The Effects of a Single Electronic Music Improvisation Session on the Pain of Adults with Sickle Cell Disease: A Mixed Methods Pilot Study

Pain screening in youth with sickle cell disease: A quality improvement study

BACKGROUND

Youth with sickle cell disease (SCD) face several challenges as they age, including increased pain frequency, duration, and interference. The purpose of this study was to (i) determine the feasibility of routine pain screening; (ii) identify and describe various clinical pain presentations; and (iii) understand preferences/resources related to engaging in integrative health and medicine (IHM) modalities within an outpatient pediatric SCD clinic.

METHODS

During routine outpatient visits, patients aged 8-18 completed measures of pain frequency, duration, and chronic pain risk (Pediatric Pain Screening Tool [PPST]). Participants screening positive for (i) persistent or chronic pain or (ii) medium or high risk for persistent symptoms and disability on the PPST were asked to complete measures of pain interference, pain catastrophizing, and interest in/resources for engaging in IHM modalities.

RESULTS

Between March 2022 and May 2023, 104/141 (73.8%) patients who attended at least one outpatient visit were screened. Of these 104 (mean age 12.46, 53.8% female, 63.5% HbSS), 34 (32.7%) reported persistent or chronic pain, and 48 (46.2%) reported medium or high risk for persistent symptoms and disability. Patients completing subsequent pain screening measures reported a mean pain interference T-score of 53.2 ± 8.8 and a mean pain catastrophizing total score of 24.3 ± 10.2. Patients expressed highest interest in music (55.6%) and art therapy (51.9%) and preferred in-person (81.5%) over virtual programming (22.2%).

CONCLUSIONS

Comprehensive pain screening is feasible within pediatric SCD care. Classifying patients by PPST risk may provide a means of triaging patients to appropriate services to address pain-related psychosocial factors.

The acute pain crisis in sickle cell disease: What can be done to improve outcomes?

The acute pain crisis (APC) is the commonest complication of sickle cell disease (SCD). Severe episodes may require treatment in hospital with strong opioid analgesic drugs, combined with additional supportive care measures. Guidelines for APC management have been produced over the past two decades gathering evidence from published studies, expert opinion, and patient perspective. Unfortunately, reports from multiple sources indicate that guidelines are often not followed, and that acute care in emergency departments and on acute medical wards is suboptimal. It is important to understand what leads to this breakdown in health care, and to identify evidence-based interventions which could be implemented to improve care. This review focuses on recently published articles as well as information about on-going clinical trials. Aspects of care which could potentially make a difference to patient experience include availability and accessibility of individual care plans agreed between patient and treating specialist, innovative means of delivering initial opioids to reduce time to first analgesia, and availability of a specialist unit away from the ED, where expert care can be delivered in a more compassionate environment. The current evidence of improved outcomes and health economic advantage with these interventions is inadequate, and this is hampering their implementation into health care systems.

Effectiveness of Medical Music Therapy Practice: Integrative Research Using the Electronic Health Record: Rationale, Design, and Population Characteristics

Background: Several clinical trials support the efficacy of music therapy (MT) for improving outcomes in hospitalized patients, but few studies have evaluated the real-world delivery and integration of MT across multiple medical centers. This article describes the rationale, design, and population characteristics of a retrospective study examining the delivery and integration of MT within a large health system. Methods: A retrospective electronic health record (EHR) review was conducted of hospitalized patients seen by and/or referred to MT between January 2017 and July 2020. MT was provided across ten medical centers, including an academic medical center, a freestanding cancer center, and eight community hospitals. Discrete demographic, clinical, and MT treatment and referral characteristics were extracted from the EHR, cleaned, and organized using regular expressions functions, and they were summarized using descriptive statistics. Results: The MT team (average 11.6 clinical fulltime equivalent staff/year) provided 14,261 sessions to 7378 patients across 9091 hospitalizations. Patients were predominantly female (63.7%), White (54.3%) or Black/African American (44.0%), 63.7 ± 18.5 years of age at admission, and insured under Medicare (51.1%), Medicaid (18.1%), or private insurance (14.2%). Patients' hospitalizations (median length of stay: 5 days) were primarily for cardiovascular (11.8%), respiratory (9.9%), or musculoskeletal (8.9%) conditions. Overall, 39.4% of patients' hospital admissions included a mental health diagnosis, and 15.4% were referred to palliative care. Patients were referred by physicians (34.7%), nurses (29.4%), or advanced practice providers (24.7%) for coping (32.0%), anxiety reduction (20.4%), or pain management (10.1%). Therapists provided sessions to patients discharged from medical/surgical (74.5%), oncology (18.4%), or intensive care (5.8%) units. Conclusions: This retrospective study indicates that MT can be integrated across a large health system for addressing the needs of socioeconomically diverse patients. However, future research is needed to assess MT's impact on health care utilization (i.e., length of stay and rates of readmission) and immediate patient-reported outcomes.

Effectiveness of music therapy within community hospitals: an EMMPIRE retrospective study

Introduction

Given the challenges health systems face in providing effective nonpharmacologic treatment for pain and psychological distress, clinical effectiveness studies of evidence-based strategies such as music therapy (MT) are needed.

Objectives

This study examined changes in patient-reported outcomes (PROs) after MT and explored variables associated with pain reduction of ≥2 units on a 0 to 10 numeric rating scale (NRS).

Methods

A retrospective review was conducted on initial MT interventions provided to adults receiving community hospital care between January 2017 and July 2020. Sessions were included if participants reported pre-session pain, anxiety, and/or stress scores of ≥4 on the NRS. Data analysis included a bootstrap analysis of single-session changes in PROs and a logistic regression exploring variables associated with pain reduction (ie, ≥2 units vs <2 units).

Results

Patients (n = 1056; mean age: 63.83 years; 76.1% female; 57.1% White; 41.1% Black/African American) reported clinically significant mean reductions in pain (2.04 units), anxiety (2.80 units), and stress (3.48 units). After adjusting for demographic, clinical, and operational characteristics in the model (c-statistic = 0.668), patients receiving an MT session in which pain management was a goal were 4.32 times more likely (95% confidence interval 2.26, 8.66) to report pain reduction of ≥2 units than patients receiving an MT session in which pain management was not a session goal.

Conclusion

This retrospective study supports the clinical effectiveness of MT for symptom management in community hospitals. However, additional research is needed to determine which characteristics of MT interventions and patients influence pain change.

Clinical Delivery and Effectiveness of Music Therapy in Hematology and Oncology: An EMMPIRE Retrospective Study

BACKGROUND

Music therapy (MT) has been shown to improve outcomes for patients with sickle cell disease (SCD) and patients with hematologic and/or oncologic conditions excluding SCD (HemOnc) in prior randomized trials. While few studies have described the clinical delivery (ie, volume, clinical settings, patient characteristics, referrals, and session characteristics) of MT and examined its real-world effectiveness, no studies have compared responses between hematology/oncology populations. The purpose of this study was to examine the clinical delivery and effectiveness of MT at a freestanding academic cancer center and compare the effectiveness of MT on pain, anxiety, and fatigue between adult patients in the HemOnc and SCD groups.

METHODS

A retrospective review was conducted of all MT sessions provided at a freestanding academic cancer center between January 2017 and July 2020. The unadjusted single-session effects of MT on pain, anxiety, and fatigue were assessed among patients reporting symptoms ≥1 out of 10 on a 0 to 10 scale. Adjustments were made for multiple sessions on the same patient using a mixed model to compare pre-session and change scores between the HemOnc and SCD groups. Patients' comments were analyzed using conventional qualitative content analysis.

RESULTS

Music therapists provided 4002 sessions to 1152 patients including 1012 in the HemOnc group and 140 in the SCD group. In the combined sample, statistically significant reductions in pain (1.48 units), anxiety (2.58 units), and fatigue (0.84 units) were observed, with changes in pain and anxiety exceeding clinically significant thresholds. After adjustment, the SCD group reported significantly greater pre-session pain (7.22 vs 5.81) and anxiety (6.11 vs 5.17) as well as greater anxiety reduction (2.89 vs 2.23) than the HemOnc group. Patients' comments contained themes including enjoyment, gratitude, and improvements in mood, pain, and anxiety.

CONCLUSIONS

This study supports the delivery and clinical effectiveness of MT for addressing the needs of patients throughout their course of treatment at an academic cancer center and justifies the inclusion of individuals with SCD within integrative oncology services.

Effects of Music Therapy on Quality of Life in Adults with Sickle Cell Disease (MUSIQOLS): A Mixed Methods Feasibility Study

Purpose

To investigate the feasibility, acceptability, and preliminary efficacy of a 6-session music therapy protocol on self-efficacy, quality of life, and coping skills in adults with sickle cell disease (SCD).

Patients and Methods

Using a mixed-methods intervention design, adults with SCD (ages 21–57; mean age 32.33) were randomized (1:1) to either 1) a 6-session music therapy (MT) intervention (n = 12) or 2) waitlist control (WLC) (n = 12) using stratified randomization where factors were age in years (≤30 vs >30), and sex (male, female). All participants completed two weeks of daily electronic pain diary entries and self-efficacy, quality of life, and coping skills measures before and after their assigned study condition to explore preliminary efficacy. MT participants were taught music exercises accessed via smartphone and subsequently interviewed to determine feasibility and acceptability.

Results

The enrollment rate was 89%. All study measures were completed, with high rates of electronic pain diary completion at baseline (70%) and 2-week follow-up (66%). Interviews revealed two overall themes related to MT participants’ experience: 1) participants learned new self-management skills and 2) MT improved participants’ ability to cope with pain. MT participants demonstrated 100% attendance. In preliminary analyses, MT participants demonstrated significant improvements (means ± SD) in self-efficacy (5.42 ± 5.43, p = 0.008, d = 1.20), PROMIS sleep disturbance (−1.49 ± 6.68, p = 0.023, d = −0.99), PROMIS pain interference (−2.10 ± 4.68, p = 0.016, d = −1.06), and ASCQ-Me social functioning impact scores (2.97 ± 6.91, p = 0.018, d = 1.05) compared to WLC participants.

Conclusion

Preliminary findings support the feasibility and acceptability of music therapy for home use in adults with SCD. While music therapy may assist adults with SCD in improving self-efficacy and quality of life, subsequent, fully-powered clinical research is needed to determine its efficacy.

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Sickle Cell Disease Care Planning for School Nurses

Schoolchildren with sickle cell disease (SCD) experience physiologic and psychologic stress that can affect school functioning, mental well-being, and physical health. Student needs are unique and individualized; however, school nurses can support students and families with SCD through comprehensive and thorough care planning efforts. In addition to components specific to individual prescriptions and other nonpharmacological therapies, school nurses should consider school access and inclusion, pain management, racism, and disease self-management when care planning. As a healthcare provider who may have several continuous years of near-daily contact with students, the school nurse is an imperative provider, educator, and advocate for students learning to manage their SCD and avoid the related complications and challenges.

Comparing Three Music Therapy Interventions for Anxiety and Relaxation in Youth With Amplified Pain

Research in pediatric hospitals has shown that active music engagement, preferred music listening, and music-assisted relaxation can decrease anxiety and increase relaxation responses. However, there is little research on the use of music therapy with pediatric chronic pain conditions such as amplified pain syndromes. The purpose of the current study was to examine the effects of 3 specific music therapy interventions (active music engagement, live patient-selected music, and music-assisted relaxation) on anxiety and relaxation levels in youth (ages 10-18) participating in a 40 hr per week hospital-based intensive interdisciplinary pain treatment program. A sample of 48 patients participated in this study which utilized a 3-period, 3-treatment cross-over design with 3 interventions delivered in a quasi-randomized order determined by when the patients started the treatment program. State anxiety was measured via the state form of the State-Trait Inventory for Cognitive and Somatic Anxiety for Children and relaxation scores were assessed with a Visual Analog Scale. Statistically significant changes were found in anxiety and relaxation outcomes across all interventions provided. Results suggest that music therapy services (using active music engagement, live patient-selected music, and music-assisted relaxation) may be an effective modality to decrease anxiety and increase relaxation levels in pediatric patients with amplified pain syndromes.

The Impact of Music on Nociceptive Processing

OBJECTIVE

Music has been shown to modulate pain, although the impact of music on specific aspects of nociceptive processing is less well understood. Using quantitative sensory testing (QST), we assessed the impact of a novel music app on specific aspects of nociceptive processing.

DESIGN

Within-subjects paired comparison of pain processing in control vs music condition.

SETTING

Human psychophysical laboratory.

SUBJECTS

Sixty healthy adult volunteers.

METHODS

Subjects were assessed for baseline anxiety, depression, and catastrophizing using validated questionnaires. QSTs measured included 1) pain threshold and tolerance to deep muscle pressure, 2) pain with mechanical pinprick, 3) temporal summation of pain (TSP) with a repeated pain stimulus, and 4) conditioned pain modulation (CPM) with a second painful stimulus. QSTs were performed in the absence and presence of music delivered through a music app.

RESULTS

We found an increase in pressure pain thresholds in both the forearm (P = 0.007) and trapezius (P = 0.002) with music, as well as a decrease in the amount of pinprick pain (P < 0.001) and TSP (P = 0.01) with music. Interestingly, CPM was also significantly diminished (P < 0.001) in the music condition. No significant difference in cold pain, anxiety, or situational catastrophizing was observed with music. Higher baseline pain catastrophizing scores were associated with less music-induced pressure pain reduction.

CONCLUSIONS

Several measures of mechanical pain sensitivity were reduced with music. TSP, a measure of central sensitization, also decreased with music, but CPM, a measure of descending modulation of pain, was not further augmented by music.

The Use of Music by Adolescents and Young Adults With Sickle Cell Disease

Pain is common and often severe in people with sickle cell disease (SCD), occurring as acute intermittent pain episodes called vaso-occlusive episodes (VOEs), as well as chronic pain conditions including bone infarctions, avascular necrosis of joints, and neuropathic pain. Analgesics such as opioids, nonsteroidal anti-inflammatory medications (NSAIDS), and anticonvulsants for neuropathic pain, although often necessary to manage these types of pain, are associated with side effects. Nonpharmacologic interventions such as to listening to music and music therapy may reduce pain. The objectives of this study were to determine whether the use of music by adolescents and young adults with SCD was helpful, and if so, the types of music that helped, and how music helped them. A convenience sample of nine English-speaking inpatients ages 13 to 21 years, with SCD and at least two prior hospitalizations for VOE, took part in interviews with music therapists. Participants were asked open-ended questions about both pain and music. Participants identified that music was helpful for pain relief as well as for mood regulation, focusing attention during cognitive tasks such as homework, distraction, relaxation, and feeling understood or connected with others. Despite this, while hospitalized, participants reported that they did not tend to use music to help with pain. These findings support the use of both music medicine and music therapy as interventions for pain and distress in adolescents and young adults with SCD.

Mechanisms of pain in sickle cell disease

Objectives

The hallmark of sickle cell disease (SCD) is acute and chronic pain, and the pain dominates the clinical characteristics of SCD patients. Although pharmacological treatments of SCD targeting the disease mechanisms have been improved, many SCD patients suffer from pain. To overcome the pain of the disease, there have been renewed requirements to understand the novel molecular mechanisms of the pain in SCD.

Methods

We concisely summarized the molecular mechanisms of SCD-related acute and chronic pain, focusing on potential drug targets to treat pain.

Results

Acute pain of SCD is caused by vaso-occulusive crisis (VOC), impaired oxygen supply or infarction-reperfusion tissue injuries. In VOC, inflammatory cytokines include tryptase activate nociceptors and transient receptor potential vanilloid type 1. In tissue injury, the secondary inflammatory response is triggered and causes further tissue injuries. Tissue injury generates cytokines and pain mediators including bradykinin, and they activate nociceptive afferent nerves and trigger pain. The main causes of chronic pain are from extended hyperalgesia after a VOC and central sensitization. Neuropathic pain could be due to central or peripheral nerve injury, and protein kinase C might be associated with the pain. In central sensitization, neuroplasticity in the brain and the activation of glial cells may be related with the pain.

Discussion

In this review, we summarized the molecular mechanisms of SCD-related acute and chronic pain. The novel treatments targeting the disease mechanisms would interrupt complications of SCD and reduce the pain of the SCD patients.

Interventions for treating neuropathic pain in people with sickle cell disease

BACKGROUND

Pain is the hallmark of sickle cell disease (SCD) and it can be severe, frequent and unpredictable. Although nociceptive pain is more common, at times, people with SCD may have neuropathic pain. The latter can occur due to peripheral or central nerve injury. This review is focused on identifying treatment of only painful sensory neuropathy in people with SCD.

OBJECTIVES

To determine the effectiveness and safety of any pharmacological or non-pharmacological therapies for treating neuropathic pain in people with SCD.

SEARCH METHODS

We searched the Cochrane Cystic Fibrosis and Genetic Disorders Group's Haemoglobinopathies Trials Register, compiled from electronic database searches and handsearching of journals and conference abstract books. We also searched trial registries, the reference lists of relevant articles and reviews and contacted experts in the field.Date of last search: 31 January 2019.

SELECTION CRITERIA

Randomised controlled trials (RCTs) (parallel or cross-over in design), quasi-RCTs of pharmacological or non-pharmacological therapies for treating neuropathic pain in people with SCD compared to placebo or another intervention in any category (i.e. pharmacological or non-pharmacological).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed all trials identified by the searches and extracted relevant data. Two authors independently assessed the risk of bias in the selected trials using the Cochrane risk of bias tool. Two review authors independently rated the quality of the evidence for each outcome using the GRADE guidelines.

MAIN RESULTS

One RCT of 22 participants with SCD, conducted in the USA was included in this review. Participants were randomly assigned to either pregabalin (n = 11) or placebo (n = 11). Oral pregabalin was administered at an initial dose of 75 mg twice daily. The drug was titrated at increments of 75 mg to a maximum of 600 mg daily or decreased by 75 mg per day if necessary, based on clinical presentation and pain level. Neuropathic pain was assessed using self-reports on the Leeds Assessment of Neuropathic Symptoms and Signs (S-LANNS) scale and the Neuropathic Pain Symptom Inventory (NPSI), where higher scores were indicative of more pain. Outcomes included self-reported pain, quality of life and withdrawal due to adverse effects measured at baseline and monthly for three months post-intervention. The overall risk of bias was low with a high risk of bias due to attrition.In relation to this reviews primary outcomes, for self-reported neuropathic pain relief, given the paucity of data, we are very uncertain whether there is a difference between the pregabalin and placebo groups at the end of three months as measured by the S-LANSS scale, mean difference (MD) -2.00 (95% confidence interval (CI) -9.18 to 5.18), or the NPSI scale, MD -11.10 (95% CI -33.97 to 11.77) (very low-quality evidence). There was no report of 'Patient Global Impression of Change' in the included trial.Although the mean quality of life scores (Short Form-36) at three months showed small increases in seven of the eight domains post-intervention in the pregabalin group as compared to the placebo group, this was very low-quality evidence and we are very uncertain whether pregabalin increases quality of life. Neither of our pre-defined outcomes of 'time to improvement of symptoms' or 'changes in sleep quality', were measured in the included trial.While treatment-related adverse effects appeared higher in pregabalin group than the placebo group at three months, this was very low-quality evidence and we are very uncertain whether there is a difference, RR 1.33 (95% CI 0.39 to 4.62) (very low-quality evidence). There was one withdrawal for adverse effects in the pregabalin group while three people withdrew or dropped out from the placebo group due to adverse effects and complications and hospitalisation related to SCD.

AUTHORS' CONCLUSIONS

The included trial provided very low-quality evidence. Self-reported pain relief was greater in the pregabalin group compared to the placebo control group but only using the S-LANSS scale and we are very unsure whether there is a difference. While the pregabalin group tended to have improved quality of life over the duration of the trial, this was very low-quality evidence and we are uncertain whether there is a difference. Adverse effects and withdrawals were similar across the treatment and placebo control group in trial. There are both insufficient trials addressing this review question and insufficient outcomes addressed in the single included RCT. Therefore, there is still a significant gap in evidence on interventions for neuropathic pain in people with SCD.

Summer Camps for Children with Sickle Cell Disease

Background

Children with sickle cell disease (SCD) face unique problems that attendance at a camp with their peers is well suited to address. However, because the staff members at ordinary summer camps are not accustomed to accommodating children with chronic diseases, the potential for significant health consequences exists.

Methods

We searched the literature in PubMed and CINAHL using the keywords summer camp, camp, sickle, and anemia to identify the unique characteristics of camps for children with SCD and the recommendations for care and/or lessons learned.

Results

Published data are limited. Accommodations to avoid triggering sickle vaso-occlusive pain have been developed empirically and extrapolated from other settings. Camp experiences provide peer learning opportunities, positive role models, and a safe area to explore personal growth. The supportive atmosphere of the camp and escape from social stigma are welcome changes from the daily routine. Camp experiences can help with education on self-care and the transition from adolescent to adult healthcare.

Conclusion

Camp offers unique opportunities for care coordination. Camps for children with SCD provide a setting for dissemination of best practices for the disease. Community-based organizations should partner in recruiting young adults with SCD as counselors. Educational material now available could be modified for use in the camp setting. All stakeholders in the care of children with SCD should work in unison to ensure these children enjoy the benefits of summer camp.