NCPD Article

Incorporating Music Therapy With Acupuncture in Managing Cancer Pain at an Acupuncture Practice

Jessica Latchman

Liem Q. Le

Anthony McGuire

acupuncture, cancer, cancer-related pain, complementary medicine, music therapy
CJON 2024, 28(3), 305-312. DOI: 10.1188/24.CJON.305-312

Background: Complementary and alternative medicine encompasses various nonpharmacologic interventions for managing pain, such as acupuncture and music therapy. Few studies have combined these two interventions in the management of cancer-related pain.

Objectives: The purpose of this evidence-based project was to compare acupuncture-only therapy versus dual therapy (acupuncture and music therapy) on pain intensity scores in patients with cancer.

Methods: This evidence-based project included 102 participants at a private acupuncture practice. One group had acupuncture only for six weeks, and another had six weeks of acupuncture and music therapy. The Numeric Pain Rating Scale was used to assess pain before and after the interventions.

Findings: Findings showed that both groups had clinically and statistically significant improvements in pain intensity scores. Although a significant difference was not noted between the two groups, acupuncture and music therapy were each found to be effective for managing cancer-related pain.

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    Pain affects more than 70% of patients with a cancer diagnosis, particularly those with advanced disease. It is considered to be one of the most distressing symptoms related to cancer (Russo & Sundaramurthi, 2019). Cancer pain may be related to tumor burden in addition to being a side effect related to chemotherapy, surgery, radiation therapy, or other forms of treatment (Russo & Sundaramurthi, 2019). Unmanaged pain is an ongoing issue for patients with a cancer diagnosis, and this problem has been amplified by the current opioid epidemic (Enzinger et al., 2021). Studies have illustrated that poor pain control is associated with decreased quality of life for patients (Rodriguez et al., 2019).

    The mainstay of treatment for cancer-related pain is opioid medication, which has resulted in many challenges for patients (Fallon et al., 2018). Some of the major barriers to opioid-based cancer pain management are fear of drug dependence and addiction, as well as negative attitudes about opioid analgesia held by patients (Rafii et al., 2021). In addition, insurance companies have made it challenging to obtain opioid medications, and providers may lack the skills, knowledge, and attitudes to appropriately manage cancer-related pain (Rafii et al., 2021). Therefore, more innovative non-opioid measures are needed to effectively manage cancer-related pain.

    Complementary and alternative medicine (CAM) presents a non-opioid approach to pain management. CAM includes practices like yoga, massage, tai chi, acupuncture, and music therapy (Deng, 2019). Acupuncture and music therapy have been used in the treatment of pain for centuries (Deng, 2019). This evidence-based project proposes that dual therapy incorporating music therapy and acupuncture may better improve patients’ pain intensity scores compared to acupuncture-only sessions. This is based on evidence that acupuncture and music therapy can improve pain independently (Deng, 2019; Wang et al., 2021; Weber et al., 2015).

    The gate control theory suggests that pain signals encounter gates, which allow or impede the transmission of pain signals (Melzack & Wall, 1965). The small fibers, which are the pain fibers, close when the sensation of pain decreases and open when pain is felt (Melzack & Wall, 1965). Factors that may diminish pain and close these gates include pain medications and CAM, which includes acupuncture and music therapy (Moayedi & Davis, 2013). Because music therapy and acupuncture are known effective modulators in diminishing the perception of pain, incorporating dual therapy consisting of acupuncture and music therapy may result in a decreased perception of pain by patients (Moayedi & Davis, 2013). A literature review indicated that no prior studies have been done on the effect of dual therapy on cancer-related pain. Most studies examined either the outcome of acupuncture on pain intensity or the effect of music therapy on pain, but not the combination (Behzadmehr et al., 2020; Deng, 2019; Greenlee et al., 2017; Jang et al., 2020; Miller et al., 2019; Scarborough & Smith, 2018; Tao et al., 2016).

    Purpose

    The purpose of this project was to implement and evaluate the impact of dual therapy versus acupuncture-only sessions on pain intensity at an acupuncture practice. The question addressed by this project was as follows: Will incorporating music therapy with acupuncture result in decreased pain scores when compared to acupuncture-only therapy in adult patients with a cancer diagnosis seen at an acupuncture practice for a six-week period?

    Methods

    Sample and Setting

    The target population was adult patients with a cancer diagnosis aged 18 years or older with cancer-related pain who were currently receiving acupuncture treatments. This included adult English-speaking patients of any race, ethnicity, or gender with a cancer diagnosis. Patients who declined to complete the demographic questionnaire, provide pain scores, or have music therapy included during their acupuncture sessions were excluded. This was an evidence-based project, so patients with non–cancer-related pain were not excluded. Patients did not use any analgesics, including opioids, during the intervention; however, they may have been using or been prescribed opioids for cancer-related pain before the study. The project was conducted over 12 weeks with 102 patients with a cancer diagnosis. The first 50 consecutive patients received only acupuncture for six weeks, and then the next 52 patients were given the option to receive acupuncture with ocean sounds music for six weeks. Each patient had one preintervention pain score and one postintervention pain score. The duration of the intervention for each group was limited to six weeks to generate pilot data for future studies. The setting for this project was the private office of a doctor of oriental medicine who independently practices acupuncture in Tampa, Florida. The project was approved and given a letter of exemption by the University of South Florida Institutional Review Board.

    Measures

    The Numeric Pain Rating Scale (NPRS) was used to measure pain intensity scores before and after the intervention. The NPRS is a validated 11-point numeric self-rating tool used to measure pain on a scale ranging from 0 (no pain) to 10 (worst possible pain). The patients were asked to indicate the numeric value that best described their pain intensity at the time of their visit. The NPRS has high test–retest reliability (intraclass correlation coefficient = 0.81) and validity (r = 0.941) in measuring cancer-related pain (Alghadir et al., 2018). Participants were also given a demographic questionnaire with questions regarding age, sex, race and ethnicity, cancer diagnosis, and whether opioids had been used for pain management prior to the project.

    Intervention and Data Collection

    Each patient was given an informational letter about the project. The acupuncture-only sessions and dual therapy sessions were each 25 minutes in duration. Patients in each group were asked to indicate their preintervention pain intensity scores prior to the insertion of the first acupuncture needle, and the postintervention pain intensity scores were collected when the final acupuncture needle was removed. Ocean sounds music therapy, if opted into by the patient, was initiated at the beginning of each acupuncture session, and ended when the last acupuncture needle was completely removed. Ocean sounds music therapy was chosen as the type of music for the project because it was shown to reduce pain in prior studies (Lim et al., 2021; Tang et al., 2021; Wang et al., 2022). The difference in pain intensity scores of the dual therapy group before and after the intervention was then compared to the difference in pain intensity scores of the acupuncture-only group.

    The demographic questionnaire and the NPRS were administered by the clinician at the standard clinic visit. Patients were asked to circle their pain intensity scores on a picture of the NPRS on a sheet provided before and after the intervention. The demographic data and pain scores were collected at the end of each visit. The data were then entered into a password-protected Microsoft Excel spreadsheet and deidentified to ensure patient privacy.

    Data Analysis

    Data were checked for accuracy and imported into SAS, version 9.4. Categorical data were described using frequencies and percentages, and a chi-square test was used to compare the intervention groups. The change in pain score was derived by subtracting the postintervention NPRS scores from the preintervention scores. The pain scores and associated changes were also assessed for normality. Numeric data were described using medians and interquartile ranges and/or means and SDs as appropriate and compared between patients treated with and without music therapy using the Mann–Whitney U test for non-normally distributed data and t tests for normally distributed data. All statistical tests were two-sided with an alpha of 0.05. An effective outcome was determined if a pain intensity difference of at least 1.41 points on the NPRS was observed between groups, which was deemed by a previous study to be a clinically meaningful difference in pain intensity (Kendrick & Strout, 2005).

    Results

    The demographic and clinical characteristics of the participants are outlined in Table 1. The project consisted of mainly female (n = 66, 65%), non-Hispanic White patients (n = 66, 65%) aged 65 years or older (n = 42, 41%). Patients listed specific cancer diagnoses on the demographic form, which included breast cancer, prostate cancer, multiple myeloma, lymphoma, lung cancer, thyroid cancer, and leukemia. These cancers were then grouped into solid tumors or hematologic malignancies. The most common type of cancer diagnosis was solid tumors (n = 90, 88%). In addition, less than one-third of the patients had received opioids for pain management before the study (n = 28, 27%). Patients in the dual therapy group were older than the participants in the acupuncture-only group. The dual therapy group had more non-Hispanic White males aged 65 years or older when compared to the acupuncture-only group. However, the differences observed between the groups in age (p = 0.276) and race and ethnicity (p = 0.283) were not statistically significant. The proportion of patients with solid tumor cancers in the acupuncture-only group (n = 46, 92%) was higher than compared to those in the dual therapy group (n = 44, 85%), but the difference was not statistically significant (p = 0.786).

    TABLE1

    The participants in the dual therapy group had a higher incidence of cancer-related pain (n = 52, 100%) before the intervention, which was significant (p < 0.001), when compared to the participants in the acupuncture-only group (n = 40, 80%). The dual therapy group (n = 16, 31%) had a higher use of opioids before the study compared to the acupuncture-only group (n = 12, 24%).

    TABLE2

    The total sample had a median preintervention pain score of 8 (range = 3–10) on the NPRS (see Table 2). The median postintervention pain score was 3 (range = 0–7). The median preintervention pain score for the acupuncture-only group (8, interquartile range = 7–9) was slightly higher than the dual therapy group (7.5, interquartile range = 6–9). The median postintervention pain score was 3 for both groups. The postintervention pain scores for both groups were significantly lower than the preintervention scores (p < 0.0001), as shown in Figure 1. However, as shown in Figure 2, the comparison of the difference in pain scores between the acupuncture-only group and the dual therapy group was not statistically significant (p = 0.25).

    FIGURE1

    Discussion

    The aim of this evidence-based project was to implement and evaluate the impact of dual therapy on pain intensity scores at an acupuncture practice. The preintervention median pain score for the acupuncture-only group was slightly higher than that for the dual therapy group; however, the median postintervention pain score for both groups was similar. In addition, the postintervention scores for both groups were lower than the preintervention scores, and the difference was statistically significant for each group. However, the comparison of the difference in pain scores between the acupuncture-only group and the dual therapy group did not show statistical significance.

    FIGURE2

    In a systematic review by Jang et al. (2020), which included 1,216 participants who had pain induced by cancer treatment, differences in pain intensity between acupuncture and control groups using the Brief Pain Inventory–Short Form were found. However, the study did not specify type of cancer, stage of cancer, size of tumor, type of surgery, or type of chemotherapy. A retrospective study conducted by Miller et al. (2019) showed clinically significant reductions in mean pain scores after the first acupuncture treatment and during the course of all treatments. The study included 68 adult patients with a cancer diagnosis who received acupuncture for pain management. Pain was measured using the Edmonton Symptom Assessment Scale. However, the study lacked a control arm, and the effects may have been because of a placebo response. It is uncertain whether patients received concomitant opioid or adjuvant therapies, which could be a confounding bias. In addition, the study results may have been affected because the duration of the effect of acupuncture on pain was unknown. In addition, the relatively small sample size and lack of population heterogeneity may have resulted in limited generalizability. The results in this evidence-based project were consistent with previous studies and showed that in the acupuncture-only group, study participants had a statistically significant decrease in pain intensity scores from pre- to postintervention.

    Studies using music therapy in the treatment of cancer pain have also shown a reduction in pain intensity scores. A randomized controlled trial conducted by Deng et al. (2021) with 160 patients with a cancer diagnosis undergoing surgery for breast cancer demonstrated that treatment with music therapy showed an improvement in pain intensity versus usual care using the visual analog scale. However, the study could not be generalized because it was conducted at a single facility. Another randomized crossover trial with 24 adult resident patients with a cancer diagnosis showed significantly lower pain and anxiety scores on the visual analog scale in patients who had received music therapy (Fernando et al., 2019). This study’s limitations included a small sample size and lack of heterogeneity, which limited generalizability. A retrospective study by Gallagher et al. (2018) with 293 patients showed significant reduction in pain scores on the NPRS. Limitations of this study included observational bias based on the therapist’s opinion (Gallagher et al., 2018). Finally, a randomized controlled trial performed by Tang et al. (2021) with 100 patients diagnosed with small cell lung cancer showed that patients in the music therapy group had lower pain scores on the visual analog scale when compared to the control group. However, the power of the study may have been affected because the sample size was relatively small, and the study did not examine the long-term effects of music therapy on relieving pain. In the current evidence-based project, the combined effect of music therapy and acupuncture (dual therapy) showed a clinically significant reduction in pain scores on the NPRS from pre- to postintervention.

    Although no studies have explored the effect of dual therapy on pain intensity in patients with a cancer diagnosis, some studies have examined its effect on well-being in nurses and in patients with fibromyalgia. Wang et al. (2022) observed in a randomized crossover study with 36 nurses that light acupuncture and five-element music therapy resulted in improvement in nurses’ mental well-being. A randomized controlled trial by Weber et al. (2015) with 120 patients with fibromyalgia found statistically significant improvement in fibromyalgia symptoms. In the current evidence-based project, a greater reduction in pain intensity was not observed for the dual therapy group compared to the acupuncture-only group. However, both groups had a statistically and clinically significant reduction in pain when the interventions were applied.

    Limitations

    Limitations that may have affected the project results include the small number of participants and the short duration of the intervention because each intervention was done for only six weeks. Patients in both groups had different types of cancers, and this heterogeneity could have masked any differences between treatment groups. Therefore, future studies are needed to evaluate the effect of dual therapy on a single type of cancer. In addition, a longer duration of treatment may have shown a difference between groups because the dual therapy group showed improved pain scores in a previous study (Deng et al., 2021). Other limitations include the lack of generalizability because the project was conducted at a single practice site with a demographically homogeneous sample. Future studies may need to include multiple sites with a larger patient population. The results of the project may have also been affected because different acupuncture points on each participant were used based on the location of their pain. Another limitation was that patients with non–cancer-related pain could not be excluded from the sample because it was an evidence-based project, which may have affected the results. The project also focused on only the difference in pain scores between groups, which did not yield a statistical difference. Dual therapy may have affected other outcomes that were not evaluated in this project, such as anxiety or quality-of-life outcomes, for patients with a cancer diagnosis (Rodriguez et al., 2019). Because of the limited scope of the NPRS, a more comprehensive symptom assessment scale may need to be used in future studies to fully determine the impact of dual therapy on these other important measures. Finally, response bias may have affected the project results because the questionnaires and treatment were both administered by the clinician.

    Implications for Practice

    Treating cancer-related pain can be challenging for clinicians and patients. Incorporating CAM methods, such as acupuncture and music therapy, can be useful in the management of cancer-related pain (Behzadmehr et al., 2020; Deng, 2019; Greenlee et al., 2017; Jang et al., 2020; Miller et al., 2019; Scarborough & Smith, 2018; Tao et al., 2016). By increasing their knowledge of the potential benefits of music therapy and acupuncture on cancer-related pain, nurses can improve advocacy for patients.

    IMPLICATIONS

    Conclusion

    Although dual therapy did not result in lower pain scores when compared to the acupuncture-only group in the current project, both interventions resulted in clinically and statistically significant reductions in pain intensity. As a result, both music therapy and acupuncture can be incorporated into standard treatment methods in the management of cancer-related pain. In addition, although dual therapy did not result in reduced pain intensity compared to acupuncture alone, it may have affected other outcomes, such as anxiety or quality of life, for patients with cancer. Therefore, future nursing research may be needed to assess the full impact of dual therapy on pain and other outcomes.

    The authors gratefully acknowledge Ernest Amankwah, PhD, and Cindy Tofthagen, PhD, APRN, AOCNP®, FAANP, FAAN, for their invaluable time, insight, and advice on this project.

    About the Authors

    Jessica Latchman, DNP, APRN, AGACNP-BC®, ACHPN®, AOCNP®, is a nurse practitioner at the H. Lee Moffitt Cancer Center in Tampa, FL; Liem Q. Le, DAOM, MS, Diplo OM, is on the teaching staff in the Human Nutrition and Functional Medicine Department at the University of Western States in Portland, OR, and an acupuncturist at the H. Lee Moffitt Cancer Center; and Anthony McGuire, PhD, ACNP-BC™, FAHA, is an associate professor in the College of Nursing at the University of South Florida in Tampa. The authors take full responsibility for this content and did not receive honoraria or disclose any relevant financial relationships. The article has been reviewed by independent peer reviewers to ensure that it is objective and free from bias. Latchman can be reached at jessica.latchman@moffitt.org, with copy to CJONEditor@ons.org. (Submitted October 2023. Accepted January 23, 2024.)

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