Journal of Music Therapy, XX(XX), 2020, 1–24

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Comparing Three Music Therapy

Interventions for Anxiety and Relaxation
in Youth With Amplified Pain
Ashley Scheufler, MME, MT-BC
Children’s Mercy Hospital, Kansas City, MO, USA

Dustin P. Wallace, PhD

Children’s Mercy Hospital, Kansas City, MO, USA

Emily Fox, MD, MS

Children’s Mercy Hospital, Kansas City, MO, USA

Research in pediatric hospitals has shown that active music engage-

ment, preferred music listening, and music-assisted relaxation can de-
crease anxiety and increase relaxation responses. However, there is little
research on the use of music therapy with pediatric chronic pain con-
ditions such as amplified pain syndromes. The purpose of the current
study was to examine the effects of 3 specific music therapy interven-
tions (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 interdiscip-
linary 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 authors would like to thank the following: Sheri Robb, PhD, MT-BC, Cynthia
Colwell, PhD, MT-BC, and Kim Robertson, MT-BC, for valued guidance during the
planning, conduct, and write-up of this research.
This research was supported by Children’s Mercy Hospital and there was no out-
side funding.
The authors have no conflicts of interest to disclose.
Dustin P. Wallace is a pediatric psychologist and the Director of Behavioral Health
for the Rehabilitation for Amplified Pain Syndromes (RAPS) program.
Emily Fox is a pediatric rheumatologist and physician for the Rehabilitation for
Amplified Pain Syndromes (RAPS) Program at Children’s Mercy Hospital.
Ashley Scheufler is a board-certified music therapist at Children’s Mercy Hospital
and provides services for youth in the Rehabilitation for Amplified Pain Syndromes
(RAPS) program.
Address correspondence concerning this article to Ashley Scheufler, MME,
MT-BC, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108.
Phone: 816-234-3734. E-mail: alscheufler@cmh.edu.
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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 mo-
dality to decrease anxiety and increase relaxation levels in pediatric pa-
tients with amplified pain syndromes.
Keywords: music therapy; adolescent; amplified pain syndrome;
chronic pain; anxiety; relaxation

Statement of the Problem

The prevalence of chronic pain in youth is high, affecting
20%−35% of adolescents (King et al., 2011). Pain is defined as
chronic when it persists beyond the amount of time typical for
healing to occur (American Pain Society, 2012). This type of pain is
maladaptive as it no longer serves a protective purpose, yet chronic
pain can have tremendous effects on the physical body and also
reach into psychological, emotional, and social domains leading
to broad losses in function and diminished quality of life (Hoffart
& Wallace, 2014). Without adequate treatment, youth with chronic
pain are at risk of pain continuing into adulthood as well as other
physical and mental health symptoms (Kashikar-Zuck et al., 2014;
Stahlschmidt et al., 2016).
Amplified pain syndrome (APS) is a category of childhood
chronic pain conditions in which changes within the nervous
system affect how pain is being transmitted (by the peripheral ner-
vous system) and interpreted (by the central nervous system) re-
sulting in increased pain perception (Hoffart & Wallace, 2014). In
these conditions, the pain is not maintained by an illness, injury, or
other disease and remains persistent due to these maladaptive pro-
cesses in the nervous system. The term APS encompasses multiple
persistent chronic pain conditions including complex regional
pain syndrome, juvenile fibromyalgia, and other musculoskeletal
and sensory amplification conditions (Sherry, 2016). Youth with
APS may perceive themselves as less able to perform basic physical
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tasks and daily living activities due to their pain. They might also
be anxious about injuring their bodies leading to increased re-
activity to pain and subsequent avoidance of use of the affected
area (Coakley, 2016), and over time may develop a perceived lack
of competence further contributing to impairments in physical
functioning (Guite et al., 2007). As pain continues, physical im-
pairments often contribute to these youths pulling away from emo-
tional and social connections directly impacting activities of daily
living including school attendance and performance, relationships
with family and peers, and participation in activities outside of
school (Logan et al., 2017; Palermo et al., 2014).
Treatment for APS and other childhood chronic pain requires
an interdisciplinary approach that takes into consideration this
biopsychosocial experience of pain (Hoffart & Wallace, 2014).
Treatment does not focus directly on pain, and instead targets phys-
ical, emotional, social, and cognitive functioning while considering
the individual’s complex and unique history and experience of
pain. Treatments incorporate exercise-based therapies focused on
strength, endurance, daily functioning, and nerve desensitization
through interventions typically delivered by occupational and phys-
ical therapists. These are integrated with psychological interventions
often utilizing cognitive-behavioral therapy (CBT) and/or accept-
ance and commitment therapy (ACT) to promote stress manage-
ment and to treat comorbid depression and anxiety. Psychological
treatment also targets motivation and often incorporates strategies
such as acceptance of difficult experiences while pursuing actions
aligned with values and goals (Beals-Erickson & Connelly, 2018).
For highly disabled individuals, a more focused and robust ap-
proach called intensive interdisciplinary pain treatment (IIPT) can
lead to rapid improvements (Simons, 2013). IIPT programs exist in
many countries including the United States, Canada, Germany, the
United Kingdom, Sweden, France, and Australia. IIPT programs
utilize the same biopsychosocial focus and modalities to treat APS;
however, they are delivered in an inpatient or day treatment set-
ting with patients receiving around 40 hr a week of treatments
(Hechler et al., 2015). The intensive setting of IIPT also allows for
greater incorporation of interventions for parents (Pielech et al.,
2018) as well as more formal integration of creative, expressive,
and self-regulation therapies like music therapy, art therapy, yoga,
and mindfulness. Transfer of skills learned and acquired from one
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discipline to the other is emphasized (e.g., mindfulness-based strat-
egies encouraged during exercise-based therapies). Published re-
sults indicate significant improvements in daily functioning, fear
of pain, anxiety, and depression, and in many cases, patients have
also reported improvements in pain intensity (Hechler et al., 2015;
Kempert et al., 2017; Simons, 2013; Stahlschmidt et al., 2016).
Of note, music interventions have shown significant benefits for
individuals experiencing acute pain. A meta-analysis of adults with
acute or procedural pain revealed that music interventions had sig-
nificant effects on emotional distress, anesthetic and medication
use (opioid and non-opioid), self-reported pain, and on physio-
logical outcomes such as heart rate, blood pressure, and respira-
tory rate (Lee, 2016). A Cochrane review on music and pain relief
found that though the magnitude of the benefits found was small,
music listening was effective in reducing pain intensity levels and
opioid consumption (Cepeda et al., 2006). While these are im-
portant benefits, IIPT for individuals with chronic pain does not
focus on avoidance or elimination of pain. Instead, treatment seeks
to improve physical and psychological functioning and to reduce
the impact of chronic pain on life. Restoration of function in turn
leads to improvements in other domains of life and eventually to
improvements in pain itself (American Pain Society, 2012; Hoffart
& Wallace, 2014; Kempert et al., 2017).
In the setting of IIPT, treating pain-related anxiety and distress is
particularly important as these symptoms directly contribute to the
experience of pain and lead to additional impairment. Many youth
with pain enter a cycle of fear and anxiety that leads to physical and
social avoidance, and further increases in anxiety and depression
(Simons, 2016). As the cycle continues, fear and anxiety can inten-
sify muscle tension in the body further contributing to perceived
pain and greatly impacting quality of life (Coakley, 2016). This cycle
is understood not only subjectively, but it can be observed physiolo-
gically that heightened anxiety increases pain perception (Tang &
Gibson, 2005) and that pain increases anxiety (Klassen et al., 2008).
Music therapy has been found to be an effective treatment mo-
dality for reducing anxiety and distress in hospitalized pediatric
patients (Colwell et al., 2013; Whitehead-Pleaux et al., 2006), in
pediatric preoperative patients (Millett & Gooding, 2017), and
in adult patients in the hospital emergency department (Mandel
et al., 2019). A meta-analysis conducted by Tsai et al. (2014) found
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that music therapy had moderate though significant effects on anx-
iety in patients with cancer among other outcomes including de-
pression, pain, and fatigue. However, subgroup analyses indicated
interventions were more effective in adult patients.
Additionally, various music therapy approaches have shown
benefit when addressing anxiety and perceived relaxation in in-
dividuals under high arousal due to stress. For example, a meta-
analysis revealed that studies using relaxation techniques paired
with recorded music can significantly decrease arousal due to stress,
with the most benefit demonstrated in individuals under the age of
18 years old (Pelletier, 2004). Further, use of live patient-selected
and/or preferred music resulted in significant positive changes in
anxiety, fear, fatigue, and relaxation in adults undergoing chemo-
therapy treatment (Ferrer, 2007) and improvements in measures
of anxiety, perception of hospitalization, relaxation, and stress in
both children and adults undergoing brain procedures and sur-
geries (Walworth et al., 2008). As seen in adults, promoting active
engagement in the music making process can facilitate changes in
negative affect and mood which are often byproducts of stress and
anxiety (Ghetti, 2011; Rodgers-Melnick et al., 2018).
Conceptually, music therapy has much to offer the population
of youth with APS due to the stress and anxiety associated with
their condition and with intensive treatment. However, there is a
lack of research measuring the effects of music therapy in youth
with chronic pain conditions such as APS, and more specifically,
those undergoing IIPT. The goal of the present study was to de-
termine and compare the effectiveness of three well-established
music therapy interventions: live patient-selected music (LPSM),
active music engagement (AME), and music-assisted relaxation
(MAR) on relaxation levels and state-level anxiety in youth with
APS. Our first hypothesis was that all three interventions would
lead to significant improvements in relaxation, in state-level som-
atic symptoms of anxiety, and in state-level cognitive symptoms of
anxiety. A second hypothesis was that the MAR intervention (which
is relaxation-focused) would have a greater effect on participant
relaxation and somatic anxiety symptoms, whereas the AME and
LPSM interventions (which are more focused on engaging with
music) would have a greater effect on cognitive anxiety symptoms.
Third, as we are unaware of evidence to suggest that three sessions
with different content would lead to increasing response (e.g., a
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“practice effect”), we hypothesized that there would not be an ef-
fect of number of sessions on these outcomes; related to this, we
hypothesized that there would not be an interaction between inter-
vention and the number of prior sessions a youth had experienced.

Methods
Participants
Participants included 59 consecutively enrolled youth begin-
ning an IIPT program at a Midwestern United States children’s
hospital between May 2016 and November 2017. To be included
in the IIPT program, participants had to be diagnosed with amp-
lified pain, have impairment due to pain, and be between ages 10
and 19. Of the 59 participants, 48 (81%) were included in ana-
lyses. Participants were excluded only if they had no data, which
included 1 participant who dropped out of the program before
having a music therapy intervention (2%), and 10 others for whom
questionnaires were not administered (17%; in most cases, this was
due to music therapist absence or patient being developmentally
unable to complete questionnaires). Of the remaining 48, 39 had
complete data (three sessions), 5 had data for two sessions, and
4 had data for only one session. As the exposure to the different
interventions was reasonably balanced across participants with par-
tial data they were retained for analysis. Excluded patients did not
differ on age, gender, pain diagnosis, pain duration, average pain,
anxiety, depression, or catastrophizing (all p > .05). Excluded pa-
tients did not differ on ethnicity or race (Fisher’s Exact p > .05);
however, it should be noted that 92% of participants were White,
whereas in the excluded group, only 73% were White.
Participants consisted of 40 females and 8 males between 10 and
18 years of age; see Table 1 for a summary of the demographic
and baseline characteristics of the sample. All participants had pre-
viously attempted traditional outpatient treatment (e.g.. physical
therapy, counseling) for chronic pain before starting the IIPT pro-
gram. Youth participated in IIPT for approximately 40 hr per week,
with typical treatment duration of 3–5 weeks. In addition to music
therapy, during the program, these participants received phys-
ical and occupational therapy, individual and group counseling,
therapeutic art, and self-regulation such as yoga and relaxation
interventions.
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Table 1
Demographic and Baseline Characteristics (N = 48)

Characteristic Number Percent

Gender 40 female 83
Ethnicity 42 not Hispanic/Latino 88
Race
White 44 92
Black/African American 1 2
American Indian/Alaska Native 1 2
Asian/Asian American 2 4
Pain location/pattern
Widespread, constant 37 77
Widespread, intermittent 2 4
Localized, constant 6 13
Localized, intermittent 1 2
Other 2 4
Mental health diagnosis
Depression 16 33
Anxiety 27 56
Characteristic Mean SD

Age 15.5 1.9

Pain intensity (average) 54/100 18.5
Pain duration (years) 4.0 3.4

Design
This study utilized a three-period, three-treatment cross-over
design with three interventions delivered in a quasi-randomized
order. The music therapy interventions and measures were de-
livered as part of the clinical care that patients were receiving. All
patients/parents provided informed consent (or permission/as-
sent) for the research use of their clinical data as part of a broader
study investigating participant characteristics and outcomes from
IIPT. Data collection and research were approved by the hospital
IRB (#13010020).
All intervention conditions followed a similar treatment process.
Each session began with a pretest, followed by the music therapy
intervention, and ended with a posttest. In each session, the music
therapy intervention lasted approximately 30–45 min and when
combined with time for pre- and posttest measures, typically re-
sulted in a 60-min session. Music therapy sessions occurred in a
private space in the building where the IIPT program is housed.
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The music therapy interventions were delivered during individual
music therapy sessions and were conducted by a Board-Certified
Music Therapist (MT-BC) with 10 years of pediatric experience. In
addition to individual sessions, patients also received one group
music therapy session a week; no study content was introduced or
revisited during these groups.
All patients received each of the three music therapy interven-
tions, once per week for a total of 3 weeks to coincide with the
minimum duration of the hospital-based IIPT program. For the
first 6 months of this study, interventions were consistently de-
livered in this order (#1 LPSM, #2 AME, and #3 MAR). To control
for potential order effects, the order was reversed midway through
the data collection process (#3 MAR, #2 AME, and #1 LPSM).
The first intervention delivered was based on admission date, and
might have been 1, 2, or 3; thus, there were six potential sequences
in which interventions could be completed and between 5 and 12
patients completed each sequence. The independent variables
across the three sessions were three different music therapy inter-
ventions. The dependent variables were the STICSA-C and the
Visual Analog Scale (VAS).

Description of Treatment Protocol

Intervention #1—LPSM. This intervention focused on the use
of patient-selected music to elicit positive changes in anxiety and
relaxation levels. After completing pre-intervention measures,
the patient was asked to select their most preferred songs from a
songbook of popular music previously compiled by the music ther-
apist. The songbook included approximately 25 songs from mu-
sical genres including pop, rock, country, alternative, and oldies.
Most songs were released no more than 5–10 years prior to this
study apart from the oldies section, which included songs from
the 1950s–1960s. The patient was asked to bookmark their top five
song choices and indicate their order of preference. The patient
was encouraged to fully engage in the intervention by following
along with the lyrics in the songbook, by singing or moving along
to the music, and by marking or highlighting the pages with a
writing utensil when lyrics/phrases were particularly meaningful to
the patient. The music therapist then provided live singing of each
of the patient chosen songs with acoustic guitar accompaniment.
After each song, the music therapist utilized questions to provide
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an opportunity for verbal processing. Most questions were devel-
oped in the moment by the music therapist and were generally
based on the patient’s engagement with the intervention/song im-
plementation (i.e., focused on any lyrics the patient highlighted/
underlined, and/or any information the patient offered about the
song or themselves). Prompting questions were utilized to facili-
tate discussion when the patient may not initiate a response (e.g.,
“What do you like or dislike about this song?” “What lyrics stand out
to you the most?” “What do you think the singer/artist is trying to
say?”). The music therapist utilized discretion with questions based
on the patient’s level of response, however gradually honed ques-
tions to encourage identification and expression of emotions, as
well as support application of coping mechanisms both while in the
program and outside of the hospital environment (e.g., “Has there
ever been a time that you’ve felt the way the singer feels?” “How
would you cope with that situation?” “Who are your support sys-
tems?”). This process continued through each of the patient’s song
choices or for approximately 30–45 min. The patient then com-
pleted the post-intervention measures and the session concluded.
Intervention #2—AME. The goal of this intervention was to en-
gage patients in active music making which involved chant writing
(fill-in-the-blank method) as well as active instrument improvisa-
tion for the purpose of decreasing acute anxiety and improving
relaxation levels. After pre-intervention measures, the patient was
presented with a fill-in-the-blank chant writing experience (written
by the music therapist) and encouraged to complete the chant
phrases/lyrics using emotion words that most accurately repre-
sented each of the time periods discussed (past, present, and fu-
ture) within the chant (see Figure 1). Upon completion of lyrics,
the music therapist lead the patient through the chant using a small
drum to keep a steady beat and encouraged the patient to tap/
pat along while chanting the lyrics. The xylophone was then intro-
duced and the patient was shown how to transfer a steady beat to a
bourdon pattern (root and fifth of the key) on the instrument and
once again lead through the chant. The patient was also encour-
aged to utilize this instrument to further express their identified
emotions through improvisation. Elements of music were briefly
discussed (pitch, dynamics, articulation, tempo, etc.) to provide
the patient with a basis and structure for improvising emotions.
Xylophones were arranged in a pentatonic scale to provide further
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Figure 1
Chant writing example utilized in Intervention #2—active music engagement
(AME).

structure during improvisation. For grounding support, the music

therapist provided a steady bourdon pattern (I and V of the chord)
on the bass metallophone through the entire process. Format for
chant playing followed an ABACA (RONDO) form in which the
A Section consisted of the spoken chant and bourdon pattern
steady beat, and the B and C Sections provided opportunity for
the patient to freely improvise while the music therapist continued
the steady bourdon pattern. Following the intervention, the music
therapist allowed for verbal processing of the entire intervention
process based on patient’s level of responses throughout. This en-
tire process lasted approximately 30–45 min. The patient then com-
pleted the post-intervention measures and the session concluded.
Intervention #3—MAR. The focus of this intervention was to utilize
live music and guided imagery administered by the music therapist
to increase relaxation levels. After completing pre-intervention meas-
ures the patient was first asked to identify a setting in which they felt
most comfortable, calm, and safe. Using their five senses, the patient
brainstormed and wrote down aspects of this identified environment
that were particularly comforting (e.g., warm white sand, sound of
waves, smell of suntan lotion, taste of salt water, etc.) in each sen-
sory realm. The music therapist then utilized these identified en-
vironmental characteristics to customize a guided imagery script
spoken in the moment. The elements of music including timbre,
tempo, rhythm, dynamics, melody, and harmony were thoughtfully
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considered in the presentation of the music by the music therapist
in order to maximize relaxation responses (Robb et al., 1995; Tan
et al. 2012). Music was provided by the music therapist via live clas-
sical guitar (Cordoba) for its smooth timbre and a pre-recorded
synthesized pedal tone played through an Apple laptop computer
using GarageBand software. The pre-recorded pedal tone loop util-
ized the pre-set tone “Serena Swirl” on middle C (C4) and continued
through the relaxation intervention to provide grounding. To keep a
consistent tempo, the music therapist utilized an ear bud to provide a
metronome click track to serve as a reference for 60 beats per minute.
A fingerstyle picking pattern was then provided using a 4-bar chordal
progression (C-CM7-Am7-FM7) to provide limited, yet pleasing har-
monies and predictability to the listener. Given the proximity of the
patient to the music therapist in this space, sound levels from the
guitar and laptop were kept low and dynamics stable. This entire pro-
cess lasted approximately 30–45 min. The patient then completed
the post-intervention measures and the session concluded.

Data Collection Procedures

Data collection took place during normally scheduled individual
music therapy sessions which occurred one time per week over the
course of 3 weeks (typical duration of RAPS program participa-
tion) and was collected both prior to, and post-intervention within
each of the three music therapy sessions. Youth in the program are
used to responding to similar clinical questionnaires during many
of their other daily therapies.
Relaxation. Relaxation was assessed with a 100 mm VAS admin-
istered on an iPad. The screen allowed patients to slide the indi-
cator along a line with anchors of “Not relaxed at all” to “Very re-
laxed.” The slider did not indicate any numerical value; however, a
number from 0 to 100 was stored on the iPad and used for analysis.
Higher scores indicated more relaxation.
State-level anxiety. Current anxiety levels were collected via the
state form of the State-Trait Inventory for Cognitive and Somatic
Anxiety for Children (Deacy et al., 2016) and also administered
via an Apple iPad. Patients were asked to indicate how they feel
“right now, at this very moment” on 21 items which are then rated
on a 4-point Likert scale from “Not at all” to “Very much.” Robust
psychometric evaluations show the reliability and validity of the ori-
ginal STICSA in adults (Grös et al., 2007; Ree et al., 2008), which
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includes two conceptually and statistically distinct subscales. The
first, a Cognitive subscale focused on worry, difficulty with con-
centration, and negative thoughts about the future. The second, a
Somatic subscale focused on physiological symptoms such as a dry
throat, shaking, faster breathing, and sweaty hands. More recent
work has adapted the STICSA for children and adolescents (cre-
ating the STICSA-C) and has demonstrated reliability and validity
in this population (Deacy et al., 2016). In the current sample, in-
ternal reliability was calculated for the first administration of the
STICSA for each participant, and both scales had good internal
consistency (cognitive α = .89; somatic α = .88).
Pain and demographic characteristics. Pain and demographic
characteristics are assessed by questionnaires at the beginning of
the clinical program. Patients indicate their average pain intensity
with a 100 mm VAS, as well as their gender, ethnicity, race, and age.
Medical providers indicate whether patients have widespread or
localized pain, whether pain pattern is constant or intermittent,
and if patients have been diagnosed with depression or anxiety
(including primary diagnoses and adjustment disorders).

Data Analysis Plan

The primary outcomes are within subjects and we anticipated at
least medium effect sizes, so power analysis (using G*Power 3.1.9.4)
indicated a minimum sample size of 21 in order to achieve power
of 0.80 with alpha level set at .05 for repeated measures ANOVA.
Given additional complexity including presence of a covariate,
multiple planned analyses, and the desire for increased stability
and generalization from a larger sample, we sought a larger sample.
Descriptive and inferential statistics were computed to describe
the sample’s demographic characteristics and to assure no differ-
ences existed between included and excluded participants (re-
ported above and in Table 1). A series of paired t tests were con-
ducted to address the first hypothesis by evaluating the effect of
music therapy interventions on relaxation, somatic anxiety, and
cognitive anxiety. Given that each participant completed each con-
dition, a total of nine t tests (three interventions evaluated for each
of the three primary outcomes) were performed. To control for
Type I error, a Bonferroni correction was applied, setting the ef-
fective alpha level at p <.006. Effect size of these paired compari-
sons was computed with a form of Cohen’s d appropriate repeated
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measures (Lenhard W. & A., 2016), which accounts for the correl-
ation between pre- and posttest scores.
To address the second and third hypotheses, generalized
estimating equation (GEE) was used to simultaneously compare
the effectiveness of the three music therapy interventions and
evaluate for any potential effect of treatment week. GEE is statistic-
ally similar to ANOVA but is better able to appropriately model data
in the presence of both repeated measurements and a covariate.
Three GEE models were created (one for each dependent vari-
able), and the primary outcome for each was the change in the
dependent variable, computed as the pre-intervention score sub-
tracted from the post-intervention score. In order to account for
the potential impact of differences in baseline scores or regression
to the mean, baseline score of the dependent variable was included
as a covariate in each analysis. Significant results were followed up
with pairwise contrasts within GEE. The key explanatory variables
in the GEE models were intervention, week, and the intervention-
by-week interaction. If the interaction was not significant (hypoth-
esis 3), it was removed from the model prior to testing for effects of
the intervention (hypothesis 2) and week.

Results
First Hypothesis: Impact of Music Interventions on Relaxation
and Anxiety
A series of nine paired-sample t tests were conducted to evaluate
the effect of each music therapy intervention on each outcome.
Table 2 summarizes the scores before and after intervention for
each outcome, the amount of changes, the statistical significance,
and the effect size for each comparison. The effects of each music
therapy intervention were powerful, leading to statistically signifi-
cant changes in each outcome (all p < .001) with very large effect
sizes. Indeed, by interpretation guidelines for Cohen’s d, these ef-
fects range from large to very large. All interventions had very large
effects on the outcome of relaxation; very large effects were also
observed for the effect of LPSM on somatic anxiety and for AME
on cognitive anxiety. Supporting the clinical significance of these
findings, the amount of change in relaxation levels for all three
interventions exceeded the standard deviation of pre-intervention
relaxation levels. For somatic anxiety, the amount of change was
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Table 2
Paired t Test Results

Outcome Intervention Before intervention After intervention Change t(df) Effect size

***
Relaxation LPSM 33.6 (20.1) 59.0 (21.4) −25.4 (18.9) −8.6 (40) 1.39 (0.91–1.88)
AME 32.6 (18.4) 54.7 (19.1) −22.0 (18.0) −8.1 (43) *** 1.25 (0.77–1.72)
MAR 35.7 (18.7) 63.2 (20.9) −27.5 (20.3) −9.2 (45) *** 1.44 (0.99–1.90)
Somatic anxiety LPSM 25.3 (7.4) 18.5 (6.3) 6.8 (4.2) 10.3 (40) *** 1.53 (1.04–2.02)
AME 24.7 (7.7) 19.5 (6.4) 5.3 (4.9) 7.1 (43) *** 1.01 (0.56–1.45)
MAR 24.8 (8.2) 17.4 (5.4) 7.4 (6.1) 8.2 (45) *** 1.11 (0.67–1.54)
Cognitive anxiety LPSM 21.2 (6.8) 17.7 (5.9) 3.5 (3.1) 6.0 (40) *** 0.96 (0.45–1.36)
AME 22.9 (6.3) 19.2 (6.3) 3.7 (3.1) 8.0 (43) *** 1.20 (0.73–1.67)
MAR 21.4 (7.2) 17.7 (6.4) 3.7 (4.6) 5.5 (45) *** 0.78 (0.35–1.20)

Note. AME = active music engagement; LPSM = live patient-selected music; MAR = music-assisted relaxation. To control for Type I error,
a Bonferroni correction was applied, setting the effective alpha level at p <.006. Effect size is Cohen’s d for repeated measures with 95%
confidence interval (calculated with Lenhard & Lenhard (2016)).
***
p < .001.
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close to the standard deviation of before intervention levels. For
cognitive anxiety, the amount of change was approximately half of
the standard deviation of before intervention levels. Additionally,
although not tracked formally, there were no reported adverse ef-
fects for any of the three music interventions. Overall, these results
provide strong support for the first hypothesis: music interventions
can lead to significant improvements in relaxation and state-level
anxiety.

Second Hypothesis: Differential Impact of Interventions on

Relaxation and Cognitive Anxiety
The second hypothesis was that the MAR intervention would
have a greater impact on relaxation and somatic anxiety symptoms,
whereas LPSM and AME would have a greater impact on cognitive
anxiety. This was tested with three GEE models (one for each out-
come), where the intervention-by-week interaction was removed
since it was not significant (more details below). Independent vari-
ables in the models included intervention, week of program, and
baseline level of the outcome. To address hypothesis 2, analysis fo-
cuses on the column labeled “intervention.” Please see Table 3 for
a summary of the GEE models.
The GEE model for relaxation indicated a statistically significant
impact of intervention (χ 2(2) = 7.15, p < .05), indicating that there
was a difference in change in relaxation level between at least two
of the interventions. Follow-up pairwise comparisons indicated
that the difference was between AME and MAR (p < .01), with MAR
intervention leading to a greater reduction in self-reported relax-
ation levels. There were no other significant pairwise comparisons
for relaxation. This result is partly consistent with the hypothesis,
as we also expected the MAR intervention to have a greater effect
on self-reported relaxation as compared to LPSM.

Table 3
Test Statistics for GEE Models

Outcome Intercept Intervention Week Baseline

Relaxation 76.29 (1) *** 7.15 (2) * 7.76 (2) * 17.93 (1) ***
Somatic anxiety 7.34 (1) ** 12.12 (2) ** 0.30 (2) 38.11 (1) ***
Cognitive anxiety 2.30 (1) 0.56 (2) 4.12 (2) 16.30 (1) ***

Note. All values are Wald chi-squared, with degrees of freedom in parentheses.
***
p < .001. **p < .01. *p < .05.
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The GEE model for somatic anxiety indicated a statistically sig-
nificant impact of intervention (χ 2(2) = 12.12, p < .01), indicating
that there was a difference in change in relaxation level between
at least two of the interventions. Follow-up pairwise comparisons
indicated that the difference was again between AME and MAR (p
< .001), with the MAR intervention leading to a greater reduction
in somatic anxiety levels for patients. This result is partly consistent
with the hypothesis, as we also expected the MAR intervention to
have a greater effect on somatic anxiety as compared to LPSM.
The GEE model for cognitive anxiety indicated no statistically
significant impact of intervention. This indicates that all inter-
ventions led to similar changes in cognitive anxiety. Given these
nonsignificant results, no follow-up pairwise comparisons were con-
ducted. This result is not consistent with the hypothesis, as we ex-
pected that the LPSM and AME interventions would have a greater
effect on cognitive anxiety as compared to the MAR intervention.

Third Hypothesis: Lack of Interaction With or Effect of

Treatment Week
The GEE models conducted to address the second hypothesis
also address the third hypothesis. We evaluated the interaction
between intervention and week by adjusting each GEE analysis
to include the interaction effect. A significant finding would in-
dicate that an intervention performed differently based on the
week of the program it was delivered. In this case, there were no
statistically significant interactions for any of the outcomes, spe-
cifically including relaxation (Wald χ 2(4) = 1.56, p > .05), somatic
anxiety (Wald χ 2(4) = 6.91, p > .05), and cognitive anxiety (Wald
χ 2(4) = 2.78, p > .05). These results are consistent with the hypoth-
esis, indicating that the interventions did not work differently
based on the week in which they were delivered.
From the same analyses, the column “week” would indicate an ef-
fect of the number of prior sessions on that outcome, independent
of the effects of intervention (i.e., a practice effect). These results
indicate no effect of week for cognitive anxiety or somatic anx-
iety. However, for self-reported relaxation, there was a statistically
significant effect for week (χ 2(2) = 7.76, p < .05), indicating that
changes in self-reported relaxation were different upon different
weeks of the program. Follow-up pairwise comparisons for week
of program on the outcome of relaxation indicated a statistically
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significant difference between week 2 and week 3 (p < .05), with
patients experiencing a greater increase in self-reported relaxation
levels in the third week, after accounting for effects based on inter-
vention. This result is partly consistent with the hypothesis, as there
was no effect of week observed for either cognitive anxiety or som-
atic anxiety; however, there was a significant effect of week on self-
reported relaxation.

Discussion
In this study, we sought to determine and compare the effect-
iveness of three music therapy interventions on relaxation levels
and state-level anxiety in youth with amplified pain syndromes. Not
only was this effect positive and statistically significant, but the level
of improvement suggests clinically significant changes in these vari-
ables, as evidenced by large to very large effect sizes for each inter-
vention on each outcome.
Regarding specific outcomes, while all interventions resulted
in significant improvements in relaxation, the MAR intervention
demonstrated the greatest reduction in overall relaxation levels.
This was our expectation, as the MAR intervention was designed
to more passively engage the patients utilizing criteria set forth by
Robb and colleagues (1995) in their work with children under-
going burn treatments. Similar processes utilized by Tan and
colleagues (2012) further demonstrated that music can elicit re-
laxation responses within this intervention. These findings are
particularly relevant to adolescents with chronic pain who are
known to be prone to overactivity and arousal of the autonomic
nervous system and struggle to engage in effective relaxation un-
assisted (Coakley, 2016). Of note, while the MAR intervention led
to greatest improvements in relaxation, it was statistically different
only from AME and not from LPSM.
Regarding somatic anxiety, we again expected the MAR inter-
vention to have the greatest effect. As with the outcome of relax-
ation, the MAR intervention was significantly better than the AME
intervention for decreasing somatic anxiety, but the difference be-
tween MAR and LPSM was not statistically significant. The hypoth-
esis was based on evidence that individuals might have increased
emotional, physical, and cognitive engagement with the AME and
LPSM interventions. This engagement with the music might elicit
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reactions associated with positive or negative stress, which may re-
sult in symptoms of somatic anxiety. There are a few reasons this
differential effect may not have been observed between MAR and
LPSM. First, use of patient-selected music can have the ability to
arouse emotion and encourage full and active immersion in the
music. This process may bring some emotions to surface level
where they can then be processed verbally. This is helpful and may
assist the patient in moving toward coping with, or resolution of
current emotions. It might also provide a space to simply be ac-
tively present with and accepting of the emotion thus providing a
level of relief from anxiety (Nolan, 1997). A second explanation
may be that the use of LPSM could have provided the patient with
a sense of familiarity and subsequent comfort and calming, and
even serve as a distraction from symptoms of anxiety (Mitchell &
MacDonald, 2006).
Finally, for the outcome of cognitive anxiety, we expected AME
and LPSM would demonstrate a stronger effect than the MAR
intervention, as both interventions were developed to increase
whole body engagement across all domain areas, thus more dir-
ectly target thinking. Although positive changes occurred in each
of the three interventions for cognitive anxiety, no intervention
was significantly better than the others. This may be due to shared
factors across the interventions, as each utilized a similar structure
that encouraged active engagement and participation in the music
therapy process. In accordance with Robb’s (2003) Contextual
Support Model, each of the three interventions provides structure
and predictability, support for autonomous behaviors (through
choice making and control), and involvement (the music therapist
meeting the patient where they are to encourage maximum par-
ticipation). In turn, successful outcomes typically ensue which in-
cludes use of cognitive reappraisal and the ability to actively cope
during perceived stressful experiences.
While we hypothesized that there would not be any effect
of treatment week on the outcomes, there was one exception.
Specifically, patients demonstrated greater changes in relaxation
levels in the third week regardless of intervention type. In retro-
spect, this is likely due to the many other relaxation-based interven-
tions delivered throughout the program, as patients received daily
training in yoga, mindfulness, relaxed breathing, or other inter-
ventions. It is thus likely that relaxation became a skill that grew
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with practice over time, leading to the observed improved response
in the third week.
It is important to note that the focus of IIPT programs such as
the one discussed within this manuscript remains on decreasing
the impact of pain by improving stress and pain management strat-
egies and restoration of function. In the setting of IIPT, pain man-
agement strategies in the form of pharmacological interventions
are minimized due to little evidence of benefit (Eccleston et al.,
2019), and the potential for negative side effects. Evidence shows
that successful treatment of APS places an emphasis on function
rather than pain, and that an interdisciplinary treatment approach
can best facilitate positive change and lasting effects (Hechler et al.,
2015). Within this approach, treatment modalities unique to each
discipline are employed to achieve improvements in symptoms and
function across a wide spectrum of domain areas. Due to its ability
to foster relaxation, creative expression, and active coping, music
therapy is one such treatment modality that can affect positive
change in the symptoms of APS. Though up until now, this was a
theoretical benefit as music therapy had not been systematically as-
sessed in this population. The findings of the current study suggest
that music therapy interventions positively affect relaxation and
state-level anxiety in youth with amplified pain syndromes.

Limitations and Future Directions

There are limitations of this study, many of which stem directly
from the use of a clinical intervention delivered within a clinical
sample. One such limitation is the absence of a control group.
This is because music therapy is part of the standard care delivered
within this IIPT program, and it was not felt ethical to withhold
a component of the treatment. To improve confidence that the
music therapy itself resulted in these changes, future studies might
find creative options to utilize a control group, such as having
teens complete relaxation and anxiety measures during a different
hour of the day. Similarly, the music therapy was delivered to youth
receiving many other concurrent treatments. While the current re-
sults focused on in-session changes in relaxation and anxiety which
were not felt to be overly influenced by other treatments, future
studies may wish to evaluate these same interventions in youth with
chronic pain who are not currently enrolled in intensive treatment.
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Another limitation included the lack of control over the timing
of music therapy sessions within the program day. Program par-
ticipants generally rotate between physical therapy, occupational
therapy, and music therapy. Because of this, a patient may be
coming straight from a physically demanding session and thus be
experiencing greater physiological and/or psychological stress. As
the pretest was administered right at the start of the music therapy
session, these factors may have influenced the pretest results on
the STICSA-C and relaxation VAS. Additionally, the sample had
limited racial and ethnic diversity, which should be taken into
account when considering the generalizability of these findings.
Not measuring changes in pain could be viewed as a limitation by
some. While patients are asked by medical providers to report their
pain level once per day, no other pain scores are collected during
the program. Therefore, music therapy did not focus on how music
could be used to reduce pain in the moment, but instead focused
on factors relevant to longer-term pain improvements like anx-
iety and ability to self-regulate arousal. Indeed, current results do
demonstrate consistent improvements in relaxation and anxiety,
which are known to contribute to pain over time. As the effects of
these interventions may contribute to adolescents’ ability to self-
regulate more effectively over long periods of time, future studies
may wish to explore whether these short-term changes serve as me-
diators of long-term functioning and health such as pain interfer-
ence and pain-related self-efficacy. Finally, future studies may wish
to evaluate the dissemination of the current interventions. While
these were developed based on existing music therapy research,
they were nonetheless all delivered by a single therapist. Evaluation
of the ability to train other music therapists to deliver the inter-
vention consistently and whether the intervention can be adapted
within other IIPT programs would be of definite interest.

Conclusion
Music, like pain, is a multidimensional experience that influ-
ences the entire individual and the inclusion of music therapy is
consistent with a biopsychosocial approach to treating youth with
chronic pain. However, no research has examined the use of music
therapy for youth with APS. These results represent a starting
point for music therapists working with this population and pro-
vide insight into treatment approaches that can be beneficial for
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these youth. Results show that when utilized within an interdiscip-
linary treatment environment, specific music therapy interventions
elicited positive changes in relaxation and current somatic and
cognitive anxiety levels in youth with amplified pain syndromes.
Replication of this project with a larger sample size and a con-
trol group would lead to more confidence in these preliminary
findings.

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