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Marion Doctor, LCSW
Denver, Colorado

Guest Editor
Christine Tuden, MS, MT-BC
Galveston, Texas

Management of pain for burn patients during debridement is specific music therapy interventions that have been developed
a challenge for all clinicians working within the burn care as effective music therapy for pain management. These tech-
team. Applying the gate control theory of pain, Prensner takes niques are well explained and provide a clear understanding
a systematic approach to address the “chronicity and intensity” and rationale for music therapy in burn care. Prensner also
of procedural pain by developing specific music therapy pro- describes the use of multiple therapy protocols during a treat-
tocols. Prensner contends that the structure and innate qual- ment session and uses several case examples to demonstrate
ities of music make it a versatile therapeutic modality, which application of the protocols. By using both physiologic and
can affect both the physiologic and psychological aspects of psychosocial outcome measures, the author is able to provide
the pain experience. She clarifies the value of music therapy as a holistic determination of intervention effectiveness. Al-
another strategy for pain management that can enhance con- though an elaboration on the assessment process for deter-
ventional treatment approaches offered by the burn care team. mining which protocol to implement would have been a use-
Prensner makes numerous valid assertions on the benefits ful addition, this section does invoke the reader to consider
of music therapy in pain management, but primarily takes a different scenarios. For example: How actively were patients
cognitive-behavioral approach in discussing the music thera- involved in the process? Did most patients receive individual
pist’s role in assisting patients in this area. In addition to this music therapy sessions before the procedure? Further, could
theoretical orientation, attention can also be given to the role the frequency or number of music therapy interventions dur-
of the patient in the music therapy process. As an adjunct to ing debridement influence patient outcome? The answers to
Prensner’s article, I encourage the reader to keep in mind that these questions would certainly provide a more in-depth un-
a concern in working with any patient in the medical setting is derstanding of the approach used by the author.
the need to involve the patient actively in the therapeutic pro- When using specific music therapy protocols, Prensner’s
cess. It is important to remember that only the patient fully approach is to divert the patient’s attention away from the
understands his or her own pain experience. When defining painful stimulus. The author uses the words, “redirect and
music therapy, both the therapeutic relationship and music distract,” to describe methods of coping. Although these tech-
exist simultaneously within the healing process. In addition, niques can be successful, it should be noted that in some
we need to consider situations where using music may be instances using music as a means of assistance and integration
inappropriate or counterproductive to the patient’s needs. In could be more empowering for the patient. Prensner’s state-
these cases where music may be overstimulating, the therapist ment that interventions should “engage the patient’s atten-
needs to rely on the therapeutic alliance to assist the patient tion as much as possible” is an important concept. In an en-
through the difficult or painful period. vironment such as the debridement room, where loss of
In one case example Prensner describes a female patient control is a critical issue for all patients, active music engage-
who coped with pain by singing during her dressing change, a ment techniques offer patients the chance to regain control
technique the patient used with the music therapist on the over their pain and discomfort. Developing techniques that
previous day. This scenario clearly illustrates the therapist’s involve and engage patients through the process can foster a
ability to help patients identify their individual strengths and sense of self-control and independence. In addition to Pren-
coping skills and achieve a level of increased independence. sner’s protocols, another technique to consider is drumming
Some patients cope better by singing familiar songs, and some in combination with deep breathing. Rhythmic drumming is
may need to participate in creating music, whereas other pa- alternated with deep breathing exercises, in which the patient
tients respond better to passive music listening with imagery. takes a deep breath and then beats on the drum as loudly as
Regardless of the therapeutic intervention, the patient should possible while exhaling. This action allows the patient to have
always be encouraged to participate actively in the assessment a physical release for the pain he or she is experiencing. When
process. Once coping skills are identified and further devel- patients have an increased awareness of their physiologic and
oped, the most successful interventions are those where pa- emotional responses to pain, they can begin to alter their re-
tients learn and use the techniques on their own. sponses and regain control.
There is a multitude of strategies used by music therapists to Music therapy is a 2-fold modality, in which the music and
cope with pain and anxiety. In her article Prensner defines 4 the rapport developed between therapist and patient play

Journal of Burn Care & Rehabilitation
Volume 22, Number 1 Prensner et al 83

complementary roles. Consequently, a greater emphasis on Prensner’s article does propose the need for further study
the role and the importance of the therapeutic relationship of the processes and benefits of music therapy with burn
would have been a useful addition to Prens- patients. Certainly, it would be desirable to expand on our
ner’s discussion. Although the protocols are well developed current research base and determine whether music therapy
and explained, the patient will not respond well to them unless interventions are most effective before, during, and/or af-
trust and rapport are established. Certainly, it is a component ter the debridement process. Further, for patients with se-
that should not be considered secondary in the treatment vere burns and for whom debridement can last several
process. hours, coping skills can be severely tested or become inef-
The latter part of the article briefly describes some prelim- fectual. Identifying effective music therapy protocols for
inary research findings using 3 interventions. These data pro- patients with severe burns (⬎50% TBSA) deserves much of
vide good insight into the benefits of these therapeutic inter- our attention. Another area to investigate is that of care-
ventions. I certainly look forward to the future publication of giver involvement in pain management. Ample research
more detailed and specific information on a number of addi- opportunities remain. I commend Prensner for taking this
tional factors, including the age range, TBSA burn percentage, important preliminary look into this developing area of mu-
and frequency and duration of sessions for the subjects sic therapy and highlighting the need for further
involved. examination.

Music Therapy for Assistance with Pain and Anxiety

Management in Burn Treatment
Jennifer D. Prensner, BM, MT-BC,*† Charles J. Yowler, MD,* Lori F. Smith, BS, MT-BC,†
A. Louise Steele, MMEd, MT-BC,† Richard B. Fratianne, MD*
Cleveland, Ohio

The management of pain is one of the primary issues in burn care. Pain is not only a physiologic
experience, but a psychological one as well. With this in mind, the treatment of burned patients
must incorporate a holistic view of pain management and healing. Cognitive, behavioral, and
pharmacologic interventions all have a role in pain management. Studies, as well as clinical expe-
rience, have shown that musical intervention has been helpful in assisting patients with pain
management in a variety of medical settings. Music is an element of normal life that can be eas-
ily adapted for the needs of individual patients and their current environment while providing a
means for self expression and for normalizing the environment. This article examines the ratio-
nale for using music therapy with burned patients, describes several protocols that have been
adapted to meet the specific needs of burned patients, and summarizes our preliminary find-
ings, which demonstrate significant response to music therapy protocols employed on our
patients. (J Burn Care Rehabil 2001;22:83– 88)

Pain is one of the most prevalent issues confronting the set of observable behaviors that indicate a patient
the burned patient. Pain sensation is the experience of is experiencing pain. Emotional factors, such as anx-
pain as reported by a patient, whereas pain behavior is iety and depression, can have an effect on both pain
sensation and behavior.1 Psychological issues that can
affect the perception of pain may include: fear of
From the *Burn Center, MetroHealth Medical Center, Cleveland, OH,
and †The Cleveland Music School Settlement, Cleveland, Ohio. complications or sequelae of the injury, coping with
Reprint requests: Richard B. Fratianne, MD, Department of environmental factors, fear of the unfamiliar stimuli
Surgery, MetroHealth Medical Center, 2500 MetroHealth
Drive, Cleveland, OH 44109-1998.
encountered, stress related to the injury and hospital-
ization, and outside stressors seemingly unrelated to
Copyright © 2001 by the American Burn Association.
0273-8481/2001 the actual illness.2 Additional contributing factors in-
Journal of Burn Care & Rehabilitation
84 Prensner et al January/February 2001

clude: the nature of the illness, its degree of severity, nificantly affected musculoskeletal and verbal pain re-
the nature of the response to pain by the individual, actions in postoperative obstetric and gynecologic pa-
and the individual’s history of previous physical and tients. Additional evidence of the combined effects of
mental ailments.3 The close relationship between music and relaxation techniques on physiologic as-
physical pain and contributing psychological factors pects of pain has been acquired using electroencepha-
necessitates that both be managed simultaneously in lography,12 finger temperature,13 and electromyo-
the treatment of patients with burns. graphy.14 Music has also been observed to affect both
the sensory and affective aspects of pain perception in
cancer patients.10,15,16 During dental procedures,
music was found to suppress pain in 90% of the sub-
jects tested.17,18
The gate control theory of pain perception is one of
the more widely accepted theories for the control of
perceived pain.4 The main premise of this theory is
that if a pain intervention can stimulate the larger-
diameter sensory nerve fibers, it acts as a diversion, or MetroHealth Medical Center is the county hospital
closes the gate, of the smaller, slower-conducting fi- serving residents of Cuyahoga County and serves as a
bers which transmit pain to the brain.3 Pain percep- campus of the Case Western Reserve University
tion has 3 main components: 1) sensory-discrimina- School of Medicine. MetroHealth operates a Level I
tive; 2) motivational-affective; and 3) cognitive- Trauma Center for children and adults and a verified
evaluative. The cognitive-evaluative factors affect burn center serving Northeast Ohio. The Compre-
pain perception by the level of anxiety, the situation in hensive Burn Care Center at MetroHealth comprises
which trauma occurs, attention and distraction levels, both an inpatient unit and a 24-hour ambulatory
and competing sensory stimuli.5 Cognitive strategies burn treatment clinic. The music therapy service at
employed in pain and anxiety management may be MetroHealth is provided by a contractual arrange-
classified as 1) imagery; 2) self-statements; and 3) ment between the Burn Center and The Cleveland
attention-diversion devices.6 Imagery strategies in- Music School Settlement. The music therapist is as-
volve envisioning events that are inconsistent with signed full time to the medical center with service
pain. Attention-diversion deals with redirecting at- primarily to the Burn Center.
tention from the pain to another event, passive or One of the most prominent problems faced by
active, in an effort to distract oneself from the pain.1 burned patients is the chronicity and intensity of their
Music therapy incorporates all of these cognitive pain. This pain often leads to problems with compli-
strategies and can be effectively adapted for a wide ance in treatment.19 Furthermore, management of
range of cognitive and physical function levels. pain is very difficult because of the variability in the
Music exists as one of the few sources of needs intensity of pain experienced both minute to minute
satisfaction that can follow people into the hospital and during the prolonged course of the healing pro-
and can be made available in virtually any setting.7 cess. Overmedication can result in sedation that limits
The use of music to assist with pain and anxiety man- physical and occupational therapy. As a result, alter-
agement can be defined as the combination of “au- nate methods to redirect and distract patients from
dioanalgesia” (the use of sound or music to reduce their suffering are often used.20
pain), and “anxiolytic music,” (the use of music or In the treatment of burns, several nonpharmaco-
sound to reduce anxiety). The application of one or logic treatments for pain and anxiety have been used.
both of these concepts is referred to as music assisted A number of studies suggest that behavioral ap-
relaxation (MAR). proaches can be effective in assisting burned patients
Music therapy has been proven effective with pain in managing their pain and anxiety. However, scientific
and anxiety management on a variety of levels. data substantiating these interventions is limited.20
Bolwerk8 found that music incorporating simplistic Numerous music therapy protocols have been used
repetitive rhythms was found to decrease anxiety in to assist in different facets of burn treatment with
patients with myocardial infarction. Music in combi- particular attention to related pain and anxiety needs.
nation with several relaxation techniques was also Music therapy protocols are used to assist with spe-
found to decrease the mean amplitude of corticoste- cific routine procedures, including dressing changes,
roid levels as well as increase reentrainment of circa- range of motion exercises,21 and intravenous (IV)
dian rhythms in the subjects studied.9 Radziewicz line placements. Music therapy may also provide
and Schneider10 and Locsin11 found that music sig- emotional support, reality orientation, and sensory
Journal of Burn Care & Rehabilitation
Volume 22, Number 1 Prensner et al 85

stimulation as well as opportunities for self-expression and anxiety, heart rate, pulse rate, verbal feedback
and the acquisition of age-appropriate cognitive and from patients and their families, and behavioral ob-
expression skills. Several traditional music therapy servations by staff of patients’ tension levels. Proto-
protocols have been used to assist patients with pain cols are selected and adapted to fit rehabilitative
and anxiety management, including various imagery needs, while engaging the patient on as active a level
strategies with music listening and muscle relaxation as possible. Because of the fact that burn pain is con-
with music (Table 1). stant and often very intense, it is important that music
In the MetroHealth Burn Center, the music ther- therapy protocols engage the patient’s attention as
apist is accessible to all patients. Patients are seen much as possible and thereby assist the patient in
individually, in small groups, and in cotreatment with redirecting attention from pain and anxiety onto the
other therapies, as appropriate. The music therapist music. At this burn center, selected protocols have
determines which protocols to use based on initial been used which incorporate facets of traditional pro-
and ongoing assessments of patients and weekly tocols but which have been adapted or modified to
meetings with the burn team. The Burn Center uses meet the specific needs of this population. The fol-
several sets of clinical pathways specific to the learning lowing protocols incorporate both traditional and
and treatment needs of both acute and intensive care original material and are adapted for effective use with
patients.24 The pathways emphasize the importance burned patients based on the music therapist’s
of a continuum of care and incorporate music experience.
therapy. Song Phrase Cued Response (SPCR) is defined as
having the patient listen to a song in order to provide
Adapted Music Therapy Protocols Effective a specific response at a designated time in the song.
with Burned Patients This protocol is designed to assist the patient with
Since incorporating music therapy as part of its treat- focusing attention on the music and away from the
ment program in 1998, the Burn Center has identi- painful stimulation. The tasks required of the patient
fied several music therapy protocols as being particu- necessitate concentration, but are simple enough not
larly effective in its treatment of burned patients. The to cause undue frustration. SPCR is usually used in
effectiveness of the music therapy protocols is deter- conjunction with other protocols, either as a facilita-
mined by measures that include self-report of pain tor or a catalyst. For example, SPCR assists with fo-

Table 1. Music-assisted relaxation protocols

Protocol Active/Passive Main Strategy Description

Music-assisted progressive muscle Active Tense/release muscle Systematic tensing/releasing of muscle groups, following
relaxation groups verbal directives (Jacobson,22 1938) with music
selected to foster effectiveness.
Music listening Passive Listen Listening to carefully selected music matched to patient’s
preferences and needs (Maranto,23 1991).
Music vibroacoustic therapy Passive Listen/tactile Applying low frequency pitches of carefully selected
music directly to the body, incorporating patient’s
needs/limitations (Maranto,23 1991).
Entrainment Passive (can be Alter physical rhythms Altering a specific physical rhythm/mood by matching it
active) with music, then gradually adjusting it toward the
therapeutic goal (Maranto,23 1991).
Music-elicited imagery Active Imagery Experiencing and/or discussing improvised images
elicited by specifically selected music (Maranto,23
Music and directed imagery Active Imagery Using specially selected music and suggestion with a very
relaxed person to foster progression toward the
therapeutic goal (Maranto,23 1991).
Music and guided imagery Active Imagery Using specially selected music and suggestion with a very
relaxed person to explore issues related to or causing
the condition (Maranto,23 1991).
Music and biofeedback Active Biofeedback Utilizing music carefully selected to elicit/cue relaxation
(Maranto,23 1991).
Journal of Burn Care & Rehabilitation
86 Prensner et al January/February 2001

cusing attention, providing a structure to range of identify a special place and describe it to the music
motion exercises with instruments, and providing an therapist. The patient is then instructed to concen-
actively engaging alternate focal point during adver- trate on his special place and try to imagine what it
sive situations. If a patient seems inattentive to a mu- would be like to be there. The images are sung by the
sic therapy intervention, SPCR can be used to assist music therapist as improvised lyrics integrated with
the patient in focusing on the therapist and gradually cues for rhythmic deep breathing and APMR. Tempo
increasing interaction. The outcome of this protocol and volume are gradually decreased. The patient’s
is measured by the level of the patient’s participation individualized MBI music can be recorded on cassette
in the protocol; ie, does the patient demonstrate the tape and left with the patient for independent use.
ability to attend to the task, interact with the thera- MBI’s effectiveness is determined by the patient’s
pist, respond on cue, provide appropriate responses, participation: observable signs of muscular relaxation,
etc. relaxed affect, decrease in eye movement, positive
Adapted Progressive Muscle Relaxation (APMR) is verbal feedback, or falling asleep.
the organized and systematic relaxation of muscle The Relaxation Response Elicitation (RRE) is de-
groups to music, adapted to avoid causing additional signed to assist with relaxation or regulation of vital
pain through physical tension. The patient is in- rhythms or both while providing therapeutic interac-
structed to visualize small lights of a specially selected tive musical stimulation to patients who are able to
color. The color is selected by the music therapist to give minimal overt responses to auditory stimulation.
elicit the desired temperature sensation for the pa- When an injury occurs, the natural rhythms of the
tient’s current comfort needs. This visualization aids body are interrupted, and the body’s healing process
the patient in focusing attention by providing a sim- often further taxes the systems through elevated vital
ple specific subject to concentrate on. Furthermore, rhythms. In order to reduce the stress put on these
contrary to traditional progressive muscle relaxation, physiologic systems, the music therapist selects a vital
this adaptation avoids the physical tensing of muscles rhythm to address (usually heart rate), based on the
which may be painful for burned patients because of patient’s current ability to respond. The speed of
the tissue damage and tight dressings. Structure for the vital rhythm selected is closely approached or
deep breathing is provided by cues from the therapist matched by the tempo of the music. Over the course
and repetitive rhythmic accompaniment. Through- of the session, the tempo is gradually adjusted, incor-
out the protocol’s application, the tempo of the mu- porating principles of entrainment to assist in using
sic (and volume, if desirable) are gradually decreased, the rhythm of the music to adjust therapeutically the
to assist patients in slowing their respiratory rates. patient’s targeted vital rhythm. The rhythm of the
This protocol can be recorded on cassette tape, and a music can be reinforced, if desired, by rhythmic tap-
tape player can be provided for the patient’s use dur- ping on a drum or patient’s bedrail to emphasize the
ing their hospital stay. The recording allows the pa- tempo and increase response. Contrasting musical
tient to use the technique in other settings (such as styles and tempos can be alternated to foster re-
before surgery or during outpatient visits) to assist sponse, elicit attention, and avoid habituation to the
deep breathing and emotional regrouping. The effec- musical stimulation. If the patient’s responses be-
tiveness of the protocol is determined by the patient’s come more overt, the emphasis of the session can be
participation: observable signs of muscular relaxation, adapted to engage the patient more actively. RRE’s
relaxed affect, decrease in eye movement, positive effectiveness is determined by successful entrainment
verbal feedback, or falling asleep. of the vital rhythm tracked, decrease in observable
Music Based Imagery (MBI) provides a relaxation signs of tension, and increase in observable positive
experience specifically designed for the individual pa- responses.
tient. Due because of a large amount of aversive stim-
ulation faced by burned patients, traditional relax-
ation and imagery techniques are inadequate. MBI
uses familiar images described by patients as the fo- Because of the perceived successful application of Re-
cus, which assists them in concentrating as well as laxation Response Elicitation, Adapted Progressive
evoking pleasant memories involved in the scenario. Muscle Relaxation, and Music Based Imagery, a pilot
Because the patient must describe and focus on the study was conducted with 63 burned inpatients who
images, MBI requires that he be able to clearly com- received 1 of the 3 protocol interventions. The ses-
municate with the music therapist and not be cur- sions were conducted in the patients’ rooms by the
rently involved in an acute episode of reality-distort- music therapist. Baseline data was collected before
ing psychosis. MBI begins by having the patient music therapy intervention for those protocols com-
Journal of Burn Care & Rehabilitation
Volume 22, Number 1 Prensner et al 87

paring vital rhythms or observable tension levels. Vi- rate. Using RRE, the music therapist was able to de-
tal rhythms or tension levels were tracked throughout crease the heart rate markedly.
the intervention and the progression, and end results A 28-year-old female was admitted for inpatient
were compared with baseline. Verbal feedback from care after a house fire with scattered burns totaling 7
the patient or family was provided either spontane- to 8% TBSA. She participated in music therapy to
ously during the session or at the conclusion of the assist with pain and anxiety management during her
protocol. The findings of the pilot study are shown in dressing change. The patient demonstrated excellent
Table 2. participation in MBI before and after her dressing
change. However, during the wound treatment the
patient demonstrated reluctance to participate audi-
bly in the music-making process. Therefore, the mu-
Music therapy is effective with a wide variety of age sic therapist used verbal SPCR to encourage active
groups and function levels. At times the responses can participation by the patient. While engaging in
be quite dramatic, as the following cases demonstrate. SPCR, the patient began singing, instead of stating,
A 6-year-old male with burns totaling approxi- the desired word or phrase. The length of the pa-
mately 30% TBSA was admitted to the inpatient unit tient’s responses continued to increase. The patient
after a scald accident. During a visit by the occupa- continued to sing entire songs with the therapist
tional therapist, the patient refused to range his fin- throughout the remainder of her dressing change.
gers and arms. However, when the music therapist On the following day the patient did not have music
used a familiar children’s song with finger play, the therapy intervention, but the medical staff reported
patient completed range of motion exercises indepen- that the patient sang to herself during her dressing
dently. On another day, while attempting to place an change. An analysis of the data collected indicated
IV, the medical staff met with difficulty because of that with music therapy intervention, the patient ex-
edema in the extremities. Consequently, the patient hibited a more stable pulse rate, lower anxiety levels,
was very agitated, which elicited great concern from and a steady decrease in tension.
the patient’s mother. The therapist requested time to A 48-year-old male was admitted for treatment fol-
assist the child with relaxation, before the procedure lowing an industrial flash flame electrical source burn
was resumed. As the therapist played and sang famil- to the upper body and face, covering approximately
iar children’s songs, the tempo of the music was grad- 5% TBSA. During the course of the patient’s treat-
ually slowed to foster relaxation. After approximately ment, the patient participated in a number of music
10 minutes the pediatrician returned to attempt again therapy protocols, including Song Adaptation, Ther-
to place the IV. The child opened his eyes and con- apeutic Instrument Play, Therapeutic Singing, and
tinued to remain totally calm until the procedure was MBI. The protocol that the patient responded to
resumed. most effectively was MBI, particularly after wound
A 7-year-old male was admitted after a flash flame dressing changes. The patient stated that MBI as-
to the upper body, approximately 24% TBSA. The sisted him by taking the edge off of his pain. The
patient participated in a combination of the MBI, patient also stated that Therapeutic Singing assisted
SPCR, and music listening before, during, and after him with pain management during dressing changes.
his dressing change. During the course of treatment Furthermore, as an outpatient, this patient encour-
with music therapy intervention, the child demon- aged 2 fellow patients to contact the music therapist
strated a marked decrease in pulse rate, a more natural and obtain tapes of an MBI session to assist with their
trend in pain and anxiety levels, and lower tension pain management.
levels. His individual MBI session was taped and was An 83-year-old male was admitted for inpatient
used at other times of high stress, including before care after a scald to his lower extremity. This patient
surgery. A few days after surgery, while heavily se- fully participated in the MBI protocol administered
dated, the patient demonstrated an elevated heart before and after his dressing change, and SPCR, Song

Table 2. Responses to adapted music therapy protocols

Total Not Fell Percent

Protocols Patients Successful Neutral Successful Asleep Success

Relaxation Response Elicitation 35 14 N/A 21 N/A 60

Adapted Progressive Muscle Relaxation and/or Music Based Imagery 28 0 1 22 5 98
Journal of Burn Care & Rehabilitation
88 Prensner et al January/February 2001

Choice, and Therapeutic Singing during his dressing spective study to evaluate Adaptive Progressive
change. The next day, medical staff related that dur- Muscle Relaxation and Music Based Imagery.
ing debridement, the patient requested music ther-
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