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.

Limitations and Future Directions

Many VR and MT studies miss either the appropriate controls (eg, nonimmersive VR, pink noise vs ambient music, and passive music listening) and/or blinding of both research staff and study participants. Moreover, most of the VR and MT studies focused on pain intensity, when VR and MT may change the nature of affect associated with pain experience (eg, distressing or frightening), pain quality (eg, sharpness of pain) and the effectiveness based on pain location (eg, distinct body representation).^[38] Magnitude-based inferences related to clinical relevance are based on the examination of outcomes beyond the statistical significance. Based on the studies we reviewed (Table 1), there is a need for additional systematic meta-analyses^[34] that account for heterogeneity of the studies. Only such approach allows for quantifying the efficacy of MT and VR and their potential to implement their uses routinely to optimize clinical outcomes. Future randomized placebo-controlled clinical trials and comparative effectiveness research will also help define the clinical relevance of VR, MT, and combined VR-MT. Finally, it is important to consider whether and how expectancies and contextual placebo effects may influence the effectiveness of VR-MT interventions.^[51]

Despite these limitations, recent studies have illustrated increased pain tolerance especially in patients who self-selected their musical experience^[62,83] or were immersed in VR contexts.^[43] The hypoalgesic properties of both MT and VR could be further explored in the context of combined VR-MT applications. Virtual reality brings the unique opportunity to reach a high level of engagement on multiple sensory and cognitive levels, as well as the specialization necessary for creating MT-based clinically meaningful experiences that lead to pain reduction. This may help bridge the gap between MT and MM. The possibilities of VR-MT interventions range from minimal contact, using speakers or mobile phones, to use of spatial sound-enabled VR headsets. Stereo 360° cinematographic rendering of virtual scenes could transport patients to the stage of a rock concert, where they are able to change positions and alter which instruments they hear best, or place them in the middle of an operatic finale. Although studies have examined the effects of adding sensory components to VR interventions, exploring multiple VR-MT contents may elucidate the differential effects unique to certain pain disorders and patient predictors of beneficial outcomes.

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Table 1. Description the studies discussed in this review.
Reference	Intervention	Participants	Sample size	Study design	Control group(s)	Measurement type*	Pain	Measurement outcomes	Effect size for Pain intensity outcome (Hedges' g)†
Ambron et al. (2018)¹	VR	Phantom limb pain patients	n = 2	Case study	n/a	Subjective	Intensity	Numerical pain scale (NRS)	Missing data
Carrougher et al. (2009)⁵	VR	Burn injuries patients	n = 39	Within-subjects	One session w/VR, one session w/out VR (order counterbalanced)	Subjective	Intensity (worst pain), time spent thinking about pain, unpleasantness, and opioid equivalents	Graphic rating scale (GRS)	GRS, worst pain: 0.536 Opioid equivalents: −0.171
Demeter et al. (2015)¹¹	VR	Healthy participants	n = 62	Within-subjects	Baseline, tonic noxious heat stimulation only	Subjective and objective	Intensity and threshold	NPS, latency of intolerability, temperature at which pain was first perceived, and thermal sensory analyzer (TSA)	NPS heat intensity: −0.671
Ford et al. (2018)¹⁵	VR	Burn injury patients	n = 10	Observational study	n/a	Subjective	Intensity	Satisfaction questionnaire (no pain ratings)	Missing data/
Gutierrez-Maldonado et al. (2012)²⁵	VR	Healthy participants	n = 45	Within-subjects	No VR	Subjective	Threshold, tolerance, intensity, self-efficacy, and catastrophizing	Pain Catastrophizing Scale (PCS) and Visual Analogue Scale (VAS)	Strongest pain intensity: −0.126
Hoffman et al. (2000)²⁷	VR	Burn injury patients	n = 2	Within-subjects	Videogame only during wound care	Subjective	Intensity	VAS	Missing data
Hoffman et al. (2000)²⁸	VR	Burn injury patients	n = 12	Within-subjects	Control condition: no distraction during physical therapy	Subjective	Intensity	VAS	Average pain: −1.12 Worst pain: −1.11
Hoffman et al. (2004)³⁰	VR	Healthy participants	n = 8	Within-subjects	No VR during thermal stimuli	Subjective and objective	Intensity (time spent thinking about pain, unpleasantness, worst pain, amount of fun, amount of nausea, and presence)	GRS and fMRI	Missing data
Hoffman et al. (2004)³³	VR	Healthy participants	n = 39	Between-subjects	Low-tech VR	Subjective	Cognitive, sensory, and affective components of pain	Rankings from 0–10	−1.49
Hoffman et al. (2006)³²	VR	Healthy participants	n = 77	Between-subjects	No distraction	Subjective	Cognitive, affective, and sensory components of pain	Rankings from 0–10	Missing data
Hoffman et al. (2007)³¹	VR	Healthy participants	n = 9	Within-subjects	No analgesia, opioids	Subjective, objective	Intensity	GRS, blood oxygen level–dependent assessments of brain activity (fMRI)	Worst pain intensity VR−/opioid− vs VR+/opioid−: −1.32 VR−/opioid− vs VR−/opioid+: −0.367 VR−/opioid− vs VR+/opioid+: −2.46
Hoffman et al. (2008)²⁹	VR	Burn injury patients	n = 11	Within-subjects	No VR during wound care	Subjective	Worst pain, pain unpleasantness, time spent thinking about pain, and fun	GRS	Worst pain: −1.05 Unpleasant: −1.09
Jeffs et al. (2014)³⁷	VR	Burn injury Patients	n = 30	Between-subjects	Passive distraction and standard care	Subjective	Intensity	Adolescent pediatric pain tool	Missing data
Jin et al. (2016)³⁹	VR	Chronic pain patients	n = 20	Within-subjects	Self-mediated session (regular distracting activities)	Subjective	Intensity	VAS	−0.96
Johnson et al. (2016)⁴⁰	VR	Healthy participants	n = 32	Within-subjects	Baseline (no sound, no VR), sound only	Objective	Tolerance	Pain tolerance times	Sound only vs baseline: 0.293†† Head mounted device (HMD) only vs baseline: 1.01†† HMD 1 sound vs baseline: 1.01†† HMD 1 sound vs sound only: 0.941†† HMD 1 sound vs HMD only: 0.430††
Jones et al. (2016)⁴¹	VR	Chronic pain patients	n = 30	Within-subjects	n/a (pre–post pain scores)	Subjective	Intensity	NRS	−0.741
Kipping et al. (2012)⁴⁴	VR	Burn injuries patients	n = 41	Between-subjects	Distraction	Subjective, objective	Intensity	VAS, heart rate (HR), oxygen saturation (OS)	Subject VAS, dressing removal: −0.465 Subject VAS, dressing application: −0.420
Loreto-Quijada et al. (2014)⁵⁰	VR	Healthy participants	n = 77	Between-subjects	No VRq	Subjective, objective	Intensity, tolerance, threshold, time perception, and pain sensitivity range	VAS, PCS	Missing data
Maani et al. (2011)⁵²	VR	Burn injury patients	n = 2	Case study	n/a	Subjective	Intensity/unpleasantness	GRS	Missing data
Maani et al. (2011)⁵³	VR	Burn injury patients	n = 12	Within-subjects	No distraction during wound care	Subjective	Intensity/unpleasantness	GRS	Worst pain ≥7: Worst pain: −1.33‡‡ Unpleasantness: −2.13‡‡ Time thinking about pain: −2.44‡‡ Worst pain <7: Worst pain: −0.40‡‡ Unpleasantness: −0.75‡‡ Time thinking about pain: −1.79‡‡
Sano et al. (2015)⁷³	VR	Phantom limb pain patients	n = 6	Within-subjects	n/a	Subjective	Pain total score (sensory and affective components)	Short Form McGill Pain Questionnaire	−0.230
Schmitt et al. (2011)⁷⁵	VR	Burn injury patients	n = 54	Within-subjects	No VR	Subjective	Sensory, affective, and cognitive components	GRS	−0.516
Smith et al. (2017)⁸⁰	VR	Healthy participants	n = 25	Within-subjects	Neutral, pleasant, threatening, socially positive, and socially negative contexts	Subjective, objective	Intensity (threshold)	Pressure pain Thresholds (PPTs) and PCS	Missing data
Sulea et al. (2014)⁸¹	VR	Healthy participants	n = 6	Within-subjects	No VR	Subjective	Intensity	"Perceived level of pain on a 0–10 scale"	Missing data
Wiederhold et al. (2014)⁸⁶	VR	Chronic pain patients	n = 40	Within-subjects	Pain focus condition	Subjective, objective	Intensity	HR, skin temperature, "self-report questionnaire … on a scale of 1 to 7"	Mean pain rating: −0.848 (pilot cohort)
Bradt et al. (2015)⁴	Music therapy (MT), music medicine (MM)	Cancer pain patients	n = 31	Between-subjects	n/a	Subjective	Intensity	NRS	MT, pre-therapy to post-therapy: −0.366 MM, pre-therapy to post-therapy: −0.450 MT vs MM: 0
Colwell et al. (2013)¹⁰	MT, MM	Hospitalized pain children	n = 32	Between-subjects	n/a	Subjective, objective	Pain/anxiety	HR, blood pressure (BP), OS, Wong-Baker FACES Pain Rating Scale	Pain rating score, post-treatment: Music listening vs music composition: 0.21 Music listening vs Orff-based: 0 Music composition vs Orff-based: −0.18
Mondanaro et al. (2017)⁶³	MT	Postspine surgery pain patients	n = 60	Between-subjects	Standard care	Subjective	Intensity	VAS	VAS, MT Preintervention vs postintervention: −0.44 VAS, after intervention: −0.31
Bradt et al. (2016)³	MT	Chronic pain patients	n = 55	Between-subjects	Waitlist (no music received at time of study)	Subjective	Intensity, interference, and self-efficacy	Westhaven-Yale Multidimensional Pain Inventory (MPI), Pain Self-Efficacy Questionnaire (PSEQ), NRS	MPI: −0.08, −0.24‡ NRS: −0.61, 20.27‡
Gutgsell et al. (2013)²⁴	MT	Hospital inpatients	n = 200	Between-subjects	Standard care alone	Subjective	Intensity	NRS, Functional Pain Scale	NRS: −0.69 "Change Score" from baseline
Madson et al. (2010)⁵⁴	MT	Solid organ transplant pain patients	n = 58	Within-subjects	Pre-test/post-test design	Subjective	Intensity	10-Point Likert-type scales	−0.30§
Ames et al. (2017)²	MM	Postoperative pain patients	n = 41	Between-subjects	Controlled non–music listening	Subjective	Intensity	VAS, NRS, and opiate intake	VAS: −0.12∥ NRS: 0.00∥ Opioid intake, IV: 0.30 Opioid intake, epidural: 0.26
Chan et al. (2007)⁷	MM	Interventional pain patients (C-clamp procedure)	n = 66	Between-subjects	45-min uninterrupted rest period	Subjective and objective	Intensity	Systolic and diastolic pressure (SBP and DBP), HR, respiratory rate (RR), OS, and UCLA Universal Pain Assessment Tool	UCLA Universal Pain Assessment, MT vs control at 45-min timepoint: −1.37
Chantawong et al. (2017)⁸	MM	Patients undergoing loop electrosurgical excision procedure (LEEP)	n = 150	Between-subjects	No music listening during procedure	Subjective	Intensity (pain, anxiety, and satisfaction)	VAS	VAS, pain score difference from baseline: −0.26
Dobek et al. (2014)¹²	MM	Healthy participants	n = 12	Within-subjects	No music during painful stimulus	Subjective and objective	Intensity	fMRI, State-Trait Anxiety Inventory (STAI), Crowne-Marlowe Social Desirability Scale, PCS, TSA	Average pain rating: −2.21 Maximum pain rating: −2.57
Garza-Villarreal et al. (2015)¹⁷	MM	Fibromyalgia patients	n = 22	Within-subjects	Pink noise	Subjective, objective	Intensity	PCS, fMRI	Missing data
Guetin et al. (2012)²²	MM	Lumbar pain, fibromyalgia, inflammatory disease, and neurological disease patients	n = 87	Between-subjects	Standard treatment only	Subjective	Intensity	VAS	VAS at day 60: −0.79
Jafari et al. (2012)³⁶	MM	Post–cardiac Surgery patients	n = 60	Between-subjects	No music	Subjective	Intensity	NRS	Intensity directly after intervention: −0.64 Intensity 30 minutes after intervention: −0.91 Intensity 1 h after intervention: −0.96
Karalar et al. (2016)⁴²	MM	Renal calculi pain patients	n = 89	Between-subjects	No headphones or music or music without noise canceling headphones	Subjective	Intensity	VAS	Music+/Headphones+ vs music−/headphones−: −1.23 music+/headphones+ vs music+/headphones−: −0.63
McCaffrey et al. (2003)⁵⁷	MM	Chronic osteoarthritis pain patients	n = 66	Between-subjects	No music listening (quiet sitting)	Subjective	Intensity	Short Form McGill Pain Questionnaire (Pain Rating Index, VAS)	PRI: 1.64¶ VAS: 2.05¶
McCaffrey et al. (2006)⁵⁸	MM	After hip or knee surgery	n = 124	Between-subjects	Standard postoperative care	Subjective, objective	Intensity	Pain medication intake, NRS	Pain rating, average of days 1–3: −1.12 Pain medications administered: −0.31
Meeuse et al. (2010)⁵⁹	MM	Interventional pain (sigmoidoscopy)	n = 307	Between-subjects	Standard of care	Subjective	Intensity	VAS	−0.122
Mercadie et al. (2015)⁶¹	MM	Fibromyalgia patients	n = 81	Between-subjects	Environmental sounds	Subjective	Intensity	VAS	Active situations, music vs sound: −0.02# Passive situations, music vs sound: 0#
Mitchell et al. (2006)⁶²	MM	Healthy participants	n = 54	Within-subjects	White noise	Subjective and objective	Intensity, tolerance, and perceived control	VAS, pain rating index of the McGill Pain Questionnaire	Pain intensity (VAS): Relaxing music vs white noise: −0.340; preferred music vs white noise: −0.760; relaxing music vs preferred music: −0.431
Nilsson et al. (2005)⁶⁴	MM	Open hernia repair pain patients	n = 75	Between-subjects	Silence	Subjective, objective	Intensity	Cortisol, blood glucose, immunoglobin A levels, BP, HR, OS, and NRS	Pain NRS; intraoperative MT vs control: −0.74; postoperative MT vs control: −0.97
Onieva-Zafra et al. (2013)⁶⁵	MM	Fibromyalgia patients	n = 55	Between-subjects	No music listening	Subjective	Sensory, affective, evaluative, and intensity	McGill Pain Questionnaire Long Form, VAS	VAS after 4 wk: −1.67
Özer et al. (2013)⁶⁷	MM	Open heart surgery pain patients	n = 87	Between-subjects	Standard of care	Subjective and objective	Intensity	BP, HR, OS, RR, and unidimensional verbal pain intensity scale	Post-test pain (verbal pain intensity scale): −2.16
Schneider et al. (2018)⁷⁶	MM	Postoperative (orthopedic) pain	n = 42 (n = 65 for pain logs collected, as several patients completed the exercise multiple times)	Within-subjects	Pre–post intervention pain scores	Subjective	Intensity	NRS	−0.69
Shabandokht-Zarmi et al. (2017)⁷⁷	MM	Hemodialysis patients, during fistula puncture	n = 114	Between-subjects	Headphone (no music) or control (no intervention)	Subjective	Intensity	VAS	Music vs control: 1.87; Music vs headphone-only: 1.96
Vaajoki et al. (2012)⁸²	MM	Laparotomy recovery	n = 168	Between-subjects	No music listening	Objective	n/a	Analgesic use, length of hospital stay, and adverse events	Missing data
Villarreal et al. (2012)⁸³	MM	Healthy participants	n = 48	Between-subjects	Environmental sounds, noise	Subjective	Intensity	VAS	Missing data
Yeo et al. (2013)⁸⁸	MM	Cystoscopy related pain patients	n = 70	Between-subjects	No music during procedure	Subjective	Intensity	VAS, physiological functions (hemodynamic values; mean arterial pressure; heart and respiration rates)	VAS: −1.16

Negative values for Hedges' g indicate a higher value in the control group than in the treatment group. For measures evaluating pain, a negative Hedges' g reflects a decrease in the treatment compared with the control group.
For measures evaluating measures such as threshold, a negative Hedges' g value indicates a higher pain threshold in controls compared with the treatment group. Hedges' g: |0.2| = small effect size; |0.5| = medium effect size; |0.8| = large effect size.
* "subjective" indicating measurements based on subjects' self-reported perceptions of their experience; "objective" indicating measurements independent of subject bias. Missing data = case studies or studies in which
mean and/or SD were not reported.
† Hedges' g: (mean [tx grp] − mean [control grp])/(combined SD).
‡ (Week 8, follow-up)—data taken from "Change Score" from baseline.
§ Comparison between pre-MT and post-MT.
∥ Average of 4 time-points.
¶ Average of 3 time-points, reflecting change in pain level (D1, D7, and D14).
# Average of 3 time-points.
** Calculated using pain score difference before and after intervention.
††Using log10-transformed times.
‡‡subjects stratified based on "worst pain" in the no VR condition.
fMRI, functional magnetic resonance imaging; VR, virtual reality.

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

Limitations and Future Directions

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