients that we are dedicated to decreasing and alleviating pain.

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    Ayda Grace, a young oncology patient, strums Debbie’s guitar at the Children’s Hospital of Pittsburgh of UPMC.

    Pain is caused by numerous factors, including injuries to the body as a result of automobile accidents or sports collisions; diseases such as cancer; genetic, heart, and other defects or abnormalities; and illnesses like pneumonia or sepsis. The International Association for the Study of Pain defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”[i] Physiological pain occurs when a noxious stimuli activates the sensory nerve endings and neurotransmitters carry pain signals to the brain via the central nervous system. Here is a simple example:  when a hammer accidentally hits our thumb rather than its intended target, the nerves in the thumb quickly send off a signal to the brain via the central nervous system. This pain signal may recirculate for a while as the brain processes the information about what happened, but usually the pain signal slows down and eventually stops, since the brain knows the trauma is over and the pain will soon subside.

    But, in cases of chronic or lengthy illnesses, or uncertainty about the source of pain, emotions and hormones often kick in and heighten the sensation of pain even though the physical stimuli is not present. In other words, fear and anxiety can take over and change our perception of reality. Unfortunately, pain causes stress, and as a result, stress hormones such as cortisol and epinephrine increase, and these exacerbate the pain and decrease the effectiveness of the immune system. Music therapy can be helpful in many pain/stress situations, especially when combined with medication and other therapies, as evidenced by review of over 50 research studies looking at pain and music therapy. How does this work?

    In general, I classify pain in one of the three following categories: acute, chronic, and procedural. Acute pain might be illustrated by the “hammer” scenario or another such trauma to the body; however, acute pain may also be caused by the onset of a broken leg, being hit by a baseball,  appendicitis, the flu, a kidney stone, and similar episodes of trauma or illness. In cases of acute pain, music therapy can help pediatric patients by distracting them with singing or guided relaxation. The bonus of these two music activities is that singing with slower, deeper breathing can increase oxygen intake, which in turn decreases damaging stress hormones. A few case studies may best demonstrate how a music therapist might work with intention to decrease pain.

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    Debbie plays her guitar for a patient named Jonathon at the Children’s Hospital of Pittsburgh of UPMC.

    David, a 5-year-old boy, was in an automobile accident. Although properly restrained in his car booster seat, he was thrown from his mother’s vehicle when it was struck by an oncoming truck that crossed the center line. David sustained a fracture of his femur and pelvis, and he had lacerations on his face and arms. His body cast and the cuts all over his body made him feel quite uncomfortable. They were fresh, recently sutured, and described as “stabbing” him and causing acute pain. A family member shared with me that David loved frogs, and I knew a cute song about frogs sitting on logs. The song invites patients to insert their own “feeling words” into some of the verses. During the first meeting with David, he smiled, apparently for the first time since the accident, and enjoyed hearing the song. The morning of the second visit found David ready to sing along and express himself with some “feeling words.” He was able to say he was mad and hungry. Each day and each music therapy visit included opportunities for self-expression, which resulted in David smiling more and feeling better. David was healing physically, but his ability to express his emotions helped to distract him from his pain and release emotions lingering from the accident. He anticipated his next music therapy session eagerly and knew he would be able to talk about his pain and feelings. His trauma surgeon occasionally watched from the sidelines as David enjoyed music therapy and appeared relatively pain free for the duration of the session.

    Heidi is a 4-year-old cancer patient who was receiving chemotherapy for her leukemia. Treatment left her chronically nauseous, achy, tired, and cranky. She was hospitalized during treatment because her immune system was compromised and her chronic symptoms were better managed inpatient. Heidi was always happy to see me, smiling, and eager to get started when I arrived at her door. Sometimes, she pushed herself up on her pillow and waited to see which instruments I brought with me. At other times, she asked me to position myself on her bed so she could sit on my lap, and she settled lazily in my arms so that she was able to reach out and strum my guitar. Heidi had a very sweet voice, and even when feeling sick, she sang with enthusiasm. Heidi’s mother welcomed me and enjoyed seeing her daughter taking pleasure in the normal activity of music and smiling as broadly as she did before getting cancer. There were some days when Heidi was feeling too ill to sit up, but she asked me to stay and sing to her, as if she somehow knew intuitively that the music was good for her body, spirit, and soul. I provided soothing music in a rocking meter, and I concentrated on helping Heidi relax and rest by singing her name and stories about her healing. Mom frequently expressed her gratitude. When Heidi experienced relief, so did mom!

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    Larry gives Debbie a kiss as she plays guitar for him at the Children’s Hospital of Pittsburgh of UPMC.

    Larry is a 12-year-old boy whom I have known for most of his life. Mitochondrial disorder has caused Larry chronic and procedural pain and dozens of visits to the hospital during my 11 years at Children’s. I have been with Larry for many enjoyable music and family experiences, as well as in darker times of illness and painful procedures. Due to his mitochondrial disorder, Larry does not absorb medication in the same way that most people do, and he might receive five times the amount of medication with little impact. For example, if we are given a sedative to relieve our anxiety, we may feel drowsy and comfortable, while Larry barely feels any change. During many of Larry’s visits, he and I developed a close relationship and realized that music therapy was a great distraction during painful procedures, such as having an infected line removed, getting a new line such as a peripherally inserted central catheter, or PICC line, inserted, or having an invasive test.

    The physicians and staff were hesitant when I gowned up, masked, and gloved for the first sterile procedure I attended with Larry, but they quickly learned that my creative music therapy interventions would keep Larry calm and still while they addressed his medical issues. Larry was very fond of the silly song “Down by the Bay,” and in order to give him a sense of control (in a situation where he had very little control), I asked Larry to assign verses to each staff member in the room. For example, Larry would point to a nurse and say, “You have to do the next verse, and I want your verse to be about a hippopotamus.” It can be challenging to find a word to rhyme with hippopotamus, so great creativity was required! During one instance, Larry pointed to the physician doing the procedure and the physician replied, “I don’t sing.” I politely asked the doctor to reconsider and join in our fun. Hesitantly, he sang a verse, and his attention was directed to the medical task at hand. However, he became an advocate of music therapy for all of Larry’s procedures, and months later, he was offended if he was not asked to help create some silly lyrics for our song.

    Sometimes just a single visit from a music therapist can make a difference. In the Emergency Department, Janey, a 3 ½-year-old girl, was about to have an unpleasant procedure, an IV insertion in her arm. The mother was sure her daughter would kick and scream but agreed to allow me to provide music therapy for her daughter. While the staff gathered their supplies to insert the IV, I sang a few silly songs to engage Janey so that she could focus her attention on me, which in turn, detracted her attention from the medical procedure at hand.

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    Debbie provides music for Sofia as she gets a painful dressing change after open heart surgery at the Children’s Hospital of Pittsburgh of UPMC.

    As the nurse and I communicated with our eyes and a few subtle nods to indicate that the time was near for the IV to be inserted, I asked Janey if she knew her ABC’s. Janey looked at me in disbelief! She exclaimed that she was 3 ½, and of course she knew her ABC’s! I invited her to sing them with me and explained that I needed her help because I got mixed up sometimes. I began to sing:  A-B-C-D-E-F-G—-H-I-J-K-Elephants and Dogs, Lions and Tigers, Bears and Cubs…..and so on. Janey was unable to believe that I could be so dumb as to not know my ABC’s and stopped me. She patiently tried to teach me, and, as I accompanied myself on the guitar, we sang again and again until I finally got the letters right. Meanwhile, the IV team was examining Janey’s arm for good veins, prepping the skin with alcohol wipes, and finally inserting the IV. Janey occasionally looked at her arm and fleetingly paid attention to the IV prep and insertion, but her focus was on me, the music, and my ignorance of the ABC’s. Janey’s mother was shocked and pleasantly surprised that something as simple as music could distract her daughter at a time mom felt certain would be dreadful.

    Music is magical sometimes. My training educated me to help people by using carefully selected music. I am never surprised when I see a child in pain relax and fall asleep to music, or a crying child smile through tears and focus on the music rather than a painful procedure. One 9-year-old cancer patient felt very satisfied after he wrote a song about “everything going down the drain” and shared it with family and staff. He was feeling lousy from his chemotherapy when he wrote that song and felt incredibly satisfied that he found a way to safely share his true feelings. A 10-year-old transplant patient said that participation in music helped her feel as if she had choices, which helped her feel better about her life and reduced her pain and stress. For me, music repeats its magic again and again, and the power and beauty of music keeps me in a continual state of awe.

     


    [i] “IASP Taxonomy.”  IASP.  International Association for the Study of Pain,  22 May 2012.  Web.  14 Aug. 2014.

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