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Pain Medicine 2014; 15: S66–S75 Wiley Periodicals, Inc.
Sensory Art Therapies for the Self-Management of Chronic Pain Symptoms
Cindy Crawford, BA, Courtney Lee, MA, John Bingham, MS, and Active Self-Care Therapies for Pain (PACT) Working Group
and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management.
Samueli Institute, Alexandria, Virginia, USA
Methods. A systematic review was conducted, using Samueli Institute’s rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities.
Reprint requests to: Cindy Crawford, BA, Samueli Institute, 1737 King Street, Suite 600, Alexandria, VA 22314, USA. Tel: 703-299-4800; Fax: 703-535-6752; E-mail: [email protected]. Disclosures: The authors report no conflicts of interest. The authors have not presented this data and information before in any journal or presentation and have no professional relationships with companies or manufacturers who will benefit from the results of this present study. This material is based upon work supported by the US Army Medical Research and Materiel Command under Award Nos. W81XWH-08-1-0615 and W81XWH-10-1-0938. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and should not be construed as an official Department of Defense, Department of the Army, or Uniformed Services University of the Health Sciences position, policy, or decision unless so designated by other documentation.
Results. Following key database searches, 146 randomized controlled trials were included in the review, eight of which investigated sensory art therapies, as defined by the authors. Conclusions. This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement. Key Words. Self-Care; Complementary and Integrative Medicine; Chronic Pain; Rapid Evidence Assessment of the Literature; Systematic Review; Sensory Art Therapies
Abstract
Introduction
Objectives. Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients’ roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe
Although pain has classically been characterized as a generic symptom of a wide range of pathologies, chronic pain has recently been described as a disease state unto itself [1], the etiology of which may be simultaneously psychological and physical [2]. Chronic pain is most commonly of musculoskeletal origin and can be localized or a generalized body-wide pain state, as in fibromyalgia [3]. In 2010, back pain, neck pain, and other musculoskeletal disorders were among the five largest contributors to years lived with disability in the United States [4]. Although opioid medications are effective in treating acute pain, their use in chronic pain management is not well supported by the available evidence [5] and is associated with significant adverse events [6]. Complementary and
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Sensory Art Therapies for Chronic Pain integrative medicine (CIM) therapies incorporating pharmacologic and nonpharmacologic interventions have been widely used for chronic pain and have been advocated in recent literature [7], with an emphasis on interventions, such as active self-care CIM (ACT-CIM) therapies that promote self-efficacy and help patients manage their own pain [8,9]. ACT-CIM therapies are defined as those which 1) incorporate CIM with conventional medicine as a collaborative and integral part of the health care system; 2) involve shared patient care, practices, guidelines, and common goals to treat the well-being of the whole person [10]; and 3) can be performed by individuals on their own after they have become fully trained in the practice of the therapy. These patient-centered practices have the potential to improve patient outcomes by simultaneously addressing the complex physical and psychological predicates of chronic pain while avoiding some of the adverse events associated with more conventional pain management. They also acknowledge the patient’s role in their own healing, promote self-management, and appear to be relatively safe and cost-effective. Because there have been no systematic reviews conducted to date, which examine the full range of ACT-CIM used for chronic pain symptom management, a systematic review was conducted to evaluate the evidence base for these therapies. The authors detail the entire scope of ACT-CIM approaches throughout this Pain Medicine supplement and provide evidence for the following five broad categories of modalities identified in the review: mind–body therapies [11], movement therapies [12], physically oriented therapies [13], sensory art therapies, and multimodal integrative approaches [14].
This article focuses on the current literature available on randomized controlled trials (RCTs) of sensory art therapies, defined as modalities in which the participant produces creative works or is exposed to aesthetically pleasing stimuli [15]. The authors consulted subject matter experts (SMEs), the Army Surgeon General’s Pain Management Task Force, as well as the National Library of Medicine Medical Subject Heading terminology when identifying sensory art therapies [16]. Specifically, music therapy, journaling/storytelling, art therapy, dance therapy, aroma therapy, acoustic stimulation, color therapy, and play therapy are considered sensory art therapies in this review (see Figure 1). Several sensory art therapies can serve as a form of self-expression, allowing patients to externalize emotional stresses and facilitate identification and self-management of sources of distress [17]. Sensory art therapies can be used to palliate pain [18] and other symptoms [19], but some can also be an important tool for rehabilitation. Because each of the sensory art modalities described below has the capacity to become a self-management technique once an individual has been fully trained, the authors are interested in examining the quantity and quality of research on self-care sensory art therapies to determine the evidence for their efficacy and safety in treating chronic pain symptoms. Methods A systematic review was conducted using Samueli Institute’s rapid evidence assessment of the literature methodology. All articles meeting the review’s predefined inclusion criteria were assessed for methodological bias
Modality Identified By: MeSH PMTF PMTF and MeSH Samueli Institute Narrative Medicine MeSH
Journaling/Storytelling
Play Therapy Color Therapy Aromatherapy
Sensory Art Therapies Acoustic Therapy Art Therapy Dance Therapy
Sensory Art Therapies MeSH
Mind-body Therapies MeSH
Music Therapy
MeSH = Medical Subject Headings, PMTF = Pain Management Task Force
Figure 1 Sensory art therapies. S67
Crawford et al. and quality using the Scottish Intercollegiate Guidelines Network (SIGN) 50 Checklist [20]. A group of SMEs (N = 9) were assembled to assess the overall literature pool of each ACT-CIM modality in pairs using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Methodology [21]. All SMEs were then convened as a working group at a 1-day meeting during which they discussed the review results and GRADE analyses for all modalities, developed overall recommendations for the use and implementation of these modalities, and outlined next steps for moving this research field forward. The review’s full methodology is detailed in another article within this supplement [16].
Study Selection A total of 2,771 articles were yielded from database searches. Of the 146 studies that met the systematic review’s inclusion criteria (see Figure 2 for Flow Chart), eight RCTs were categorized as sensory art therapies [16]. No articles on acoustic stimulation, color therapy, dance therapy, play therapy, art therapy, or aroma therapy met the inclusion criteria for this systematic review.
Overall Quality Assessment According to SIGN 50 criteria used to assess methodological bias and quality, one study was of the highest quality (++), four were high quality (+), and three were poor quality (−). The majority of articles addressed an appropriate and clearly focused question, dropout rates, and baseline similarities between groups, as well as outcome reliability and validity either well or adequately. Studies were evenly divided in describing randomization procedures with half doing so well or adequately and the other half doing so poorly. However, criteria surrounding allocation concealment and intention-to-treat analyses were overall poorly addressed indicating that the authors of these reports failed to either successfully carry out these procedures or to describe these processes at all. Similarly, the sole multisite study [22] addressed site similarities poorly (see Table 1). Journaling and Storytelling Journaling and storytelling are types of narrative medicine which can allow for individuals to clarify their thoughts and feelings, and consequently gain self-knowledge, through the act of writing or telling their stories. These techniques
Articles Identified Through Database Searching (N = 3,145)
Articles after Duplicates Removed (N = 2,771)
Eligibility Criteria • •
• •
Population experiencing chronic pain Intervention either 1) single, active self-care CIM practice or 2) multimodal self-care practive with at least one CIM component RCT At least one relevant pain outcome (i.e., pain intensity/severity)
Articles Screened for Inclusion at Screen Phase (N = 2,771)
Articles Excluded (N = 2,501)
Full Text Articles Screened for Eligibility at Review Phase (N = 270)
Articles Excluded (N = 121)
149 Articles Included in Quality Assessment
6 Articles Reporting on Different Outcomes of the Same Study (3 Unique Studies)
146 RCTs Included in Quality Assessment
Subset of Sensory Art Therapy Studies Music Therapy Journaling/Storytelling Art Therapy Dance Therapy Aromatherapy Color Therapy Play Therapy
5 3 ------
CIM = complementary integrative medicine; RCT = randomized controlled trial
Figure 2 Flow chart of included sensory art therapy studies and eligibility criteria. S68
Sensory Art Therapies for Chronic Pain can be self-administered and have been used to treat conditions such as cognitive dysfunction, immune problems, stress, and pain, but these are often used to help individuals work through stressful or traumatic problems [23,24].
18 hours of storytelling over 12 weeks did not improve cancer pain relative to a support group control. Neither of the two poor-quality studies mentioned or reported on adverse events. GRADE Analysis
One highest quality (++) [25] and two poor-quality (−) [22,26] studies, involving 336 total participants, investigated the use of journaling and storytelling for management of chronic pain. Two conditions were studied: cancer pain (N = 2) [22,25] and fibromyalgia (N = 2) [26]. Frequency and duration (i.e., dosage) of journaling and storytelling ranged from 1 hour over an unspecified amount of time to 18 hours over 12 weeks. Results The highest quality (++) [25] study compared written emotional disclosure to two interventions; both a usual care and an attention control (i.e., pain questionnaire) group. Participants in all three study arms reported similar levels of cancer pain intensity. Adverse events were not reported on or mentioned. The total dosing for this study was 7 hours over 3 weeks (see Table 2 for full description of studies). The remaining two studies were of poor quality (−). The study looking at the management of fibromyalgia pain [26] compared written emotional disclosure (i.e., writing about an important stressful event) with a usual care group and a neutral writing group; participants in each group were further subdivided into three clusters depending on their pain-coping style (i.e., interpersonally distressed, adaptive, dysfunctional). Only in the “interpersonally distressed” cluster was 1 hour of emotional disclosure over an unspecified amount of time more effective than usual care or neutral writing in improving pain. Results for the “adaptive” or “dysfunctional” clusters were not described. The study [22] looking at cancer pain populations found that
Table 1 SIGN 50 [20] quality assessment of sensory art therapy studies Percentage (N) Poor Appropriate and clearly focused question Percentage of dropouts Randomization Allocation concealment Baseline similarities Outcome reliability/ validity Intention-to-treat analyses Multisite similarities
Adequate
Well
12.5 (1)
37.5 (3)
50.0 (4)
12.5 (1) 50.0 (4) 75.0 (6) 12.5 (1) —
12.5 (1) 12.5 (1) 25.0 (2) 50.0 (4) 25.0 (2)
75.0 (6) 37.5 (3) — 37.5 (3) 75.0 (6)
62.5 (5)
12.5 (1)
25.0 (2)
—
—
Because none of the three studies reported or mentioned adverse events, the safety of journaling/ storytelling, based on the literature, remains poorly understood. Two studies did not report any favorable effects, whereas one reported a benefit only within a specific subgroup of patients. Further, only one study [26] mentioned effect sizes, reporting that no effect (d = −1.04) occurred. Given this information and the overall poor quality of this literature pool, the SMEs were unable to make a recommendation for the use of journaling/storytelling for chronic pain symptoms. More high-quality research is needed in this area before any recommendations can be formulated for this selfmanagement technique for chronic pain (see Table 3). Music Therapy Music therapy is the applied use of the physical, emotional, social, aesthetic, spiritual, mental, and social aspects of music interventions to effect positive change in individuals’ lives and to assist them in reaching individualized therapeutic goals [27]. Music therapy is usually delivered via a trained, credentialed music therapist in a therapeutic environment. A number of research studies have examined the effectiveness of music therapy for brain development [28] and injury [29], mental disorders [30], depression [31], and dementia [32]. Once fully trained, a patient can engage in this therapy as a selfmanagement technique. Four studies identified in the review [33–36] were of high quality (+), one [37] was poor quality (−), and none met criteria for the highest quality (++). Of these five included studies, with a total of 375 participants, music therapy was evaluated as an intervention for patients with cancer pain (N = 2) [35,37], osteoarthritis (N = 1) [33], chronic nonmalignant pain (N = 1) [36], lumbar pain, fibromyalgia, inflammatory disease, or neurological disease (N = 1) [34] (see Table 3 for full description of studies). The dose of music therapy ranged widely, from 0.5 to 33.3 total hours over anywhere from 1 to 50 days. Results
100.0 (1)
SIGN = Scottish Intercollegiate Guidelines Network.
The four high-quality (+) studies [33–36] used a variety of control conditions. One study employed a usual care group [35], another a standard care group [34], whereas one [33] instructed patients to sit in silence for an equivalent amount of time to the active group, and one [36] provided no music. Despite the variability in control group strategies, all four of these studies found significant benefits of the active treatment relative to the control for cancer pain [35], osteoarthritis [33], chronic nonmalignant pain [36], and patients with lumbar pain, fibromyalgia, S69
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Total Participants, Condition
92, fibromyalgia
Huang 2010 [35]
129‡, cancer pain
Music Therapy (N = 5) McCaffrey 66, chronic 2003 [33] osteoarthritis
Crogan 2008 [22] 10§, cancer pain
Junghaenel 2008 [26]
Music therapy UC
Music Quiet
65 (5) 64 (0)
33 (0) 33 (0)
5 (40) 5 (20)
92 (0)¶
Journaling + ED Neutral writing UC
Storytelling Support group
79 (18) 78 (17) 77 (13)
ED UC Questionnaire
Interventions
0.5 hours/1 day ND
4.7 hours/2 weeks 4.7 hours/2 weeks
18 hours/12 weeks 18 hours/12 weeks
1 hour/ND 1 hour/ND ND
7 hours/3 weeks ND 7 hours/3 weeks
Number Dosage (Total Assigned Hours/Total (Dropout %) Period)
Characteristics of included sensory art therapy studies
Journaling/Storytelling (N = 3) Cepeda 234‡, cancer pain 2008 [25]
Citation
Table 2
None of the groups (emotional disclosure, usual care, pain questionnaire) were effective in reducing cancer pain intensity. In the comparison of pain-coping styles, only interpersonally distressed patients benefited significantly from ED. These patients report relatively more negative pain-related responses associated with fibromyalgia and less social support from significant others. Neither storytelling nor a support group was effective in treating cancer pain.
Conclusions
−
−
++
Quality
SF-MPQ (pain rating Music therapy is more effective + index): P < 0.001†† than sitting quietly in (music) at days 1, 7, reducing chronic 14; P = NS†† (quiet) at osteoarthritis pain symptoms. days 1, 7, 14 SF-MPQ-VAS (present pain intensity): P < 0.001†† (music) at days 1, 7, 14; P = NS†† (quiet) at days 1, 7, 14 VAS (cancer pain Soft music is more effective + sensation): P < 0.001†† than analgesics in reducing at PT, ES: d = 0.64 cancer pain. Oral Numeric Scale (pain): P = NS**†† at PT
MPQ (pain rating index): P = NS**†† at PT
MPI (pain): P < 0.001†† (interpersonally distressed participants only) at month 4, ES: d = −1.04; P = NS†† (adaptive patients, dysfunctional patients) at month 4
Likert Scale (average pain intensity): P = NS**†† at week 8
Relevant Pain Outcomes†
Crawford et al.
29‡, cancer pain
44 (9) 43 (7)
Music therapy Steady sound
15 (0) 14 (0)
Patterning music 19 (5) Standard music 22 (0) No music 23 (13)
Music therapy SC
Interventions
Relevant Pain Outcomes†
4.5 hours/3 days 4.5 hours/3 days
7 hours/1 week 7 hours/1 week ND
VAS (pain): P < 0.05** (both groups); P = NS†† at FU
SF-MPQ (pain): P = 0.002†† (patterning music, standard music); P = Sig** (all groups) at PT VAS (pain): P = Sig††. (patterning music, standard music)
33.3 hours/50 days VAS/NRS (pain): P < 0.001†† (music ND therapy) at days 60, 90
Number Dosage (Total Assigned Hours/Total (Dropout %) Period)
+
Quality
Both patterning music and + standard music therapy are equally more effective than no music in reducing chronic nonmalignant pain; pain decreased in both music groups but increased in the control group from baseline to post-treatment. Both music and sound therapy − are equally effective in reducing self-reported cancer pain.
Music therapy is more effective than standard care in reducing pain symptoms.
Conclusions
ED = emotional disclosure; ES = effect size; FU = follow-up; ND = not described; NRS = Numeric Rating Scale; NS = not significant; MPI = Multidimensional Pain Inventory; MPQ = McGill Pain Questionnaire; PT = post-treatment; SC = standard care; SF-MPQ = Short Form-McGill Pain Questionnaire; Sig = Significant but P value not given; UC = usual care; VAS = visual analog scale. * Subset of study results were also reported in Siedliecki and Good [45]; all relevant results from both results reported here. † Result reporting for two interventions: Outcome Name (construct measured): P value (group or groups that showed significance) at time point, if reported by the article’s authors. Result reporting for two or more interventions: Outcome Name (construct measured): P value (group 1/group 2) at time point, if reported by the article’s authors. Note that groups compared with each other are listed following the P value. ‡ Authors report power achieved. § Authors report power not achieved. ¶ Numbers reflect overall sample. ** Within groups. †† Between groups.
Beck 1991 [37]
Siedlecki 2009 [36]*
87‡, lumbar pain, fibromyalgia, inflammatory disease, or neurological disease 64, chronic nonmalignant pain
Total Participants, Condition
Continued
Guetin 2012 [34]
Citation
Table 2
Sensory Art Therapies for Chronic Pain
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Crawford et al.
Table 3
GRADE [21] analysis of sensory art therapy studies
Modality Journaling/ Storytelling Music therapy
Number of Participants Completed (Number of Studies)
Confidence in the Estimate of the Effect of the Intervention*
Magnitude of the Estimate of the Effect Size (Number of studies reported ES)†
Overall Safety‡
336 (3)
D
None (1)
0
0 (0)
375 (5)
B
Moderate (1)
0
+2 (1)
Reported Studies Safety (Number Studies Reporting AE)§
Strength of the Recommendation¶ None Weak, in favor
AE = adverse events; ES = effect size; GRADE = Grading of Recommendations, Assessment, Development and Evaluation; NR = not reported. * Refers to the likelihood that future research will change the confidence in the estimate of the effect; includes four possible levels of confidence based on the GRADE working group approach: A (High); B (Moderate); C (Low); D (Very Low). † Average effect size, as reported by Cohen’s d, of studies that reported this information was categorized as none (d < 0.02), small (d = 0.2–0.5), moderate (d = 0.51–0.8), and large (d > 0.8). ‡ Based on overall study sample; reflects the frequency and severity of AEs and categorized into one of the following scores: (+2), appears safe with infrequent AEs; (+1), appears relatively safe, with frequent, nonserious AEs; (0), safety either not reported by at least 50% of studies or not well understood/conflicting; (−1), appears to have safety concerns including infrequent, serious AEs; (−2), appears to have serious safety concerns, including frequent and serious AEs. § Uses same criteria as overall safety score but based only on those studies that reported safety. ¶ Strong recommendation in favor of or against: very certain that benefits do, or do not, outweigh risks and burdens; No recommendation: no recommendations can be made; or Weak recommendation in favor of or against: benefits and risks and burdens are finely balanced, or appreciable uncertainty exists about the magnitude of benefits and risks.
inflammatory disease, or neurological disease [34]. One study [36] addressed two different types of music therapy (patterning music and standard music), finding both equally effective. None of the other studies included active treatment comparison groups. This subset of studies contained the full range of doses identified by this review, 0.5–33.3 hours. One study [36] reported that no adverse events occurred, whereas the other three [33–35] did not address the topic at all (see Table 2 for full description of studies). The poor-quality (−) study [37] found that 4.5 hours of a music tape and 31.5 hours of steady nonmusical sound were equally effective cancer pain treatments. Adverse events were not described or reported on in this article. GRADE Analysis Although there have been reports of music therapy disrupting a patient’s cooperation during medical procedures [38], music therapy is considered to be minimally invasive and unlikely to cause harm. The rate of safety reporting is relatively low; however, systematic reviews [39,40] have reported music therapy techniques as safe, noting no reported adverse events across a variety of studies. Similarly, of the five music therapy studies included in this review, only one reported on adverse events, mentioning that none occurred [36], whereas the remaining four studies [33–37] did not provide any information on adverse events. The majority of studies were high quality, reporting that music therapy was either as effective or more effective S72
than the control groups, with one study [35] reporting a moderate effect size (d = 0.64) for cancer pain sensation. Further research will help refine this estimate, but there are high-quality studies available that show consistent effects. Based on this evidence, the SMEs gave a weak recommendation in favor of the use of music therapy as a self-management technique for chronic pain. In addition to more information regarding safety, a larger, high-quality RCT is needed to give a stronger recommendation for this modality (see Table 3). Discussion Sensory art therapies are well-suited for use as self-care interventions. The artistic techniques that are used in clinical practice are typically easy for patients to execute on their own and are highly feasible interventions [41– 43]. However, despite the apparent feasibility of sensory art therapies, many are not well studied as pain management interventions. In fact, no studies on acoustic stimulation, color therapy, dance therapy, play therapy, art therapy, or aroma therapy met inclusion criteria for this review. Research is needed to evaluate these widely used interventions in a pain management context. Future research in sensory art therapies should also examine dosing effects and use control groups that closely match the treatment being evaluated in order to facilitate isolation of the active components of treatment. The current research literature in this field often failed to satisfy the SIGN 50 criteria related to randomization, allocation concealment, and use of intention-to-treat analysis; future RCTs of greater methodological rigor would allow
Sensory Art Therapies for Chronic Pain more confident recommendations to be made regarding the use of these modalities. While the modalities included in this report may seem safe, they, like any other therapy, can be associated with adverse events. For example, reviews have found that journaling and storytelling can be difficult for patients who are unable to write or otherwise communicate effectively [44]. In some cases, existing symptoms may be exacerbated by narrative reflection [23]. The low rate of adverse event reporting in this literature, however, precludes this review from rendering definitive conclusions about the safety of these modalities, and as such, safety remains largely unknown. Future studies should report data on adverse events even if no such events occur. Although self-care interventions may be more costeffective than pharmacological or practitioner-delivered therapies that incur ongoing costs, no evidence-based conclusions regarding the cost-effectiveness of sensory art therapies can be made for this current literature base as no studies conducted cost analyses. Only two [26,35] of the studies included in this review reported an effect size for the treatment being studied, making it difficult to draw any conclusions about the efficacy of sensory art therapies relative to other treatment options. Future studies on sensory art therapies should calculate and report on effect sizes. Conclusions The practical feasibility of sensory art therapies is appealing, and the ability of aesthetically moving stimuli to engage a patient physically, mentally, and/or spiritually is unique. The clinical research regarding the use of sensory art therapies as self-care interventions for chronic pain patients is limited in quantity and quality. The existing evidence supported only a weak recommendation in favor of the use of music therapy and was insufficient to allow any conclusions regarding the other therapies included in this category. The safety, cost, and effectiveness of most sensory art therapies for chronic pain patients are thus left to speculation. Acknowledgments The authors would like to acknowledge Ms. Lea Xenakis and Ms. Jennifer Smith for their help with conducting the review, as well as Ms. Viviane Enslein for helping prepare the manuscript. The Active Self-Care Therapies for Pain (PACT) Working Group included the following individuals at the time of writing (see http://onlinelibrary.wiley.com/doi/10.1111/ pme.12358/full for working group affiliations): Chester C. Buckenmaier III, MD, COL, MC, US Army; Cindy Crawford, BA; Paul Crawford, MD, Lt Col, US Air Force; Roxana Delgado, PhD; Daniel Freilich, MD, CAPT, MC, USNR; Anita Hickey, MD, CAPT, MC, USN; Wayne B. Jonas, MD, LTC (Ret.), US Army; Courtney Lee, MA; Todd
May, DO, CDR, USN; Richard P. Petri, MD, COL, MC, US Army; Eric B. Schoomaker, MD, PhD, LTG (Ret.), US Army; Christopher Spevak, MD, MPH, JD; Steven Swann, MD, COL (Ret.), US Army; Alexandra York, MS References 1 Siddall P, Cousins M. Persistent pain as a disease entity: Implications for clinical management. Anesth Analg 2004;99(2):510–20. 2 Bushnell MC, Ceko M, Low LA. Cognitive and emotional control of pain and its disruption in chronic pain. Nat Rev Neurosci 2013;14(7):502–11. 3 Dieppe P. Chronic musculoskeletal pain. BMJ 2013;16(346):f3146. 4 Collaborators UBoD. The state of US health, 1990– 2010: Burden of diseases, injuries, and risk factors. JAMA 2013;310(6):591–608. 5 Kissin I. Long-term opioid treatment of chronic nonmalignant pain: Unproven efficacy and neglected safety? J Pain Res 2013;4(6):513–29. 6 Warner E. Opioids for the treatment of chronic noncancer pain. Am J Med 2012;125(12):1155–61. 7 Arnold L, Clauw D, Dunegan L, Turk D. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc 2012;87(5):488–96. 8 Carnes D, Homer K, Miles C, et al. Effective delivery styles and content for self-management interventions for chronic musculoskeletal pain: A systematic literature review. Clin J Pain 2012;28(4):344–54. 9 Hadjistavropoulos T. Self-management of pain in older persons: Helping people help themselves. Pain Med 2012;13(suppl 2):S67–71. 10 Khorsan R, Coulter I, Crawford C, Hsiao A. Systematic review of integrative health care research: Randomized control trials, clinical controlled trials, and metaanalysis. Evid Based Complement Alternat Med 2011 doi: 10.1155/2011/636134. 11 Lee C, Crawford C, Hickey A, Active Self-Care Therapies for Pain (PACT) Working Group. Mind-body therapies for the self-management of chronic pain symptoms. Pain Med 2014;15(Suppl 1):S21–39. 12 Lee C, Crawford C, Schoomaker E, Active Self-Care Therapies for Pain (PACT) Working Group. Movement therapies for the self-management of chronic pain symptoms. Pain Med 2014;15(Suppl 1):S40–53. 13 Crawford C, Lee C, May T, Active Self-Care Therapies for Pain (PACT) Working Group. Physically-oriented therapies for the self-management of chronic pain symptoms. Pain Med 2014;15(Suppl 1):54–65. S73
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groups of fibromyalgia patients. Br J Health Psychol 2008;13(Pt 1):57–60. 27 Davis W, Gfeller K, Thaut M. An Introduction to Music Therapy Theory and Practice, 3rd edition. Silver Spring, MD: American Music Therapy Association; 2008. 28 Standley J. Music therapy research in the NICU: An updated meta-analysis. Neonatal Netw 2012;31(5): 311–6. 29 Bradt J, Magee WL, Dileo C, Wheeler BL, McGilloway E. Music therapy for acquired brain injury. Cochrane Database Syst Rev 2010;(7):CD006787. 30 Gold C, Solli HP, Kruger V, Lie SA. Dose-response relationship in music therapy for people with serious mental disorders: Systematic review and metaanalysis. Clin Psychol Rev 2009;29(3):193–207. 31 Maratos AS, Gold C, Wang X, Crawford MJ. Music therapy for depression. Cochrane Database Syst Rev 2008;(1):CD004517. 32 Vink AC, Birks JS, Bruinsma MS, Scholten RJ. Music therapy for people with dementia. Cochrane Database Syst Rev 2004;(3):CD003477. 33 McCaffrey R, Freeman E. Effect of music on chronic osteoarthritis pain in older people. J Adv Nurs 2003;44(5):517–24. 34 Guetin S, Ginies P, Siou DKA, et al. The effects of music intervention in the management of chronic pain: A single-blind, randomized, controlled trial. Clin J Pain 2012;28(4):329–37. 35 Huang ST, Good M, Zauszniewski JA. The effectiveness of music in relieving pain in cancer patients: A randomized controlled trial. Int J Nurs Stud 2010;47(11):1354–62. 36 Siedlecki SL. Racial variation in response to music in a sample of african-american and caucasian chronic pain patients. Pain Manag Nurs 2009;10(1):14– 21. 37 Beck SL. The therapeutic use of music for cancerrelated pain. Oncol Nurs Forum 1991;18(8):1327–37. 38 Bellan L, Gooi A, Rehsia S. The Misericordia Health Center cataract comfort study. Can J Ophthalmol 2002;37(3):155–60. 39 Gooding L, Swezey S, Zwischenberger J. Using music interventions in perioperative care. South Med J 2012;105(9):486–90. 40 Zhang J, Wang P, Yao J, et al. Music interventions for psychological and physical outcomes in cancer: A
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Pain Medicine 2014; 15: S66–S75 Wiley Periodicals, Inc.
Sensory Art Therapies for the Self-Management of Chronic Pain Symptoms
Cindy Crawford, BA, Courtney Lee, MA, John Bingham, MS, and Active Self-Care Therapies for Pain (PACT) Working Group
and cost-effective. To date, there are no systematic reviews examining the full range of ACT-CIM used for chronic pain symptom management.
Samueli Institute, Alexandria, Virginia, USA
Methods. A systematic review was conducted, using Samueli Institute’s rapid evidence assessment of the literature methodology, to rigorously assess both the quality of the research on ACT-CIM modalities and the evidence for their efficacy and effectiveness in treating chronic pain symptoms. A working group of subject matter experts was also convened to evaluate the overall literature pool and develop recommendations for the use and implementation of these modalities.
Reprint requests to: Cindy Crawford, BA, Samueli Institute, 1737 King Street, Suite 600, Alexandria, VA 22314, USA. Tel: 703-299-4800; Fax: 703-535-6752; E-mail: [email protected]. Disclosures: The authors report no conflicts of interest. The authors have not presented this data and information before in any journal or presentation and have no professional relationships with companies or manufacturers who will benefit from the results of this present study. This material is based upon work supported by the US Army Medical Research and Materiel Command under Award Nos. W81XWH-08-1-0615 and W81XWH-10-1-0938. Any opinions, findings, and conclusions or recommendations expressed in this material are those of the author(s) and should not be construed as an official Department of Defense, Department of the Army, or Uniformed Services University of the Health Sciences position, policy, or decision unless so designated by other documentation.
Results. Following key database searches, 146 randomized controlled trials were included in the review, eight of which investigated sensory art therapies, as defined by the authors. Conclusions. This article summarizes the current evidence, quality, efficacy, and safety of these modalities. Recommendations and next steps to move this field of research forward are also discussed. The entire scope of the review is detailed throughout the current Pain Medicine supplement. Key Words. Self-Care; Complementary and Integrative Medicine; Chronic Pain; Rapid Evidence Assessment of the Literature; Systematic Review; Sensory Art Therapies
Abstract
Introduction
Objectives. Chronic pain management typically consists of prescription medications or provider-based, behavioral, or interventional procedures which are often ineffective, may be costly, and can be associated with undesirable side effects. Because chronic pain affects the whole person (body, mind, and spirit), patient-centered complementary and integrative medicine (CIM) therapies that acknowledge the patients’ roles in their own healing processes have the potential to provide more efficient and comprehensive chronic pain management. Active self-care CIM therapies (ACT-CIM) allow for a more diverse, patient-centered treatment of complex symptoms, promote self-management, and are relatively safe
Although pain has classically been characterized as a generic symptom of a wide range of pathologies, chronic pain has recently been described as a disease state unto itself [1], the etiology of which may be simultaneously psychological and physical [2]. Chronic pain is most commonly of musculoskeletal origin and can be localized or a generalized body-wide pain state, as in fibromyalgia [3]. In 2010, back pain, neck pain, and other musculoskeletal disorders were among the five largest contributors to years lived with disability in the United States [4]. Although opioid medications are effective in treating acute pain, their use in chronic pain management is not well supported by the available evidence [5] and is associated with significant adverse events [6]. Complementary and
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Sensory Art Therapies for Chronic Pain integrative medicine (CIM) therapies incorporating pharmacologic and nonpharmacologic interventions have been widely used for chronic pain and have been advocated in recent literature [7], with an emphasis on interventions, such as active self-care CIM (ACT-CIM) therapies that promote self-efficacy and help patients manage their own pain [8,9]. ACT-CIM therapies are defined as those which 1) incorporate CIM with conventional medicine as a collaborative and integral part of the health care system; 2) involve shared patient care, practices, guidelines, and common goals to treat the well-being of the whole person [10]; and 3) can be performed by individuals on their own after they have become fully trained in the practice of the therapy. These patient-centered practices have the potential to improve patient outcomes by simultaneously addressing the complex physical and psychological predicates of chronic pain while avoiding some of the adverse events associated with more conventional pain management. They also acknowledge the patient’s role in their own healing, promote self-management, and appear to be relatively safe and cost-effective. Because there have been no systematic reviews conducted to date, which examine the full range of ACT-CIM used for chronic pain symptom management, a systematic review was conducted to evaluate the evidence base for these therapies. The authors detail the entire scope of ACT-CIM approaches throughout this Pain Medicine supplement and provide evidence for the following five broad categories of modalities identified in the review: mind–body therapies [11], movement therapies [12], physically oriented therapies [13], sensory art therapies, and multimodal integrative approaches [14].
This article focuses on the current literature available on randomized controlled trials (RCTs) of sensory art therapies, defined as modalities in which the participant produces creative works or is exposed to aesthetically pleasing stimuli [15]. The authors consulted subject matter experts (SMEs), the Army Surgeon General’s Pain Management Task Force, as well as the National Library of Medicine Medical Subject Heading terminology when identifying sensory art therapies [16]. Specifically, music therapy, journaling/storytelling, art therapy, dance therapy, aroma therapy, acoustic stimulation, color therapy, and play therapy are considered sensory art therapies in this review (see Figure 1). Several sensory art therapies can serve as a form of self-expression, allowing patients to externalize emotional stresses and facilitate identification and self-management of sources of distress [17]. Sensory art therapies can be used to palliate pain [18] and other symptoms [19], but some can also be an important tool for rehabilitation. Because each of the sensory art modalities described below has the capacity to become a self-management technique once an individual has been fully trained, the authors are interested in examining the quantity and quality of research on self-care sensory art therapies to determine the evidence for their efficacy and safety in treating chronic pain symptoms. Methods A systematic review was conducted using Samueli Institute’s rapid evidence assessment of the literature methodology. All articles meeting the review’s predefined inclusion criteria were assessed for methodological bias
Modality Identified By: MeSH PMTF PMTF and MeSH Samueli Institute Narrative Medicine MeSH
Journaling/Storytelling
Play Therapy Color Therapy Aromatherapy
Sensory Art Therapies Acoustic Therapy Art Therapy Dance Therapy
Sensory Art Therapies MeSH
Mind-body Therapies MeSH
Music Therapy
MeSH = Medical Subject Headings, PMTF = Pain Management Task Force
Figure 1 Sensory art therapies. S67
Crawford et al. and quality using the Scottish Intercollegiate Guidelines Network (SIGN) 50 Checklist [20]. A group of SMEs (N = 9) were assembled to assess the overall literature pool of each ACT-CIM modality in pairs using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Methodology [21]. All SMEs were then convened as a working group at a 1-day meeting during which they discussed the review results and GRADE analyses for all modalities, developed overall recommendations for the use and implementation of these modalities, and outlined next steps for moving this research field forward. The review’s full methodology is detailed in another article within this supplement [16].
Study Selection A total of 2,771 articles were yielded from database searches. Of the 146 studies that met the systematic review’s inclusion criteria (see Figure 2 for Flow Chart), eight RCTs were categorized as sensory art therapies [16]. No articles on acoustic stimulation, color therapy, dance therapy, play therapy, art therapy, or aroma therapy met the inclusion criteria for this systematic review.
Overall Quality Assessment According to SIGN 50 criteria used to assess methodological bias and quality, one study was of the highest quality (++), four were high quality (+), and three were poor quality (−). The majority of articles addressed an appropriate and clearly focused question, dropout rates, and baseline similarities between groups, as well as outcome reliability and validity either well or adequately. Studies were evenly divided in describing randomization procedures with half doing so well or adequately and the other half doing so poorly. However, criteria surrounding allocation concealment and intention-to-treat analyses were overall poorly addressed indicating that the authors of these reports failed to either successfully carry out these procedures or to describe these processes at all. Similarly, the sole multisite study [22] addressed site similarities poorly (see Table 1). Journaling and Storytelling Journaling and storytelling are types of narrative medicine which can allow for individuals to clarify their thoughts and feelings, and consequently gain self-knowledge, through the act of writing or telling their stories. These techniques
Articles Identified Through Database Searching (N = 3,145)
Articles after Duplicates Removed (N = 2,771)
Eligibility Criteria • •
• •
Population experiencing chronic pain Intervention either 1) single, active self-care CIM practice or 2) multimodal self-care practive with at least one CIM component RCT At least one relevant pain outcome (i.e., pain intensity/severity)
Articles Screened for Inclusion at Screen Phase (N = 2,771)
Articles Excluded (N = 2,501)
Full Text Articles Screened for Eligibility at Review Phase (N = 270)
Articles Excluded (N = 121)
149 Articles Included in Quality Assessment
6 Articles Reporting on Different Outcomes of the Same Study (3 Unique Studies)
146 RCTs Included in Quality Assessment
Subset of Sensory Art Therapy Studies Music Therapy Journaling/Storytelling Art Therapy Dance Therapy Aromatherapy Color Therapy Play Therapy
5 3 ------
CIM = complementary integrative medicine; RCT = randomized controlled trial
Figure 2 Flow chart of included sensory art therapy studies and eligibility criteria. S68
Sensory Art Therapies for Chronic Pain can be self-administered and have been used to treat conditions such as cognitive dysfunction, immune problems, stress, and pain, but these are often used to help individuals work through stressful or traumatic problems [23,24].
18 hours of storytelling over 12 weeks did not improve cancer pain relative to a support group control. Neither of the two poor-quality studies mentioned or reported on adverse events. GRADE Analysis
One highest quality (++) [25] and two poor-quality (−) [22,26] studies, involving 336 total participants, investigated the use of journaling and storytelling for management of chronic pain. Two conditions were studied: cancer pain (N = 2) [22,25] and fibromyalgia (N = 2) [26]. Frequency and duration (i.e., dosage) of journaling and storytelling ranged from 1 hour over an unspecified amount of time to 18 hours over 12 weeks. Results The highest quality (++) [25] study compared written emotional disclosure to two interventions; both a usual care and an attention control (i.e., pain questionnaire) group. Participants in all three study arms reported similar levels of cancer pain intensity. Adverse events were not reported on or mentioned. The total dosing for this study was 7 hours over 3 weeks (see Table 2 for full description of studies). The remaining two studies were of poor quality (−). The study looking at the management of fibromyalgia pain [26] compared written emotional disclosure (i.e., writing about an important stressful event) with a usual care group and a neutral writing group; participants in each group were further subdivided into three clusters depending on their pain-coping style (i.e., interpersonally distressed, adaptive, dysfunctional). Only in the “interpersonally distressed” cluster was 1 hour of emotional disclosure over an unspecified amount of time more effective than usual care or neutral writing in improving pain. Results for the “adaptive” or “dysfunctional” clusters were not described. The study [22] looking at cancer pain populations found that
Table 1 SIGN 50 [20] quality assessment of sensory art therapy studies Percentage (N) Poor Appropriate and clearly focused question Percentage of dropouts Randomization Allocation concealment Baseline similarities Outcome reliability/ validity Intention-to-treat analyses Multisite similarities
Adequate
Well
12.5 (1)
37.5 (3)
50.0 (4)
12.5 (1) 50.0 (4) 75.0 (6) 12.5 (1) —
12.5 (1) 12.5 (1) 25.0 (2) 50.0 (4) 25.0 (2)
75.0 (6) 37.5 (3) — 37.5 (3) 75.0 (6)
62.5 (5)
12.5 (1)
25.0 (2)
—
—
Because none of the three studies reported or mentioned adverse events, the safety of journaling/ storytelling, based on the literature, remains poorly understood. Two studies did not report any favorable effects, whereas one reported a benefit only within a specific subgroup of patients. Further, only one study [26] mentioned effect sizes, reporting that no effect (d = −1.04) occurred. Given this information and the overall poor quality of this literature pool, the SMEs were unable to make a recommendation for the use of journaling/storytelling for chronic pain symptoms. More high-quality research is needed in this area before any recommendations can be formulated for this selfmanagement technique for chronic pain (see Table 3). Music Therapy Music therapy is the applied use of the physical, emotional, social, aesthetic, spiritual, mental, and social aspects of music interventions to effect positive change in individuals’ lives and to assist them in reaching individualized therapeutic goals [27]. Music therapy is usually delivered via a trained, credentialed music therapist in a therapeutic environment. A number of research studies have examined the effectiveness of music therapy for brain development [28] and injury [29], mental disorders [30], depression [31], and dementia [32]. Once fully trained, a patient can engage in this therapy as a selfmanagement technique. Four studies identified in the review [33–36] were of high quality (+), one [37] was poor quality (−), and none met criteria for the highest quality (++). Of these five included studies, with a total of 375 participants, music therapy was evaluated as an intervention for patients with cancer pain (N = 2) [35,37], osteoarthritis (N = 1) [33], chronic nonmalignant pain (N = 1) [36], lumbar pain, fibromyalgia, inflammatory disease, or neurological disease (N = 1) [34] (see Table 3 for full description of studies). The dose of music therapy ranged widely, from 0.5 to 33.3 total hours over anywhere from 1 to 50 days. Results
100.0 (1)
SIGN = Scottish Intercollegiate Guidelines Network.
The four high-quality (+) studies [33–36] used a variety of control conditions. One study employed a usual care group [35], another a standard care group [34], whereas one [33] instructed patients to sit in silence for an equivalent amount of time to the active group, and one [36] provided no music. Despite the variability in control group strategies, all four of these studies found significant benefits of the active treatment relative to the control for cancer pain [35], osteoarthritis [33], chronic nonmalignant pain [36], and patients with lumbar pain, fibromyalgia, S69
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Total Participants, Condition
92, fibromyalgia
Huang 2010 [35]
129‡, cancer pain
Music Therapy (N = 5) McCaffrey 66, chronic 2003 [33] osteoarthritis
Crogan 2008 [22] 10§, cancer pain
Junghaenel 2008 [26]
Music therapy UC
Music Quiet
65 (5) 64 (0)
33 (0) 33 (0)
5 (40) 5 (20)
92 (0)¶
Journaling + ED Neutral writing UC
Storytelling Support group
79 (18) 78 (17) 77 (13)
ED UC Questionnaire
Interventions
0.5 hours/1 day ND
4.7 hours/2 weeks 4.7 hours/2 weeks
18 hours/12 weeks 18 hours/12 weeks
1 hour/ND 1 hour/ND ND
7 hours/3 weeks ND 7 hours/3 weeks
Number Dosage (Total Assigned Hours/Total (Dropout %) Period)
Characteristics of included sensory art therapy studies
Journaling/Storytelling (N = 3) Cepeda 234‡, cancer pain 2008 [25]
Citation
Table 2
None of the groups (emotional disclosure, usual care, pain questionnaire) were effective in reducing cancer pain intensity. In the comparison of pain-coping styles, only interpersonally distressed patients benefited significantly from ED. These patients report relatively more negative pain-related responses associated with fibromyalgia and less social support from significant others. Neither storytelling nor a support group was effective in treating cancer pain.
Conclusions
−
−
++
Quality
SF-MPQ (pain rating Music therapy is more effective + index): P < 0.001†† than sitting quietly in (music) at days 1, 7, reducing chronic 14; P = NS†† (quiet) at osteoarthritis pain symptoms. days 1, 7, 14 SF-MPQ-VAS (present pain intensity): P < 0.001†† (music) at days 1, 7, 14; P = NS†† (quiet) at days 1, 7, 14 VAS (cancer pain Soft music is more effective + sensation): P < 0.001†† than analgesics in reducing at PT, ES: d = 0.64 cancer pain. Oral Numeric Scale (pain): P = NS**†† at PT
MPQ (pain rating index): P = NS**†† at PT
MPI (pain): P < 0.001†† (interpersonally distressed participants only) at month 4, ES: d = −1.04; P = NS†† (adaptive patients, dysfunctional patients) at month 4
Likert Scale (average pain intensity): P = NS**†† at week 8
Relevant Pain Outcomes†
Crawford et al.
29‡, cancer pain
44 (9) 43 (7)
Music therapy Steady sound
15 (0) 14 (0)
Patterning music 19 (5) Standard music 22 (0) No music 23 (13)
Music therapy SC
Interventions
Relevant Pain Outcomes†
4.5 hours/3 days 4.5 hours/3 days
7 hours/1 week 7 hours/1 week ND
VAS (pain): P < 0.05** (both groups); P = NS†† at FU
SF-MPQ (pain): P = 0.002†† (patterning music, standard music); P = Sig** (all groups) at PT VAS (pain): P = Sig††. (patterning music, standard music)
33.3 hours/50 days VAS/NRS (pain): P < 0.001†† (music ND therapy) at days 60, 90
Number Dosage (Total Assigned Hours/Total (Dropout %) Period)
+
Quality
Both patterning music and + standard music therapy are equally more effective than no music in reducing chronic nonmalignant pain; pain decreased in both music groups but increased in the control group from baseline to post-treatment. Both music and sound therapy − are equally effective in reducing self-reported cancer pain.
Music therapy is more effective than standard care in reducing pain symptoms.
Conclusions
ED = emotional disclosure; ES = effect size; FU = follow-up; ND = not described; NRS = Numeric Rating Scale; NS = not significant; MPI = Multidimensional Pain Inventory; MPQ = McGill Pain Questionnaire; PT = post-treatment; SC = standard care; SF-MPQ = Short Form-McGill Pain Questionnaire; Sig = Significant but P value not given; UC = usual care; VAS = visual analog scale. * Subset of study results were also reported in Siedliecki and Good [45]; all relevant results from both results reported here. † Result reporting for two interventions: Outcome Name (construct measured): P value (group or groups that showed significance) at time point, if reported by the article’s authors. Result reporting for two or more interventions: Outcome Name (construct measured): P value (group 1/group 2) at time point, if reported by the article’s authors. Note that groups compared with each other are listed following the P value. ‡ Authors report power achieved. § Authors report power not achieved. ¶ Numbers reflect overall sample. ** Within groups. †† Between groups.
Beck 1991 [37]
Siedlecki 2009 [36]*
87‡, lumbar pain, fibromyalgia, inflammatory disease, or neurological disease 64, chronic nonmalignant pain
Total Participants, Condition
Continued
Guetin 2012 [34]
Citation
Table 2
Sensory Art Therapies for Chronic Pain
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Crawford et al.
Table 3
GRADE [21] analysis of sensory art therapy studies
Modality Journaling/ Storytelling Music therapy
Number of Participants Completed (Number of Studies)
Confidence in the Estimate of the Effect of the Intervention*
Magnitude of the Estimate of the Effect Size (Number of studies reported ES)†
Overall Safety‡
336 (3)
D
None (1)
0
0 (0)
375 (5)
B
Moderate (1)
0
+2 (1)
Reported Studies Safety (Number Studies Reporting AE)§
Strength of the Recommendation¶ None Weak, in favor
AE = adverse events; ES = effect size; GRADE = Grading of Recommendations, Assessment, Development and Evaluation; NR = not reported. * Refers to the likelihood that future research will change the confidence in the estimate of the effect; includes four possible levels of confidence based on the GRADE working group approach: A (High); B (Moderate); C (Low); D (Very Low). † Average effect size, as reported by Cohen’s d, of studies that reported this information was categorized as none (d < 0.02), small (d = 0.2–0.5), moderate (d = 0.51–0.8), and large (d > 0.8). ‡ Based on overall study sample; reflects the frequency and severity of AEs and categorized into one of the following scores: (+2), appears safe with infrequent AEs; (+1), appears relatively safe, with frequent, nonserious AEs; (0), safety either not reported by at least 50% of studies or not well understood/conflicting; (−1), appears to have safety concerns including infrequent, serious AEs; (−2), appears to have serious safety concerns, including frequent and serious AEs. § Uses same criteria as overall safety score but based only on those studies that reported safety. ¶ Strong recommendation in favor of or against: very certain that benefits do, or do not, outweigh risks and burdens; No recommendation: no recommendations can be made; or Weak recommendation in favor of or against: benefits and risks and burdens are finely balanced, or appreciable uncertainty exists about the magnitude of benefits and risks.
inflammatory disease, or neurological disease [34]. One study [36] addressed two different types of music therapy (patterning music and standard music), finding both equally effective. None of the other studies included active treatment comparison groups. This subset of studies contained the full range of doses identified by this review, 0.5–33.3 hours. One study [36] reported that no adverse events occurred, whereas the other three [33–35] did not address the topic at all (see Table 2 for full description of studies). The poor-quality (−) study [37] found that 4.5 hours of a music tape and 31.5 hours of steady nonmusical sound were equally effective cancer pain treatments. Adverse events were not described or reported on in this article. GRADE Analysis Although there have been reports of music therapy disrupting a patient’s cooperation during medical procedures [38], music therapy is considered to be minimally invasive and unlikely to cause harm. The rate of safety reporting is relatively low; however, systematic reviews [39,40] have reported music therapy techniques as safe, noting no reported adverse events across a variety of studies. Similarly, of the five music therapy studies included in this review, only one reported on adverse events, mentioning that none occurred [36], whereas the remaining four studies [33–37] did not provide any information on adverse events. The majority of studies were high quality, reporting that music therapy was either as effective or more effective S72
than the control groups, with one study [35] reporting a moderate effect size (d = 0.64) for cancer pain sensation. Further research will help refine this estimate, but there are high-quality studies available that show consistent effects. Based on this evidence, the SMEs gave a weak recommendation in favor of the use of music therapy as a self-management technique for chronic pain. In addition to more information regarding safety, a larger, high-quality RCT is needed to give a stronger recommendation for this modality (see Table 3). Discussion Sensory art therapies are well-suited for use as self-care interventions. The artistic techniques that are used in clinical practice are typically easy for patients to execute on their own and are highly feasible interventions [41– 43]. However, despite the apparent feasibility of sensory art therapies, many are not well studied as pain management interventions. In fact, no studies on acoustic stimulation, color therapy, dance therapy, play therapy, art therapy, or aroma therapy met inclusion criteria for this review. Research is needed to evaluate these widely used interventions in a pain management context. Future research in sensory art therapies should also examine dosing effects and use control groups that closely match the treatment being evaluated in order to facilitate isolation of the active components of treatment. The current research literature in this field often failed to satisfy the SIGN 50 criteria related to randomization, allocation concealment, and use of intention-to-treat analysis; future RCTs of greater methodological rigor would allow
Sensory Art Therapies for Chronic Pain more confident recommendations to be made regarding the use of these modalities. While the modalities included in this report may seem safe, they, like any other therapy, can be associated with adverse events. For example, reviews have found that journaling and storytelling can be difficult for patients who are unable to write or otherwise communicate effectively [44]. In some cases, existing symptoms may be exacerbated by narrative reflection [23]. The low rate of adverse event reporting in this literature, however, precludes this review from rendering definitive conclusions about the safety of these modalities, and as such, safety remains largely unknown. Future studies should report data on adverse events even if no such events occur. Although self-care interventions may be more costeffective than pharmacological or practitioner-delivered therapies that incur ongoing costs, no evidence-based conclusions regarding the cost-effectiveness of sensory art therapies can be made for this current literature base as no studies conducted cost analyses. Only two [26,35] of the studies included in this review reported an effect size for the treatment being studied, making it difficult to draw any conclusions about the efficacy of sensory art therapies relative to other treatment options. Future studies on sensory art therapies should calculate and report on effect sizes. Conclusions The practical feasibility of sensory art therapies is appealing, and the ability of aesthetically moving stimuli to engage a patient physically, mentally, and/or spiritually is unique. The clinical research regarding the use of sensory art therapies as self-care interventions for chronic pain patients is limited in quantity and quality. The existing evidence supported only a weak recommendation in favor of the use of music therapy and was insufficient to allow any conclusions regarding the other therapies included in this category. The safety, cost, and effectiveness of most sensory art therapies for chronic pain patients are thus left to speculation. Acknowledgments The authors would like to acknowledge Ms. Lea Xenakis and Ms. Jennifer Smith for their help with conducting the review, as well as Ms. Viviane Enslein for helping prepare the manuscript. The Active Self-Care Therapies for Pain (PACT) Working Group included the following individuals at the time of writing (see http://onlinelibrary.wiley.com/doi/10.1111/ pme.12358/full for working group affiliations): Chester C. Buckenmaier III, MD, COL, MC, US Army; Cindy Crawford, BA; Paul Crawford, MD, Lt Col, US Air Force; Roxana Delgado, PhD; Daniel Freilich, MD, CAPT, MC, USNR; Anita Hickey, MD, CAPT, MC, USN; Wayne B. Jonas, MD, LTC (Ret.), US Army; Courtney Lee, MA; Todd
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