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HAWAI ‘IMEDICAL JOURNAL

November 2007, Volume 66, No. 11,ISSN: 0017-8594

吳慎教授與哈爾肯院長等所研究的能量音樂（藥）在美夏威夷醫學權威論文刊物上發表

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後附迪士尼癌症中心芬格樂博士與吳慎晚期癌症疼痛臨床統計科研報告 (下載高像數標準照)

論文 《SWMT音療》癌症止痛與失眠試驗方案目錄吳慎教授與美國夏威醫大學醫學院副院長哈爾肯合寫的音樂醫療科學性總結論文與迪士尼癌症中心試驗統計報告 1，迪士尼癌症中心癌痛病歷12頁 2, 迪士尼癌症中心癌痛統計表6頁 3，學術論文10頁 UNIVERSITY OF HAWAII DEPARTMENT OF ALTERNATIVE MEDICINE 夏威夷大學醫學院替代醫學研究系教授吳慎（PROF） 美國夏威醫大學醫學院代院長哈爾肯Rosanne Harrigan, EdD, APRN-Rx, FAAN University of Hawaii Assistant Dean

音樂療法與癌症疼痛處理

作者：ROSANE HARRIGAN PHD 夏威夷大學醫學院第一代理院長

SHEN WU PROF 夏威夷大學醫學院替代醫學系教授

2007年夏威夷大學醫學院呈報發表於美國夏威夷醫學專業刊物

(HAWAI‘IMEDICAL JOURNAL November 2007, Volume 66, No. 11,ISSN: 0017-8594 )

本文綜合摘要

癌症患者要忍受雙重折磨，一要忍受藥物治療時的副作用，二要接受由疼痛引起的精神上的憂鬱，二者足以影響病患的不舒適感及其生活品質。

處作者疼痛處理的替代治療，音樂治療法經多數專家的研究，已可證明可以減輕患者所感受的痛處，在癌症患者接受侵入性手術及化學藥物治療時，音樂療法可以分散病痛注意力而引導其進入另一境界中，以減低其接受治療的痛楚。又經研究，在癌症患者接受在家中和門診治療時，亦可發現類似現象，即可以減輕疼痛感受上的層次。

雖然這些研究結果在圍繞著音樂治療的成果上，似有一些問題不太瞭解其對疼痛減輕的實質性機轉，但事實已顯示，患者都能確實有效地減少其緊張及焦慮而間接地減輕其疼痛的程度，進而有效地改善患者之生活品質。

引言

RAINVILLE，HUNT和MANTYH等醫學博士們在2001年發表論文中（1，2）稱當人體組織受傷害時，產生一連串知覺上及情緒上的不舒適，而疼痛引起的感覺會使人在變化中的生活環境中，藕生物回饋（B10-FEEDBACK）作用而來調適個體的生存。

MIGUEL博士在2003年的論文中（3），稱這種生物的適應性在癌症患者中表現最為明顯，即當疼痛增劇時表示病情惡化，在疼痛減輕時表示病情好轉。又HUNT（2）在2001年及BRAD（4）在1998年研究稱癌症經過一段時間時間以後變為慢性疼痛，進而誘發焦慮及憂鬱症狀，引起不必要的更多苦楚而影響了生活品質。

WEITEN（5）等在2003年發現疼痛愈烈，其憂鬱程度亦愈深，同時其死亡的願望亦愈烈。 PLANCARTE等（6）在2003年發表稱，雅片麻醉製劑及其它的非麻醉劑的止痛藥物，用來治療疼痛時，常因副作用太大而停止使用。

因為上述種種現象，因此很多醫師們在追尋另類醫學治療，即不用藥物治療的方法，在其中，音樂療法便被引用來治療疼痛的研究與探討，結果發現其有一定的效果，而沒有一般止痛藥物的副作用，對病患更是沒有危險性。

由於疼痛原因極為複雜，其對身心雙方面都會有巨大影響，因此在使用另類醫療前，必須考量其對生理及心理上的影響。

HUNT及MNTYH在2001年論文（2）稱，純從生物學觀點來看，疼痛的感覺起緣于在皮膚及在內臟中的知覺神經織維，進入了脊椎神經，在人體中，知覺神織維對各種刺激能起不同的反應，其中，有髓的A神經織維及較小直徑而無髓的C神經織維會接受各種刺激，尤其是C神經織維特別敏感，能對有害刺激起反應，包括熱，冷，機械的或化學的刺激，當神經受刺激時，會施放出氨酸（PEPTIDE）與體內的生長因素（GROWTU FACTOR）來激發傳導入脊椎神經，然後進入前腦神經系統，在這種複雜的生理變化中，各種接受的刺激傳導到神經系統中的神經細胞會產生一連串的變化進入脊椎及腦部神經系統而施出化學物質稱為氨酸（PEPTIDE）來產生不同程度的疼痛反應，每一種疼痛刺激有不同地點部位產生，呈不同種類的化學變化，因此需要多種止痛劑才能阻斷其疼痛感覺，各種組織的損傷更能引起高度疼痛的感覺。

RAINVILLE等（1）在2001年研究稱，不論其生理上的途徑為何，疼痛是一個主觀額定及原始的感覺，很難用一個客觀憑外界觀察來衡量。

從自覺認知反應來看，有不同的因素產生持久而接受疼痛的感覺，這些因素包括各人對疼痛感覺的敏感性，是否這種疼痛會引起日後的慢性疼痛，及患者精神狀態，無論是焦慮，憂鬱或倦怠懶散等等都會影響日後會不會產生持久性慢性疼痛狀態，又患者個人的自覺認知上會調節其日後產生慢性疼痛的適應性，被動的認知反應，緊張性生活狀態，或發生殘疾等事項都會引起日後持久性疼痛的發生。

TILLEMURE及BUSHNELL等（7）在2002年稱，除了神經織維是否會確認疼痛刺激外，很多心理上的因素亦可以導致神經的感受性，其中以患者精神上注意力狀態在心理學上與疼痛的感受性有密切的關係。

ALDEN等（8）在2001年稱疼痛的感受與精神上的注意力狀態有關連。當患者注意力被引往另一個狀態時往往可使疼痛的感覺減輕許多。

TILLEMURE和BUSANELL（7）在2002年稱，其二他心裏因素如情緒及意識狀態等都能改變腦部邊緣系統的神經化學反應而來調節疼痛的感受。雖然到目前為止，尚無資料可以顯示精神狀態與神經細胞中間感受性的直接關係，當許多研究人員都認為精神狀態確能改變疼痛的感受性，誘導法的學說已顯示個人正面發心的狀態可以引起正面的反應，反之個人負面不發心（NO MOTVATION）的狀態則可致負面的結果，正面的態度（POSITIVE ATTITUDE）可以使前腦皮質部分增加一種內分泌叫做DOPAMINE的增減直接影響到前腦神經對疼痛或止痛上的不同的認知。

PLANCARTE等（6）在2003年稱，在今日醫界人士在尋求多方面的方法來治療疼痛問題，大多數醫師們還是先用藥物來治療癌症患者的疼痛。 TUEITENER等（5）在2003年稱，常用麻啡及一些麻醉性止痛，據統計在美國，末期癌症患者中有75%主訴有疼痛，其中２５%因受不住劇烈疼痛而死亡，雖然有另類醫學治療可以利用，但他們都不知道來利用。

　　ＥＲＳＥＫ等（９）於1999年論文中稱，一般醫師在已診斷為重癌症患者中，仍恐懼一般止痛的麻醉藥品會引起不良反應及副作用，一些患者會產生抗藥性，因此對此類藥物的使用上有些遲疑不決的態度，並且許多患者擔心此類止痛藥物價格過於昂貴，並懼怕這些藥物久用後會漸漸失去效果，總之，患者的態度與信心會大大影響止痛藥物的使用，因此近幾年來，醫師與患者方面對於癌症疼痛的治療上已漸漸傾向于研究應用非藥物的治療方法。

音樂療法與癌症疼痛處理的討論與研究

ERSEK 等（9）於1999年介紹另類醫療法，創造一個新的世紀來應用非藥物方法來治療癌症患者的疼痛處理方法。 OTT（10）在2002年稱在全世界約有償至64% 的癌症患者應用另類醫療隊法，很多是患者志願要求的，在美國約有70%癌症患者由其主治的腫瘤專家們合作來推行另類療法，以身體為主的能量治療，傳統醫學療法，而音樂療法則包括在身心療法中間，以減少痛楚，創造一種內在的詳和，安定及舒適的身心狀態。報告中指出，很多不住院的癌症患者中都能感受到緊張的減少，疼痛的減輕，其精神狀態較為穩定而少有被動。

KERKVILIET（11）在1990年`已應用音樂療法，一天至少聽音樂90分鐘，患者任其選擇其喜愛的音樂，醫護人員用疼痛計分標準來記錄其效果在案，在15位門診部病人才中有12人報告說有好的效果，其中7位患者有極顯著的疼痛減輕現象，其同僚BECK氏亦認為音樂是無刺激性，是無害的，能使患者感到身心舒適，免除害怕與煩躁等心理，進而達到疼痛的減輕，BECK更建議進一步可以建立一個音樂片帶圖書室，讓患者來選擇他們喜愛的音樂，盡而研究出何類音樂，特別能與神經系統相認可，而達到音樂療法的療效。

TUEBER（12）于1999年曾研究音樂療法在癌症患者接受化學治療時的影響，結果顯示它可以減少情緒上的創傷，焦慮與緊張等，有35位癌症患者在一年的研究中，當他們接受化學治療時，發現音樂療法後患者的面部肌肉較為鬆弛，而面部肌肉的緊張狀態亦減少，更令人驚奇的一點為當患者應用音樂療法愈久時，其效果有為顯著，大部分患者要求用古典音樂，而不喜歡近代的音樂，因此TUEBER氏結論為古典音樂的樂曲遠比其他音樂更有效地使患者感到更為安適及減少痛苦， BECK（11），TUEBER（12）及TILLE MURE及BUSHNELL（7）等在其研究報告中，集合其共同研究結果均認為能轉移患者的注意力對於癌症患者疼痛的減輕有極為顯著的效果。

KWEKKEBOOM（13）在2003年進一步研究來觀察音樂能否改變個人腦部傳導的感覺及疼痛的傳導系統，他觀察了58位元癌症患者在接受化學治療時分成三組來作實驗，第一組加上音樂療法，第二組用引導法來改變患者的注意力，第三組不用任何方法，專業護士們來為這58位患者來評定其主訴的疼痛分級，結果顯示音樂療法與導引者注意力的兩種方法都同樣可以減輕其疼痛的等級，雖然在實際執行時，外科醫師的發言及其他醫護人員的動作言語等都能影響患者在接受音樂治療不能集中意念，但總的來說，音樂療法可以驅開和轉移患者的注意力而有效地來減輕其痛楚。

在施行音樂療法1，先要研究患者選擇那一種音樂，WU（14）在1999年報告，研究應用中國傳統的靜坐

時應用那一類特殊的音樂，如何來影響癌症末期患者的局部疼痛症候群，他用中國《導引吐納》的原則來

訓練患者，所謂《導引吐納》，通過自然淨心吐故納新可用來平衡個體的身心，“精微之氣和精神”包括

“陰”與“陽”兩面，相當於能量的“負極”與“正極”，這兩種能量即陰又陽，會互動增減，一方面減

少時可另一方面則增加，所有中國傳統醫學的治療都是根據上述原則來平衡“陰”與“陽”兩方面的。

WU（14）在1999年並發表了氣功的鍛煉可以強化器官功能，在長期慢性患者中可以逆轉其不正常的功

能變為正常的功能，在他26個研究病例中，在末梢神經性疼痛的患者中分為二類：其一用《導引吐納》方

法來鍛煉訓練；其二為不用《導引吐納》鍛煉，兩組患者都聽看“音樂聲波能量”的視聽設備，只又獲得

亞洲政府認可註冊的專家才能為患者傳授訓練，結果顯示82%接受氣功訓練者其疼痛減輕，未接受氣功訓練

者只有481%患者有疼痛減輕，在未接受《導引吐納》鍛煉者僅有36%疼痛減輕，並且在實驗中，光接受音樂

療法而未接受《導引吐納》者有70%能減少其焦慮與緊張，而在接受音樂及《導引吐納》兩項者有100%減輕

其緊張及焦慮狀態，雖然本本實未能指出其病理實體上有如何的變化，但在功能上《導引吐納》加上音樂

療法確能減輕病痛及減低情緒上的波動。 EVANS（15）在2000年研究29個病例應用音樂療法，雖不能

指出疼痛指標上的多大分別，但確能轉移患者注意力，減輕其精神上的焦慮，在住院病人中更能改善患者

的心理狀態，減少止痛麻醉劑藥量，而使患者能忍受治療及手術等，他研究的病例雖然不多未能劃出一定

結論，但EVANS（15）最後指出他與前述幾位作者如BEEK， WEBER，KWEKKEBOON和WU等的結論不相

上下，我們宣稱音樂療法有成功的效果，是有價值醫療方法之一。

音樂療法未來研究方向與結論

很多學者們從生理學及疼痛認知感應的研究上，未來應多從生理的機構上來研究音樂治療與疼痛

處理上的關係，從量上而非從質上來客觀的研究自覺性疼痛的本質，未來應有大規模的設計研究來

獲得音樂療法對疼痛處理上來證明其具體的結論，如應用進代的MRI（核子共震檢查）也許會觀察到

音樂療法對於神經系統起何種變化，在癌症病人治療上應用MRI檢查來顯示臨床醫師有更多客觀的證

據來支持音樂療法有效的說法，如果可能話，未來音樂療法的研究應是長時期的研究與觀察。

如上所述，研究人員可以獲得更進一步的主觀的及客觀的兩個層面的所得的研究成果來指出音

樂療法對癌症患者疼痛的控制研究能達到何種曾面，而盡能發展出整套心理，社會及心靈上的方法

結論音樂療法，以使患者獲得身心兩方面的健康和舒適。

OTIS-GREEN等（16）在2000年已確忍這種多方面及多層次的方法結合音樂療法來減輕患者疼痛

的方法，為今後研究中心所要努力的目標，按照這個方式有效地整套地集合成一個醫療小組包擴臨

床醫師，心理學家，社會工作者及精神科醫師等專家來配合癌症治療，加上音樂療法等方法來促進

及支持患者的需求，用專業的態度及關係來處理並減輕患者的疼痛，在這種範式的研究下，音樂療

法引起的良好有益的結果在另類醫療中有其一定的地位，因為它可以使癌症患者減少肉體上的痛疼

痛與心靈上的苦楚。

吳慎教授與迪士尼癌症中心主管醫師芬格樂博士合作治療癌症疼痛臨床病歷

Qualitative Summary of Music Therapy Patient Assessments

Patient 2

3/3/99

Since recurrence of the disease in 1998, an intra-arterial catheter to the liver was placed and the patient is now on an intra-arterial perfusion for 96 hours once every four weeks. Patient 2's tumor markers have been increasing and are out of proportion to the patient's liver function tests, requiring patient to receive CPT-11 septemically (IV) for the tumor. Patient's bone marrow did not tolerate the drug very well which required transfusions and additional medication (i.e. Tomudex).

Patient 4

3/31/99

Patient appeared very pleasant and positive and reported feeling a lot better since the first treatment, "good enough to go out for dinner with the family on Sunday."

4/2/99

Patient's son reported that everyone who knows her has commented on her improved appearance. Patient reported feeling happier with more energy, encouraging the pursuit of activities that the she did not feel like doing before.

4/6/99

Patient appeared bright and pleasant and reported no complaints.

4/9/99

Patient reported feeling good generally with no complaints.

5/4/99

Patient asked permission to have a biopsy on her left breast in view of her primary physician's discovery of a lump on her breast.

5/7/99

Patient reported that her appetite was good and that she slept well with no problem with bowel movement and urination.

5/19/99

Patient showed marked improvement in the tumor in the right frontal masses. According to the film, two tumors were gone, and one became smaller, leading the patient to continue with Music therapy.

Patient 5

11/1/97

Patient complained of severe lower back pain which had never happened before. By the end of the treatment, the patient was no longer upset and reported feeling very happy and very relieved when the pain was gone.

11/5/97

Patient complained of terrible pain right across her lower abdomen, causing her to feel scared. By the end of the treatment session, the patient felt better and realized that the pain was gone.

11/6/97

Patient reported sleeping well after last treatment. Patient no longer dragged getting out of bed or felt lightheaded after waking up and instead felt very energized. Patient now reported experiencing a very minimal dull ache on the lower back.

11/8/97

Patient reported feeling much better but did complain of feeling tired. Patient also stated that she felt very good and very positive about her treatments.

11/11/97

Patient appeared pleasant and radiant, stating that she did not feel sick at all and has not had that kind of feeling in years. Patient complained of slight right side headache and a pinching pain above the pubic bone, but still reported feeling good generally. Patient's blood pressure went from 174/93 to 168/94 after treatment.

11/13/97

Patient progressing very well

11/14/97

Patient doing very well although high blood pressure was still a concern.

11/18/97

Patient doing rather well apart from hypertension

11/20/97

Patient continued to have high blood pressure ranging form 185/113 - 187/97.

11/21/97

Patient very positive and happy with Professor Wu's treatment.

11/25/97

Patient was very concerned and frightened over lab work result.

11/26/97

Patient feeling better today.

11/28/97

Patient stable.

12/1/97

Blood pressure continued to be a concern.

12/2/97

Patient regained her positive attitude since the last time she learned her blood result of CA 125-404 that was before Thanksgiving.

12/4/97

Patient stable.

12/5/97

Patient stable.

12/6/97

Patient stable and very pleased with her treatment.

12/12/97

Patient feeling a lot better with the treatment. 12/13/97

Patient stable.

12/16/97

Patient's general condition stable.

12/17/97

Patient stable.

Patient 6

1/28/00

Patient reported feeling as though he was lying on a massage chair during the treatment, which was a kind of feeling he had not experienced before.

2/1/00

Patient reported feeling light headed with sweat while performing the music therapy exercises the previous night. Patient stopped the exercise and opened his eyes right away because he was afraid.

2/2/00

Patient reported very unusual experience he received from Professor Wu for the last 5 days. Patient reported less pain on his left ribs and did not take pain medication the previous night.

Patient 8

11/2/97

Patient expressed feeling very weak and complained of nausea and vomiting, and of not being able to eat. Patient also complained of pain on the nephrostomy tubes area especially while standing up. After Professor Wu's treatment, the patient reported feeling better, showed some pink color on his face, spoke louder, and stated that the pain was more tolerable following treatment.

11/4/97

Patient stated that he was able to sleep the night after treatment and ate with no complaints of nausea or vomiting. Patient still complained of a dull ache in the neph tubes area while standing up.

11/7/97

Patient stated that he felt a lot better with more energy after treatment.

11/8/97

Patient reported feeling better and stated that he still has some slight pain on the right kidney area while standing up, but such pain was not as bad as it used to be. Patient starting to have rectal pain.

11/9/97

Patient reported that his right kidney/nephrostomy site did not bother him as much, though rectal pain seems to be the problem.

11/10/97

Patient complained of feeling very weak with no energy. Patient finds it difficult to defecate due to rectal pain.

11/11/97

Patient appeared alert and stated that he felt stronger generally. Although he still experienced rectal pain especially on defecation, he otherwise reported feeling O.K.

11/12/97

Patient stated that he does not feel as strong as yesterday, and that the left side of body (??) does not feel good today. Patient did have a good bowel movement this morning, though rectal pain still bothers him.

11/13/97

Patient was alert and stated that he felt pretty good. Patient complained of right kidney tube area pain, though rectal pain decreased greatly. Patient also had some discomfort around the scrotum and prostate area. Patient said he felt a lot better after the treatment.

11/20/97

Patient very lethargic and weak.

11/24/97

Patient cancelled treatment due to feeling weak. Patient 9

10/15/97

Patient stated that she felt better except for some coughing due to throat irritation from the removal of NG tubes and some incisional pain due to increased physical activity. Patient otherwise appeared calm and relaxed with some color (light pink) on her face and with a stronger hand grip.

10/17/97

Although patient has not eaten since August due to feelings of nausea and vomiting whenever she saw food, she has not felt such feelings for the last two days. Patient does not experience any increase in pain with physical activity although she still has a little bit of dull pain on the staple site.

10/18/97

Patient denied having pain but complained of not feeling too well. Patient also complained of having a lump on the left upper arm, which she showed to Professor Wu for subsequent treatment.

10/20/97 Patient stable. 10/22/97 Patient stable. Patient 10 10/18/97

Patient reported only having pain around the abdomen area when she lies down but felt better otherwise.

10/19/97

Patient was very tired and did not sleep very well last night due to cramps in the abdominal area. Since patient was at present very weak and vulnerable physically, it was very hard for her to fight off any side effects from the medication she is taking.

10/20/97

Patient appeared alert and talkative and stated that she had no pain but felt very weak.

10/21/97

Patient's general condition improved greatly with no pain noted. Although she was very weak and tired physically, her vital signs remained stable. Patient fell asleep soundly during the treatment with Professor Shen Wu's music and had another large bowel movement before the end of the treatment session.

10/24/97

Patient was awake but complained of tiredness and feeling afraid. Patient denied having pain except for soreness in the hip area due to her position and edema. Patient's lower extremities are very swollen and tender to the touch.

10/25/97

Patient complained of soreness at the hip and back area due to being in the same position for too long.

10/26/97

Patient was able to urinate last night after not being able to do so for a long while. Patient also had a bowel movement.

Patient 13

1/21/98

Patient reported a decrease in pain since the first treatment and was able to rest better.

1/23/98

Patient stable.

Patient 17

4/27/98

Patient feeling better.4/29/98

Patient reported a decrease in pain.

5/3/98

Patient feeling better although she still had some sort of hip pain that lessened in intensity.

5/6/98

Patient reported a great decrease in pain after each visit, along with a tingling sensation from the right hip down the leg instead of pain.

5/8/98

Patient progressing well.

5/13/98

Patient stated that the pain greatly decreased and was less intense compared to when she first started the treatment.

5/15/98 Patient stable. 5/18/98 Patient doing well.

Patient 18

9/11/98

Patient reported constipation from medication which she finds uncomfortable and distressful.

9/22/98

Patient reported feeling no more pain, no vaginal bleeding, and felt pretty well generally since her first treatment.

9/28/98

Patient reported nausea, vomiting, lower abdominal pain, and fatigue from chemotherapy. Patient also reported feeling a lot better, relaxed, and comfortable after the treatment.

Patient 21

10/21/98

Patient reported feeling a kind of tingling warm sensation around her body and lower abdomen during the treatment and felt very much relaxed.

10/22/98

Patient reported feeling very much at ease and comfortable with the therapy. Patient also expressed feeling as though she's in another environment at certain times during the treatment, with bright lights over and above her akin to angels.

11/3/98

After a total of 10 treatments, patient was given a 20-day supply of herbs to drink.

Patient 22

1/18/00

Patient advised not to over tired herself and to rest as much as possible.

1/20/00

Patient reported feeling no sickness, discomfort, or pain at all. Patient instead felt very healthy and energetic, but was advised to continue daily Music Therapy exercises and to rest.

1/24/00

Patient reported feeling fine except for some constipation during the last couple of days.

2/7/00

Patient reported feeling fine and did not experience any side effects from chemotherapy.

2/14/00

Patient reported feeling fine with no complaints.

2/16/00

Patient reported no complaints.

Patient 23

5/7/99

Patient appeared less tired and more sociable. Despite some irritation in the throat, which seemed to subside by the end of the treatment, patient had no complaints.

5/21/99

Patient lost a lot of weight and appeared withdrawn since the last treatment. Patient reported not being able to swallow anything.

Patient 24

4/8/98

Patient complained of pain and tightness around mid-chest wall area especially when she attempts to move or turn. Patient also reported dryness of mouth from chemotherapy, along with a loss of taste sensation and appetite.

4/9/98

Patient reported sleeping better last night. Patient also reported her pain was less intense around the diaphragm and back. Patient's appetite was fair.

4/10/98

Patient reported having saliva back and no longer has dry mouth.

Patient 25

10/22/98

Patient complained of nausea and vomiting due to chemotherapy, a decrease in appetite, and weak physical condition. Patient also reported tremendous pain on the right lower pelvic area down to the thigh as well as the lower back.

10/27/98

After four treatments, patient denied having any more pain and was no longer on morphine.

Patient 26

12/9/97

Patient's blood pressure rose to 104/70 after treatment. Patient also reported feeling better.

12/12/97

Patient doing well.

12/15/97

Patient stable.

12/19/97

Patient stable. Professor Wu reassured patient that the blister on the umbilical area was a good response to the her application which drew all the poisons from the internal organs to the outside of the body.

12/22/97

Patient stable.

12/26/97

Patient stable.

12/29/98

Patient reported no complaints

1/4/98

Patient complained of right intermittent shoulder pain but otherwise felt O.K.

1/6/98

Patient stable.

醫學論文在國際學術大會中發表並無數次獲獎

MUSIC THERAPY AND CANCER PAIN MANAGEMENT

Rosanne Harrigan, EdD, APRN-Rx, FAAN*

Prof. Shen Wu, Music Therapy Founder **

From the Department of Alternative Medicine, University of Hawaii John Burns School of Medicine, Honolulu, Hawaii, USA.

* Professor and Dean, Department of Complimentary and Alternative Medicine, University of Hawaii, John A. Burns School of Medicine.

**Founder of Music Therapy and Professor of Medicine, Department of Complimentary and Alternative Medicine, University of Hawaii John Burns School of Medicine.

Summary

When coupled with the often debilitating side-effects of pharmacological interventions, chronic cancer pain may elicit feelings of anxiety and depression and therefore adversely affect patient wellbeing and quality of life. As an adjunctive form of pain management, music therapy has been shown to address some of these hardships by providing patients with an alternative effective means by which to reduce their subjective experiences of pain. Studies investigating the efficacy of music therapy during invasive cancer procedures and chemotherapy demonstrated the role that attentional states play in distracting patients from, and therefore minimizing their experience of, the pain associated with such treatments. Other studies examining diverse outpatient populations revealed similar findings, illustrating well the cognitive-affective dimensions of pain perception. Although these findings fail to adequately address the ambiguity surrounding music therapy's role in cancer pain management, music therapy has nonetheless been shown to significantly reduce anxiety and, in so doing, indirectly lessen the intensity of pain while improving patient quality of life.

Introduction

Defined as an unpleasant sensory or emotional experience associated with tissue damage (Rainviile et al, 2001), pain plays an indispensable role in providing organisms with a regulatory bio-feedback mechanism with which to safeguard their survival and maintain their integrity in an ever-changing environment (Hunt and Mantyh, 2001). This beneficial adaptation is well demonstrated in me field of oncology, wherein an increase in the severity of pain often signifies a deteriorating condition, and a decrease in pain a correspondingly improving condition (Miguel, 2003). Over a sustained period of time, however, chronic cancer pain may actually lead to anxiety and depression (Hunt and Mantyh, 2001), thereby contributing significantly to unnecessary suffering and a decrease in patient quality of life (Bral, 1998). Indeed, the presence and intensity of pain have been shown to correlate directly with the incidence and severity of depression, along with a higher prevalence of a patient's desire for death (Weitzner et al, 2003). Although opioids and other analgesics have been the mainstay in combating these problems, many patients do not respond well to conventional pharmacological therapies either because of the undesirable side-effects of these medications or simple non-compliance (Plancarte et al, 2003).

In view of these drawbacks, more and more individuals are turning to alternative, non-pharmacologic approaches in managing their pain.

This article will:

1. Discuss variables contributing to the development of persistent, non-nociceptive pain;

2. Suggest additional psychological factors that mediate pain perception;

3. Propose musical therapy as an innovative non-pharmacologic treatment for cancer pain management;

4. Describe experimental studies involving music for pain control with cancer patients; and

5. Provide details of a specific musical intervention drawn from Chinese spirituality in meditating late-stage complex regional pain.

While novel, music therapy is one such field that shows great promise as an adjunctive therapeutic component in cancer pain management which, unlike its analgesic counterparts, poses little to no risk to the patients.

The Development of Persistent, Non-nociception

Given the multi-dimensional nature of pain, which is itself a function of mind and body, a broad understanding of both its physiological and cognitive-affective dimensions must be considered before any discussion of alternative treatments can take place. From a biological standpoint, then, the sensation of pain begins with pain pathways comprised of sensory fibers that convey nociceptive and non-nociceptive information from the skin and most internal tissues to the spinal chord (Hunt and Mantyh, 2001). Within the human body, there are a variety of sensory fibers that evoke unique responses to different kinds of stimulation. Of them, myelinated A fibers and small diameter unmyelinated C fibers have been shown to convey the bulk of nociceptive information. C fibers in particular have been shown to respond to all forms of noxious stimulation, whether thermal, mechanical, or chemical in origin. When stimulated, these fibers synthesize peptides and express growth factors mat together trigger signal-transduction pathways from the spinal chord to the limbic or sensory areas of the forebrain. Derived from innervated tissue, these growth factors maintain the biochemical and physiological status of sensory neurons. Whenever any tissue in the body is

damaged or inflamed, these neurons will undergo a series of phenotypic changes derived from new patterns of gene expression in the spinal chord and brain. That is, peptide or growth factor

receptor expression can shift, and new molecular signatures can be expressed, each of which reflect different chronic pain conditions. Since each pain state generates a unique set of neurochemical changes in sensory neurons and the spinal chord, different types of analgesics are required to block the highly variable peripheral actions of these growth factors in order to prevent much of the hyperalgesia that accompanies tissue damage.

Despite these decidedly objective physiological pathways, pain is first and foremost a subjective state that cannot be validated or invalidated with certainty by an external observed (Rainville et al, 2001). From a cognitive-affective point of view, several variables may contribute to the development of persistent, non-nociceptive pain. These variables include one's subjective perception of pain severity- where the intensity of acute onset pain serves as a good predictor of the intensity of subsequent chronic pain— and the patient's emotional state at the time of acute pain, where anxiety, depression, and lassitude have been shown to contribute to persistent pain states. In addition, a patient's own cognitive processes have been shown to regulate the experience of chronic pain such that maladaptive coping, passive cognition, perceived stress or stressful life events, or disability may lead to the development of persistent pain.

Additional Psychological Factors that Mediate Pain Perception

Apart from these cognitive processes, a number of additional psychological factors may also mediate pain perception. Among them, a patient's attentional state is perhaps the most studied psychological variable mediating pain perception (Villemure and Bushnell, 2002). A variety of studies investigating the role of attentional state have demonstrated that pain is perceived as less painful when individuals are distracted from it (Alden et al, 2001). Other psychological factors, such as mood and emotional state, may also regulate pain by altering the neurochemistry of the limbic system and other cortical areas of the brain involved in pain perception (Villemure and Bushnell, 2002).

Although virtually no study to date has directly addressed the relationship between neural mechanisms and the emotional modulation of pain perception, researchers have proposed several theories of emotion that seek to reconcile this disparity. Motivational Priming Theory, for instance, postulates the

existence of an appetitive primary motive system associated with positive affect and an aversive primary motive system associated with negative affect Both systems operate as opponent processes,

where positive affect is associated with increased dopamine levels in the frontal cortical areas of the brain, and vice versa. The release or inhibition of dopamine in turn influences cognitive functioning in the dopaminergic systems of the forebrain involved in pain and analgesia.

Even amid the promise that such theories hold for the development of multidisciphnary pain intervention strategies, the medical establishment continues to rely almost exclusively on Pharmaceuticals in managing cancer pain (Plancarte et al, 2003). At present, relying solely on opioids and other analgesics has failed to effectively improve the quality of life for many cancer patients. Statistically speaking, of the 75% of advanced cancer patients in the United States who reportedly experience pain, 25% of them continue to die in severe pain despite the availability of alternative pain management treatments (Weitzner et al, 2003), Ersek etal (1999) sought to investigate these staggering statistics by conducting a qualitative study of patients diagnosed with terminally invasive or metastatic cancer. Among those factors hindering patients' use of pain management strategies were fears of the side effects posed by analgesics, along with concerns about subsequent addiction and tolerance to these medications. In addition, many patients expressed concerns about the cost of medication, as well as a potential decline in function without the aid of prescription drugs. Overall, the study demonstrated that patient attitudes and beliefs greatly influence analgesic use, thereby underscoring the importance of exploring non-pharmacologic approaches in the management of cancer pain.

Musical Therapy as an Innovative non-Pharmacologic Cancer Pain

In view of the recommendations presented by Ersek et al (1999), the burgeoning field of Complementary and Alternative Medicine (CAM) signifies a new era in the development of innovative non-pharmacologic treatments which together hold great promise for cancer pain management. With anywhere between 7% and 64% of worldwide cancer patients using CAM treatments during some stage of the disease, many researchers in the field have suggested that these patients are themselves primarily responsible for the rise in CAM use for pain and symptom management (Ott, 2002). At present, roughly 70% of patients in cancer research and treatment centers

in the United States depend on CAM therapies; compelling oncology professionals to develop a basic knowledge of these therapies and to incorporate where appropriate evidence-based CAMs into their clinical practices. Broadly speaking, CAM domains encompass

mind-body, manipulative body-based, energy, and a host of other alternative medical systems drawn from a variety of esoteric traditions. Music therapy specifically fells beneath the mind-body domain, which seeks to reduce stress and develop an inner calmness, stability, and non-reactivity of the mind by quieting the mind and body. Reports indicate that many cancer patients in ambulatory settings found mind-body techniques helpful in enabling them to become more compassionate caregivers of their own experience without being drawn into the drama of past events or speculations of future events. As a result, they experienced decreased stress and suffering along with fewer mood disturbances.

Experimental Studies Involving Music for Pain Control with Cancer Patients

In examining more closely these anecdotal reports, a study conducted by Susan Beck sought to explore the effects of music on cancer patients' pain perception (Kerkvliet, 1990). By using a visual analogue pain scale to measure the effects of at least 90 minutes of music exposure each day, patients listened to selections that they found most pleasing. Of the 15 outpatients in the study, 12 reported at least some beneficial response to music therapy, while 7 of those experienced a moderate to great response. Beck postulated that the non-threatening qualities of music put patients at ease and enabled them to better express their fears and frustrations. By facilitating communication, music therapy therefore helped to motivate patients to relax, providing them with greater pain relief in the process. According to Beck, the next step in the evolution of music therapy involves building a music library from which patients can choose their own favorite musical selections, as well as investigating some of the underlying neural mechanisms involved in music's apparently beneficial effects. Weber et al (1997) sought to further explore these decidedly beneficial findings by examining the influence of music therapy on cancer patients during chemotherapy as a means of reducing some of the emotional trauma, anxiety, and tension associated with cancer treatment. The one-year pilot project involved 35 cancer patients who were given the option of listening to music during chemotherapy treatment from a variety of different musical genres and styles. "

Findings indicated that music did indeed improve the quality of life for these patients, as measured by more relaxed facial expressions and decreased muscle tension. Surprisingly, the longer therapy continued, patients became more greatful to the music they listened to. Furthermore, a majority of the

participants preferred classical music to other genres, including new age, prompting Weber et al (1997) to conclude that classical music must by virtue of its melodic design have a way of calming patients more significantly than other types of music. Together, the findings of Beck"(KeikvIfet, 1990) and Weber et al l997) support the aforementioned notion that attentional states may distract cancer patients from their pain (Vaiemure and Bushnell, 2002). Accordingly, Kwekkeboom (2003) sought to take these findings one-step further by examining whether music may also play a role in altering the perception and transmission of pain impulses by activating the limbic system and other sensory regions of the brain. In assessing the validity of this hypothesis, the study used a controlled experimental design in which 58 cancer patients were randomly assigned to one of three conditions during a noxious medical procedure: an experimental music intervention group, an experimental distraction intervention group, or a control group. Research nurses helped participants to complete pain rating scales and other measures of anxiety before and after the procedure. As a whole, no significant differences were found in pain, anxiety, and perceived control outcomes between the music intervention and distraction groups, suggesting that music may simply serve as a mode of distraction. It is important to note, however, that several confounding variables may have negatively affected the outcome of the study, including the relatively early phase of treatment for some patients- who would want to be fully present and not distracted from what was going on- along with added distraction from the voices of the surgeon and other personnel which would have made it difficult to concentrate on the music during the procedure. Despite these mitigating variables, the study nonetheless confirmed that, in the very least, music may serve as a useful distraction in effectively decreasing cancer patients' subjective experience of pain.

Description of a Specific Chinese Spirituality Musical Intervention

Whereas a majority of the representative research into music therapy and cancer pain management required that patients select their own genre of music, Professor Wu (1999) sought to assess the clinical efficacy of a specific musical genre drawn from Chinese spirituality in mediating late-stage complex regional

pain syndrome (CRPS-I). Defined literally as "vital energy training," music therapy is based upon the traditional Chinese system of medicine that regards illness as the end result of a fundamental imbalance of Qi, the universal vital energy. Qi itself consists of YIN and YANG, or negatively and positively charged forms of energy. Although mutually interdependent, these two types of energy are in opposition to one another such that when one increases, the other decreases. All forms of treatment within the Chinese system therefore attempt to reestablish equilibrium between these opposing forces.

Surprisingly, a number of anecdotal reports suggest that music therapy training has the potential to reverse structural abnormalities and improve function among patients with long-term disabilities. In examining the validity of these reports, Professor Wu (1999) assigned 26 adult patients with CRPS-I to one of two independent groups: an experimental music therapy training group and a control group. Although both groups were instructed to listen to recordings of various musical compositions while viewing associated visual images, only the experimental group received subsequent music therapy training by certified Asian masters. Results indicated that 82% of music therapy patients reported less pain by the end of the first training session compared to only 45% of the control patients. By the end of the last training session, roughly 91% of patients reported a transient (within-session) reduction in pain compared to only 36% of the control group. Moreover, while only 70% of the control group reported a between-session reduction in anxiety, 100% of the music therapy patients reported a decline in the anxiety they experienced as a direct result of the training they received. Although the study ultimately failed to demonstrate any dramatic changes in structural abnormalities or unproved function, music therapy training was nevertheless helpful in managing some of the subjective dimensions of CRPS-I, including pain and emotional distress.

In considering the broad differences in experimental design and methodology employed by the aforementioned studies, Evans (2002) sought to investigate music therapy's overall effectiveness in patient care by conducting a systematic review of 29 such studies. As a whole, the meta-analysis indicated that music has no effect when patients are asked to think about and rate the severity of their pain. However, there was some evidence to suggest that music may serve as an effective diversion in reducing patient anxiety. Music was shown to improve the mood of hospital patients, reduce

the need for sedation and analgesia during procedures, and improve patient tolerance during these procedures. As a caveat to these findings, however, many of the studies in the review failed to arrive at any definitive conclusions due to their small sample sizes and inadequate funding, the latter of which may have stifled a more in-depth examination of music therapy's potentially

beneficial prospects. Nevertheless, even despite these shortcomings, Evans (2002) successfully validated the effectiveness of music therapy in a manner consistent with the findings of Beck (Kerkvliet, 1990), Weber et al 1997), Kwekkeboom (2003), and Wu (1999).

Directions for Future Research and Conclusion

Given the paucity of research surrounding the relationship between the physiological and Cognitive-affective dimensions of pain, future research should seek to address the underlying physiological mechanisms involved in music therapy's role in pain management. Quantitative, as opposed to qualitative, assessments would more definitely examine this relationship from an objective standpoint despite the inherently subjective nature of pain. In addition, studies with greater sample sizes and more controlled experimental designs would more conclusively assess the efficacy of music therapy as an adjunctive pain management strategy. Studies employing magnetic resonance imaging (MRI) techniques, for instance, may better elucidate some of the underlying neural mechanisms involved in music therapy. That is, having cancer patients listen to a standardized repertoire of music while undergoing an MRI scan may potentially clarify some of the ambiguity surrounding music therapy by providing clinicians with solid empirical evidence to support their findings. Where possible, future research should also seek to conduct long-term studies examining the impact of music therapy over an extended period of time.

By employing these proposed modifications, researchers may ultimately arrive at a better understanding of pain from both a subjective and objective standpoint and, in so doing, develop more comprehensive intervention strategies in the treatment and management of cancer pain. As a step in the right direction, clinicians have already begun to develop more comprehensive models for cancer pain management that seek to integrate the psycho-social-spiritual dimensions of health and wellbeing.

Otis-Green et al (2002), for instance, recognized the multi-dimensional nature of cancer pain and have accordingly developed a multidisciphnary model that seeks to provide the most effective pain management techniques to a variety of patients within cancer research centers. According to this model, effective and comprehensive pain management should be carried out by a team of health care practitioners comprised of psychologists, social workers, spiritual care providers, and

psychiatrists. By integrating these disciplines, clinicians can be sure to promote more fulfilling, supportive, and professional relationships in managing the pain and suffering of their patients. Within such an inclusive context, music therapy and its correspondingly beneficial effects will most surely represent but one aspect of a more holistic approach towards minimizing the pain and suffering associated with cancer.

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