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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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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. 10 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. 11
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