The Final Beauty 01-04-16

A Randomised Control Trial to Investigate
Whether Music in Conjunction with
Osteopathic Manual Therapy has an Effect
on Decreasing Stress and Pain in Patients
with Musculoskeletal Back Pain.
Emily Coulthard–Jones 33357365
Leeds Beckett University Student Research Project
April 2016

Emily Coulthard–Jones33357365
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Osteopathy and Music
[Cite your source here.]
Abstract
Background and objectives:Osteopathyandmusichave been observed inliterature toreduce both
stressand perceivedpain independentlytoeachother.Researchconcernedwithmusiciswidely
contradictoryandresearchregardingmusicand osteopathyisalmostnon-existent. Thisstudyaims
to establishwhethermusiccanbe usedas a useful mediuminconjunctionwithosteopathicmanual
therapyinreducingindicatorsof stressandpaininpatientswithnon-peripheral, musculoskeletal
back pain(paincausedbythe muscularor skeletal system).
Methods:A randomisedcontrol trial designwasadoptedwithtwelve participantsrecruitedfromthe
studentosteopathicclinicatLeedsBeckettUniversity.Participantswere randomlyassignedtoone
of twogroups:musicaccompanyingosteopathicmanual therapy (intervention) orosteopathic
manual therapyalone (control).Quantitative measurementsof heartrate,bloodpressure,self-
perceivedpainandself-perceivedstresswere recordedbefore andaftertreatment.
Results:Changesinoutcomeswere analysedusingamatchedpairedt-testtodetermine whether
there wasa significantdifference betweenmeasurementsbefore andaftertreatment,andthen
againbetweenthe twogroups. The resultsof the study suggested thatthere wasnostatistical
significance betweenheartrate,bloodpressure andself-perceivedpainbeforeandaftertreatment
inthe interventiongroup. A statistical significancewasseenbetweenself-perceivedstressbefore
and aftertreatmentinbothgroups,howeverthe difference betweenthe twogroupswasnot
statisticallysignificant.
Conclusions:The resultsfail tosupportthe theorisedeffectsof musiconstressandpainin
conjunctionwithosteopathicmanual therapy.Minimal effectswereobservedoneachof the
measurementoutcomes of stressandpain.Additional research usinglargerparticipantsamplesare
requiredtoinvestigate the reliabilityof these resultsandconclusions.
Keywords: Music; Stress;Pain; OsteopathicManual Therapy; AutonomicNervousSystem.

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Table of Contents
Abstract.......................................................................................................................................2
Glossary of Terms......................................................................................................................... 5
Introduction.................................................................................................................................6
Musculoskeletal Back Pain.........................................................................................................6
Osteopathic Manual Therapy and the Treatment of Musculoskeletal Spinal Pain.......................... 8
Osteopathic Manual Therapy and the Cervical Spine ............................................................... 8
Osteopathic Manual Therapy and the Thoracic Spine .............................................................. 9
Osteopathic Manual Therapy and the Lumbar Spine.............................................................. 10
Osteopathic Manual Therapy................................................................................................... 12
The Stress Response............................................................................................................ 14
Osteopathy and the Stress Response.................................................................................... 15
Music..................................................................................................................................... 17
Music and its Effect on Pain ................................................................................................. 17
Music and the Stress Response ............................................................................................ 18
Music and Manual Therapy.................................................................................................. 20
Gap in the Research................................................................................................................ 21
Aims....................................................................................................................................... 23
Hypothesis ............................................................................................................................. 23
Null Hypothesis....................................................................................................................... 23
Method...................................................................................................................................... 23
Methodological Approach....................................................................................................... 23
Recruitment and Participation................................................................................................. 24
Ethical Considerations............................................................................................................. 28
Method of Data Collection ...................................................................................................... 29
Method of Data Analysis ......................................................................................................... 30
Results....................................................................................................................................... 31
Heart Rate.............................................................................................................................. 32
Systolic BloodPressure............................................................................................................ 33
Diastolic Blood Pressure.......................................................................................................... 35
Self-Perceived Pain ................................................................................................................. 38
Self-Perceived Stress............................................................................................................... 39
Discussion.................................................................................................................................. 41
Heart Rate and Blood Pressure................................................................................................ 41

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Self-Perceived Pain ................................................................................................................. 42
Self-Perceived Stress............................................................................................................... 42
What does all this suggest? ..................................................................................................... 42
Strengths and Limitations........................................................................................................ 44
Conclusion ................................................................................................................................. 45
Acknowledgments...................................................................................................................... 46
References................................................................................................................................. 47
Appendices ...................................................................................... Error! Bookmark not defined.

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Glossary of Terms
ACTH - Adrenocorticotropic hormone
ANS – Autonomic Nervous System
CPD – Continued Professional Development
CRH – Corticotrophin-releasing hormone
ESH – European Society of Hypertension
ESS – Epworth Sleepiness Scale
FOAD – Foetal Origins of Adult Disease
FPSR – Faces Pain Scale-Revised
FVC – Forced Vital Capacity
GAS – General Adaptation Syndrome
GOsC – General Osteopathic Council
HVLA – High Velocity Low Amplitude
HPA axis – Hypothalamic-pituitary-adrenal axis
IASP – International Association for the Study of Pain
IBS – Irritable bowel syndrome
NICE - National Institute for Clinical Excellence
NRS – Numeric Rating Scale
PNS – Parasympathetic Nervous System
SNS – Sympathetic Nervous System
SPSS – Self-Perceived Stress Scale
VAS – Verbal Analogue Scale
VRS – Verbal Rating Scale

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Introduction
Musculoskeletal Back Pain
Accordingto the Office forNational Statistics(2014) the mainreasonfor the 131 milliondaysof sick
leave in2013 was due to “back, neckand muscle pain”.
Cervical pain,commonlyreferredtoasneckpainis experiencedbypeopleof varyingages,health
and lifestyle.AccordingtoCohen(2015) cervical painisone of the topleadingcausesof disability
and itis thoughtthat around30% of people peryearsufferfromof cervical pain.A highprevalence
of cervical painwasalsodocumentedinasystematicreviewbyFejer(2005) whichnotedthat more
womensufferfromcervical pain thanmen.Thissystematicreview included56papersinvestigating
the prevalence of cervical painworldwide.Paperswere excludedif theycontainedcontent
surroundingotherareasof pain.
Thoracic pain,alsoknownas mid-backpainisa lesscommoncomplaint,althoughthoughttobe as
debilitatingascervical orlumbar(lowback) pain.Ithas been estimatedthatthoracicpainprevalence
isbetween3%and23% (Manchukonda etal.,2007). Similarlyastudyinvestigatingthe prevalenceof
thoracic painestimatedthataround13% of people exhibitthoracicpainwithinayear(Leboeuf-Yde
et al.,2009). Thisstudyuseda large sample size of 34,902 Danishtwinstoinvestigate the prevalence
of cervical,thoracicandlumbarspine pain.The sample,althoughlarge isn’trepresentativeof the
target populationasitincludedonlyDanishtwins.Thereforeamore variedsample isrequired.
Lowerback pain(lumbarpain) isthe mostcommonarea of reportedbackpainwithapproximately
30% of people sufferingwithlumbarpain(Manchikanti etal.,2014). Othersourcesclaimwiththe
prevalence of lumbarpainbeingbetween60% to 70% for firsttime sufferersand15% to 45% aftera
yearaccording to the WorldHealthOrganisation(WHO) (Duthey,2013).It isdifficulttoestimate an
exactfigure forthe prevalence of backpaindue to the numberof people notreportingorseeking
medical advice fortheirbackpain.
The sensationof painiscausedby a stimulationof nociceptors(sensoryneurons) byanoxious
stimulus(potentiallyharmful stimulus) (LoeserandTreede,2008).Thistransmitspainsignalstothe
spinal cordand brain,causinga sensationof pain.Nociceptorsare foundinthe skin,muscles,joints
and viscera(organs) (Skevington,1995).Three differenttypesof neuronsare usedtoconveycomplex
messagestothe central nervoussystem(CNS) aboutthe nature andintensityof the pain,A-beta
fibres,A-deltafibresandC-fibres.Itisthe brainthat summatesincomingsignalsanddetermines
painperception.

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Melzackand Wall (1965) presentedthe paingate theorysuggestingthatlightpressure,vibrationand
touch promptsactivationof the heavilymyelinatedA-betafibrescausingquickimpulsesof non-
painful sensations.Thiscausesaninhibitionof spinal cordstimulationbyA-deltafibreswhichresults
ina painful sensationinresponse toaninjury.
Activationof A-deltafibres isfeltas‘sharp’paindue to the afferentfibressendingfastimpulsesof
painperceptiontothe spinal cordand up to the brain.The primaryactivationof A-deltafibresleads
to the brainperceivingacute painwhichisoftendescribedassharpor shooting. If the stimulusis
prolonged,slowconductingC-fibresare thenactivatedandthe perceptionof painbecomesadull
ache,burningor throb.
C-fibreshave arole inthe inflammatoryresponse,whichwhenstimulatedcause the release of
cytokines.These cytokinescause vasodilationandinflammationloweringthe levelatwhichnerves
are stimulated.Thisincreasedsensitivitycaneventuallyleadtosensitisationwhichiswhere the
nervesare at a constant level of stimulation.Thisresultsinapersistentperceptionof pain.
It has beenfoundthatpatientssufferingwithacute orchronicpainhave reducedmental capacity
for problemsolving,attention,memory,andprocessingof information,theyare alsopredisposedto
a wide varietyof psychologicalconditionssuchasdepression,anxietyandhighstresslevels (Hart,
Wade and Martelli,2003).
Melzack and Casey(1968) suggestedthatlevelsof painperceptionwere notdirectlyrelatedtothe
intensityof the painfulstimulus,butalsotothe individual andtheirenvironment.Theysuggested
that “paincan be treatednotonlybytryingto cut downthe sensoryinputby anaestheticblock,
surgical interventionandthe like,but alsobyinfluencingthe motivational-affectiveand cognitive
factors as well.”Thussuggestingthatpainiscausedby a combinationof physiological,psychological
and sociological stimulation.
The umbrellaterm‘musculoskeletalbackpain’iscervical,thoracicorlumbarpain thatis concerned
withthe musculature orskeletal system.Itisthoughtthathavingbad spinal posture causes
imbalancesbetweenthe tissuesof the spine which mayeventuallycause musculoskeletal pain(Kim
et al.,2015). Musculoskeletal painisacommonconditionseeninosteopathicclinicswhere
osteopathscommonlytreatusingthe principle that“structure andfunctionare reciprocally
interrelated”(Ward,2003). That is,that whenthe structure of the bodyischangedphysicallythen
the functionof the correspondingcomponentsof the bodyare inhibited.

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Osteopathic Manual Therapy and the Treatment of Musculoskeletal Spinal Pain
Osteopathicmanual therapyisacomplementaryhealthapproachthataimsto aidthe body through
its“self-regulation,healingandhealthmaintenance”(Penney,2010) through the importance of the
structure and functionof the musculoskeletal system(DiGiovannaetal.,2005). Osteopathicmanual
therapyisa combinationof treatmenttechniquestoaidthe patientinreturningtohealthincluding
“myofascial release,craniosacral,HighVelocityLow Amplitude(HVLA) manipulation,Balanced
LigamentousTension(BLT),Muscle EnergyTechnique,biodynamic,strain-counterstrain,etc.”
(Cerritelli etal.,2015). Osteopathstreata range of conditionsincludingthose of the spine.
Osteopathic Manual Therapy and the Cervical Spine
Franke etal. (2015) conducteda systematicreview investigatingthe effectthatosteopathicmanual
therapyhad onchronic nonspecificneckpain,thatis,cervical painwithoutaclearcause. It only
includedstudiesthatconsideredosteopathicmanual therapyasa whole,wherebythe practitioner
chose whattreatmentapproachwas appropriate toindividual patients,ratherthanasingle specific
technique.Thisapproachrepresentedosteopathicmanual therapyaswouldbe seeninan
osteopathicpractice muchbetterthanif a specifictreatmenttechniquewasinvestigatedseparately
therefore improvingexternalvalidity.The systematicreview wasasmall scale studywith only three
randomisedcontrol trial studies meetinginclusioncriteria.Twostudiesconcludedthatosteopathic
manual therapyreduced the symptomsof cervical pain(Tempel etal.,2008; Mandara et al.,2010).
On the otherhand anotherrandomisedcontrol trial (Schwerlaetal.,2008) includedinthis
systematicreviewconcludedthatosteopathicmanual therapywasfoundnottohave a significant
effectinreducingcervical pain.Thisparticularrandomisedcontrol trial howeverdidstill suggest
strongevidence forreducingaverage painthresholdsinchronicnonspecificneckpain.
SimilarlyMandaraetal. (2010) investigatedthe efficacyof osteopathictreatmentinconjunction
withanti-inflammatorymedicationforchroniccervical painincomparisontoa shamtreatmentwith
anti-inflammatorymedication.Conclusionssuggestedthatosteopathicmanual therapymayhave a
positive effectonreducingpainlevelsinpatientspresentingwithchroniccervical pain.Itwas
observedthatthe average painVAS(visual analogue scale)ratingsdecreasedsignificantly(<0.05)
more withosteopathictreatmentthanwithout.Theydidhoweveralsoconclude thatthissignificant
difference betweenthe osteopathicmanual therapyandthe shamtreatmentgroupsreducedafter
six sessions.
Bischoff etal. (2006) aimedtoidentifywhetherosteopathicmanual therapycouldbe effective in
reducingpaininpatientssufferingwithchronicnon-specificneckpain.Incomparisontothe

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previoustwostudies(Mandara etal.,2010; Cerritelli etal.,2011) thisstudyhad a largersample size
of forty-nineparticipantsand wasalsoa randomisedsham-control trial.The shamgroupreceived
ultra-soundonce aweekfortenweeksandthe treatmentgroupreceivedosteopathicmanual
therapyeverytwoweeksfortenweeks.Thislongitudinalstudywill have ledtomanyextraneous
variablestooccur due to lackof control outside of the study. Resultsshowedasignificantdifference
(P< 0.0005) betweenpre-studyNRS(numericratingscale) scoresandpost-studyNRSscoresinthe
treatmentgroupsuggestingthatosteopathymaybe aneffectivetreatmentforreducingcervical
pain.Thissignificant difference wasalsoseenbetweenthe inter-groupresults(P=0.002).
All of the above studiesidentified, sufferedfromsmall samplesizes(Bischoff etal.2006; Schwerlaet
al.,2008; Tempel etal.,2008; Mandara et al.,2010; Franke etal.,2015). This implieslessclinical
significance andtherefore more pinningextensive researchandrepetitionsof previousstudiesto
investigatethe effectsof osteopathicmanual therapy toconfirmthe reliabilityof these effectsfor
the treatmentof cervical pain(Franke etal.,2015).
Osteopathic Manual Therapy and the Thoracic Spine
Lessresearchhas beenfocusedonpatientswithpainaroundthe midorthoracic spine region.Bjersa
(2013) lookedintothe effectsthatosteopathicmanual therapyhadonchronicpain,thoracic
stiffnessandbreathingimpairmentafterathoracoabdominal oesophagusresection. Eight
participantsreceivedosteopathicmanual therapyonce aweekfortenweeks.The treatment
includedasetof specificthoracictechniques,althoughothertechniquescouldbe usedif the lead
osteopathsawneedforthem.These tenweeksmayhave givenrise toanumberof extraneous
variablesdue toparticipantactivitylevelsoutsideof the study.Thisthenmayhave affectedthe
overall resultsof the study,andtherefore the interpretationandconclusionsof the results.Results
suggestedthatosteopathicmanual therapycouldbe auseful tool forreducingthoracicstiffness,
chronicpain andbreathingimpairments.Toassessthese outcomesmeasurementsof forcedvital
capacity(FVC);thorax excursion, thoracicandabdominal movementduringrestandmaximal and
minimal breathing, thoraciclateral flexion,thoracicflexion,analgometer, abrief paininventory
scale, the International Physical ActivityQuestionnaire andinterventionquestionnaire,were
recorded.
Measurementsof breathing mechanicssuggestedthatthere wasnosignificantdifference post-
treatment. Itwasproposedthatthoracic mobilityincreasedpost-treatment,althoughflexionof the
thoracic spine indicatednosignificantdifference.A veryslightreductioninpainafter treatmentwas
observedusinganalgometer, howeveritwasnotstatisticallysignificant.Thisstudywassmall-scale,

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therefore makingitdifficulttogeneralise tothe largertargetpopulation.The studydidnothave a
control group meaningthe interventiongroupcouldnot be comparedtoassessdifferencesin
outcome measurementsandreducingstatistical reliability.
In additionFryeretal. (2004) investigatedthe effectof ahighvelocitylow amplitude (HVLA) thrust
manipulation,atechnique commonlyusedbymanual therapistssuchasosteopaths,onpaininthe
thoracic spine measuredusinganalgometerbefore andaftertreatment.The studyusedafairly
large sample of 96 asymptomaticparticipantswhowere randomlyallocatedintoone of three
groups.These groupswere a HVLA thrustto a restrictedsegmentinthe thoracicspine,extension
mobilisationtoasegmentof the thoracic spine anda shamgroup whoreceivedlaser-acupuncture
(althoughthe laserwasturnedoff).Resultsconcludedthatbothmanipulation(P=0.04) and
mobilisation(P<0.01) causeda significantreductioninpainandthatthe sham group(p=0.88) had no
significantdifference.However,the difference inthe inter-groupresultsrevealedthatmobilisation
significantlyreducedpainwhencomparedtothe control group(P=0.01) whereasmanipulationdid
not (P=0.67). Thisleadtoconclude that incomparisontomanipulation,mobilisationof the spine
provedtobe more effectiveinreducingpaininthe thoracicspine.Thiswaslaterconfirmedina
similarstudybyPecos-martinetal. (2015) whichalsolookedintothe effectsthatthoracic
mobilisationhadonpainand activityof the erectorspinae muscles.Resultsshowed painandactivity
was significantlyreducedaftermobilisationincomparisonto the shamgroup.
The aforementionedstudybyFryer etal. (2004) useda sample of asymptomaticvolunteerswhichis
not representativeof patientsvisitinganosteopathicclinicascertainpersonalitieswillwantto
volunteerandall patientsvisitinganosteopathicclinicforthoracicpainare symptomatic. The study
was alsoconductedonosteopathicstudents,whoare a veryselectsample groupthatare not
representative of the targetpopulationof osteopathicpatientsandwhomayshow desirabilitybias.
Havingsaidthisit appearsthat paininthe thoracicspine isreducedwiththe use of osteopathic
techniquessuchasmobilisationandmanipulation,howeverthese are veryselecttechniques.These
are notthe onlytechniquesosteopathsuse duringtreatment andsocannot be generalisedtoan
osteopathictreatmentsessionleadingtothe studyhavinga lackof external validity.
Osteopathic Manual Therapy and the Lumbar Spine
The most well documentedareaof researchinthe fieldof osteopathyisthe efficacy of osteopathic
manual therapyonlowback pain.Thisresearchbase ledthe National Institute forHealthand
Clinical Excellence (NICE) (2009) tosuggestosteopathictreatmentintheirguidelinesforlow back
painas an alternative treatmenttoconventionalmedication.“Treatmentmaybe providedbya

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range of healthprofessionalsincludingchiropractors,osteopaths,manipulative physiotherapistsor
doctorswho have hadspecialisttraining”(NICE,2009).
The UK BEAMtrial (BMJ, 2004), Licciardone (2003), Brimhall,andKing(2005), Vismaraetal. (2012),
Orrock and Myers (2013), Licciardone andAryal (2014), Licciardone,KearnsandMinotti (2013),
Frank etal. (2014) have all helpedshape thisperceptionaroundthe efficacyof osteopathicmanual
therapyon reducinglowbackpain.
The back pain exercise andmanipulation(UKBEAM) randomisedtrial (BMJ,2004) aimedto
investigatethe ‘bestcare’forlowback painingeneral practice intermsof exercise classes,spinal
manipulationoracombinationof the two.1,334 participants were recruitedfromgeneral practices
regardingtheirlowbackpain.Data was gatheredonparticipants’general health,theirbackpain,
psychological wellbeingandalsotheirbeliefs,recordswere made of anyadverse effects.
Measurements were takenbefore participantswere randomisedinto the three groups, atone
month,three monthsandtwelve monthintervalsafterthe intervention. Interventionsincluded
“back to fitness”anexercise programmedesignedforlow backpain,a“spinal manipulation
package”designedanddeliveredbyamultidisciplinarygroupof osteopaths,chiropractorsand
physiotherapists, andfinallyacombinationof the two.Resultsof thistrial suggestedthata
combinedapproach(SD=0.47) was mosteffective inreducinglow backpainafterthree monthin
comparisontothe exercise group(SD=0.35) andthe spinal manipulationgroup(SD=0.39). Thiswas
alsoseenaftertwelve months.Thisstudywasalarge scale,randomisedtrial whichproduced
generalisable resultswhichare representative tothe targetpopulationof the UK.
Licciardone,Brimhall andKing(2005) conductedaretrospective systematicreviewandmeta-
analysisof randomisedcontrol trialsinvestigatingthe efficacyof osteopathictreatmentonlow back
pain.Six studieswithatotal of 525 participantswere identifiedduringthe inclusion/exclusionstage
of the study. It wasconcludedthatin all six studiesthere was ahighlysignificantdecrease (P=0.001)
inpain levelswithpatientspresentingwithlow backpainafterreceivingosteopathicmanual therapy
incomparisonto theircounterpartshamgroups.Thissystematicreviewwasthoroughinitsanalysis
and wasable to draw strongconclusionsfromthe six studiesselected;howeversix isstill afairlylow
numberof studies.Itiscommonfor a systematicreview withasmall sample size tocommonly
reportpositive findingsintheirconclusionsincomparisontotheirlargercounterpartsashasbeen
seeninothersystematicreviews(Gargetal.,2008). From thisitwas concludedthatmore studies
were neededtoimprove the researchbase forthe efficacyof osteopathyforlow backpain.

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In addition,asingle-blindedrandomisedcontrol trial conductedbyLicciardone etal. (2003)
concludedthatosteopathicmanual therapywasauseful treatmentapproachtoreducingpainin
patientssufferingwithchroniclowbackpain.The studylastedsix monthsandconsistedof ninety-
one participantsrandomisedintoone of three groups:osteopathicmanual therapy;sham
manipulation;no-intervention(control).Datawascollectedonmental health,painandsatisfaction
levelsbefore treatmentandatone,three andsix monthintervals.Resultssuggestedthatboththe
participantswhoreceivedosteopathictreatmentandshamtreatmentreportedlowerpainscores
(P=0.01 andP=0.003 respectively)afterone monthof treatment,three month (P=0.001,P=0.01
respectively)andsix months (P=0.02,P=0.02 respectively) incomparisontothe no-intervention.This
similaritybetweenshamgroupandosteopathictreatmentatone monthsuggestsa placebotype
effectoccurring.Alternativelythe similaroutcomesmayhave beeninpartdue to the osteopathic
practitionersinvolvedbeingintheirthirdandfourthyearsof study,rather thanqualifiedosteopaths.
Licciardone etal. (2014) wenton to produce a large scale studyof 230 participantsto investigate
betterwhetherosteopathicmanual therapycanbe usedto reduce low back pain.He observedlow
back painbeingcausedbyfive biomechanical dysfunctionswhichincluded:non-neutral lumbar
dysfunction, pubicshear, innominate shear,restrictedsacral nutation, andpsoassyndrome.The
studywas a double-blindrandomisedcontrol trial witha2 x 2 factorial design.Participantsreceived
osteopathicmanual therapytreatmentat0, 1, 2, 4 and 6 weekintervalswhichincludedarange of
osteopathictechniquesthatthe leadosteopathdeemedappropriate tothe patient.Significant
reductioninlowbackpainwas observedinall five biomechanical dysfunctionswithosteopathic
manual therapy.Thiswasa large scale studythatcan be generalisedandisrepresentativetothe
target populationof Americaasit hadgood external validity.
Osteopathic Manual Therapy
As wasaforementioned,osteopaths are guidedbyfourmainprinciplesasprofessedbyAndrew
TaylorStill,the founderanddeveloperof osteopathy.
1) The body is a unit
The body isseenasone unit,anydisruptiontoitcausesdisruptionthroughoutthe whole body.
2) Structureand function areinterdependent
The functionof the body isdirectlyrelatedtothe structure.If the structure isdisturbedthenthe
functionisalsocompromised.

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3) Body is self-sufficient– tendsto cure itself and alwaystendsto the normal
It has itsowninternal healingmechanismsuchashomeostasis.
4) Rule of theartery – supreme
The bloodsupplymustbe ingood healthforthe healingprocesstooccur.
(Penney,2010),(Stark,2013)
The biopsychosocial model of healthisanintegratedhealthmodelthatconsidersthe biological,
psychological andsocial make upof a person.Thismodel reflectsthe principlesof osteopathy.
Osteopathscommonlytreatwithinthe boundariesof this biopsychosocial modelof health. Whilst
painis the mostcommonpresentingsymptomtreatedinosteopathicclinics,osteopathyhasalso
beenobservedtohave otherhealthbenefits suchreducinganxietyandstress,reducingfatigueand
improvingoverallwell-being(Weze atal.,2007; Henderson etal.,2010; Dugailly etal.,2012;
Wiegandetal.,2015).
In a randomisedcontrol trial Dugaillyetal. (2012) investigatedthe effectof general osteopathic
treatmentonanxiety,global self-perceptionandbodysatisfactioninasample of 34 asymptomatic
female volunteers.Participantswere randomlyallocatedintotwogroups:osteopathicmanual
therapyconsistingof avarietyof osteopathictechniquesorthe control groupconsisting of no
treatment,restingsupinefor30 minutes.Datawascollectedbefore andafterthe intervention.It
was concludedthatosteopathicmanual therapysignificantlyhelpedreduce anxiety(P=0.0001),
improve global self-perception(P=<0.0001) and bodysatisfaction(P=0.006) in comparisontothe
control group.The sample hadhighgenderbiasandso wasnot representative tothe target
population of symptomaticpatientsvisitinganosteopathicclinic therebyleadingtopoorexternal
validity.Internal validity wasstrongintermsof the studybeinga randomisedcontrol trial asthis
reducesthe possibilityof confoundingvariables.Itwastherefore advisedtoassessthe effectsthat
osteopathicmanual therapyhasona largerand more variedsample.Nonetheless itcanbe
concludedthatthese are encouragingresultsintermsof the effectthatosteopathicmanual therapy
may have onpsychological conditionssuchasanxiety.
In contrastto thisa pilotstudybyWiegand etal. (2015) exploredthe effectsof osteopathicmanual
therapyon fatigue,self-perceivedstressandself-perceiveddepressioninsmall sampleof 28 first
yearosteopathicmedical students.Participantswererandomly assignedtoone of three groups: an
osteopathictreatmentgroupwhichinvolvedavarietyof techniques, ashamgroupwhichinvolved
osteopathictechniquesdirectlyrelatedtothe core withaimsto reduce levelsof stress,fatigueand

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depression, andfinallyacontrol groupwhichreceivednotreatmentatall.Participantswere asked
to rate theirlevelsof fatigue,stressanddepressionusing the EpworthSleepinessScale (ESS) the
PrimaryCare Evaluationof Mental DisordersPatientHealthQuestionnaire9(PHQ-9) depression
scale and the Self-PerceivedStressScale (SPSS) respectivelyat 0, 2 and 4 weekintervalsof the study.
Resultssuggestedthatosteopathicmanual therapysignificantlyreducedlevelsof fatigue (P=0.019)
betweenpre andpost-resultsincomparisontothe shamgroup(P=0.678) andthe control group
(P=0.051). Depression scoreswere seentoslightlydecrease afterosteopathicmanual therapy
similarlytothatfoundinthe sham (P=0.260) and control groups(P=0.343). Nostatistical significant
difference were seenbetweenpre-testscoresandpost-testscoresof stressinthe osteopathic
manual therapygroup(P=0.139), the shamgroup (P=0.906) and finallythe control group(P=0.086).
The conclusionis that there isa possibilityforthe use of osteopathicmanual therapyforthe
treatmentof depressionandfatigue,howeveralarger,more representative sample isneededto
improve statistical reliability.Participantsshouldalsobe naive toosteopathictechniquesasthis
sample mayhave beenunderstoodthe aimsof treatmentandthe studyandtherefore causing
responderbias.
There has beenevidence tosuggestthatosteopathicmanual therapyhasaneffectonstressand the
activationof the parasympatheticnervoussystem, abranchof the autonomicnervoussystemthat
calmsthe bodyand allowsthe bodyto‘restand digest’ (Weze etal.,2007; Henderson etal.,2010).
Activationof the opposingbranchof the autonomicnervoussystem, the sympatheticnervous
system(SNS) causesanopposite effect,aheightenedresponse,alsocalledthe stressresponse.The
stressresponse isusedto helpwithanyphysical oremotional painthatmaybe inflictedonthe
personandaims to helpthe individualcope withaspecificstressor (Anisman,2014). The stress
response usesacombinationof the (SNS) andanegative feedbackloopcalledthe hypothalamic-
pituitary-adrenal axis(HPA axis) toallow the persontoreactappropriatelytoastressor (McEwen,
2007).
The Stress Response
A stressormaycome froman external orinternal stimulus (McEwenandLasley,2002). Whena
stressorisencounteredthe amygdalainthe brainstimulatesthe hypothalamuscausingactivationof
the SNS (McEwenandLasley,2002). Thisactivationcausessignalstobe sentto the medullaof the
adrenal glandsstimulatingthe releaseof the stresshormonesepinephrine(adrenaline)and
norepinephrine(noradrenaline) (Anisman,2014). It isthese hormonesthatcause the ‘fightor flight’
response firstnotedbyWalterCannon(1929).

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Specifically,the resultanthormoneaction causesthe bronchial tubesinthe lungstodilate allowing
for an increase inoxygentoenterthe blood.Heartrate alsoincreases,whichinturnenhancesthe
speedatwhichoxygenrichbloodispumpedaroundthe bodyto appropriate musclesandvital
organs neededduringthe response.Glycogeninthe bloodisbroken downtosupplyenergyinthe
formof glucose.Simultaneously,the pituitaryglandreleasesendorphinswhichactas the body’s
ownpainkillers (McEwenandLasley,2002).
If a stressorcontinuesandthe levelsof epinephrineinthe bloodbegintodropthen a cascade of
eventsoccurwithinthe HPA-axis(Anisman,2014).Initiallythe amygdalastimulatesthe
hypothalamuswhichthenreleasescorticotrophin-releasinghormone (CRH).Inturnthisstimulates
the anteriorportionof the pituitaryglandtorelease adrenocorticotrophichormone (ACTH)
(Anisman,2014). Ultimatelythisstimulatesthe release of the hormone cortisolfromthe adrenal
cortex intothe bloodstream (McEwenand Lasley,2002). Whenreleasedcortisol increasesblood
sugar levelsbyincreasingthe breakdownof storedglucose throughgluconeogenesis,toallow foran
increase inenergyinthe blood.Cortisol alsoaidsthe breakdownof fat,carbohydratesandproteins
inmuscles toprovide energyfor‘fightorflight’ (Anisman,2014).
The HPA-axishoweverperformsasanegative feedbackloop:the cortisol releasedactsasan
inhibitorbybindingtoreceptorcellsinthe hypothalamusandpreventingCRHand ACTHrelease,
whichfinallyreducescortisol inthe blood (Cranston,2014). Due to thisdrop in serumcortisol,the
parasympatheticportionof the ANSengagestocounterSNSactivationoverall (Goldsteinand
McEwen,2002).
Osteopathy and the Stress Response
Henderson etal. (2010) investigatedthe effectof anosteopathictechnique calledribraising onthe
autonomicnervoussystem(ANS) byassessingsalivaryflow rate,alpha-amylase activityandcortisol
levelswhichare all salivarybiomarkersof the ANS.The pilotstudyusedasample of 14 participants
randomlyallocatedintoeitherthe ribraising grouporplacebo(lighttouch) group. Findings
suggestedthatthe sympatheticnervoussystemwasinhibitedinthe osteopathicmanual therapy
group.Thiswas shownbya statisticallysignificantdecrease insalivaryalpha-amylase levels
immediatelyaftertreatment(P=0.014) andten minutesaftertreatment(P=0.008).A difference in
alpha-amylasewasalsofoundintwoof the participantsinthe placebogroup.Nostatistical
significance wasfoundinanyotherparametersineithergroups.Thisstudyusedasmall sample of
participantswhomayhave all reacteddifferentlytoribraising,withthe pressure neededforan
effectbeingdifferentbetweeneachindividual.All participantswere healthy,andthereforeanon-

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observable effectmayhave followed.If participantswithincreasedtone of the (SNS) hadbeen
recruitedribraisingmayhave causedmore of an observable effect.Nostatistical analysiswasused
betweenthe twogroupsmeaningcomparisonsof effectcouldnotbe made.
The conclusionsmade byHendersonetal. (2010) in thispilotstudysuggestthatitmay not be simply
the techniquesusedinosteopathicmanual therapythatcause aneffectonreducingsympathetic
tone but lighttouchmay alsohave a role to playinthisobservation.Touchisa compulsorypartto
any osteopathicexaminationandtreatmentwhichhasbeenseentocause psychological and
physical responses.These psychological effectswere observedbyWeze etal. (2007) ina large scale
trial including147 volunteerswhoself-reportedpoorpsychologicalhealthandmental wellbeing.
Participantswere subjectedtofortyminutesof lightbutfirmtouchforfoursessions.Measurements
were recordedbefore the firsttreatmentandafterthe lasttreatmentusingaverbal analogue scale
(VAS) forphysical andpsychological functioning,anda EuroQoL (EQ-5D) for measuringhealth.
Resultsconcludedthatpsychological parametersof stressandfatigue andphysiological pain
decreasedsignificantly(P=0.0004).Thissuggeststhatthe safe use of touchcan activelyimprove
psychological andphysiological conditions.Howeverthisstudyusedonlyone groupandlackeda
control group meaningthere isnobaselinedatatocompare the lighttouchgroup’sstatistically
significantresultsto.Havingonlyone groupmeantthatthe participantswere notblindedtothe
aimsof the research.Participantsmayhave conformedtothe study’saimsintheirresponses
causingresponderbiasleadingtoresultsthatare lessvalid.
In a similarrandomisedcontrol trial Turkeltaubetal. (2014) investigatedwhethertouchcould
improve participant’sself-perceptionof energy,pain,stressandthe feelingof tension.In
comparisontoWeze et al. (2007), Turkeltaub etal.,(2014) usedtwo differinggroups,one
interventiongroupwho received15minutesof seatedlow-intensitymassage,andthe otherthat
received15minutesof seatedhigh-intensitymassage,howeveronce againacontrol group wasnot
used.29 participantsvolunteeredforthe study,all of whomwere nursesorstudentnurses,and93%
of those beingfemale.Bothgroupsfoundsignificantimprovementsinall outcomes,althoughthe
groupreceivinghigh-intensitymassage reportedalargerstatistical significance inimprovingenergy
(P=0.03), pain(P=0.001), stress(P=0.002) andtensionlevels(P=0.001).Thisstudywasan
improvementtoWeze etal. (2007) in termsof two differinggroups,howeverhadasmaller
participantsample whichreducesthe generalisabilityof the results.The sample alsohadstrong
genderbias,andincludedonlynurseswhichare notrepresentative of the targetpopulation.Again
thisstudylackeda control group forcomparisonas to whetherthe interventionitselfwasthe cause

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of the significantdifference inenergy,pain,stressandtensionscores,orwhetheranyextraneous
variablescausedthese noteddifferences.
Overall researchsuggeststhatosteopathyandthe simpleactof physical touchmay cause effectsto
not onlyphysiological complicationssuchaspain,butalsonegative psychological moodsas seenin
stressor fatigue (Weze etal.,2007; Henderson etal.,2010; Dugailly etal.,2012; Turkeltaub etal.,
2014; Wiegandetal.,2015). Similareffectshave been seeninresearchwhere musicisused asan
interventionforreducing stressandpain (Yamishitaetal.,2006; Chan etal.,2007; Mitchell etal.,
2007; Nilsson,2008; Korhan et al.,2011; Horne-ThompsonandBramley,2011; Lai and Li,2011;
Bellieni etal.,2013; Liuand Petrini,2015).
Music
Music has beenusedasa powerful tool foraidingthe restorationof healthforhundredsof years
and isa well-documentedmediumforreducingbothphysical pain(Mitchell etal.,2007; Horne-
ThompsonandBramley,2011; Bellieni etal.,2013) andpsychological conditions(Yamishitaetal.,
2006; Chan etal.,2007; Nilsson,2008; Korhan etal.,2011; Lai and Li,2011; Liu and Petrini 2015).
Music and its Effect on Pain
Evidence thatmusicisa useful tool forpainhas beeninvestigatedbyHorne-Thompsonand Bramley
(2011) withreductionsinpainbeingseeninterminallyillparticipantsafterreceiving40minutesof
combinedphysiotherapyandmusictherapyweeklyforeightweeks.19participantsina palliative
care unitwere usedforthisstudyalthoughit includedonlyone interventiongroupwithoutacontrol
groupmeaningthere wasa lack of control and comparison.Itcannot be knownwhetherany
difference inresultsweredue tothe interventionorwhetheritwasdue to extraneousvariables.
Statistical analysiswasnotusedforthe analysisof thisstudyandso therefore itcannotbe
concludedthata significantdifference wasfound.
CorrespondinglyMitchell etal. (2007) researchedthe effectsof musiconrelievingchronicpainin
318 participantsandobservedthatmusicappearedtorelax anddistract(P=<0.001) patientsfrom
theirpainand gave thema betteroutlookonlife (P=<0.001).Thus suggestinglong-termbenefitson
painlevelsinpatientswithchronicpain.A questionnairewassentto850 patientswhowere
registeredwiththe Glasgowhospital painclinicwitha37.4% response rate.Thisisa relativelygood
response rate fora questionnaire,althoughitisstill verylow therefore reducingthe validityof
results.Questionnairesare knownforlack of validityasparticipantscannotexpresstheirtrue
feelingswhencompletingaquestionnaire.Althoughwithaquantitativequestionnairesuchasthis
one resultsare highlyreliable astheyare likelytobe similarif the studywasrepeated.Thiswasa

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large scale studyand therefore createdgreaterstatistical reliability,increasedexternal validityand
the sample ismore likelytobe representativeof the largertargetpopulation.
Chi et al. (2015) foundthat musicappearedtocause a statistical reductionincancerpainlevels
(P=0.027) afterlisteningtorelaxingmusicfor30 minutesfourtimesincomparisontothe control
group.Relaxingmusicwasdescribedas“aslow and constantrhythmwithorchestral effectsand
relaxingmelodies,predictable dynamics,harmonicconsonance,recognisable instrumental qualities,
a tempoof 60 to 80 beatsperminute (similartothe restinghumanheartrate) and low-frequency
tonesandpitch” (Chi etal.,2015). The efficacyof the methodologyisquestionable asthe
participantswere notblinded.Althoughtheyself-perceivedtheirpaintobe lower,the amountof
opioidusage betweeninterventionandcontrol groupsstayedthe same throughoutthussuggesting
a ‘Hawthorne’effect. Thisiswhere the participantswere conscious of the study’saimsand
measurementsof painwhichmayhave causedachange in theirbehaviourtoconformtosuitthe
needsanddemandsof the study.
Music and the Stress Response
It was foundthatduring2013-2014, 39% of all absencesatwork were due tostress(Healthand
SafetyExecutive,2014). Stressismostcommonlycausedbystimuli suchaswork,relationships,
moneyandpain,and isseenas a yellowmedical flag (Linton,2005). Literature suggeststhatmusic
may have an effectonthe autonomicnervoussystembyreducingthe activityof the sympathetic
nervoussystemandactivatingthe parasympatheticnervoussystem(Nilsson,2008).Thiseffectis
commonlyassessedbymeasuringself-perceivedstressandheartrate,diastolicbloodpressure,
systolicbloodpressure andrespiratoryrate whichare physiological indicatorsof the autonomic
nervoussystem(Yamishitaetal.,2006; Chan etal.,2007; Korhan et al.,2011; Lai and Li,2011; Liu
and Petrini 2015). Howeverthisliterature iswidelycontradictoryincludingstudiessuggestingmusic
has beneficial effectsonthese parameterswhereasothersproposingmusichaslittle ornoeffect.It
has beensuggestedthatthe cause of these contradictionsmaybe asa resultof the complexityof
music.Music iscomposedof melodies,rhythmandharmoniesandincludesrangesinpitch,volume,
tone and source (Yamishitaetal.,2006). These variablesmake researchwithmusiccomplicatedby
addinga complex dimensionasto whetheranyresearchresultshave been affectedbythe different
componentsof the musicusedor the interventionbeingstudied(Perez-Lloretetal.,2014).
Lai and Li,(2011) lookedatthe effectof listeningtomusicon biochemical markersof stressandself-
perceivedstressamongfirst-linenursesinTaiwan.The resultsindicate thatthose seated listeningto
musicreporteda significantreductioninself-perceivedstresslevels(P=0.05) anddecreasesin

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biochemical stressindicessuchasheartrate,fingertemperature,cortisol levelsandmeanarterial
pressure (P=0.05). 54 nurseswere contactedwhoself-perceivedthemselvestobe >6/10 on a
numericstressratingscale.The studywasa randomisedcontrolledcrossovertrial where subjects
were exposedtoeithera30 minute sequence of music thenchairrestora sequence of chairrest
thenmusic.Participantswere notblindedwhichmayhave ledtoa ‘Hawthorne’effectresultingina
lack of validity,andpoorexternal validityof the study.Howeverthe studywasrandomisedwhich
reducedpotential researcherbias.
Korhanet al. (2011) investigatedthe effectof musiconanxietybymeasuringchangesinblood
pressure,heartrate and respiratoryrate inpatientsreceivingmechanical ventilatorysupport.
Findingssuggestedthatmusiccanbe usedas a useful tool inreducingthese physiological changesin
comparisontoa control groupreceivingnomusic.A conveniencesample of 60participantswasused
to investigatethese changeswithone group(n=30) listeningtoclassical music,andthe othergroup
(n=30) in silence.After90minutesof musica significantdifferencewasobservedinreducingheart
rate (p=0.024), diastolicbloodpressure(P=0.001) and systolicbloodpressure(P=0.001) suggesting
that musicmay cause a reductionof anxietyandstresslevels.Howeverthisstudyfocusedon
patientsreceivingmechanical ventilatorysupportwho mayalreadyhave hadhighlevelsof anxiety
and therefore resultsmaybe exaggeratedinreducingthese physiological markersof anxiety.The
sample wasalsoa convenience sample andtherefore isunlikelytobe representative of the target
populationmeaningresultsare lessgeneralisable.
The findingsof Korhan etal. (2011) are congruentwiththose of Liuand Petrini (2015) whoexamined
the effectsof musiconpain,anxietyandothervital signsinpatientsafterthoracicsurgery.A total
numberof 112 participantswere usedinthisrandomisedcontrol clinical trial.The intervention
group(n=56) receivedstandardcare and30 minutesof musicforthree days,incomparisonto the
control group (n=56) whoreceivedonlystandardcare treatment.A significantdifferencebetween
groupswas detectedinthe reductionof pain(P=0.019),anxiety(P=0.020),systolicanddiastolic
bloodpressure (P=0.001) and heartrate (P=0.039), thus suggestingmusichelpsreduce pain,stress
and anxietyinpost-operative patients.Thisstudyusedalarge patientbase,anduseda gold
standardmethodologywitharandomisedcontrol trial.Howeverthe studywasnotblindedtoeither
participantsornursescontributingtothe studytherefore potential biasmaynothave been
eliminatedreducingvaliditydue toa ‘Hawthorne’effect.
However,challengingthese findingsChan etal. (2008) foundthatmusichad no significanteffecton
changesto heartrate after15 (P=0.551) or 30 minutes(P=0.326) of listeningtomusic.The 101

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participantsselectedfromanintensive care unitall listenedtomusicfor30 minuteswhile heart
rate,bloodpressure andrespirationrate were recordedbefore,at15 minute and30 minute
intervals.A similarrandomisedcontrol trial byTan etal. (2014) foundthat musichad no significant
effectonreducingsystolic(P=0.810) or diastolic(P=0.866) bloodpressure in100 participants.These
studiestherefore concludedthatmusiccannotbe usedto reduce heartrate (Chan et al.,2008) or
bloodpressure (Tanetal.,2014) respectively.
Music and Manual Therapy
Verylittle tonoresearchhas beencompletedinvestigatingthe effectsthatmusichason manual
therapyor more specifically,osteopathy.Mercadie etal. (2013) useda repeatedmeasuresstudy
designtoestablishwhethermusiccouldbe usedtoimprove osteopathicmanual therapy,andalsoto
establishwhethermusiccouldbe usedtoimprove empathybetweenosteopathandpatient.The
same 12 asymptomaticparticipantswere subjectedtothree differinggroupsandinterventions.
These groupswere synchronisedmusicwithboththe participantandthe osteopathlisteningtothe
same musicat the same time;desynchronisedmusicwhere the musicwasthe same but was
desynchronisedbetweenosteopathandparticipant; andacontrol group, where the participantsand
osteopathinvolvedlistenedtowhite noise.Havingwhite noise asacontrol meantthat the
osteopathandthe participantswere bothblindedtothe study.The interventionslasted20minutes,
and occurredonce a weekforthree weeks.Participantswereassessedbefore andaftereach
treatmentforheartrate, bloodpressure,andhow theyperceivedthe treatment.Resultssuggested
that musichad nosignificanteffectonheartrate,systolicordiastolicbloodpressure,although
participantsdidperceivetreatmentincludingmusictobe more pleasantandphysicallyeffective
(P=0.023). This studyuseda repeatedmeasuresdesignmeaninganordereffectmayhave been
seen.However,the orderof eachinterventionwasrandomisedforeachparticipanttoreduce the
chance of this.The studywas alsodouble blindedreducingpotential bias.Althoughresults
suggestedthatmusicwasnot a useful mediumwhenusedinconjunctionwithosteopathy,itwas
suggestedthatmore researchbe done usinga largersample size toimprove agreaterstatistical
reliability.
Similarlyanotherstudyaimedtoresearchthe effectsof musicasan analgesicforpainduring
physical therapy(Bellienietal.,2013). Resultsfoundthatmeanpainscaleswere lowerafterlistening
to music,thusagreeingwiththe hypothesisthatlisteningtomusiccan helptodecrease painlevels.
The study consistedof 25 adultpatientswhowere randomlygiventwophysical therapytreatments
for musculoskeletal pain: one withmusic,andone without.Theywere givenafive point
questionnaire before andaftertreatmentregardingtheirpainandstresslevelsonthatday.In the

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physical therapywithmusicgroup,astatistical significance (P=0.032) inthe reductionof painwas
found.Nostatistical significance wasreportedinthe reductionof physical therapywithoutmusic.
Physical therapywithorwithoutmusicwasnotfoundto have a statistical significance inreducing
stress.These resultssuggestthatmusiccouldbe auseful mediuminreducingpaininpatients
presentingtomanual therapistsformusculoskeletal conditions.Howeveritshouldalsobe
mentionedthatthe studysample wassmall andthereforenotveryrepresentative tothe larger
population.
Cooke etal. (2007) investigatedthe effectof aromatherapymassage withmusiconstressand
anxietyon365 emergencynurses.Onlyone groupwasusedwhichreducesexternal validityof the
study.Participantsreceived15minutesof aromatherapymassage whilstlisteningtomusicthrough
headphones.Lavenderaromatherapyspraymistwasusedbefore the massage,andmeasurements
of stress,anxietyandalsodataaboutsickleave were recordedbeforeandaftermassage.Results
suggestedthatanxietyandstresslevelsreducedaftermusicandmassage withthe majorityof
participantsperceivingthemselves(n=333) to have ‘noanxiety’aftertreatmentincomparisonto
participantsperceptionsbefore (n=59) the intervention.Itisunknownhow muchof an effectthe
aromatherapyspraymay have hadon participant’sreactionstothe intervention,makingitan
extraneousvariable tothe study. Evidence thatmusicandphysiotherapywasalsoseeninan
investigationbyHorne-ThompsonandBramley(2011) withreductionsinpainbeingseen in
terminallyillparticipantsafterreceiving40minutesof combinedphysiotherapyandmusictherapy
for eightweeks.
Gap in the Research
Currentlythere isnoresearchto suggestthatmusiccan improve the efficacyof osteopathicmanual
therapy inreducingstressandpainby measuringaparticipant’sself-perceivedstress,self-perceived
painand physiological measurementsof the autonomicnervoussystem:heartrate,diastolicblood
pressure andsystolicbloodpressure.
Researchsuggeststhatosteopathy isauseful tool inreducingpaininmusculoskeletal backpainas
seenbyLicciardone etal. (2003), Fryeret al. (2004), Licciardone,Brimhall andKing(2005),Bischoff
et al. (2006), Tempel etal. (2008), Mandara etal. (2010), Vismaraetal. (2012), Bjersa(2013), Orrock
and Myers(2013), Frank etal. (2014), Licciardone,KearnsandMinotti (2013), Licciardone etal.
(2014), Franke etal. (2015), and Pecos-martinetal. (2015). Howevermore researchisneededinthis
fieldtoincrease the knowledgeaboutthe efficacyof osteopathicmanual therapyon
musculoskeletal spinalpain.Manyof these studiesuse onlyone osteopathictechnique whichcauses

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a lack inexternal validity.More studiesincludingmultiple techniquesof osteopathicmanual therapy
that reflectsthatof normal clinical practice are needed.
On the otherhand osteopathyhasbeenseentocause pain.Bellieni etal. (2013) reportedthatit is
commonin clinical practice forpaintobe provokedbysimple eventssuchasspecial tests,passive
and active movementswhichcancause the patientacute pain.Bellini etal. (2013) suggestedthat
musiccouldalsobe usedtoavoidthe pain provokedbyosteopathy,eitherbybeingarelaxing
element,oradistractionforthe patient. Musichas beenseenasa useful mediuminreducingpain,
howeverthese observationsare oftenfoundusingparticipantssuchascancerpatients(Chuang,
2010), hospitalisedpatients(Chan etal.,2007; Korhan et al.,2011), and inpatientsaftersurgery
(Vaajoki,2011; Liu andPetrini, 2015). These participantsdonot representthe majorityof
osteopathicpatientsvisitingosteopathsformusculoskeletal pain(Penney,2010).There are also
inconsistenciesinwhethermusicreducespain,andsoitis suggestedthatmore researchisneeded.
Osteopathyhasalsobeenobservedtohave effectsin activatingthe PNS branchof the ANSand in
doingso inhibitingthe SNSandreducingstress(Weze etal.,2007; Henderson etal.,2010; Dugailly et
al.,2012; Turkeltaub etal.,2014). Howeverresearchiscontradictorywithotherstudiesincluding
that by Wiegand etal.,(2015) suggestingthatosteopathydoesnotreduce participant’sself-
perceivedstressanddepressionlevels.
Similardiscrepanciesare seeninresearchregardingthe ANSwhenusingmusicasanintervention
(Yamishitaetal.,2006; Chan et al.,2007; Nilsson,2008; Korhan etal., 2011; Lai and Li, 2011; Liuand
Petrini 2015). Measurementsof heart rate and bloodpressure are recordedasindicesof the ANS,
and researchiscontradictoryas to whetherornot musicreducesheartrate,diastolicandsystolic
bloodpressure.Ithasbeensuggestedthatthismaybe because musicisa complex medium.
There isminimal researchregardingthe use of musicasa mediumforimprovingosteopathicmanual
therapy.There haspreviouslybeeninvestigationsintothe effectsthatsynchronisedand
desynchronisedmusichasonosteopathicmanual therapyandperceivedempathybetween
practitionerandpatient(Mercadie etal.,2013). Mercadie etal. (2013) callsformore researchinthe
fieldof osteopathyandmusic.The lackof researchholdstrue inotherprofessionsof manual therapy
such as physiotherapyandchiropractic.
Althoughsome researchexiststhere isstillaneedformore regardingthe use of musicand manual
therapyforthe treatmentof painandstress.By carryingout thisresearchthe resultsand
conclusionscanbe usedto furtherinvestigate the effectsof musicandosteopathyonstressand

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painin patientspresentingtoan osteopathicclinicwithmusculoskeletal spinal pain. Thishasthe
potential toimprove qualityof care forpatientsbyreducingtheirstressandperceivedpain. This
leadstothe question,canmusicbe usedin conjunctionwithosteopathicmanual therapy to
decrease stressandpaininpatients presentingtoanosteopathicclinicwithnon-peripheral
musculoskeletal disorderscompared toosteopathicmanual therapy withoutmusic?
Aims
Thisstudyaimsto establishwhether musiccanbe usedas a useful mediumin conjunctionwith
osteopathicmanual therapyinreducingindicatorsof stressandpaininpatientswithnon-peripheral,
musculoskeletal backpain (paincausedbythe muscularor skeletal system).
Hypothesis
Music and osteopathicmanual therapy combinedwill have alargereffectonreducing indicatorsof
stressand paininparticipantswhencomparedto osteopathicmanual therapy alone.These
indicatorsare perceivedpain,perceivedstress,bloodpressure andheartrate.
Null Hypothesis
Music and osteopathicmanual therapy combinedwill have noeffectonparticipant’sperceivedpain,
perceivedstress,bloodpressure orheartrate whencomparedto osteopathicmanual therapy alone.
Method
Methodological Approach
To accuratelyrepresent the constructsstressand pain,a randomisedcontrol trial usinga
quantitative methodological approachwasused.Thisdesignwaschosen tobestinvestigate whether
musicand osteopathicmanual therapycombinedcanbe usedto reduce stressand paininpatients
withinanosteopathicclinical practice. Randomisedcontrol trialsare recognisedasa‘goldstandard’
for producingconclusiveevidence of the subjectbeinginvestigated (Akobeng,2005; Bondemark&
Ruf,2015). Participants of thisstudy were randomlyallocatedtoeither receiveosteopathicmanual
therapy alongwithmusic(interventiongroup) orosteopathicmanual therapyalone (control group).
By usingrandomisationof the twogroups, selectionandallocationbias isreducedthusimproving
internal validity.Randomisationalsomeantanyextraneousvariablesof external activitiessuchas
dailystressorscouldbe ruledoutas theywouldbe equal inboththe interventionandcontrol group.
Havingresultsfroma control givesbaselinedatainwhichreliablestatistical testscan be usedto
investigatewhetheranyeffectsare true effectsordue to randomerror. Statistical tests canthen

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helpformulate whetherthe null hypothesis orthe hypothesis canbe supported. A negativecontrol
groupwas usedto recognise whetheranyconfoundingvariablesorpotential biaseswereaffecting
results.Internal validity isimproved withthe use of acontrol and the randomisationof groups,
althoughthe methodof recruitingparticipantswasnotrandomisedandthusreduces validity
(Shuttleworth, 2008).
The fellowfourthyearosteopathicstudents recruited foradministeringtreatmentto the twogroups
were blindedastowhetherparticipantswerelisteningtomusicthroughearphonesornot.This
helpedeliminate apotential ‘Hawthorne’effectwherebythe osteopathsconformedtothe aimsof
the research.A double-blindedstudywouldhave helpedtoreduce potential biasfurther.However
thiswas notpossible because participantswouldbe aware asto whethertheywere listeningto
musicor not. By usinga randomisedcontrol trial methodology itwasmore likelythatacausal effect
be identified betweenmusicandosteopathyonthe constructs stressandpain (Hoet al.,2008).
Quantitative dataof the indicesof stressandpain wascollected toallow forreliable statistical
analysisandcomparisons toinvestigatethe cause-and-effectrelationshipbetweenmusic,
osteopathy, stressandpain. Usinga quantitative approachmay potentially improvereliability and
produce resultsthatare easily replicabledue tothe objectivenature of thisdata. The outcome
measurementsusedforthispiece of researchreflectevery-dayappointmentsinosteopathicclinical
practices makingthemmore easily generalisable tothe targetpopulationof patientsseeking
osteopathicmanual therapy.Usingthese indices helpedtoimprove external validityof the study.
Quantitative datainherentlylacks truthvalue asdatagatheredisnotan in-depthrepresentation of
participant’s true responses(Hickson,2008).Qualitative researchis oftenmore in-depthintermsof
the truth value with resultsfrequently reflectingopinionsandattitudes.Howeverthistype of
research oftenlacksreliabilityand ishard to generalise tothe targetpopulationthereforemakingit
difficulttoreproduce (Hickson,2008).
Havinga methodological designusingasingle blinded,randomisedcontrol trial meansthatthe
constructsof stressandpain are accuratelyrepresentedininvestigatingthe effectsthatmusicand
osteopathy have onthese indices.
Recruitment and Participation
Thisstudytook place at the studentosteopathicclinic, QueensSquare WellnessCentre using the
available treatmentrooms.Permissionwas grantedfromthe clinictocarry out the research and
ethical approval wasgrantedbyLeedsBeckettFacultyof HealthandSocial Science ResearchEthics

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Committee. The participantsappropriateforthisresearchprojectwere patientsattendingthe Leeds
BeckettUniversityosteopathicstudentclinic fora diagnosednon-peripheral musculoskeletal spinal
disorderoverthe periodof 2015/2016. That is,patientsattendingthe clinicforpurelyneck,upper,
midor lowerback paincausedbythe musculature and/orskeletal system.
Usingquantitative researchmeantthatthere wasneedfora large participantquotatoavoidType II
statistical error.Thisiswhere conclusionsof resultsreject the null hypothesisbutatthe same time
the null hypothesiscannotbe rejecteddue tothe datacollected. A powercalculation (Survey
System,2012) indicatedthatasample of 96 wouldbe neededwithaconfidence intervalof 95% and
a confidence level of 10takingintoaccount the 30,000 patientswhosee anosteopath inthe UK per
year(General OsteopathicCouncil,2006).
Participantswere recruited usingaposter(Appendix 1) placedinthe receptionarea andtreatment
roomsof QueensSquare WellnessCentre forcurrentpatientstoview.A patientwhomatched the
inclusioncriteriaonthe posterand whoshowedaninterestinpartaking inthe study were advisedto
requestaparticipantinformationsheet (Appendix2) andconsentform(Appendix 3).Usingthis
technique ensuredthatparticipationwasvoluntary,asparticipantswere abletodecide whetheror
not theymetthe criteriaand hadthe time todecide if theywantedtocommitto the studyor not.
Volunteersamplingisanethicallysound andadvantageous formof samplingintermsof
convenienceandtime.Alongsideopportunitysampling itismostcommonlyusedin clinical settings,
such as the osteopathicstudentclinic.However,volunteersamplingisunrepresentative tothe
entire targetpopulation of osteopathicpatients asitleadstoparticipantbias as certainparticipants
are more attractedto the posterandtherefore are more likelytovolunteer(McLeod,2014).
The gold standard samplingmethodwouldbe the use of randomsamplingmeaningall patients
attendingthe studentosteopathicclinic wouldhave hadanequal andunbiasedchance of being
selected.Howeverthistype of samplingwouldhave beentime-consuming,and doesnotalways
resultina representative sampleof the targetpopulation (McLeod,2014). Thissamplingmethodis
alsolessethicallysoundasthose chosenmaynot normallyvolunteerandtherefore mayhave felt
pressuredintoparticipating.
Patientswithadiagnosednon-peripheral musculoskeletaldisorderwere usedtoeliminate a
confoundingvariables causedfromdifferencesinthe source andthe type of pain.The difference in
the area of neckor back painmay have causeda variable tothe study,howeverthe studywas
investigatingthe level of painthe participantperceivedthemselvestobe in,ratherthan the area or
form.

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Participantswere attendingthe clinicwithaself-perceivedverbal numericpainscore (1almostno
pain- 10 highestlevelof pain) between>4and<8. Participantswhose self-perceivedpainwashigher
than a score of 8 onthe numericpainratingscale were excludedastheyare classedasvulnerable
and are unlikelytobe treatedinanosteopathicclinic. Participants alsoperceivedthemselvestobe
stressedona verbal numericscale of 1 (almostnostress) to10 (highlevelof stress) withtheirscore
betweenthe rangesof >4 and <10. The ranges over4 were chosenbecause itwas thoughtthat
patientswithhighlevelsof stressandpainpriortoresearchmay give a largereffecttothe results
than if theirlevel of stresswere low atthe start(Lai & Li, 2011). Participantshadnoknownhearing
difficultiestoenable themtolistentomusicthrougha single-sidedBluetoothheadset whilst
listeningtotheirosteopath.
Participantswere excludedif theyhadanyknowncardiovascular conditions,orif theywere taking
any medicationthatcouldaffectheartrate or bloodpressure.Thiswastopreventanyconfounding
variables affectingthe physiological indicatorsof stressandthereforethe resultsof the study.
Participantswere alsoexcludedif theyhadimpairedhearingorwere under18 who were deemedto
be vulnerable andwhocouldnotgive validinformedconsentwithoutthe needforachaperone.
Finally,participantswere excluded whocould notgive consent,i.e.those whocouldnot speak
English.
Afterreceivingtheirparticipantinformation sheet(Appendix 2) andconsentform (Appendix 3),
participantswere askedtobringthe inclusion andexclusion criteria(Appendix4) andthe health
screeningquestionnaire (Appendix 5) completed alongwiththe consentform (Appendix 3) totheir
nextappointment.The participantwasgivenatleast24hoursfor thisinorder to make an informed
decision.
On arrival of theirnextappointmentthe leadresearchercheckedandsignedtheircompletedforms.
If participantsmatchedall the inclusion criteriatheywere randomlyallocatedusingsealed
envelopes(Appendix6) toone of twogroups: musicwithosteopathic manual therapy orosteopathic
manual therapywithoutmusic.
Before anymeasurementswere taken,the participantwasgiventenminutesrestingtime during
theirconsultationtoavoidanyincreasedindicatorsof stressfromtheirjourneytothe clinic(i.e.if
they had run totheirappointment,measuresof heartrate andbloodpressure would be elevated).
Theirbloodpressure and heartrate was recordedusingthe bloodpressure monitor.Thiswasalways
appliedtothe leftarmto standardise the process.Their self-perceivedpainandself-perceivedstress

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were alsomeasuredandrecordedontheirparticipant recordsheet(Appendix 7) bythe lead
researcher.
All participantswore the single-sidedheadsettoblindthe leadosteopathastowhichgroup the
participantwasin. If the participant wasa part of the ‘musicgroup,’ ‘Musique de Soins:Osteopathie’
(Dury,2004) was playedthrough the single-sidedBluetoothheadset.The type of musicforthisstudy
was controlledbyusingthe same trackto avoidextraneousvariablessuchasdifferences inmusic
causingan effectondata. ‘Musique de Soins:Osteopathie’ (Dury,2004) had beencreatedforthe
use as backgroundmusicin osteopathicclinical settings, similartobackgroundmusicdesignedfor
customersinshoppingcentres(Armitage,2015). Thisparticularmusicwas usedduringa study
regardingmusicandosteopathy byMercadie etal. (2013). ‘Musique de Soins:Osteopathie’ (Dury,
2004) wasusedas the independentvariable and isamixture of classical musicandnatural sounds
whichhas beenfoundtobe a relaxingformof musicincomparisontosittinginsilence orlisteningto
otherstylesof music,suchas heavymetal (Labbe etal.,2007). Labbe et al.,(2007) observedthat
self-selectedmusicwasthe mosteffectiveform forreducingstresslevelsin56 college students.
These conclusionswere made afterself-selectedmusicwasseen
to significantlyreduce state-anxietylevels(P=0.01),heartrate
(P=0.00), state anger(P=0.00) and statistical increase in
relaxationlevels(P=0.00) inthisrandomcontrol trial.
The participantwasinstructedbythe leadresearcheronhow to
adjustthe volume of the headsettoa volume thatrepresented
backgroundmusic– ‘unobtrusiveaccompanimenttoanactivity’
(Dictionary.com, n.d.). The volumewasneverloudenoughtobe heardbyanyone otherthanthe
participant. Theywere alsoadvisedthatif atany pointthe headsetbecame uncomfortablethey
shouldremove it,howeverindoingsoterminatingtheir participation.The single sidedBluetooth
headsetwasrequiredtobe wirelesstoavoidinterruptionandobstructionof treatment.Itneededto
be one sidedinorderfor the participanttobe capable of hearingthe leadosteopath.The
PlantronicsVoyagerLegendBluetoothMonoHeadsetwasappropriate forall of the criteriaspecified
(Figure 1). Lastlythe earpiece wasdisinfectedandcleanedbeforeandaftereveryuse usingsterile
wipes.
Osteopathicmanual therapywasthen appliedfor15 minuteswhichincludedarange of techniques
that the leadosteopathdeemedappropriateforthatindividual patient.Thisimprovedthe external
Figure 1. (Amazon,2014)

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validityof the studybyaimingtokeepthe participant’sexperience asclose toa normal osteopathic
consultationandtreatmentasroutinelypossible.
Immediatelyaftertreatmentthe leadresearchermeasuredandrecordedthe participant’sblood
pressure,heartrate,self-perceivedpainandself-perceivedstressforthe secondtime.The
participantwasthengiventhe debriefingdocument (Appendix 8).Bymeasuringthe participants
immediatelyaftertreatmentthe errorcomponentof potential environmental changeswasreduced.
However,participantscompletingthe studydidsoat differenttimesof the daywhichmayhave
increasedthe chance of environmental changescreating error.Thiserrorwascontrolledusingthe
same technique of measuringheartrate,bloodpressure and self-perceivedstressandpain.
All data wastransferredtoone encryptedexcel document(Appendix9). Fellowfourthyear
osteopathystudents competentinosteopathicmanual therapywere recruitedfor the applicationof
treatment(Appendix10).They were blindedtothe studyandwere unaware whetherornottheir
patientwaslisteningtomusicduringtreatment.Consent(Appendix 11) wasgained fortheir
participationinthisstudy. A Gantt chart (Appendix 12) anda flow diagramillustratingthe
participationprocess(Appendix13).
Ethical Considerations
Thisstudygainedethical approval onthe 17th
of October2015.
The participants’ full historyof healthwasknownpriortothe studycommencingandany participant
deemedunsafe totreatosteopathicallywere unable topartake inthe study. Atthistime theywere
advisedtoseekappropriate treatment.
Duringthe study,participantswere requiredtodress downintotheirunderwearorshortsand a lose
t-shirt.Thisiscommonpractice duringosteopathicexaminationandtreatmentandconsentwas
gainedandpatientdignity upheldbythe osteopathsinvolved.Osteopathicexaminationand
treatmentincludesphysical touchthroughout,consentwas gainedbythe leadosteopath.
As withall osteopathicmanual therapy therecouldbe temporaryside effectssuchaslocal painand
discomfort.Ina studyregardingadverse effectsdue to osteopathicmanual therapy,4% of patients
were foundtohave worseningsymptomsforuptotwo dayspost-treatment,andseriousside-
effectswere seentobe rare (BritishSchool of Osteopathy,2014).All studentosteopaths were
supervisedbyatutorin clinic,and were considered safe asosteopathicpractitioners. Treatment
couldnot be controlledas itwould have beenunethical totreatall participantsinthe same way,

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“The emphasisisontreatingthe individual,takingall theircircumstancesintoaccount,ratherthan
justtreatingthe condition”(EuropeanSchool of Osteopathy,2015).
The Data ProtectionActof (1998) statesthe importance of keepingdatafroman identifiable human
source anonymisedtopreventanyunauthorisedpersonsseeingit(BBC,2014). Appropriate
safeguardingof informationandresultswere filedinsecure lockingcabinetsinthe student
osteopathicclinic,orona secure personal computersystemwithpasswordprotectionenabledonall
files.All datawas anonymisedandaparticipantnumberusedtoreplace names.Onlythe researcher
and supervisorsawthe informationandresults.The data will be retainedforaminimumof five
yearswiththe suggestedamountof time being15 years,withelectronicsourcesbeingregularly
backedup (Hickson,2008). Afterthisallottedtime the datawill be permanentlydestroyedfromany
electronicsources,andanypapersourceswill be shredded.
Participantswere giventhe optiontowithdraw duringthe studywithout reason,andany
informationgainedfromthemwouldbe excluded.
Method of Data Collection
The dependentvariablesof stressandpainare complex themesthatmake the measurement
procedure difficultinproducinganaccurate representationof these subjects.Three different
measurementoutcomes forstresswere usedtoallow forcomparisonsbetweenself-perceived
stressand the physiological measurementsof stress. Thesemeasurementoutcomeswere self-
perceivedstress,heartrate andbloodpressure. Self-perceivedpainwasalsomeasuredto
investigatethe effects thatosteopathyandmusichadonthis construct.
To record measurementsof bloodpressureandheartrate the OmronM6 comfortbloodpressure
monitorwasused. A validationpaperbythe EuropeanSocietyof Hypertension(ESH) (Chahine etal.,
2014) wasproducedforthe Omron M6 Comfort device whichfoundthatitachievedapass
regardingthe ESH International Protocol Revision2010 requirements (O’Brienetal.,2010). The
OmronM6 Comfortdevice wasauthenticatedinapaper(Colemanetal.,2008) whichfoundthatit
achievedGrade A for systolicanddiastolicbloodpressure measurementsinregardstothe protocol
setout by the BritishHypertensionSociety (O’Brienetal.,1993). Inthis same studythe device was
alsofoundto be accurate enoughtosatisfythe Advancementof Medical Instrumentation
requirements (Whiteetal.,1993).
Otherformsof measuringthe physiological markersof stresscouldhave been:measuringlevelsof
cortisol insaliva,bloodorurine;vagal tone of the parasympatheticnervoussystemorsalivaryalpha-

Page | 30
amylase levels (El Feghalietal.,2007). However,these measurements were notappropriate forthis
environmentandresearchproject,andwould needcomplex machinery,andbiochemistrytobe
considered.The use of simply measuringbloodpressureandheartrate were deemed more suitable
for clinical use asthey are commonlymeasuredinanosteopathicclinical settings.
“The patient’sself-reportisthe mostaccurate and reliableevidence of the existence of painandits
intensity,and thisholdstrue forpatientsof all ages,regardlessof communicationorcognitive
deficits”(HerrandGarand, 2001).
The easiestsolutiontoenumeratehealth
isto ask for an estimatednumber
(McDowell,2006). Measurementsof self-
perceivedstressandself-perceivedpain
were found usingaNumericRatingScale
(NRS) (Figure 2) between 1and10.
Hjermstadetal. (2011) identifiedthe NRS
as a useful tool inmeasuringself-reported
painintensityinmostsettings.The NRS
was foundtobe more sensitive inself-
ratedpain incomparisontothe Verbal AnalogueScale (VAS),the Verbal RatingScale (VRS)andthe
FacesPainScale-Revised(FPSR).The NRSwasalsofoundtohave a higherlevel of responsivity(that
isthe numbersbetween 1and 10 were usedequallytoeachother) butalsodetecteddifferencesin
genderintermsof pain perception (Ferreira-Valente,Pais-RibeiroandJensen,2011). It is free and
easyto use,andis commonlyusedin osteopathicclinicstorate painlevels.Osteopathsare
comfortable withthe NRSandcan explainitwithease topatients.Itisthe mosteffectivewayof
measuringhealthinthe formsof painandstressand is foundtobe just as effective asawhole
questionnaire (McDowell,2006).
Method of Data Analysis
Data was anonymisedand collectedfromparticipants andanalysedusingSPSS(Statistical Package
for the Social Sciences) software. Inordersupportorrejectthe null hypothesisa pairedsample t-test
was usedtoinvestigate whetherthere wasasignificantdifference between the meansof eachof
the four dependentvariables before and aftertreatment.Thiswasused totheninvestigate whether
there wasa statistical significance betweenthese outcomes withorwithoutmusicusinga95%
confidence interval and significance value of 0.05.
Figure 2. (McCafferyandPasero,1999)

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Results
Data was collected from12 participants whowere returningpatientsvisitingQueensSquare
WellnessCentreforadiagnosednon-peripheral musculoskeletal disorderpriortothe study. The
participants were agedbetween21and 75. Demographicdatawas recorded fromparticipantsand
can be seeninTable 1.
Demographic Characteristics Intervention (N=6) Control (N=6) Total P value
Age
43.33 36.00
39.17 0.525
Female 3.00 4.00 3.50 1.00
Male 3.00 2.00 2.50 1.00
Weight (kilos) 65.33 61.83 63.58 0.764
Height (feet and inches) 5.72 5.78 5.75 0.785
Table 1: Meandemographical databetweenthe twogroups.
Figure 1. Differencebetween heart ratebefore(M=75.33, SD=5.32) and after(M=74.33, SD=8.76)
the musicintervention t(5)0.297, p=0.778. Error bars(P=0.05) havea confidenceinterval of 95%.
Heart Rate Before and After Musicand OsteopathicManual Therapy Intervention

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Heart Rate
An observabledifference canbe seenbetweenthe meanheartrate before (M=75.33, SD=5.32) and
after(M=74.33, SD=8.76) osteopathicmanual therapywithmusic althoughthisdifferencesisnot
statisticallysignificant t(5)0.297, p=0.778. Thissuggeststhat the variance was more likely due to
chance and random error.Figure 1 illustratesthe difference of heartrate before andafter
osteopathicmanual therapy withmusic.The errorbarson the chart overlapindicatingthere isno
statistical significance betweenthe measures of heartrate.
Similarlynostatistical significanceof heartrate was observedinthe control groupbefore (M=73.33,
SD=9.83) and after(M=71.83, SD=9.66) osteopathicmanual therapywithoutmusic t(5)0.416,
p=0.694. Figure 2 shows these results. Once againthe errorbars overlap meaningnostatistical
significance wasfound.
A comparisonof the change in heartrate before andafterosteopathicmanual therapybetweenthe
musicgroup (M=74.83, SD=5.96) and the control group (M=72.58, SD=8.69) showednostatistical
significance t(5)0.679,p=0.528. Thiscan be visualisedinFigure 3.
Heart Rate Before and AfterOsteopathic Manual Therapy without Music
Figure 2. Differencebetween heart ratebefore(M=73.33, SD=9.83) and after(M=71.83, SD=9.66)
osteopathicmanualtherapy (control) t(5)0.416,p=0.694. Error bars(P=0.05) havea confidence
interval of 95%.

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Systolic Blood Pressure
No statistical significance wasobservedbetween systolicbloodpressure before (M=113.83,
SD=10.52) and after(M=107.17, SD=9.89) treatmentwithmusic;t(5)2.118, p=0.088. The error bars
do notoverlap inFigure 4 demonstratingnostatistical significance betweenthesemeasures.
Similarfindingsintermsof statistical significance canbe seen between systolicbloodpressure
before (M=119.17, SD=11.34) and after(M=119.33, SD=13.38) osteopathicmanual therapy without
musict(5)0.087, p=0.934 (Figure 5).
Lastly there wasno statistical significance t(5)1.293,p=0.253 foundbetween the systolicblood
pressure of the groupwithmusic(M=110.50, SD=9.45) and the group withoutmusic(M=119.25,
SD=12.18). Thistherefore suggests thatthe use of musicinconjunctionwith osteopathicmanual
therapy doesnothave a significanteffectondecreasing systolicbloodpressure therefore supporting
the null hypothesis.Thisisillustratedin Figure 6where the errorbars overlap.
A Comparison of Heart Rate between Osteopathic Manual Therapy with and without Music
Figure 3. Differencebetweenheart ratewith music (M=74.83, SD=5.96) and withoutmusic
(M=72.58, SD=8.69) and osteopathicmanualtherapy t(5)0.679,p=0.528. Error bars(P=0.05) have
a confidenceintervalof 95%.

Page | 34
Systolic Blood Pressure Before and After Music and Osteopathic Manual Therapy Intervention
Figure 4. Differencebetween systolic blood pressurebefore(M=113.83, SD=10.52) and after
(M=107.17, SD=9.89) the musicintervention t(5)2.118, p=0.088. Error bars(P=0.05) havea
confidenceintervalof 95%.
Systolic Blood Pressure Before and After Osteopathic Manual Therapy without Music
Figure 5. Differencebetween systolic blood pressurebefore(M=119.17, SD=11.34) and after
(M=119.33, SD=13.38) osteopathicmanualtherapy (control) t(5)0.087,p=0.934. Error bars
(P=0.05) havea confidenceintervalof 95%.

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Diastolic Blood Pressure
No statistical significance wasseenbetween diastolicbloodpressure before(M=72.33, SD=5.16) and
after(M=70.50, SD=5.65) osteopathicmanual therapy withmusict(5)0.885, p=0.417. A visualisation
of thisis illustratedin Figure 7.
There wasalso nosignificantdifference inthe control group t(5)0.000, p=1.000 betweenthe mean
scoresof diastolicbloodpressure before (M=78.67, SD=11.38) and after(M=78.67, SD=7.99) Thiscan
be seenin Figure 8.
The resultsof diastolicbloodpressure betweenthe twogroupscanbe viewedinFigure 9.The
diastolicbloodpressurebetweenthe music(M=71.42, SD=4.78) group and the non-musicgroup
(M=78.67, SD=9.36) wasnot statisticallysignificant;t(5)1.459,p=0.204. Suggestingthatmusicduring
osteopathicmanual therapy doesnothave asignificanteffectondecreasingthe meandiastolic
bloodpressure supportingthe null hypothesis(Figure 9).
A Comparison of Systolic Blood Pressure between Osteopathic Manual Therapy with and
without Music
Figure 6. Differencebetweensystolic bloodpressurewithmusic (M=110.50, SD=9.45) and
withoutmusic(M=119.25, SD=12.18) and osteopathicmanualtherapy t(5)1.293,p=0.253. Error
bars(P=0.05) havea confidenceintervalof 95%.

Page | 36
Diastolic BloodPressure Before and AfterMusic and Osteopathic Manual Therapy Intervention
Figure 7. Differencebetween diastolic blood pressurebefore(M=72.33, SD=5.16) and after
(M=70.50, SD=5.65) the music interventiont(5)0.885, p=0.417. Error bars(P=0.05) havea
Diastolic Blood Pressure Before and After Osteopathic Manual Therapy without Music
Figure 8. Differencebetween diastolic blood pressurebefore(M=78.67, SD=11.38) and after
(M=78.67, SD=7.99) osteopathicmanualtherapy (control) t(5)0.000,p=1.000. Error bars(P=0.05)
havea confidenceintervalof 95%.

Page | 37
A Comparison of Diastolic Blood Pressure between Osteopathic Manual Therapy with and
without Music
Figure 9. Differencebetween diastolic blood pressurewith music (M=71.42, SD=4.78) and without
music (M=78.67, SD=9.36) andosteopathicmanualtherapy t(5)1.459,p=0.204. Error bars(P=0.05)
Self-Perceived Pain Before and After Music and Osteopathic Manual Therapy Intervention
Figure 10. Difference between self- perceived pain before(M=4.83, SD=0.98) and after(M=2.50,
SD=2.50) the musicinterventiont(5)2.445, p=0.58. Error bars (P=0.05) havea confidenceinterval
of 95%.

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Self-Perceived Pain
A statistical significantdifference wasnotfoundbetweenself-perceivedpain scores before (M=4.83,
SD=0.98) and after(M=2.50, SD=2.50) treatmentwithmusic;t(5)2.445, p=0.58. Thisdifference can
be seenin Figure 10.
There wasa statistical significantdifference betweenself-perceivedpain scores before (M=4.67,
SD=1.21) and after(M=2.67, SD=1.37) treatmentwithoutmusic;t(5)7.746,p=0.001. Thisstatistical
significance canbe viewedin Figure 11where the error bars donot overlap.
There wasno statistical significance t(5)0.000,p=1.000 betweenthe participant’s self-perceivedpain
inthe music(M=3.67, SD=1.51) groupcomparedwiththe non-music(M=3.67, SD=1.35). This
suggestsmusicduring osteopathicmanual therapy doesnothave asignificanteffectondecreasing
the meanself-perceivedpain incomparisontotreatmentwithoutmusic.Thiscanbe seeninfigure
12 where the errorbars overlapwhichsupportsthe null hypothesis.
Self-Perceived Pain Before and After Osteopathic Manual Therapy without Music
Figure 11. Difference between self-perceived pain before(M=4.67, SD=1.21) and after (M=2.67,
SD=1.37) osteopathicmanualtherapy (control) t(5)7.746,p=0.001. Error bars (P=0.05) havea

Page | 39
Self-Perceived Stress
There wasa statistically significantt(5)6.742,p=0.001 difference foundbetweenself-perceived
stressscoresbefore (M=8.00, SD=1.10) and after(M=4.67, SD=1.97) treatmentwithmusic. This
significantdifferencecanbe viewedin Figure 13where the errorbars do not overlap.
Figure 14 representsastatistically significantt(5)7.050,p=0.001 difference betweenself-perceived
stressbefore (M=6.17, SD=1.83) and after(M=4.00, SD=1.90) treatmentwithoutmusic.
The differencesof self-perceivedstress scoresbetweenthe music(M=6.33, SD=1.47) groupand the
non-music(M=5.08, SD=1.83) groupwere not statisticallysignificant t(5)1.091,p=0.325. This
suggestsmusicduring osteopathicmanual therapy doesnothave asignificantlydecreaseself-
perceived stressandsosupportsthe null hypothesisasseeninFigure 15.
A Comparison of Self-Perceived Pain between Osteopathic Manual Therapy with and without
Music
Figure 12. Difference between self-perceivedpainwithmusic (M=3.67, SD=1.51) andwithout
music (M=3.67, SD=1.35) and osteopathicmanualtherapy t(5)0.000,p=1.000. Error bars(P=0.05)

Page | 40
Self-Perceived Stress Before and After Music and Osteopathic Manual Therapy Intervention
Figure 13. Difference between self- perceived stress before(M=8.00, SD=1.10) and after(M=4.67,
SD=1.97) the musicinterventiont(5)6.742, p=0.001. Error bars(P=0.05) havea confidence
interval of 95%.
Self-Perceived Stress Before and After Osteopathic Manual Therapy without Music
Figure 14. Difference between self-perceived stressbefore(M=6.17, SD=1.83) and after(M=4.00,
SD=1.90) osteopathicmanualtherapy (control) t(5)7.050,p=0.001. Error bars(P=0.05) havea

Page | 41
Discussion
A randomisedcontrol trial wasdesignedinanefforttoanswerthe question;canmusicbe usedin
conjunctionwithosteopathicmanual therapytodecrease stressandpaininpatientspresentingwith
non-peripheral musculoskeletal disorderscomparedtoosteopathicmanual therapywithoutmusic.
Thisstudyhypothesisedthatmusicandosteopathywouldhave alargereffectonreducingstressand
painin participantswhencomparedtoosteopathicmanual therapyalone.Datawascollectedon
heartrate, bloodpressure,self-perceivedpain,andself-perceivedstress.The resultsof thisstudy
suggestedthatthe hypothesiscannotbe supported,andtherefore the null hypothesisisassumedto
be true.
Heart Rate and Blood Pressure
Elevatedheartrate and bloodpressure are physiological indicatorsof stressandthe stressresponse.
The effectthatmusichas had on these indiceshasbeenvariedandcontradictoryinliterature.Some
researchsuggeststhatmusicreducesheartrate andbloodpressure (Korhanetal.,2011; Lai and Li,
A Comparison of Self-Perceived Pain between Osteopathic Manual Therapy with and without
Music
Figure 15. Difference between self-perceived stresswith music (M=6.33, SD=1.47) and without
music (M=5.08, SD=1.83) andosteopathicmanualtherapy t(5)1.091,p=0.325. Error bars(P=0.05)

Page | 42
2011; Liu andPetrini,2015) and othersincluding Chanetal.(2008) andTan etal. (2014) suggests it
doesnot.
In thisstudyitwas foundthat musicdidnothave a statistical significance onreducingheartrate
(P=0.694) whenusedinconjunctionwithosteopathic manual therapy.Thisresultisinaccordance
withChanet al.(2008) who foundthatmusichad no statistical significanteffectonheartrate in
participants.
Similarly,neithersystolic(P=0.088) nor diastolicblood (P=0.417) pressure were foundtobe
significantlyaffectedbymusicandosteopathycombined.Thisfindingisconsistentwiththatof Tan
et al.(2014) whofoundthat ina studyof 100 participants,musicwasnotobservedtohave a
significanteffectonsystolicordiastolicbloodpressure.These findingsuggeststhatheartrate and
bloodpressure asphysiological indicatorsof stressare notreducedbymusicand osteopathic
manual therapycombinedandthussupportingthe null hypothesis.
Self-Perceived Pain
Anotherfindingthatassumesto supportthe null hypothesiswasthatof self-perceivedpain.Self-
perceivedpaindidnotsignificantlydecrease (P=0.58) withmusic.Literature hassuggestedthat
musicshouldbe a useful tool inreducingpainlevels(Mitchell etal.,2007; Horne-Thompson and
Bramley,2011; Bellienietal.,2013) whichis contradictorytothe findingsinthisstudy.
Self-Perceived Stress
On the contrary self-perceivedstresswasfoundtosignificantly(P=0.001) decrease afterthe
interventionof musicandosteopathicmanual therapycombined.However,thisfindingwasalso
seeninthe control group.There was alsono statistical significancebetweenthese twogroups
suggestingosteopathicmanual therapyalonereducesstress,andthatmusichad noeffect.These
resultscoincide withasimilarstudybyTurkeltaubetal.(2014) wherebyhigh-intensitymassagewas
seentoreduce self-perceivedstresssignificantly.Otherevidence of thishasbeenobservedinsimilar
therapiesthatuse directtechniquesinvolvingtouchsuchaswithmassage (Cooke etal.2007) and
physiotherapy(Horne-ThompsonandBramley,2011).
What does all this suggest?
Resultsof thisstudysuggestthatmusicis not a useful mediumwhencombined withosteopathic
manual therapyinreducingstressandpainin patientspresentingtoan osteopathicclinic.These
conclusionsare suggesteddue tonosignificantdifference beingobserved inthe interventiongroup
for heartrate,bloodpressure, self-perceivedstressand self-perceivedpainincomparisonto

Page | 43
osteopathicmanual therapyalone.Musichasbeenseenasa complex theme withmultiple
dimensions(Yamishitaetal.,2006; Perez-Lloretetal.,2014) therefore suggestingthatmusicmaybe
exceedinglydifficulttouse andcontrol for researchpurposes.Havingsaidthat,the musicof this
studywas controlledusingone trackof music.This controlled the variablesthatdifferentmusic
typesmayhave presented. Howeverpeople have varyingtastesinmusicgenresasseenbyLabbe et
al.(2007) who establishedthatself-selectedmusicwasthe mosteffective inreducingstress.
Physiological indicatorsof stressexhibitedevidence thatmusicdidn’thave anyeffectondecreasing
stress.These physiological indicesare more objective thanthe subjective formof self-perceived
stress.Therefore the statistical significance seeninself-perceivedstressincomparisontothe
physiological markerssuggestsa‘Hawthorne’effectmaybe influencingthese outcomes.That is,
where the participantsmayaltertheirbehaviouroranswersinorderto benefitthe study.However
self-perceivedstresshasmore truthvalue onhow the participantactuallyfeelsthusimprovingthe
internal validityof the study.
Self-perceivedpain wasfoundtodecrease significantly(P=0.001) inthe control group with
osteopathicmanual therapyalone.Osteopathicmanual therapycausedareductioninpainwhichis
consistentwithliterature thatsuggeststreatmentreducespaininpatientswithback pain
(Licciardone,2003; BMJ, 2004; Fryeretal.,2004; Brimhall,andKing,2005; Bischoff etal.2006;
Schwerlaetal.,2008; Tempel etal.,2008; Mandara etal.,2010; Vismaraet al.,2012; Bjersa,2013;
Licciardone,KearnsandMinotti,2013; Orrock and Myers,2013; Licciardone andAryal,2014; Franke
et al.,2015). Osteopathyhasalsobeensuggestedbythe National Institute forHealthandClinical
Excellence (2009) as a recommendedalternative therapyforchroniclow backpain(BMJ,2004;
Licciardone,KearnsandMinotti,2013).
Howeverself-perceivedpainwasnotfoundtobe significantinthe interventiongroup.This
unexpectedresultmayhave beenaconsequenceof the participantnotlikingthe musicused.This
may have beenreflectedintheirself-perceivedpain.Inasimilarstudy(Mercadie etal.,2013) the
effectsof musicwere investigatedonheartrate,bloodpressure andhow patientsperceived
treatment.Nostatistical significance wasfoundinreducingheartrate orbloodpressure.However
the subjective resultof howpatientsperceivedtheirtreatmentwasfoundtobe statistically
significant.Patientsfoundtreatmentwithmusictobe more pleasantandphysicallyeffective.This
statistical significance inthe subjective outcome of patients’perceptionsuggeststhatmusicisa
mediumthatisperceivedtobe useful evenif physiologicallyitappearstohave nosignificantresults.

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Conclusionscanbe made forthe currentstudythat musiccombinedwithosteopathicmanual
therapy doesnotaffectstressand painmore so thanosteopathicmanual therapyalone.This
conclusioniscontradictorytoresultsfoundbyBellieni etal.(2013) who determinedthatmusichada
significantanalgesiceffectforpainduringphysical therapy.Thisresultwasalsosimilarina trial
wherebyterminallyill participantsreceivedphysiotherapyandmusicwhichfoundpainlevels
reducedsignificantly(Horne-ThompsonandBramley,2011).These contradictionssuggestthatmore
researchwithlargersample sizesandimprovedmethodologiesare neededtoestablishthe reliability
of the resultsfoundduringthiscurrentstudy.
Strengths and Limitations
Limitationstothisstudywere discoveredbefore,duringandafterthe collectionof data.These
limitationsgive directionforfurtherresearchinthe fieldof musicandosteopathy.Thisresearch
lackeda pilotstudy whichcouldhave foreseenthe needto alsoblindthe participants.Thiscould
have beenachievedwiththe use of white noise aswasseenbyMercadie etal.(2013). By double-
blindingthe participantsandreducingthe possibilityof the ‘Hawthorne’effect,musicmayhave
beenseentohave a statisticallysignificanteffectonstressandpainwhencomparedtothe control
group.
To improve external reliabilityof the studythe participantexperience waskeptasclose toan
osteopathicpatient’sexperienceaspossible.Indoingsothe practitionerdifferedbetween
participantswhichintroducedavariable tothe study.Thisvariable was causedby osteopaths
treatingslightlydifferentlyintermsof style,strengthandskill level.Thiswouldhave ledto different
emphaseson a range of diverse techniques beingadopted duringtreatmentalteringoutcomesand
thusreducingreliability.
The single-sidedheadsetfacilitatedthe control of anypotentialeffects thatmusicmayhave had on
the osteopathhadthe musicbeenplayedintothe roomduringtreatment.Osteopathsmayhave
beendistractedbymusicleadingtoachange inthe efficacyorrhythm of theirtreatment.By
controllingwhetherornotthe osteopathcouldhearmusicledto improvedvalidity.Thisalso
improvedreliabilityof the studybyreducingthe chance that thisvariable mayhave hadon
measurementoutcomesleadingtothe resultsbeingmore generalisable.
Each participantwasunique intheirownway,forexample the numberof treatmentstheyhad
receivedpriortothe research,the amountof stressor painthat theywere under,theirabilityto
cope withstressand painand theirmusicpreference.A randomisedcontrol trial designwasadopted
to minimize the effectof these variables.Randomisingparticipantsled toanequilibriumof these

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baseline systematicdifferencesbetweenthe interventionandcontrol group(Akobeng,2005). The
validityof the studywasthusimprovedbyattemptingtobalance these confoundingvariables
betweenthe twogroups.Howeverinsmall studiessuchasthisone,randomisationdoesnotalways
leadto a balance inthese variables.Thismayhave ledtodifferencesbetweengroupsregardingthe
numberof variablesresultinginchangestooutcome measurementsandtherefore statistical
significance betweengroups.
Finallythe biggestchallengetothisstudywasthe issue of participants.The difficultyof attaining
participantslayinthe lack of advertisementof the study.More postersandemailssenttopotential
participantsmayhave increasedthe small sample size.The sampleof 12 is notveryrepresentative
of the targetpopulationof 30,000 osteopathicpatientsinthe UK (General OsteopathicCouncil,
2006). There is a higherchance of the sample havingunusual characteristics andanomalies which
leadstoa significantimpactonthe final outcomesandresults.A small sample commonlyhas alarge
standarderror whichresultsin reduced accuracy inherently decreasingvalidity of the results.A
sample size of 40 was neededtobe clinicallysignificantwhichwasnotmet.Usinga largersample
size wouldhave minimisedchance anderroroccurringtherebyimprovingthe reliabilityof the results
and the statistical analysis(Akobeng,2005).
Qualitative measurementsof stressandpainshouldbe usedalongsidequantitativemeasurements
to gaindata that is highintruth value andthusimprove the validityof results.Thiscouldbe inthe
formof a thematicanalysis,lookingforcommonthemesfrominterviews.
Otherareas of interestmayleadawayfromthe effectof musicon stressandpain.Questionsmaybe
formedaroundthe opinionsandattitudesof patientsandthe general publicregardingosteopaths
whoplaymusicduringtreatment.Forexample doesthe use of musicalterthe reputationand
expectationsof osteopathicmanual therapy?There isalarge gap inknowledge aroundthe medium
of musiccombinedwithosteopathicmanual therapywhichcan be explored.Furtherresearchis
requiredtodeterminethe reliabilityof the resultsfoundbythisstudy.
Conclusion
Music wasfoundto have no statistical significanceinreducingstressandpainandthusanswering
the question, “canmusicbe usedinconjunctionwithosteopathicmanual therapytodecrease stress
and paininpatientspresentingtoanosteopathicclinicwithnon-peripheral musculoskeletal
disorderscomparedtoosteopathicmanual therapywithoutmusic?” Itcantherefore be concluded
that resultsfromthisstudycan be assumedtosupportthe null hypothesisthatmusicand

Page | 46
osteopathicmanual therapycombinedhave noeffectonparticipant’sperceivedpain,perceived
stress,bloodpressure orheartrate whencomparedto osteopathicmanual therapyalone. These
resultsinform the slowlyexpandingliterature aroundosteopathicmanual therapy andcanbe
applied toshape furtherresearcharoundthe effectsof musicandosteopathicmanual therapyon
stressand pain.
Acknowledgments
I would like to acknowledgemy family and friendsforall their supportduring my fouryearsat
university,withoutthemI would nothavemanaged emotionally to completethis course.A special
mention to my Mum,Katyand Dad,Paul,who withoutwhich I would notbe alive to write this,I owe
everything to them.Lastly,I would like to dedicatemy workto my Grandad Alan who passed away
during my final year,I will makehim and the rest of my family very proud.

Page | 47
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