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Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: https://www.tandfonline.com/loi/idre20
Vibroacoustic treatment to improve functioning
and ability to work: a multidisciplinary approach
to chronic pain rehabilitation
Elsa A. Campbell, Jouko Hynynen, Birgitta Burger, Aki Vainionpää & Esa Ala-
Ruona
To cite this article: Elsa A. Campbell, Jouko Hynynen, Birgitta Burger, Aki Vainionpää &
Esa Ala-Ruona (2019): Vibroacoustic treatment to improve functioning and ability to work: a
multidisciplinary approach to chronic pain rehabilitation, Disability and Rehabilitation, DOI:
10.1080/09638288.2019.1687763
To link to this article: https://doi.org/10.1080/09638288.2019.1687763
Published online: 13 Nov 2019.
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ORIGINAL ARTICLE
Vibroacoustic treatment to improve functioning and ability to work:
a multidisciplinary approach to chronic pain rehabilitation
Elsa A. Campbell
a,b
, Jouko Hynynen
c
, Birgitta Burger
a
, Aki Vainionp€
a€
a
c
and Esa Ala-Ruona
a,b
a
Department of Music, Art and Culture Studies, University of Jyv€
askyl€
a, Finland;
b
VIBRAC Skille-Lehikoinen Centre for Vibroacoustic Therapy and
Research, Eino Roiha Foundation, Jyv€
askyl€
a, Finland;
c
Department of Rehabilitation, Sein€
ajoki Central Hospital, South Ostrobothnia Healthcare
District, Finland
ABSTRACT
Purpose: To study the use of Vibroacoustic treatment and an added self-care intervention for improving
the functioning and ability to work of patients with chronic pain and potential comorbid depressive and
anxious symptoms.
Materials and methods: A mixed methods study with four single cases. Participants received bi-weekly
Vibroacoustic practitioner-led treatment sessions for five weeks, followed by a one-month washout period
without treatments. Then, participants conducted four self-care vibroacoustic sessions per week for five
weeks, followed by another month-long washout period. Participants kept diaries of their experiences
during this time. Quantitative scales included the World Health Organization Disability Assessment
Schedule 2.0, Visual Analogue Scales (pain, mood, relaxation, anxiety, and ability to work), Beck’s
Depression Inventory-II, and Hospital Anxiety and Depression Scale (Anxiety only). The use of physio-
logical markers was also explored.
Results: The greatest improvement was from the practitioner-led sessions, but self-care was beneficial for
pain relief and relaxation. Participants became more aware of sensations in their own bodies, and during
washout periods noticed more clearly the treatment effects when symptoms returned. An added self-care
phase to standard Vibroacoustic treatment could be beneficial for maintaining the effects from the more
intensive Vibroacoustic treatment as part of multidisciplinary rehabilitation.
äIMPLICATIONS FOR REHABILITATION
Chronic pain and comorbid mood disorders negatively impact functioning and ability to work.
Vibroacoustic treatment with a self-care phase could be beneficial for managing the symptoms of
chronic pain if implemented within a naturalistic multidisciplinary rehabilitation context.
In four single cases, this study shows functioning, pain, and depression improved after Vibroacoustic
treatment with self-care.
ARTICLE HISTORY
Received 23 April 2019
Revised 25 September 2019
Accepted 28 October 2019
KEYWORDS
Vibration; music;
rehabilitation; chronic pain;
mood disorders
Introduction
Painful musculoskeletal conditions affect 20–33% of the world’s
population [1]. They are the second greatest contributor to dis-
ability and, in addition to mobility restrictions, are linked to
depression, early retirement, and a reduced ability to socially par-
ticipate [2,3]. Chronic pain is subject to not only genetic factors,
but is also influenced by our past experiences of pain and the
context in which it occurs [4]. Our emotional state, anxiety, mem-
ories, and attention/distraction are all factors which augment or
diminish our experience of pain [5] and therefore factors which
also influence our ability to function.
The biopsychosocial model outlines that physical illnesses such
as pain are a result of the interaction between physiological, psy-
chological, and social factors, and mediated by socioeconomic fac-
tors, which may exacerbate the presentation of pain [4,6].
Interactions between emotional disorders, maladaptive cognition
(e.g., poor coping skills), disability, physical deconditioning (due
to decreased physical activity), disrupted social functioning, and
nociceptive dysregulation suggests that approaches to chronic
pain management should focus on more than simply the
pain sensation.
Multidisciplinary rehabilitation for symptom management
The goal of rehabilitation is to achieve optimal functioning.
Building up one’s resources supports this process by providing a
facilitating environment, developing one’s performance in inter-
acting with their environment [7], regulating inappropriate adap-
tive stress responses posited to cause disorders such as
depression and chronic fatigue syndrome [8], and reducing the
calamitous impact poorly managed symptoms can have on
healthcare systems [9]. Multidisciplinary approaches to pain man-
agement yield significant improvement in pain, physical and per-
ceived functioning, emotional distress, pain acceptance and
coping, and in the decreased use of maladaptive and passive cop-
ing strategies [10,11]. Coordinated interdisciplinary approaches
offer the best clinical care for patients with chronic pain and are
also the most cost-effective approach [12].
CONTACT Elsa A. Campbell elsa.campbell@vibrac.fi Department of Music, Art and Culture Studies, University of Jyv€
askyl€
a, Seminaarinkatu 15, Musica (M
Building), P.O. Box 35 (M), 40014, Finland
ß2019 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION
https://doi.org/10.1080/09638288.2019.1687763
Vibroacoustic treatment in multidisciplinary rehabilitation
Vibroacoustic treatment is one example of a multi-modal
approach to pain management. At Sein€
ajoki Central Hospital,
Vibroacoustic treatment is delivered as part of multidisciplinary
rehabilitation. It consists of three elements: low frequency sinus-
oidal sound vibration between 20–120 Hz, clients’preferred music,
and practitioner support [13]. Described as a “two-pronged
approach”, the tactile sinusoidal vibration elicits a relaxation
response whilst the music listening element is beneficial for psy-
chological symptoms [14]. Previous research has shown it is bene-
ficial for eliciting a relaxation response, pain relief [14,15] and
comorbid depression, anxiety, and insomnia [13], muscle tension
and spasms [16], physical discomfort, fatigue, anxiety, and per-
ceived general health [17], as well as being a suitable intervention
to facilitate better outcomes in physiotherapy [13,18].
Applied within multidisciplinary care, Vibroacoustic treatment
is part of an individually-tailored combination of standard
pharmacological interventions as well as physiotherapy, (music)
psychotherapy, and occupational therapy [19]. The team coordi-
nates and develops the treatment plan based on a patient’s
needs, working towards improving patients’quality of working
life or to work towards evaluation points assessing patients’cap-
ability of returning to work. Given the impact of chronic pain and
comorbid mood-related symptoms on functioning, interventions
applied to improve these symptoms could aid in improving one’s
functioning and ability to (return to) work.
Underlying mechanisms of vibroacoustic treatment
Although the underlying mechanisms of Vibroacoustic treatment
are unknown, some theories exist. Stimulation of subcutaneous
sensory mechanoreceptors (Pacinian corpuscles) sensitive to vibra-
tion and deep pressure [20] serves to potentially block afferent
pain transmission [14,21]. Another theory relates to the relaxation
response [22] and the concept of sympathetic resonance. Wigram
[23] showed that applied vibrations are systematically felt in the
same areas of the body (e.g., 40 Hz is commonly felt most
strongly in the thigh muscles). Our bodies have natural resonant
frequencies (e.g., each muscle) which may be activated or
entrained through vibrotactile stimuli at the same frequency [24].
The vibration can stimulate sympathetic resonance through this
matched oscillation, acting as a driving force [21]. In general, the
higher the frequency within the low frequency range, the smaller
the muscle and the closer to the head the frequency is perceived;
i.e., 40 Hz is felt in the thighs, 60 Hz is felt in the chest [23].
Oscillatory dysfunction is suggested to play a significant role in
developing and maintaining chronic pain [25], with disruption on
the gamma band (around 40 Hz) related to thalamocortical dysre-
gulation. This, in addition to clinical evidence and previous studies
[15], supports the application of 40 Hz to act as a driving force for
resolving this disrupted frequency band [21].
The second element of Vibroacoustic treatment –music listen-
ing –is also beneficial for pain relief, as well as reducing analgesic
consumption [26] and physiological arousal, and is known to
affect physiological parameters such as heart rate, respiration, and
stress hormones [27]. It can be a directed approach to facilitating
therapeutic change by manipulating or selecting music based on
characteristics which will influence these variables, such as a
tempo. Music perception is also influenced by our past experien-
ces [28] and can elicit memories and images [29]. As pain percep-
tion is also influenced by past experiences thereof, music listening
has the potential to influence how we perceive pain, altering our
perception thereof through emotional responses.
Combined, the low-frequency sound vibration and the music lis-
tening can work towards altering the client’sperceptionofpain,
facilitated by the practitioner and the practitioner-client relationship.
Self-care as an element of rehabilitation
Orem [30] describes self-care as “an essential human regulatory
function”[p.33]andasitisinherentinone’s daily activities, it
should be viewed as an integral part of rehabilitation. The concept
of self-care comprises an individual’s responsibility towards healthy
behaviours required for functioning, as well as those needed to
manage chronic health conditions [9]. Barriers to conducting self-
care are mostly related to having comorbidities, and include logis-
tics of carrying out the practice, need for support, compound effects
of conditions and medications, the emotional effects of the disease,
and the physical limitations of conducting it [31]. The outcomes of
self-care activities, on the other hand, include decreased pain, dis-
ability, and depressive symptoms [32], and improved cognitive
symptom management, energy, fatigue, and self-rated health [33].
Although applications of low frequency sound vibration and music
listening are generally afforded by a practitioner or therapist, Picard
and colleagues [34] reported on a self-care approach to vibroacous-
tic treatment. Participants conducted sessions of combined music
and pulsed vibration to manage their widespread pain and tender-
ness. Results showed improved indices of pain interference, relax-
ation, muscle tension, and energy levels [34].
As suggested by previous research of practitioner-led
Vibroacoustic treatment, it can be effective for relieving both psy-
chological and physiological symptoms [13,35,36]. The aim of this
study was to assess the impact of Vibroacoustic treatment with a
self-care element on functioning, chronic pain, and possible comor-
bid symptoms, implemented within a multidisciplinary rehabilitation
context. The aim of this study was not to compare across partici-
pants, rather to gain insight into how this treatment could be bene-
ficial to patients who are typically difficult-to-treat at this unit.
Materials and methods
The study was in ABA
1
B
1
form. In Phase I, participants received
bi-weekly Vibroacoustic practitioner-led treatment sessions for five
weeks at a specialised rehabilitation unit at Sein€
ajoki Central
Hospital followed by a month-long washout period (Phase II)
without treatment. Thereafter, participants conducted four self-
care Vibroacoustic sessions per week for five weeks at home
(Phase III), followed by a second month-long washout period
(Phase IV). The purpose of the washout periods was to assess the
duration of treatment effect. Each participant served as his/her
own control. As per standard practice at this unit, patients engage
in various treatments (such as physiotherapy, [music] psychother-
apy, and/or pharmacotherapy) concurrently or consecutively and
this study took place within this naturalistic setting. Although a
limitation in terms of comparison across participants, this study
aimed to explore participants’responses to the treatment within
the context of their individual rehabilitation programmes.
Tampere University Hospital ethical committee granted ethics
approval to conduct this study (ETL: R18007).
Phase I: Practitioner-led vibroacoustic treatment sessions
A Next Wave Physioacoustic chair is used at this facility (see
Figure 1). Sonus Health Editor v3.26c software is used to play the
low frequency treatment programme through loudspeakers
located in the neck, back, thigh, and calf areas of the chair; the
2 E. A. CAMPBELL ET AL.
frequency range of this software is 27–113 Hz. Participants
received their bi-weekly practitioner-led sessions in this chair, with
their preferred music playing through headphones, and interact-
ing/discussing sensations and observations with the practitioner,
JH, before and after the treatment programme. Participants were
assisted in getting on/off the chair and told to inform the
Practitioner if any discomfort were to arise during the stimulation.
At this facility, a typical treatment programme used for ena-
bling relaxation and pain relief centres around 40 Hz, based on
clinical experience and previous reports of this frequency dis-
cussed in section Underlying mechanisms of Vibroacoustic treat-
ment. tailored the treatment programmes to suit the participants’
individual needs, gradually increasing the volume as they became
accustomed to the sensation. A treatment programme contains
several steps and parameters such as scan,cycle,strength,action,
and time.Scan modulates around the fundamental frequency,
e.g., 31 Hz, by moving from this to a higher and lower frequency,
e.g., 29–34 Hz, much akin to a radar, so that several scans of the
fundamental frequency are completed during a two- to three-
minute phase. Cycle or pulsation refers to the speed of the ampli-
tude change –the time taken from silence to designated peak
volume, e.g., 11 s. In practice, the longer the cycle and the wider
the scanning range, the greater the relaxation effect. The wave-
like sensation elicited through this pulsation may be compared to
that of a massage chair. The strength of the programme can be
adjusted both globally across all speakers and locally at individual
speakers so that the programme strength can be increased and
specific areas of the body can also be targeted. Action refers to
the directional movement; either head-to-toe, vice versa, or no
movement. The faster the cycle, the faster the action movement.
Although it is standard practice that a treatment programme
of lower intensity is used at the beginning of a treatment phase
with each new client, the rule of thumb otherwise is to tailor the
treatment programmes to suit the needs of each individual. This
means that if a client suffers more from shoulder pain, higher fre-
quencies within the 20–120 Hz range are used whilst frequencies
closer to 20 Hz would be used for patients whose pain is in larger
muscle areas of the body. Given the individual nature of each
treatment phase and each rehabilitation process for each client,
no direct comparison is possible; however, an idea of treatment
responses of patients who receive VA treatment in addition to
other therapies as part of their individual rehabilitation process
can be cleaned. This is important in understanding how VA treat-
ment may function in relation to other therapies offered as part
of rehabilitation.
Phase III: Self-care sessions
Participants conducted their self-care sessions using a Taikofon
FeelSound Player (see Figure 2), a small, cushion-like device with
an in-built transducer, an audio cable, and Bluetooth function.
The frequency range of Taikofon is 20–20 000 Hz. Participants
used an android phone (Huawei Y5) to play the pre-installed
Vibroacoustic treatment programme. The participants were free to
place the cushion anywhere on their body, thereby offering tar-
geted stimulation to e.g., the lower back.
All participants used the same 23-min, 40 Hz self-care treat-
ment programme for each self-care session. The duration of the
cycle or pulsation was 6.8 s. They could adjust the programme vol-
ume/strength using the phone’s volume control.
Patients were instructed in how to use the self-care device
using the Bluetooth function on both the Taikofon and the
Huawei phone. They were instructed to use the device four times
per week and to use it at the same time each day. If they had
multi-site pain or wished to use the device in various places, par-
ticipants were instructed to record where they placed the device
in their diaries.
Participants
Participants were recruited following a purposive sampling
method. Patients with chronic pain were contacted by JH regard-
ing study participation; four patients gave informed consent. The
mean age of the three females and one male was 43.25 (±11.03)
years (see Table 1 for an overview of demographics).
Participants 1 and 2 had pain in neck/shoulder areas, whilst
Participant 1 also had pain in her thighs, and back, and tingling
in both her feet. Participant 3 had pain in her hips, legs, feet,
backside, as well as tingling in her left knee and soles of her feet.
Finally, Participant 4 had pain in his calves as well as in his pain
ranging from his right eyebrow back towards his neck, shoulders,
and along his spine with tingling in his hands and along his back.
As mentioned earlier, the aim of this study was not explicitly to
compare the intervention across participants –as their profiles
are so varied –rather to depict the variety of patients treated as
Figure 2. Taikofon FeelSound Player used in Phase III (self-care sessions).
Dimensions: 48 cm long, 12 cm wide, 35 cm high. Image reproduced with kind
permission from the copyright holder: Flexound Systems Oy.
Figure 1. Physioacoustic recliner chair used in Phase I (practitioner-led) sessions.
Dimensions 184cm long, 78.5 cm wide, 120 cm high. Image reproduced with
kind permission from the copyright holder: Next Wave Oy.
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 3
this unit and how such a two-armed intervention could be
received by difficult-to-treat patients such as these.
Data collection
A mixed-methods approach was taken consisting of participant
diaries, questionnaires/scales, and physiological data. The data
were collected in a concurrent-parallel design [37] such that each
would support the others in exploring individual responses to
both treatment conditions and the washout periods. The quantita-
tive results comprise primary (functioning and ability to work),
secondary (pain, mood, anxiety, and relaxation), and exploratory
outcomes (physiological measures: [para-]sympathetic nervous
system activity, galvanic skin response, and respiration rate).
Participants wrote their diaries beginning at Phase I until the end
of Phase IV. Quantitative outcomes were assessed at five measure-
ment points. Measurement points 1 and 2 were the beginning
and end of practitioner-led sessions in Phase I; Measurement
Points 3 and 4 were the beginning and end of the self-care ses-
sions in Phase III; Measurement Point 5 was follow-up, at the end
of the second washout period in Phase IV. All quantitative scales/
questionnaires and physiological measurements were completed
at these time-points.
Qualitative data collection and analysis
Each participant wrote a diary to reflect their responses to the
treatment conditions and washout periods, also reflecting on
what they perceived to positively or negatively influence their
symptoms. The instructions were rather open-ended to afford as
rich and organic a description as possible. Each participant’s diary
was separately fully analysed with Qualitative Content Analysis
[38] following an inductive approach. Inductive analysis allows
findings to emerge from the raw data without pre-defined
assumptions, theories, or hypotheses, but is still guided by evalu-
ation objectives or research questions [39]. The diary transcripts
for Participant 1 were first read through several times, based on
which a coding frame was developed. The frame comprised the
code label describing the code meaning, a description of this
meaning, and illustrative text examples. Analytic memos were
also written during the analysis process, which were used in
developing the categories and themes. If new codes subsequently
emerged from other participants’data, the coding frame was
adjusted accordingly and applied to all data. Through this pro-
cess, categories emerged developing into broader main themes
and sub-themes. Similarities and differences between participants
were explored and findings are tabulated according to the phase
in which they were recorded by the participant.
Quantitative data collection and analysis
All quantitative data are presented as single cases, showing indi-
vidual scores for each outcome at each measurement point.
Interpretation guidelines for individual outcomes, as suggested by
Dworkin and colleagues [40], referring to the smallest clinically
relevant change in individual patients’outcomes, the Minimum
Clinically Important Difference (MCID), were used where available
for data analysis. Additionally, interpretation cut-off points for VAS
outcomes that are available for pain [41] were also used. As these
benchmarks for other VASs are unavailable, the pain cut-off points
have been applied to all VAS outcomes as general indicators of
each variable’s current status. The interpretation guidelines are
discussed for each scale separately.
World Health Organisation Disability Assessment
Schedule (WHODAS)
The World Health Organization Disability Assessment Schedule 2.0
(WHODAS) is a 12-item self-complete scale used to standardise
assessment of health and disability across all diseases with appli-
cations in both clinical and general populations. Cronbach’sawas
reported as ranging from 0.83–0.92 [42]. The MCID for WHODAS
has not been established.
Visual Analogue Scales
Pain, mood, relaxation, anxiety, and ability to work were measured
using Visual Analogue Scales (VAS). These scales are 100 mm horizon-
tallineswithanchorsoneitherend;theanchorsinthiscasewere
0mm¼unbearable pain, 100 mm ¼no pain, 0 mm ¼depressed,
100 mm ¼happy; 0 mm ¼tense, 100 mm ¼relaxed; 0 mm ¼anxious,
100 mm ¼no anxiety; and 0 mm ¼completely unable to work;
100 mm ¼best working ability. The polarities of these scales are used
in this direction at this facility and, in order to retain coherence in
their standard protocols, this formulation of the VAS was retained
despite the usual format being, for example, 0¼no pain,
100 ¼unbearable pain. Participants were asked to mark the line to
represent how they were feeling at that time. Test-retest reliability for
pain was reported as r¼0.94 [43], r¼0.82 for mood [44], and
r¼0.59 for anxiety [45].ForVASforpain,theMCIDissuggestedas
10–20% reduction for minimal improvement, 30% for moderate
improvement, and 50% corresponding to substantial improvement
[40]. Interpretation VAS pain cut-off points applied to all VAS out-
comes are 0–4mm ¼severe [pain], 5–44mm ¼moderate [pain],
45–74mm ¼mild [pain], and 75–100mm ¼no [pain] [41].
Beck’s Depression Inventory-II
Beck’s Depression Inventory-II (BDI-II) is a self-report, 21-item scale
used to assess the severity of depressive symptoms. Scores range
from 0–63 points and items are rated on a four-point scale from 0
Table 1. Participant demographics showing ICD-10classifications and medications.
Participant Sex Age Type of pain Diagnoses (ICD-10) Medications
1 Female 33 Musculoskeletal and
neuropathic
M54.5 lower back pain; M54.6 Pain in thoracic
spine; R29.8 Other unspecified symptoms
and signs involving nervous and
musculoskeletal systems; muscle weakness
Paracetamol; gabapentin; venlafaxine;
amitriptyline; tramadol; tramadol including
paracetamol
2 Female 37 Musculoskeletal and
neuropathic
S13.4 Sprain and strain of the cervical spine;
S44.3 Injury of axillary nerve; Nerve damage
in right hand; Depression; neck/shoulder/
back pain
Escitalopram; gabapentin; paracetamol
3 Female 58 Musculoskeletal M79.7 Fibromyalgia; M47.8 Other spondylosis;
lumbosacral spondylosis L4–L5
Buprenorphine; esomeprazole; paracetamol;
pregabalin; amitriptyline
4 Male 45 Musculoskeletal M79.7 Fibromyalgia; sleep apnea Tramadol; paracetamol; amitriptyline;
pregabalin; pantoprazole
ICD-10 refers to the International Statistical Classification of Diseases and Related Health Problem.
4 E. A. CAMPBELL ET AL.
(e.g., “I do not feel like a failure”) to 3 (e.g., “I feel I am a total fail-
ure as a person”). Scores can be interpreted as 0–13pts ¼minimal;
14–19pts ¼mild depression; 20–28pts ¼moderate depression;
29–63pts ¼severe depression. Cronbach’sawas reported as 0.92
for outpatients and 0.93 for college students [46]. A category
change (e.g., from moderate to mild depression) and a 5-point
reduction are used as MCID benchmarks here [40].
Hospital Anxiety and Depression Scale –Anxiety subscale
The anxiety subscale of the Hospital Anxiety and Depression Scale
(HADS-A) is a seven-item, self-complete scale used to assess the
non-somatic cognitive and emotional aspects of anxiety in general
medical populations. It is a four-point scale ranging from 0–3,
(e.g., “I feel ‘wound up’”,0¼not at all, 3 ¼most of the time).
Scores can be interpreted as 0–7pts ¼normal; 8–10pts ¼border-
line anxious; and 11–21pts ¼abnormal anxiety. Cronbach’sa
ranges from 0.78–0.93 [46]. The MCID corresponds to a 1.57-point
decrease in the HADS anxiety subscale [47].
Physiological data
Raw ECG signal, respiration, and galvanic skin response (GSR) data
were recorded using the NeXus-10 physiological monitoring and
biofeedback platform. BioTrace þsoftware was used to analyse
the respiration rate and pain-related arousal respectively, and
Kubios software was used to analyse the raw heart rate data
recorded with ECG. All measurements were taken in the same
soundproof treatment room with an ambient temperature of
22 C; the first and last self-care sessions were conducted at the
facility to control for the measurement environment.
ECG/[para-]sympathetic nervous system activity. The NX1-EXG2-
Snap cable was used to detect heart rate data via ECG signal. ECG
data pre-processing and analysis were performed using Kubios,
version 3.1.0.1. The threshold-based method was used to remove
artefacts. These are detected by comparing each beat-to-beat
interval against a local average interval; if an interval differs more
than a specified threshold from the local average, it is marked as
an artefact. Kubios also adjusts these thresholds with mean heart
rate. The minimum thresholds were selected to remove the arte-
facts without affecting the remaining data. The raw signals were
de-trended using the smoothness priors method before analysis.
Kubios analysis software provides indexes for autonomic nervous
system assessment. Parasympathetic nervous system (PNS) activ-
ity, such as during resting or recovered states, decreases heart
rate and increases heart rate variability. When we are stressed
and the sympathetic nervous system (SNS) is activated, our heart
rate increases and heart rate variability decreases [48]. The PNS
index reflects Mean RR (mean of time interval between successive
R-waves), RMSSD (root mean square of successive RR interval dif-
ferences), and S1 (%), whilst for SNS these are Mean HR, Stress
index, and SD2 (%). These indexes were used to evaluate partici-
pants’stress responses at the five measurement points as an
objective measure of pain [49]. A PNS/SNS value of zero refers to
the mean population values, e.g., non-zero PNS values show how
many standard deviations below (negative integers) or above
(positive integers) the parameters are relative to normal popula-
tion averages and vice-versa for SNS values.
The Taskforce of the European Society of Cardiology and the
North American Society of Pacing and Electrophysiology [50] rec-
ommends five-minute recordings for short-term HRV assessment.
Five-minute segments were extracted from the beginning and
end of the first and last practitioner-led sessions (Measurement
Points 1 and 2) and the first and last self-care sessions
(Measurement Points 3 and 4), and a five-minute measurement
was taken as follow-up (Measurement Point 5) at the end of the
second washout period.
Galvanic skin response and respiration rate
The galvanic skin response sensor measures arousal through
tracking sweat gland activity; expressed in microsiemens (mS), the
value increases with the level of arousal, and normally decreases
during relaxation. Ag-AgCI finger electrodes measure relative
changes in skin responses [51]. The electrodes were placed on the
distal phalanx of the digitus secundus and digitus medius of the
participants’left hands. The respiration sensor, consisting of an
elastic belt worn around the navel, measures relative expansion of
the abdomen during inhalation and exhalation. Mean galvanic
skin response and respiration data values from the same five-
minute segments as the ECG data were extracted for analysis
using BioTrace þsoftware (V2017A).
Data integration
After both qualitative and quantitative data were separately ana-
lysed, these were integrated for each participant by exploring the
qualitative findings’parallel manifestations in the quantitative
data. For example, changes in functioning described in partici-
pants’diaries were compared and contrasted with WHODAS out-
comes. Experiences of both qualitative and quantitative aspects
were explored to ascertain whether the objective and subjective
reports were congruent. Due to the parallel-convergent design of
the data collection, the experiences participants reported either in
their diaries or by completing the scales were recorded within the
same timeframe (rather than successively) and may, therefore,
afford a richer description of their overall experiences. The qualita-
tive data also provided richer contextual information about how
participants responded to the treatment sessions in between
measurement points.
Presentation of results and findings
An overview of results and findings is first provided to give an
impression of the general outcomes across all participants.
However, the main focus is on the individual participants’treat-
ment responses and therefore an in-depth, integrated qualitative
and quantitative presentation of each participant follows the gen-
eral overview.
To simplify the quantitative data presentation and discussion,
only the post-treatment data are shown (Figures 1–4), signifying
the general change in variables over the course of the protocol
(between sessions), rather than a detailed description of the
within-session changes through the pre-/post-treatment out-
comes. The quantitative results are narratively discussed using
MCID [40] and interpretation guidelines [41] for interpret-
ation purposes.
Results
Overall quantitative results
Primary outcomes
Participants 2, 3, and 4 showed an improvement in functioning
during both treatment conditions. After the first washout period,
Participants 2 and 4 reported worse functioning (Measurement
Point 3) and all participants had worse functioning after the
second washout period. For Participant 1, functioning appeared
to have deteriorated throughout the process. The same was seen
for participants’ability to work; whilst this tended to improve
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 5
during the treatment conditions and deteriorate during the wash-
out phases for Participants 2, 3, and 4, neither practitioner-led nor
self-care sessions seemed to impact Participant 1’s ability to work.
Secondary outcomes
Relaxation was the outcome which improved most substantially
during both treatment conditions for each participant. The clear-
est effects were generally seen from Measurement Points 1-2, the
practitioner-led sessions, and although the improvements from
Measurement Points 3-4 were also substantial, the scores at the
beginning of this self-care phase were also worse from not having
received treatments for one month (e.g., Participant 3,
Measurement Point 3). The effect of the Phase I and III sessions
for BDI-II outcomes appear to have been generally worse after the
second washout. Neither treatment condition seems to have had
a strong impact on HADS-A outcomes; however, only Participant
3 recorded abnormal anxiety at the beginning of the study, and
the effect was as a result greater for her compared to those
beginning with normal or borderline level anxiety.
Exploratory outcomes
For all participants, physiological outcomes seem to indicate that
the PNS activity increase and GSR decrease were associated with
pain relief. Respiration rate, however, seems to contradict the
expectation that slower respiration would be associated with a
greater relaxation response. These exploratory outcomes, there-
fore, did not always support the other quantitative outcomes, as
discussed later.
Overall qualitative findings
Four main themes, (1) Pain as a barrier, (2) Adjusting to the new
status quo, (3) Approaches to symptom management, and (4)
Symptom nexus emerged from the analysis of all four participants’
diaries. Five sub-themes traversed all participants’experiences
(see Table 2 for overview of overlapping main- and sub-themes).
These –under the main theme titles –are displayed presently.
Individual participants’qualitative findings are detailed in
Tables 3–6.
Main theme 1: Pain as a barrier
Only one sub-theme, Pain inhibits relief, was individual to
Participant 2, whilst Pain inhibits functioning was common to all
participants. Pain as an inhibitor to functioning was seen in activ-
ities such as lowered capacity to do housework/drive. Pain was a
hindrance, also, in how Participants 2–4 were able to rest, e.g.,
waking up because of pain.
Main theme 2: Adjusting to the new status quo
Throughout the process, all participants became more aware of
changes in their bodies or functioning by tracking progress whilst
they actively engaged in the rehabilitation process. Although the
level of functioning varied across participants, they became aware
of sensations such as how long they could carry out activities
before they started to feel pain. The experience of having better
and worse days during the rehabilitation process was also evident
for all participants.
Main theme 3: Approaches to symptom management
In addition to this awareness, actively trying to integrate the self-
care practice during Phase III into their daily lives was a sub-
theme for all participants, adjusting it to suit their own needs and
schedules (e.g., changing its placement on the body when symp-
toms, for example, in the lower body were stronger, or conduct-
ing the practice in the mornings rather than the evenings).
Relaxation was also a tool and outcome of the Vibroacoustic
treatment sessions. It appeared for all stages that inducing a
relaxation response afforded pain relief.
Main theme 4: Symptom nexus
This final main theme was manifest for only Participants 2 and 3,
those with greater mood issues. They struggled with disability
and the frustration they felt associated with this change in level
of functioning. This was underlined in the emerging of the rela-
tionship between their symptoms (functioning, pain, and mood),
and the sense of accomplishment and positive mood they associ-
ated with managing their pain. Possibly due to having an ambigu-
ous diagnosis (fibromyalgia), meaning-making was important for
Participant 3.
Integrated individual results and findings
Integrated outcomes for participant 1
Participant 1’s low ability to work was interestingly not reflected
in her WHODAS scores (see Figure 3), however it was seen in her
diary entries (see Table 3), exemplified by entries such as “Came
Table 2. Overlap of the qualitative main themes with sub-themes across all participants.
Theme
Theme 1: Pain as a barrier Theme 2: Adjusting to the new status quo
Participant
Pain inhibits
functioning
Pain inhibits
mood
Pain inhibits
relief
Pain as a barrier
to rest & recovery
Changes in level
of functioning
Recognising
needs/limitations
/sensations
Rehabilitation as a
dynamic process
1
2
3
4
Theme 3: Approaches to symptom management Theme 4: Symptom nexus
Participation to
manage
symptoms
Analgesic
intervention
Relaxation to
improve pain
Process of
integrating and
adjusting self-
care practices
Intertwined relationship
between symptoms
Success-
dependent
mood
Symptom genesis
meaning-making
1
2
3
4
6 E. A. CAMPBELL ET AL.
home, wasn’t able to go for a walk (100 m)”(Main theme: Adjusting
to the new status quo). This related to her being aware of her
needs and engaging in health behaviours, such as resting when
needed. She recorded her daily activities according to distances
walked (usually 1km), whether she did aerobics/swam that day,
resting periods, and additional analgesics she took to manage her
pain. For Participant 1, the sub-theme Pain inhibits functioning
manifested in her pain-related physical limitations, “I could only
do small bits [of aerobics] because of the pain”.Her mood was
rarely affected by lower functioning; her HADS-A scores improved
by MCID during practitioner-led sessions, though generally her
depression and anxiety scores were minimal.
Pain and relaxation scores varied from mild to severe but she
recorded moderate-substantial improvements in both during
Phases I and III; she also reported about this relaxation response
from a practitioner-led session in her diary; “Relaxed a lot. Best
experience, evening pains were less”(Main theme: Approaches to
symptom management). Relaxation was moderate at Measurement
Point 1 and mild Measurement Point 2, and from moderate to
relaxed from Measurement Point 3 to Measurement Point 4, sug-
gesting there was a greater impact on level of relaxation during
the self-care sessions. Pain improved from moderate
(Measurement Point 1) to mild (Measurement Point 2) during
practitioner-led sessions, but remained in the same category dur-
ing the self-care phase. Contrary to the stable self-care scores, she
noted in her diary that applying the self-care device to her legs
helped the pain and at times she fell asleep. The general trend in
SNS outcomes from Measurement Points 1–2 (Phase I) and
Measurement Points 3–4 (Phase III) support the increased relax-
ation she experienced during both treatment periods.
She engaged in several approaches to symptom management
–mostly analgesics, but also receiving other therapies such as
physiotherapy –and she recognised that when she was more
active than usual, she needed to take extra analgesics (Main
Table 3. Qualitative findings for Participant 1 showing protocol phase and illustrative quote.
Main theme Sub-theme Phase Illustrative quote
Pain as a barrier Pain inhibits functioning II Evening aerobics; I could only do small bits because of the pain.
Pain inhibits mood I Until Friday, mood very high-spirited but the pain started to erode away at
that on Friday.
Adjusting to the new
status quo
Recognising limitations/needs/sensations I Came home, wasn’t able to go for a walk (100 m).
Rehabilitation as a dynamic process I Reduced [analgesic] in the morning –300 mg (from 600 mg). Experience:
noticed the lower dose in my back.
Approaches to symptom
management
Analgesic intervention II From Wednesday-Saturday I was travelling and in pain and took extra
medication. Immediately when I’m up for longer, it requires
extra medication.
Relaxation to improve pain I 12:00 Vibroacoustic treatment “basic treatment”. Relaxed a lot. Best
experience, evening pains less.
Process of integrating and adjusting
self-care practices
III Vibroacoustic treatment [self-care] on the legs, because they are so sore.
[Next day] Vibroacoustic treatment from Friday helped a lot with
the legs.
Phase I: Practitioner-led sessions; Phase II: Washout 1; Phase III: Self-care phase; Phase IV: Washout.
Figure 3. Primary, secondary, and exploratory quantitative outcomes for Participant 1 at Measurement Points 1–5. MP1-5: Measurement Points 1–5. Primary outcomes:
WHODAS scores (raw 0–48 pts); 0 ¼no impaired functioning; Ability to work Visual Analogue Scale (0–100 mm): 0 ¼completely unable to work, 100 ¼best working
ability; Secondary outcomes: Visual Analogue Scales (0–100mm); Pain, mood, relaxation, anxiety; e.g., 0 mm ¼unbearable pain; 100 mm ¼no pain; Beck’s Depression
Inventory-II (0–63 pts); 0 ¼minimal depression; Hospital Anxiety and Depression Scale –Anxiety subscale only (0–21 pts); 0 ¼no anxiety; Exploratory outcomes;
Parasympathetic nervous system; lower PNS activity <0>higher PNS activity; Sympathetic nervous system index; lower SNS activity <0>higher SNS activity;
Galvanic skin response (arousal); microsiemens (mS); higher score ¼greater arousal (X ¼no reading); Respiration rate; higher score ¼faster breathing rate.
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 7
theme: Approaches to symptom management). She wrote, how-
ever, that she “did not really notice the effects of the [self-care]
treatment”and that she “did not relax as well as in the
[Physioacoustic] chair”.
Integrated outcomes for participant 2
Participant 2 had a moderate ability to work (see Figure 4)
throughout the study, however within this category her ability
decreased by 50% from Measurement Points 3-4, the self-care
phase, which corresponds to substantial change with the MCID
[40] whereas there had been no change during the practitioner-
led sessions. She reported improved functioning with WHODAS in
both treatment conditions; despite a greater improvement during
the self-care phase, the overall scores during Phase I were none-
theless better than during Phase III.
The immediate effects of the Phase I sessions are seen in the
diary entries, also (see Table 4). Before the first Vibroacoustic ses-
sion, she had difficulty driving because of her swollen and painful
hands (Main theme: Pain as a barrier; “The pain –mostly burning
and neuralgia –was strong. It was very difficult to hold on to the
steering wheel”). The treatment relieved her pain and driving
home was easier (Main theme: Approaches to symptom manage-
ment; “A wonderful feeling! Driving home was much better”) indicat-
ing immediate positive results from the practitioner-led sessions.
During the self-care phase, she noted she was able to do more
gardening than in previous years, indicating an increase in func-
tioning, but also that she was in more pain because of this
increased activity (Main theme: Adjusting to the new status quo;“I
nevertheless did more physical, heavier work outside in the garden
and inside the house. Maybe my legs are reacting to this changing
situation”). WHODAS outcomes show that the improvement dur-
ing Phase III was greater than during Phase I and that during the
first washout period her functioning decreased, evidenced by the
increased WHODAS score at Measurement Point 3. The VAS for
pain and WHODAS outcomes support the increase in pain and
improvement in functioning during the self-care phase. VAS for
ability to work, however, highlights a lesser ability to work during
the self-care phase, which could be related to the increased pain
as a result of having greater functioning.
Participant 2 explained that relaxation reduced the burning
sensation in her neck/shoulder (sub-theme: Relaxation to improve
pain). She also reported this relaxation response during the first
self-care sessions, suggesting that pain relief was an auxiliary out-
come to relaxation. The VAS outcomes for pain improved from
moderate to mild during Phase I, and remained moderate during
self-care, suggesting the practitioner-led sessions were more
beneficial. Although relaxation improved from moderate to mild
from Measurement Points 3-4, the post-treatment scores during
the practitioner-led scores were nonetheless consistently mild. The
respiration rate outcomes further support her subjective response
to the practitioner-led sessions, with decreased respiration rate
from Measurement Points 1–2, however PNS activity increased
and SNS activity decreased only during the self-care phase, sug-
gesting less alert/stressed state during this time. Respiration rate
also increased at Measurement Points 3–4. Arousal (GSR), pain,
mood, depression, anxiety, and relaxation changes paralleled each
other, on the other hand.
The reduced ability to work coincided with an increase in
depression and anxiety, and linked to her adjusting to her lower
level of functioning since the car accident: “Anxious, angry, tired
feeling which was somehow eased after psychotherapy. It again
became overwhelming. Will I ever learn that my functioning will
never again be 100%after the accident?”(Main theme: Adjusting to
the new status quo). Being unable to work also made her feel
lonely: “I miss adult company”, suggesting that her lower function-
ing intertwined with her mood. After the first washout period,
Figure 4. Primary, secondary, and exploratory quantitative outcomes for Participant 2 at Measurement Points 1–5. MP1-5: Measurement Points 1–5. Primary outcomes:
WHODAS scores (raw 0–48 pts); 0 ¼no impaired functioning; Ability to work Visual Analogue Scale (0–100mm): 0 ¼completely unable to work, 100 ¼best working
ability; Secondary outcomes: Visual Analogue Scales (0–100mm); Pain, mood, relaxation, anxiety; e.g., 0 mm ¼unbearable pain; 100 mm ¼no pain; Beck’s Depression
Inventory-II (0–63 pts); 0 ¼minimal depression; Hospital Anxiety and Depression Scale –Anxiety subscale only (0–21 pts); 0 ¼no anxiety; Exploratory outcomes;
Parasympathetic nervous system; lower PNS activity <0>higher PNS activity; Sympathetic nervous system index; lower SNS activity <0>higher SNS activity;
Galvanic skin response (arousal); microsiemens (mS); higher score ¼greater arousal (X ¼no reading); Respiration rate; higher score ¼faster breathing rate.
8 E. A. CAMPBELL ET AL.
functioning, depression, and anxiety scores were also worse; the
deterioration in BDI-II and HADS-A scores were also clinically rele-
vant, implying that her overall situation had become worse after
the practitioner-led treatments stopped.
Her ability to manage her symptoms was important for her,
because it allowed her to participate and function in social events,
which she noted was another means of symptom management:
“When I can be a part of something, doing things with adults etc.,
everything feels good”(Sub-theme: Participation to manage symp-
toms). She was aware of both the connection between her pain
and mood, and between being able to participate and her mood.
When she was successful with pain management and participa-
tion, her mood was positive: “The trip to [club event] was success-
ful. Great! JI managed the pains with analgesics. I tried to break
up the standing, sitting, movement, so that my body wouldn’t react
to the pain. It was fairly successful”(Main theme: Approaches to
symptom management).
Integrated outcomes for participant 3
Although she recorded only a mild inability to work with VAS (see
Figure 5), P3’s functioning according to WHODAS was relatively poor.
Pain was a barrier (see Table 4) to functioning and working ability,
evidenced by having to leave work because of headaches (Sub-
theme: Pain inhibits functioning; “pain continued during the night and
next day, had to take migraine meds as well as leave work”). When she
felt less pain, she felt better and could manage to carry out more
activities such as housework. A lesser ability to work paralleled worse
pain, mood, relaxation, and anxiety levels, and she highlighted the
pain-mood connection: “Mood is good when I don’t have any pain”
(Main theme: Symptom nexus). This is seen in the clinically relevant
VAS (pain and mood), BDI-II, and HADS-A improvements. Her condi-
tion affected her mood when she felt despondent about the future:
“Mind a bit glum, I just feel that healthy days aren’t coming or even a
relatively good day”(Sub-theme: Success-dependent mood), but she
also acknowledged that her symptoms were gradually improving:
“even though, on the other hand, there have been [good days] and
gradually, like, I’ve improved really slowly”(Sub-theme: Success-
dependent mood). The self-evaluated success of the rehabilitation
process for her appeared to be related to having more healthy days
and when she felt as though she did not have many, her mood was
subsequently low. According to the VAS outcomes (see Figure 5),
pain, mood, relaxation, and anxiety all improved after Measurement
Point 1, the first three remaining in the mild category and anxiety as
no anxiety until the end of the self-care phase.
The immediate effects of the practitioner-led and self-care ses-
sions are seen in this participant’s diary entries (see Table 5). The
relaxation response she felt during the practitioner-led sessions
Table 4. Qualitative findings for Participant 2 showing protocol phase and illustrative quote.
Main theme Sub-theme Phase Illustrative quote
Pain as a barrier Pain inhibits
functioning
I The pain –mostly burning and neuralgia –was strong. It was very difficult to hold on to the
steering wheel
Pain inhibits mood II I have finally resigned as the secretary of the shooting club, which wasn’t possible because of my
physical state …It wasn’t possible to write because of the pain. And “failing”always affected
my mood
Pain as a barrier
to relief
III Today I didn’t do Taikofon. The pain meant I didn’t have enough patience
Pain as a barrier to
rest & recovery
IV I can’t sleep any longer. Face is sore. I was tossing in bed in vain!
Adjusting to the
new status quo
Changes in level of
functioning
II The first big drop into the ravine was having to stop playing the 5-row accordion, which I’d played
since I was 7. Playing released feelings and endorphins J…It’s difficult to change your activities/
actions to become a listener
III I nevertheless did more physical, heavier work outside in the garden and inside the house. Maybe my
legs [pain] are reacting to this changing situation
Recognising
limitations/
needs/sensations
I A new observation about my own body, is that the vibration treatment doesn’t feel the same on both
sides of my body. The program was changed slightly during the phase to be slightly stronger, i.e.
more massage-like. The right side of my body doesn’t function in the same way as the left. It
feels missing
Rehabilitation as a
dynamic process
II Hands are again swollen. I decided not to be afraid of the pains. I already started to get pissed off with
this illness, pain, low mood, and that nothing can be done. JLJLJ
Approaches to
symptom
management
Participation to
manage
symptoms
I Mood was nevertheless positive and expectant. Research intrigued me. When I can be part of
something, doing things with adults etc., everything feels good, when I don’t have those possibilities
now through working life
Analgesic
intervention
II The trip to [location] was successful. Great! JI managed the pains with analgesics. I tried to break up
the standing, sitting, movement, so that my body wouldn’t react to the pain. It was fairly successful
Relaxation to
improve pain
I I was able to deeply relax, at least in the second half of the program. Relaxation clearly reduced the
burning feeling in the neck/shoulder (from 75–35 mm). A wonderful feeling!
Process of
integrating and
adjusting self-
care practices
III I carried it out lying on the bed, because there was no other peaceful place on offer. …It’s hard to
find a quiet time in the evenings here Taikofon doesn’t give the same relaxation as Vibroacoustics.
Legs feel tense. Vibroacoustics also helped my legs. Taikofon doesn’t. …Taikofon helps with lighter
relaxation, but when your whole body is shouting with tension and pain, the cushion isn’t enough
for that
Symptom nexus Intertwined
relationship
between
symptoms
III Mind was somehow restless and relaxation didn’t quite happen. The pain usually affects me like that. I
get a restless feeling, even though I don’t have big worries or the like
Success-
dependent mood
II Mood somehow good. It’s probably because I was able to manage the pain and participate in the
journey J
IV This week I’ve been feeling quite blue, because the pains have been continuous and doing everything
slowly and it still affects the pains
Phase I: Practitioner-led sessions; Phase II: Washout 1; Phase III: Self-care phase; Phase IV: Washout 2.
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 9
reminded her of a time before the pain started (“Treatment was
wonderful, few times almost fell asleep, good day, like before the
pain, about 2 1
=
2years ago”, Main theme: Approaches to symptom
management). The physiological outcomes also show an increase
in relaxation response from Measurement Points 1-2 (practitioner-
led sessions) with increased PNS and decreased SNS activity as
Figure 5. Primary, secondary, and exploratory quantitative outcomes for Participant 3 at Measurement Points 1–5. MP1-5: Measurement Points 1–5. Primary outcomes:
WHODAS scores (raw 0–48 pts); 0 ¼no impaired functioning; Ability to work Visual Analogue Scale (0–100mm): 0 ¼completely unable to work, 100 ¼best working
ability; Secondary outcomes: Visual Analogue Scales (0–100mm); Pain, mood, relaxation, anxiety; e.g., 0 mm ¼unbearable pain; 100 mm ¼no pain; Beck’s Depression
Inventory-II (0–63 pts); 0 ¼minimal depression; Hospital Anxiety and Depression Scale –Anxiety subscale only (0–21 pts); 0 ¼no anxiety; Exploratory outcomes;
Parasympathetic nervous system; lower PNS activity <0>higher PNS activity; Sympathetic nervous system index; lower SNS activity <0>higher SNS activity;
Galvanic skin response (arousal); microsiemens (mS); higher score ¼greater arousal (X ¼no reading); Respiration rate; higher score ¼faster breathing rate.
Table 5. Qualitative findings for Participant 3 showing protocol phase and illustrative quote.
Main theme Sub-theme Phase Illustrative quote
Pain as a barrier Pain inhibits
functioning
I A heavy headache started the previous night, took several [analgesics], pain continued during the night and next
day, had to take migraine meds as well as leave work.
III Pains reduced noticeably as well as the numbness, feeling better !mood better !can manage to do more
Pain as a barrier to
rest & recovery
I 4.30 I got up to take a [analgesic]. Getting up at 7.00 somewhat helped the headache.
Adjusting to the
new status quo
Changes in level of
functioning
IV The “chair treatment”in the hospital was just wonderful; I was able to relax, not that much that I would fall
asleep, pains disappeared, in the beginning this was for a few hours, then at the end they started to come
back only the next day …With the cushion I didn’t experience big changes, maybe more from the music
which helped to relax, but sure the vibrations felt wonderful on my back. …Overall the pains are in my
opinion less and changed a lot and are more tolerable, normally I don’t notice them anymore, I just notice
them if I want to go and do something e.g. housework, 1h is my limit after which the pain starts.
Recognising
limitations/
needs/sensations
I This week I had a new symptom when I sit or lie on the sofa, I get tingling in my legs (normally it’s numbness).
I didn’t have this for a few years.
Rehabilitation as a
dynamic process
III Already when I think about this whole cushion phase the cushion þmusic somehow helped the pain, sometimes
not, but there was a big effect on mood and also to concentration e.g. in the evening the last time I think I
was able to concentrate on breathing and my thoughts didn’t wander so much, afterwards I felt relaxed, calm
and the pain was gone. I think sometimes I noticed if I were to get my own cushion the bad days would
come just now and then. …
Certainly, doing the exercises which I do about 3 times a week, walking to work every day and in the evening
little walks have also helped the pain and the physio, to which I’ve gone every week.
Approaches to
symptom
management
Analgesic intervention I Backpain …Had to take analgesics at work for the pain and in [Location] for the neuralgia.
Relaxation to
improve pain
I Treatment was wonderful, few times almost fell asleep, good day, like before the pain, about 2 1
=
2years ago.
Process of integrating
and adjusting self-
care practices
III Cushion under calves, neuralgia in right calf, full volume
Feeling wonderfully relaxed, tried to concentrate on breathing, no pain in calves, left toes were numb during
the day, little pain in back, feeling also tired but still glum.
Symptom nexus Intertwined
relationship
between symptoms
II Mood is good when I don’t have any pain.
Success-
dependent mood
III Mind a bit glum, just feel that healthy days aren’t coming or even a relatively good day, even though on the
other hand there have been and gradually, like I’ve improved really slowly
Symptom genesis
meaning making
I Tired in the morning, pains changing position and numbness, weather þ1, windy, cloudy, does the weather
affect it?
Phase I: Practitioner-led sessions; Phase II: Washout 1; Phase III: Self-care phase; Phase IV: Wash.
10 E. A. CAMPBELL ET AL.
well as decreased arousal (GSR) and increased PNS activity also at
Measurement Points 3–4. PNS activity increased and GSR
decreased to a greater degree during the practitioner-led sessions,
suggesting that the self-care sessions were not as relaxing as the
practitioner-led sessions. Contrary to this, respiration rate
decreased much more during the self-care phase. Although there
appeared to be a negative trend in the physiological outcomes,
she wrote: “Already when I think about this whole cushion phase,
the cushion and music somehow helped the pain, sometimes not,
but there was a big effect on mood and also concentration”(Main
theme: Adjusting to the new status quo), highlighting that
although she did not experience pain relief during self-care ses-
sions comparable to that of practitioner-led treatments, she expe-
rienced other positive effects. She marked improvement for the
concentration item of WHODAS, as she found concentration
slightly difficult at the beginning of the study and not at all diffi-
cult at the end, also supported by the qualitative findings that
she was less distracted: “I think I was able to concentrate on
breathing and my thoughts didn’t wander so much”(Sub-theme:
Rehabilitation as a dynamic process).
Throughout the process, she became conscious of new sensa-
tions, or those that had returned after years of absence: “This
week I had a new symptom when I sit or lie on the sofa, I get tin-
gling in my legs (normally it’s numbness). I didn’t have this for a
few years”(Sub-theme: Recognising limitations/needs/sensations). In
comparing the practitioner-led and self-care sessions, she noted
that her pain stayed away longer as Phase I continued (“I was
able to relax, not that much that I would fall asleep, pain disap-
peared; in the beginning this was for a few hours, then at the end it
[pain] started to come back only the next day”, sub-theme:
Changes in level of functioning). She noticed that her pain was
generally less frequent as the process continued (“Overall the pain
is, in my opinion, less, and it changed a lot and is more tolerable,
normally I don’t notice it anymore, I just notice it if I want to go
and do something e.g., housework, one hour is my limit after which
the pain starts”, Sub-theme: Changes in level of functioning). Ability
to work VAS scores improved too during the self-care sessions
and at the end of the process she discussed increasing her work-
ing hours with her MD –further supporting her ability to work
had improved.
Integrated outcomes for participant 4
Participant 4’s positive response to the practitioner-led treatment
sessions (see Figure 6) was most clearly seen in improved func-
tioning, pain, relaxation, and mood. During the first session, he
experienced pain relief (nerve pain in his head), however it
returned as soon as he left the treatment room (see Table 6). It
was a large adjustment for him, as the difference between the
pain and no-pain was so noticeable: “I felt quite anxious then
[when the pain came back] because the contrast was so big”(Sub-
theme: Changes in level of functioning). However, as this phase
continued, he noticed the pain stayed away for longer: “It helped
my legs a lot!! They were lighter and I was painless for many days”
(Sub-theme: Rehabilitation as a dynamic process). He also noticed
other changes. He usually applied cooling gel to reduce night-
time leg pain, but could reduce the amount of gel he applied
during Phase I (Main theme: Adjusting to the new status quo).
Although the general trend of respiration rate and PNS/SNS activ-
ity suggest he was less relaxed from Measurement Points 1–2 and
Measurement Points 3–4, arousal (GSR) was greatly reduced dur-
ing the practitioner-led sessions. Relaxation (VAS) showed a slight
decrease from Measurement Points 1–2, however the score still
fell within the mild tension category at Measurement Point 2. BDI-
II improvement during Phase I was clinically relevant, as was the
improvement in the HADS-A score during Phase III.
Figure 6. Primary, secondary, and exploratory quantitative outcomes for Participant 4 at Measurement Points 1–5. MP1-5: Measurement Points 1–5. Primary outcomes:
WHODAS scores (raw 0–48 pts); 0 ¼no impaired functioning; Ability to work Visual Analogue Scale (0–100 mm): 0 ¼completely unable to work, 100 ¼best working
ability; Secondary outcomes: Visual Analogue Scales (0–100mm); Pain, mood, relaxation, anxiety; e.g., 0 mm ¼unbearable pain; 100 mm ¼no pain; Beck’s Depression
Inventory-II (0–63 pts); 0 ¼minimal depression; Hospital Anxiety and Depression Scale –Anxiety subscale only (0–21 pts); 0 ¼no anxiety; Exploratory outcomes;
Parasympathetic nervous system; lower PNS activity <0>higher PNS activity; Sympathetic nervous system index; lower SNS activity <0>higher SNS activity;
Galvanic skin response (arousal); microsiemens (mS); higher score ¼greater arousal (X ¼no reading); Respiration rate; higher score ¼faster breathing rate.
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 11
Participant 4 did not notice a great change in his pain when
conducting the self-care sessions, however his pain was in the
mild category at all Measurement Points. He reported in his diary
that he was able to relax using the self-care device, noticing
some pain relief (Theme: Approaches to symptom management).
This can also be seen in the VAS pain outcomes, with improved
pain from Measurement Points 3–4.
The quantitative results show that all outcomes were worse
after the treatments stopped, at Measurement Point 5. He noted:
“After the treatments stopped, I had a lot more pain. Nerve pain in
my head and legs has returned. I have been sleeping worse”(Sub-
theme: Process of integrating and adjusting self-care practices).
Although Phase III improvement margins were comparatively nar-
rower than during Phase I sessions, his condition during self-care
was also better than before the study began. He more easily
noticed the benefit of the self-care sessions after the treatments
had ended, because his symptoms deteriorated at that point; this
is also supported by the quantitative Measurement Point 5 scores.
Discussion
This study aimed to assess the impact of practitioner-led
Vibroacoustic treatment sessions and self-care on functioning,
chronic pain, and possible comorbid mood disorders within a
multidisciplinary rehabilitation setting. As self-care is a part of
regulatory function inherent in one’s daily activities and to be
viewed as an integral part of rehabilitation [30], the self-care
phase was introduced to the Vibroacoustic treatment protocol as
a means of protracting patients’rehabilitation processes. As in
previous research of Vibroacoustic treatment [13–15,17], partici-
pants in this study experienced pain, mood, and insomnia relief.
The outcomes from the limited applications of Vibroacoustic as a
self-care intervention [34] support these participants’experiences
of increased energy and relaxation. The comparatively greater
improvement in relaxation scores by participants in this study are
also in line with previous research [13–15]. Patients receiving
Vibroacoustic treatment within multidisciplinary care, as with the
participants in this study, also reported relaxation as the variable
of greatest improvement, even by those previously unable to
reach a state of relaxation using other methods [52].
Although relaxation was greatly improved in the patients pre-
sented here, as there was no comparison with other relaxation
techniques or the possibility to explore the specific active agent
within the VA treatment triad which elicited the relaxation
response, this is an area for future research and investigation.
Self-care as an integral part of a rehabilitation process
Self-care as a concept adheres to several principles: attributes,
such as one’s ability to perform self-care, and decision-making;
antecedents, such as social support, perceived and actual physical
and psychological health condition, prior experiences, and self-
efficacy; and outcomes, including improved functioning, coping,
and physiological and psychological symptoms [30]. These ele-
ments can be seen in the participants’experiences presented
here. As self-care is intrinsically involved in rehabilitation and
one’s daily health behaviours, the emerging self-care-related
behaviours were noted already during the practitioner-led phase,
laying the foundation for these to become fully realised during
the self-care phase.
Awareness of change
Improved symptoms noticed by participants (such as concentra-
tion) contributed to how they perceived improved functioning
and their increased ability to work, evidenced by Participant 3’s
gradual increase in working hours. Awareness, as one of the
attributes of self-care described by Orem [30], was also exhibited
by other participants. As perceived disability and emotional dis-
tress negatively influence one’s ability to work [53], Participant 3’s
awareness of her improved symptoms could have been a boost
towards affording her a sense of self-efficacy and control over her
symptoms. Participant 3 also noticed improvement in cognitive
functioning, a reported effect of self-care practices [33]. The quan-
titative outcomes support the improvement in mood which could
have afforded this positive change.
A similar situation occurred for Participant 2; in becoming
aware of the gradual increase in sensation in her right leg during
the practitioner-led sessions, although she was not yet at the
stage where she could return to work, she only noticed this asym-
metrical sensation during Vibroacoustic treatment, and it became
a way of tracking treatment progress.
Table 6. Qualitative findings for Participant 4 showing protocol phase and illustrative quote.
Main theme Sub-theme Phase Illustrative quote
Pain as a barrier Pain inhibits functioning I I was in more pain than usual. I wasn’t able to do anything in the evening. I felt as
though I had a heavy cold and I was frozen solid under a blanket. I woke to a heavy
cramp in my leg during the night.
Pain as a barrier to rest
& recovery
II I’ve had a lot of pain. Sleeping poorly at night and back and legs have been painful. I’m
constantly getting electric shock in my legs.
Adjusting to the new
status quo
Changes in level of
functioning
I The pains returned quite quickly. I felt quite anxious then because the contrast was
so big.
I Relaxed again really well [during the treatment]. I was able to put less creams on my
legs when I go to bed (cooling gel etc).
Recognising limitations/
needs/sensations
I I relaxed again much deeper. If I relax properly, I’m in more pain in the evening. The
night was again rather good.
Rehabilitation as a
dynamic process
I It helped my legs a lot!! They were lighter and painless for many days. It’s terrible that
it’s stopping almost like in the middle of the treatment, now that it’s beginning to
help the pain!!!
Approaches to symptom
management
Relaxation to
improve pain
I I relaxed well again. After the treatment, my strength was rather gone, but returned
quickly. Nerve pain in my head was less.
Process of integrating and
adjusting self-
care practices
III It has worked with varying success. I intermittently put it on my neck when going to
sleep. Relaxed quite well and I’m able to fall asleep better. The same music is already
starting to be irritating.
I have tried to use the cushion religiously. If I use it too late, the only effect is
tiredness. I don’t notice great changes to the pain. Able to manage to relax.
Phase I: Practitioner-led sessions; Phase II: Washout 1; Phase III: Self-care phase; Phase IV: Washout.
12 E. A. CAMPBELL ET AL.
Participant 4 noticed how beneficial self-care had been when
symptoms returned during the second washout period. Although
the effects were subtler than the comparatively greater effects he
felt from the practitioner-led sessions, he exhibited awareness of
the changes from the treatments, and then as a result of
their absence.
With greater awareness, one potentially begins to recognise
potential barriers. All participants noticed some barriers to func-
tioning and self-care, including influence from comorbidities such
as mood, also shown elsewhere [31]. Improvements recorded dur-
ing self-care included decreased pain and depression, and
improved functioning, which were also previously reported [32].
Mourning one’s past identity
Patients with persistent pain are also commonly emotionally
impacted by the chronic illness (as seen with Participants 2 and 3)
and the link between pain and poor mental wellbeing, sometimes
mourning the loss of their former selves [54]. Frustration with
poor functioning, loneliness, inadequacy resultant of the new
experience of low functioning, and embarrassment due to non-
working status are all aspects of this emotional impact.
Participant 3 felt that Vibroacoustic treatment reminded her of a
time before her pain; her mood was low, fearing that she would
not return to this former self. Patients often feel disappointed
when they realise that they must settle for symptom reduction
rather than a cure [54]. This supports Participant 2’s struggle to
accept that her functioning would never again be at 100%.
Patients with chronic pain also often believe that a change in
functioning corresponds to a complete loss of functioning, as was
the case for Participants 2 and 3 [55]. They at times struggled to
accept the new level of functioning as they had been accustomed
to more activity, social functioning, and participation before the
onset of their pain.
Social functioning
Participant 2 understood the importance of socialising to her
rehabilitation process, noticing improvement in her pain and
mood when she was able to participate in social events. In con-
trast, Participant 1 may have not felt the need to return to work
because of her support system outside the workplace which was
lacking for Participant 2 whilst on disability leave. One’s ability to
participate is influenced by one’s biological functioning, which
refers to the general physical functioning and the extent to which
this limits one’s activities [56]. Social functioning is an important
element predicting pain self-efficacy and pain severity [57], with
lower social functioning and biological functioning predicting
higher pain severity. The importance of being able to retain or
regain one’s social functioning is underscored by Participant 2’s
experiences and need for socialising. The fact the self-care was at
home, without the same level of professional support, was an
issue for her. Despite the intensive rehabilitation offered at the
hospital, she wished for a longer Vibroacoustic treatment period,
having found the bi-weekly sessions beneficial from the social
point-of-view as well as the physical treatments. When psycho-
logical symptoms were greater (e.g., feeling low because of dis-
ability), participants’feelings of control over their symptoms was
impacted. Prior experiences of greater functioning resulted in frus-
tration with the current level, as described in previous research
[55]. Their negative responses to pain or inability to conduct day-
to-day activities affected their health-related behaviours (e.g., skip-
ping self-care sessions) and disability negatively impacted their
social interactions (inability to attend birthday parties/
club events).
Comparing objective and subjective reports
The differences between the qualitative and quantitative data
were seen in instances where, for example, Participant 4 reported
the self-care intervention was ineffective for pain relief, but the
VAS for pain indicated otherwise. The improvement in pain during
self-care was clinically relevant, however he felt the effects were
much weaker than the practitioner-led sessions in which there
was no clinically important difference. His pain at Measurement
Point 4 was objectively better than Measurement Point 1, but he
only noticed the deterioration in symptoms after the self-care had
ended. The effects from self-care were perceived as subtler than
those of the practitioner-led sessions. The physiological outcomes
were mixed. He reported decreased PNS and SNS activity, how-
ever increased arousal (GSR), during the practitioner-led phase.
During the self-care sessions, SNS activity increased, supporting
his claims that these sessions were not as relaxing as the previous
treatment condition. Higher RMSSD (vagal tone) scores are associ-
ated with higher pain intensity in those with chronic pain com-
pared to controls without chronic pain [57]. This was also seen,
for example, at Measurement Point 4 for Participant 4; his RMSSD
score at the beginning of the treatment phase was 28.5 ms (VAS
pain 69 mm), and 26.6 ms (VAS pain 88 mm) at the end of the
treatment phase. Patients with fibromyalgia, such as Participant 4,
have been shown to exhibit decreased PNS activity and increased
SNS activity compared to controls [58]. This could explain
Participant 4’s increased SNS level at Measurement Point 1 when
his pain was mild and the decreasing PNS during the practitioner-
led sessions when his VAS pain score was worse. From a within-
session perspective, although not the focus of this present study,
those entering a relaxation response have been shown to exhibit
increased heart rate and decreased respiration whilst meditating
[59]. Participant 4’s physiological outcomes showed an increase in
heart rate from 69 to 71 beats per minute and a decrease in res-
piration rate from 15 to 13 breaths per minute at Measurement
Point 2. He also marked relaxed on the VAS for relaxation. Arousal
also reduced from 2.08–1.67 mS during this session. The within-
session changes may indicate a general trend over time such that
the decreased respiration rate from 3–4 and increased SNS activity
(including heart rate) may represent a relaxation response over
time. Galvanic skin response (GSR), as a physiological measure of
arousal and mental/emotional states, has been shown to reduce
with meditation and music listening as so-called stress-relieving
methods, but may also indicate the level of concentration; if one
is disturbed when engaging in these activities, GSR peaks [60].
This could account for higher mean GSR levels (e.g., Measurement
Point 4, Participant 4), possibly resulting in difficulty reaching a
more relaxed state during the comparatively short self-care treat-
ment time.
Anxiety is potentially another confounding variable. It has
been shown that the relationship between pain and anxiety is not
always unidirectional, in that when anxiety is not related to
experimental pain, the pain is perceived as less intense compared
to when anxiety is associated with the pain source [61]. The
music, despite being participant-chosen, may have influenced
physiological responses. Music chosen by participants has been
shown to arouse autonomic nervous system responses (e.g., heart
rate, muscle tension) even though participants reported reduced
anxiety and an increase in relaxation [62]. This could partly
explain the disparity between the physiological, VAS, and ver-
bal reports.
Similarly, in assessing subjective and objective reports of activ-
ity in patients with chronic lower back pain [63], self-report meas-
ures did not correlate with the objective measurement of physical
VA TREATMENT IN MULTIDISCIPLINARY REHABILITATION 13
activity. There were strong correlations, however, between object-
ive and subjective reports in controls who were asymptomatic.
Comparison with asymptomatic controls is not possible in the
present study; however, symptoms such as pain (as suggested by
van Weering and colleagues [63]) may account for the disparity in
subjective and objective records.
These conflicting reports emphasise the complex interactions
between physiological responses and perceptual experiences of
the multi-modal experience of chronic pain and multidisciplinary
approaches to its management.
Limitations
As this study took place within a naturalistic setting, participants
were receiving various other interventions either concurrently or
successively. To some degree, the qualitative findings show some
pre- and post-treatment changes, however the overall effect of
both treatment conditions is compounded by additional therapy
regimens. This has both positive and negative attributes. The effi-
cacy of the interventions cannot be assessed using this approach.
However, as Vibroacoustic treatment is delivered to difficult-to-
treat patients with various diagnoses receiving various treatments
at this unit, adding this self-care intervention to the naturalistic
setting gives a more accurate representation of how it would
work in practice, therefore assessing effectiveness. Effectiveness
studies look at clinical practice and the real-life circumstances.
The “ideal”unidimensional scale for measuring pain is the VAS
[64], because it is independent of language, however, a mix of
subjective and objective reports should be used given the dispar-
ity in what a patient or researcher/healthcare giver may evaluate
as a successful intervention. As perceived functioning and chronic
pain are subjective to each individual patient, their experiences of
this approach - relative to their standard care - is, in essence, the
most important tool for intervention evaluation. In addition to the
other treatment participants were receiving, medication changes
were also a compounding variable for Participant 1 because she
changed medication dosage during the protocol. Although it is
also a part of one’s rehabilitation process, this influences her pain
and may account for the relatively little pain reported with VAS.
In relation to the study design, although comparison across
individual cases is not possible, the outline aimed to give impres-
sions of how participants with various levels of functioning may
respond to Vibroacoustic treatment with added self-care. Barlow
and colleagues [65] expressed the necessity of non-RCT studies in
evaluating processes, as such studies are required to explore
whether the resources needed to conduct larger, randomised
studies are justified. The present study serves as a way of explor-
ing the potential responses of a highly varied target group, and
whether chronic pain patients with possibly comorbid mood dis-
orders may benefit from this “two-pronged”approach. As the field
is still small, these more in-depth studies are needed before larger
studies can be considered. This was, however, an issue for out-
come measures, as the small sample meant quantitative analyses
could not be conducted. On the other hand, the mixed methods
design highlighted the complexity of the individual chronic pain
experience. As Morgan and Morgan [66] succinctly wrote: “No
amount of research in the nomothetic tradition can effectively
reveal the likelihood of successful treatment in an individual case”
(p. 185).
The comparatively lower intensity of the Phase III sessions
compared to the Phase I sessions was also discussed by partici-
pants. Although the self-care device is indeed much smaller than
the Physioacoustic chair, the aim of this study was not to
compare efficacy of one approach to the other, rather to explore
whether a self-care phase could be useful as an additional inter-
vention for patients at home.
Conclusion
Outcomes from a self-care phase added to standard Vibroacoustic
treatment protocol at the multidisciplinary rehabilitation unit at
Sein€
ajoki Central Hospital indicate that both interventions may be
beneficial for improving functioning, pain, mood, and relaxation.
Participants found the effects from the practitioner-led sessions
were more distinctly manifested by the end of that phase; the
self-care sessions appear to have been beneficial for less severe
pain and related symptoms. This self-care approach could be
applied directly after practitioner-led sessions to prolong the
effects, or as an intervallic or intermediate intervention applied
between intensive practitioner-led phases. The mentality and skills
developed during a rehabilitation process may support prolonged
relief, potentially helping to avoid relapse. As previous research
has supported the combination of Vibroacoustic treatment and
physiotherapy [13,17], the self-care device could be implemented
as a way to improve physiotherapy outcomes when conducting
exercises at home.
Acknowledgments
The authors wish to thank the helpful comments and time given
by Olivier Brabant, Anna-Kaisa Ylitalo, and Nerdinga Snape in the
analysis and data presentation discussions for this article.
Declaration of interest
The authors report no declarations of interest.
Funding
This work was supported by the Faculty of Humanities and Social
Sciences, University of Jyv€
askyl€
a, Finland, and the Otto Malm
Foundation, Finland.
ORCID
Elsa A. Campbell http://orcid.org/0000-0003-4888-0310
Birgitta Burger http://orcid.org/0000-0002-0694-3582
Esa Ala-Ruona http://orcid.org/0000-0003-3873-5179
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