Virtual Reality, Music, and Pain: Developing the Premise for an Interdisciplinary Approach to Pain Management

Emily Honzel; Sarah Murthi; Barbara Brawn-Cinani; Giancarlo Colloca; Craig Kier; Amitabh Varshney; Luana Colloca


Pain. 2019;160(9):1909-1919. 

In This Article

Music and Pain

Music-based therapies have been used to mitigate acute[34] and chronic pain[9] as observed using subjective measures (eg, pain rating scales) and objective methods (eg, fMRI).[13]

Neurobiological Bases of Music and Their Relationship With Pain

Several studies have sought to explain the neural underpinnings of the human experience of music in general.[47] Neural responses to music are centered in the nucleus accumbens, a major reward brain center, and its dopaminergic stimulator, the ventral tegmental area.[60,71,72] The activation of the mesolimbic reward system and the release of dopamine in response to music has demonstrated its pleasure-giving capability.[45,46] This highlights the unique ability of music to connect and engage with multiple parts of the brain and music-evoked emotions.[45] Reybrouck et al. compiled results from 12 studies that used network science algorithms. They concluded that music activates the auditory cortex, the brain reward system, and areas associated with the mind wandering, with distinct changes associated with perceptual, action-related, cognitive, affective, and evaluative processes.[70] Studies have also shown that this pathway of anatomical substrates is shared with the perception of pain, indicating that the 2 may be more closely linked than once believed.[48]

The quantitative understanding of MT treatments as they relate with pain has also been explored. Dobek et al.[12] used fMRI to examine neural activity related to painful stimuli in subjects listening to music they enjoyed vs controls who had no music, finding altered neural patterns indicative of decreased pain when music was playing. Garza-Villarreal et al. found that listening to music reduced pain in fibromyalgia through top-down regulation of the modulatory network, with higher connectivity between the left angular gyrus, the right dorsolateral prefrontal cortex and the left caudate (lCau), and decreased connectivity with the right anterior cingulate cortex, the right supplementary motor area, and the precuneus and right precentral gyrus. Pain reduction levels were correlated with the connectivity of the left angular gyrus to the right precentral gyrus.[17] If these results are further confirmed, listening to music to activate the pain modulatory systems could open up new strategies for nonpharmacological treatments of pain.

Acute Pain

Many studies have shown MT to be effective in treating acute pain.[2,42,54,56,58,63,67,76,77,88] For example, preferred music reduced subjective perception of pain in postcardiac surgical patients compared with controls (P = 0.0001).[36] Forty-five minutes of MT reduced heart rate, respiratory rate, oxygen saturation, and pain in patients undergoing C-clamp application after percutaneous coronary intervention in comparison with controls receiving uninterrupted rest.[7] However, results regarding MT's efficacy are conflicting.[8,10,59,61] The discrepancy in results may be due to various factors, including inadequate study designs and controls or subjectivity of musical experiences (eg, music anhedonia).

Chronic Pain

Parallel to studies in VR, MT has suggested effectiveness in managing chronic pain.[3,14,18,22,24,57,65] For example, Bradt et al.[3] explored the feasibility of an 8-week vocal MT treatment program on chronic pain disorders in a population of older Afro-American inner-city adults. The study established the feasibility of the intervention and demonstrated large effect sizes for self-efficacy at weeks 8 and 12, a moderate effect size for pain interference at week 8, and no improvements for general activities and emotional functioning, paving the road for further research in MT.

Music-based therapies have also been explored in the context of opioid use disorders. Some studies found that music reduced opioid intake,[64] yet others reported that while the music was enjoyable to the patients, the amount of analgesic used did not differ in music-treated patients vs controls.[82] In a recent preliminary research report, Chai et al.[6] discussed the future of using music as an adjunct to opioid administration by establishing the feasibility of the intervention and determining experimentally key points of relevance for clinical endpoints (eg, music features, patients' preferences, motivation, and engagement).

Technical Applications

The range of music-based interventions offered under the umbrella of "Music therapy" is incredibly wide. Activities range from music listening, to vocal therapy, to music production using instruments. It is worth noting that MT, as strictly defined, requires active participation on behalf of the subjects in the presence of a therapist. Most "MT" studies may be more accurately described as music medicine (MM), which usually involves listening to prerecorded music without the presence of a therapist. However, Bradt et al. examined the impacts of MT vs MM and showed that both interventions resulted in equal decreased pain and improved psychological outcomes in cancer patients.[4]

Overall, these studies bring up the interesting notion that, for music to be an effective aesthetic intervention, listeners must engage with what they are experiencing (eg, vocalization and improvisation). In MT, this is often accomplished by a music therapist acting as a guide. In MM, the unguided nature of the intervention makes this more difficult to control for.