View of The Effect of Music Therapy on Pain and Anxiety of Children Diagnosed with Leukemia during Bone Marrow Aspiration and Lumbar Puncture Procedures

The Effect of Music Therapy on Pain and Anxiety of Children Diagnosed with Leukemia during Bone Marrow Aspiration and Lumbar Puncture

Procedures

NasrinGhanbari¹, Hamid Reza Khankeh^2*, Kian Norouzi³, Ali ZadehMohammadi⁴

1 Master Student,Pediatric Nursing, Tehran University of Social Welfare and Rehabilitation Sciences, Iran

2*Professor, Nursing Department, Tehran University of Social Welfare and Rehabilitation Sciences, Iran

3Associate Professor,Nursing Department, Tehran University of Social Welfare and Rehabilitation Sciences, Iran

4Associate Professor, Family Research Institute, ShahidBeheshti University of Tehran, Iran

Abstract

Background: Pharmacological and non-pharmacological approaches can be mainly used to relieve children's pain and anxiety.Music therapy can be a part of patient care in nursing practices. It can be used as a non-invasive intervention for relieving pain and anxiety.

Methodology: This is a randomized clinical trial on 50 leukemia children whoundergoingbone marrow aspiration and lumbar punctureprocedurs in Children's Hospital of Kermanshah, Iran. Participants in this study were randomly assigned into two groups: One group listened to children's selective music by headphones half an hour before and during the invasive procedures and the other did not. The data were analyzed using SPSS17, independent t-test,paired t-test, Chi-square, Fisher exact, and U Mann-Whitney test.

Findings:No significant difference was found in terms of children's anxiety in pretest stage in intervention and control groups (P=0.796). In posttest stage, however, a significant decline was seen in anxiety in intervention group (P=0.000). The pretest pain score was not significant between two groups (P=0.730). The pain score, however, declined during (P=0.000) and after (P=0.000) intervention in the intervention group. Conclusion:Music therapy is one of the most widely-used methods incomplementary and alternative medicine,which is readily accepted by patients. Therefore, music therapy is recommended to be used as a non-invasive, easy, inexpensive, and effective method for reducingpain and anxiety ofleukemia children as well as other patients. More studies are advised in terms of different types of cancer in various hospitals.

Keywords: Music Therapy, Pain, Anxiety, Children, Leukemia.

Introduction

There are several procedures performed on cancer children, which cause pain and anxiety for children and stress for their families. This is particularly important when these procedures might be repeated during diagnosis and treatment of different types of cancer (1). Leukemia is the most common childhood cancer, accounting for 37.6% of cancer during this stage of life (2).The suspicion of leukemia is usually based onthe patient's history, physical symptoms, and peripheral blood test which containimmature leukocytes, along with low number of blood cells.A definitive diagnosis ismade based on the aspiration or bone marrow biopsy. Bone marrow specifically shows steady infiltration of blast cells. When the diagnosis is confirmed,lumbar puncture is performed to determine the central nervous system involvement (3). In fact, successful treatment of childhood cancer depends on a number of invasive procedures such as aspiration andbone marrow biopsy,spinal injections, and venipunctures to carry out and assess the effect of treatment (4). During these procedures, children might experience a great deal of fear and anxiety due to the real backache or pain forecast (5, 6, and 7).Studies ononcological patients point to the weak management of pain, More than 80% of cancer patients experience asignificant pain during the treatment (8). Pain assessment is a substantial component of the nursing process,and the American Pain Society(2000) introduced pain as the fifth vital sign,It advises the forecast for stressful and painful processes for children and essential measures for meeting such processes (9).Careful management of pain during the course of the disease or injury can reduce or prevent the anxiety symptoms, Pain is remembered by children who experience repeated painful procedures as a result of cancer or otherimmune system problems. Child's memory ofpainful procedures early in the treatment course can lead to a fear and anxiety forecast prior to the next measures andanxiety disorders such as fear of blood or needle phobia, making the reception of next stages more difficult (10). While anxiety is quite common among children, Highly-prevalent anxiety is specifically reported among children with serious health problems, undergoingnumerous medical procedures including cancer children (11). The study by Buchanan (2008) showed that almost 27% of children diagnosed by Acute LymphoblasticLeukemia (ALL) areat increased risk of clinically significant anxiety,The study indicated that the numbers of leukemia children who experience anxiety are twice as many as the children's general population (12). Therefore, in order to reduce thephysical and psychological effects of painful interventions and prevent the long-term consequences, nurses must be capable of managing painful procedures. To this end, a wide range of approaches are

advised includingpharmacological and non-pharmacological methods (9). It has been found thatpharmacological treatments are effective in reducing pain and anxiety related to medical procedures; however, they might be associated with alarming side effects (13).Also,despite using pain killers, some patients have stated the pain in painful procedures (14). Today, non- pharmacologicalrelief methods have attracted the nursing systems (15).Complementary and Alternative Medicine is widely used to prevent the diseases and promote the public health (16). According to the advice by WHO in terms ofcomplementary medicine, human beings are rightful to use the most effective and inexpensive global medical methods for treating different types of diseases (17).Music therapy, as one of complementary methods, traditionally plays a key role in improving human health and controlling pain. Music therapy is a supportive profession, which can be used by patients diagnosed with different types of physical and psychological problems or social-emotional disorders (18). The effect of music has been proven on human's physiological and emotional responses. According to thegate control theory of pain, pain receptors work with each other in order to send the pain messages to the brain. Therefore, a distracting factor such as music can block the specific ways of pain transfer and reduce the perceived pain (19). Nursing researchers have used the music therapy intervention for patients of all ages in different fields includingintensive care, surgery, delivery, and palliative care. However, few considered the cancer children, It is essential to study the issue due tothe need for repeated hospitalizations and multiple invasive procedures in children with leukemia and the fact that invasive procedures does not reduce children's pain and anxiety (5). According to the studies, controlling pain is the second important factor after right diagnosis for the patient and family (8). Therefore, this article aimed to study the effect of music therapy onpain and anxiety of children diagnosed with leukemia during bone marrow aspiration and lumbar puncture procedures.

Materials and Method

This is a randomized clinical trial performed in Kermanshah, Iran. A total of 50 children diagnosed with acute leukemiaundergoing chemotherapy were enrolled as the sample. They visitedthe Chemotherapy Clinic of Children's Hospital of Kermanshah, Iran, from March to August 2016 for bone marrow aspiration and lumbar puncture procedures. The inclusion criteria were as follow:

- 6-12 year-old children

- Developing leukemia (lymphoblastic or myeloblastic)

- Lack of mental retardation , visual and aural problems - No history of ear surgery

-

-

-

The subjects were excluded if the procedure was incomplete, the procedure was repeated for more than once, anti-anxiety or pain killer was prescribed by the physician, and the headphones was removed by the child.

Research Instrument

Data were collected using four questionnaires: Patient Medical - Personal History Questionnaire,Revised Children's Manifest Anxiety Scale (RCMAS), FLACC Behavioral Pain Assessment Scale,and self-reporting Wong-Baker Faces Pain Rating Scale (WBFPRS). The demographic characteristics included age, gender, order of birth, father's and mother's education, place of residence (city or village), andclinical background information including (disease duration, history of hospitalization, number ofbone marrow aspiration and lumbar punctureprocedures, and the length of invasive procedures).

RCMAS

The instrument was designed by Reynolds and Richmond (1978) to assess the symptoms of general anxiety of children and adolescents (up to 19 years old). The scale consists of 38 items. A total Anxiety score is computed based on 28 items, which are divided into three anxiety subscales: physiological anxiety, worry/oversensitivity, and concerns/concentration. The remaining nine items on the RCMAS constitute the Lie subscale. In this test, the children are asked to answer by "Yes" or "No". Each item is scored on a zero to one scale. The anxiety score can range from 0 to 28,The lie score from 0 to 9. A low score on the anxiety scale suggests lower levels of anxiety and lower scores on lie subscale suggests the honesty of subject for answering the questions. Multiple studies have been conducted for the validity of RCMAS. The construct and content validity has been verified in many studies. Reynolds and Richmond reported 0.56 to 0.80 for the internal consistencyof three subscales. The total internal consistency was reported 0.80 (20). In Iran, Taghavi and Alishahi (2005) studied the validity and reliability of

RCMAS. The reliability was reported 0.67 and 0.66 using retest and bisection methods, respectively.Divergent validity and correlation were used for investigating RCMAS, According to this study, RCMAS was appropriate to be used in Iran (21). The study by Reihani (2014) verified the reliability (0.78) of RCMAS (22).

FLACC Behavioral Pain Assessment Scale

The scale consists of five sections (Face, Legs, Activity, Cry, andConsolability). Each item is scored on a 0-2 scale, with higher score representingmore reaction to pain. The score of each item is recorded separately and the overall pain score is the total sum of the items. The scale is scored in a range of 0–10 with 0 representing no pain and 10 representing the maximum pain. The overall score is classified into three categories:

1-3: Mild pain 4-6: Moderate pain 7-10: Severe pain (23).

The scale was first designed by Merkel and Lewis (1997) in order to assess the postoperative painof the children between the ages of 0 months and 7 years (24). Other studies have verified the scale to assess the pain severity in painful procedures such asperipheral venipuncture, lumbar puncture, and other invasive proceduresamong the children between the ages of 5 to 16 years. The study by Nilsson (2008) showed that a correlation was found between the observed behavior score of two researchers and the self-report through the ColouredAnalogue Scale during the procedure (r=0.59, P<0.05).

Interrater reliability during the procedure was supported by adequate Kappa statistics for all items and for the total FLACC score(P<0.001,K=0.85).Bagherian et al (2012) verified the validity using content validity by 10 nursing lecturers (9). The reliability was 0.74 and 0.85 in the studies by Tavasoli et al. (2008) (26) and Rostami et al. (2014) (27).

Wong-Baker Faces Pain Rating Scale (WBFPRS)

The scale was developed by Wong and Baker (1998) that consists of face and number.

Prior to the procedure,full description is provided by the researcher proportional to age of the child in relation to the scale. The numerical section is explained for children older than 7 years, with zero representing No Pain, 1-2, Low Pain; 3-4, Hurts a Little Bit; 5-6, Hurts Much More; 7-8, Severe Pain; and 9-10, Hurts Worst. The second section, which is

above the numerical scale, shows a series of faces ranging from a happy face at 0, "No hurt" to a crying face at 10 "Hurts worst". The child must choose the face that best describes how they are feeling because they are not able to realize the meaning of numbers or cannot count. The scale used for individuals between the ages of 3 to 18 years (28). Wong and Hockenberry (2003) studied the validity and reliability of WBFPRS (3).

Numerous other studies assessed the construct validity, concurrent validity, and test - retest this scale (3). The results showed that WBFPRS is valid and reliable to measure the procedure pain (29). Alhani et al. (2010) verified the validity and reliability of WBFPRS using content validity and test-retest (r=1) (30). The study by NikFarid (2008) showed that the reliability was 0.82 using the content validity method by nursing lecturers (31).

Method

The researcher selected the subjects among the children diagnosed withleukemia who visited the hospital forbone marrow aspiration and lumbar puncture. Oral and written consent was taken from the parents and subjects after briefing the subjects. Then, demographic characteristics were obtained using a questionnaire. The subjects were assigned into two groups: Intervention (25 members) and Control (25 members) using random block. The anxiety score was asked from both groups using RCMAS, thenthe subjects were asked to forecast their pain usingWBFPRS. Next, for subjects in the intervention group the childish music, selected by the research consultant, was played 30 minutes prior to and during the invasive procedures (NIA headphones, made in China, were used ) when the nurses and physician were preparing the chemotherapy procedure.Disposable covers were used to prevent the infection. The participants in the control group received the routine care. Note that anti-anxiety and pain killers are notroutinely used in this center. During the invasive procedures, the pain was assessed using FLACC Pain Assessment Scale. Both groups rested for half an hour after the completion of procedure. Then, the anxiety and pain scores were recorded using RCMAS and WBFPRS.The data were analyzed using SPSS17, independent t-test, paired t-test, Chi-square, Fisher exact test, and U Mann- Whitney test.Kolmogorov Smirnov test was employed for verifying the normality of quantitative data, Qualitative data were investigated by Chi-Square. Significance level was considered 0.05.

Ethical considerations were taken into account including the permission of Ethics Committeeprovided by Tehran University of Social Welfare and Rehabilitation Sciences

(Ethics Code: IR.USWR.REC.1395.11), official letter from Kermanshah University of Medical Sciences, explanation of objectives and nature of the study for the parents and subjects, and written consents.

Findings

A total of 55 patients were enrolled in the study of which 5 were excluded (3 patients from control group; 2 patients received more than one invasive procedure and one had used EMLA ointment, 2 patients from the intervention group because they stopped using the headphones before finishing the procedure). As a result, 50 patients entered the study assigned in control and intervention groups. 20% of the subjects underwent lumbar puncture, 4% underwent bone marrow aspiration, and 76% experienced both procedures at the same time (Table 1). The results showed that both groups are matched in terms of age (p=0.88), gender (p=1.000), order to birth (p=0.76), father's education (p=0.68), mother's education (p=0.84), and place of residence (p=0.73) (Table 2). Clinical background variables indicated that were not different in terms of length of development (p=0.76), the frequency of procedures (p=0.24), and history of hospitalization (p=0.20).

However, the length of invasive procedure was shorter in intervention group than the control (p=0.003) (Table 3).

Table 1: Comparing Control and Intervention Groups in Terms of Procedure

Variable Group Intervention Control Total

No. % No. % No. %

Type of

Procedure

BMA 1 4 1 4 2 4

LP 5 20 5 20 10 20

Both 19 76 19 76 38 76

Total 25 100 25 100 50 100

The mean duration of invasive procedures was 6.43±1.73 minutesin intervention group, while it was 7.97±1.69 minutes in control group

Table 2: Demographic Characteristics

Variable Intervention Control Test P-Value

Mean±SD

Age (Year) 9.04±1.8 8.96±1.8 T=0.156 0.88

Gender (Number) Female 11 11

X²=0.000

1.000

Male 14 14

Order of Birth ^First 17 18

X²=0.095 0.76

Second and After 8 7

Place of Residence City 19 20 X²=0.117 0.73

Village 6 5

Father's Education

Illiterate 5 3

X²=1.515 0.68

Secondary School 5 7

Diploma 10 12

Academic Education 5 3

Mother's Education

Illiterate 5 3

X²=0.83 0.84

Secondary School 5 7

Diploma 13 13

Academic Education 2 2

The results of RCMAS before the start of procedure showed that no significant difference was found between the intervention and control groups in terms of the score of anxiety (p=0.796), while the score of anxiety after the procedure showed that the reported anxiety was less in intervention group than the control group (p=0.000) (Table 4).

Table 3: Background Clinical Variables

Variable Intervention Control Test P-Value

Length of Leukemia Development (Month)

19.7±^{11.2 17.4}±^{10.8 T=0.45 0.76}

Frequency of Procedure 11.08±5.27 9.44±4.53 T=1.17 0.24

(times) Frequency of Hospitalization (times)

8.9±5.3 7.1±4.2 T=1.31 0.20

Length of Procedure (Minute)

6.43±1.73 7.97±1.69 T=-3.16 0.003

Table 4: Comparing Anxiety between Intervention and Control before and after the procedure

Variable Intervention Control Test P-Value

Mean±SD

Anxiety

Before 21.04±1.38 21.24±2.42 T=0.260 0.796

After 12.6±^{3.06 19.3}±^{2.61 T=8.317 0.000}

A review of pain scores before and after the procedure showed that no significant difference was found between the intervention and control groups in terms of the reported pain scores, andboth groups forecasted equal pain (p=0.730), while, after the procedure, the reported pain score was significantly less in intervention group than the control group (p=0.000) (Table 5).

The results of observing behavioral reactions during the procedure showed that the pain scores were significantly less in intervention group compared to control group (p=0.000) (Table 5).

Table 5: Comparing Pain in Intervention and Control Groups Before, During, and After the Procedures

Variable Stage Intervention Control Test P-Value

Mean±SD

Pain

Before 8.56±1.583 8.40±1.633

U Mann- Whitney

=0.345

0.730

During 4.320±1.249 8.160±1.462 T=-9.982 0.000 After 4.24±1.855 8.40±1.528 T=-8.657 0.000

In this article, the mean score of reported anxiety was 15.7±4.04 among the girls and 16.1±4.70 for boys. The mean score of experienced pain was 6.64±2.67 among the boys and 5.91±2.72 among the girls. The results of independent t-test showed that no significant difference was found between boys and girls in terms of the pain and anxiety scores.

Table 6: Comparing Pain and Anxiety between Boys and Girls Before and After the Procedure

Variable Stage Girls Boys Test P-Value

Mean±SD

Anxiety

Before 20.95±^{2.55 21.28}±^{2.83 T=0.428 0.67}

After 15.7±4.04 16.1±4.70 T=0.301 0.76

Pain

Before 8.27±1.66 8.64±1.54 T=0.812 0.42

After 5.91±2.72 6.64±2.67 T=0.956 0.34

Discussion

This article aimed to determine the effect of music therapy on pain and anxiety of children diagnosed with leukemia undergoing bone marrow aspiration and lumbar puncture procedures. The results showed that music therapy can help reduce children's pain and anxiety during the invasive procedures. Distraction is the most commonly used method for painful procedures of short duration, butsuch distraction must be attractive for children (4). The commonly accepted hypothesis is that music, as a cognitive factor, causes distraction, directing the focus of child towards something enjoyable and encouraging (32). Music therapy has a number of merits with immediate effect, sometimes permanent effect on patients, family members, and care staff. Music penetrates physical and emotional obstacles, attracts people to each other, reduces isolation, and increases social interactions (33). People's perception of music is effective in its power of treatment. Certain music can create various effects in people with different perceptions (34). Therefore, moods, tastes, age, cultural traditions, geographical locations, and religious background need to be taken into account while selecting music. Music consultants were used in this regard, meaning that music was selected proportional to the

Iranian children. Findings showed that the hypothesis was verified (music was effective in reducing the children's anxiety and pain). The results are consistent with those of the study by Shabanloei (2010) on the effect of music on patient's pain and anxiety duringbone marrow aspiration and biopsy,The result of this study showed that music group displayed lower pain and anxiety after intervention (22). The study by Nguyen (2010) on the effect of music on the anxiety and pain of leukemia children undergoing lumbar puncture showed that the pain and anxiety scores were lower in music group than control group (5). The study by ZamanZadeh (2013) showed that music was effective in reducing the anxiety of the patients undergoingcholecystectomy. The results are consistent with our study (35). The results of the study by Zhou (2014) on reducing the anxiety of patients undergoingradical mastectomy are consistent with ours (17). Zhou believed that music therapy sessions can reduce the women's anxiety undergoingmastectomy. The results of the study by Zengin (2012) on the effect of music on reducing the pain and anxiety of patients undergoing subclavian catheter port placement are consistent with ours (15). According to Zhou's study, the patients in music therapy group experienced less pain and anxiety compared to control group. Unlike our study, Danhauer (2010) studied the effect of music on the anxiety of patients during bone marrow biopsy. He stated that music was not effective on the pain and anxiety scores of the participants, and no significant difference was found in both groups before and after intervention in terms of the anxiety score (36). In Danhauer's study, the subjects in music group listened to music during the procedure,whileno certain time was taken into account prior to the invasive procedure. Therefore, the length of intervention was not similar for the participants. On the other hand, no certain criterion was used for selecting the music appropriate with the age. These factors can be effective in the results. The study by Hooks (2014) on the effect of music on perceived pain of the patients undergoing knee surgery showed that the reported pain score was lower in music group than the control group;

however, no significant difference was found between two groups in terms of the requested opium (16). Unlike our study through which music is the only intervention method for reducing pain, Hooks used opium along with music for reducing the pain.

no significant difference was found on the pain and anxiety scores of boys and girls in this study, while the study by Nilsson (2009) reported greater anxiety of female than male undergoing coronary angiography (37).it is advised to consider the effect of gender in future studies with more subjects at different ages.

Limitations

Lack of blinding in the control group was one of limitations. Since headphones were used in the intervention group and using headphones without music for blinding in the control group could create an unpleasant feeling, blinding was excluded, which is likely to be effective in results.

The subjects were selected in one center. Generalization of results might not be logical to other clinical situations due to few numbers of participants. Therefore, using music therapy is advised among more participants at different age and clinical situations.

Conclusion

The children diagnosed with chronic and serious diseases such as cancerare exposed to a number of examinations and treatment based on the complications and diagnostic measures. Tolerating these procedures is sometimes more difficult than the disease and can cause pain, stress, and anxiety among children. They can independently use the technique. Therefore, this technique is recommended to be used as non-invasive, inexpensive, and effective method in reducing the pain and anxiety of children diagnosed withleukemia and other patients.

Acknowledgment

This article is a part of master degree thesis of Pediatric Nursing Management, approved by the Research Department of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran, (IRCT2016052528074N1). A debt of gratitude is owed to esteemed Children's Hematologist and Oncologist and the manager of Chemotherapy Clinic of Mohammad Kermanshahi Hospital of Kermanshah, Iran ,and all the patients who provided valuable support.

References

1. GhasemiA,GharaviFardM,SabzevariAR.General Anesthesia for Lumbar Puncture and Bone Marrow Aspiration/Biopsy in children with cancer.Italian Journal of pediatric hematology oncology 2013 March:vol. 3.No. 2.

2. MarcdanteK.Nelson essentials of pediatrics.6th.ELSEVIER

3. Wong DL,HockenberryMJ.Wong's nursing care of infants and children (pp.1- 440).st.Louis:Mosby.2011

4. LandierW,M.TseA.Use of Complementary and Alternative Medical Interventions for the management of procedure-Related pain and anxiety and distress in pediatric oncology:An Integrative Review.Journal of pediatric Nursing2010; 25:566-579.

5. Nguyen TN,NilssonS,Hellstrom A-L,BengtsonA.Music therapy to reduce pain and Anxiety in children with cancer undergoing Lumbar Puncture:A Randomized clinical Trial Journal of pediatric oncology Nursing 2010;27(3):146-15.

6. L.AnghelescuD,L.BurgoyneL,G.FaughnanL,M.HankinsG,P.SmeltzerM,Pui C.H.

Prospective Randomized crossover Evaluation of three Anesthetic Regimens for painful procedures in children with cancer.J pediatr2013January; 162(1):137-141.

7. lannalfiA,BeniniG,CaprilliS,LippiA,TucciF,MesseriA.Painful procedures in children with cancer:comparison of moderate sedation and General Anesthesia for Lumbar puncture and Bone Marrow Aspiration.Pediatric Blood Cancer2005;45:933-938.

8. Yazarloo, M., Hojjati, H., Gharebagh, Z.A. The effect of spiritual self-care education on stress of mothers of premature infants admitted to NICU of hospitals affiliated to golestan university of medical sciences (2019). Pakistan Journal of Medical and Health Sciences, 2020, 14(3), pp. 1615–1619.

9. BagherianS,BorhaniF,AbbasZadehA,TehraniH,PashandiS.The severity of pain in children with Thalassemia during venipuncture and prior to Blood Transfusion, Health and Developmental Journal of Medical Sciences 2012;1(2):138-46.[Persian]

10. PaoM,BoskA.Anxiety in Medically III children/Adolescents. Depress Anxiety2011January;28(1):40-49.doi:10.1002/da.20727.

11. Yolme ABS, Hojjati H, Akhoundzadeh G. The effect of Islamic semanticism on self- reporting and lifestyles of mothers of adolescents with thalassemia. International Journal of Adolescent Medicine and Health. 2020 Feb. DOI: 10.1515/ijamh-2019- 0192.

12. Buchanan N,MaloneyK,TsangS,StorkL,C.NegliaJ.P,Kadan-LottickN.S.Risk of depression,anxiety and somatization one month after diagnosis in children with standard risk ALL on COGAALL0331[Abstract].Journal of clinical oncology 2008;26(15)np.

13. A.KlassenJ,LiangY,TjosvoldL,P.KlassenT,HartlingL.Music for pain and anxiety in children undergoing medical procedures: A systematic Review of Randomized controlled Trials .Ambulatory pediatrics 2008;8:117-128.

14. Negar RanjbarHajabadi , Roya Ebrahimi , SakineFarhadi , Hojjati Hamid , Mahboubeh Tabrsa4. (2020). The Relationship between Frequency of Prayer and

Death Anxiety in Cancer Patients. Indian Journal of Forensic Medicine & Toxicology, 14(3), 2163-2167. https://doi.org/10.37506/ijfmt.v14i3.10748Zengin S,KabulS,SarcanE,DoganM,YildirimC.Effect of music therapy on pain and anxiety in patients undergoing port catheter placement procedure.Complementary Therapies in Medicine 2013;689-696.

15. E.HooksH.Effect of music intervention on the patient's perception of pain after knee Replacement surgery. May 2014.Electronic Thesis and Dissertations paper2321.http://dc.etsu.edu/etd/2321.

16. Zhou K,LiX,LiJ,LinM,DangSh,WangD,Xin X.A Clinical randomized controlled trial of music therapy and progressive muscle relaxation training in female breast cancer patients after radical mastectomy:Results on depression ,anxiety and length of hospital stay.European Journal of oncology Nursing;2014:1-6.

17. Hosseini N, Akhoundzadeh G, Hojjati H. The effect of child-parent relationship therapy on social skills of Preschool Children: a semi-experimental study.

International Journal of Adolescent Medicine and Health. 2019. DOI: 10.1515/ijamh- 2019-0151

18. Hojjati H, Afra A, Dehghani A, Alostany S, HajarDehghan B, Pourkhani S. The effect of music therapy on hemodynamic in patients undergoing caesarean section in Hakim Jorjani Hospital in Gorgan. Medical - Surgical Nursing Journal 2013; 2(3,4): 122-127.

19. Reynolds CR.Concurrent validity of ''What I think and feel:'' the revised children's manifest anxiety scale.J Consult ClinicalPsychology 1980;48(6).

20. TaghaviMR.Standardization children's Manifest Anxiety Scale(RCMAS)for Different levels of Education students in Shiraz.Journal of social sciences and Humanities of shiraz university.2005;24(4):179-88[Persian]

21. ShabanloeiR,GolchinM,EsfahaniA,DolatkhahR,RasoulianM.Effect of music therapy on pain and anxiety in patients undergoing Bone Marrow Biopsy and Aspiration.AORN J June 2010;91:746-751.

22. Nilsson S,FinnstromB,KokinskyE,EnskarK.The use of Virtual Reality for needle- related procedural pain and distress in children and adolescents in a pediatric oncology unit.Eur. J oncology Nurse 2009;13(2):102-9.

23. .S.I Merkel,TVoepel-Lewis,J.RShayevitz,SMalviya.TheFLACC:a behavioral scale for scoring postoperative pain in young children.Pediatric Nursing1997;23(3):293-297.

24. Nilsson S,FinnstromB,KokinskyE.The FLACC behavioral scale for procedural pain assessment in children aged 5-16 years.PediatricAnaesth 2008;18(8):767-74

25. TavasoliH.Comparison of effect of orientation programs play fast,think on pain and anxiety,injection procedures and parental satisfaction in children before school age thalassemia.Gilan[Msc Thesis],Tehran,Iran:TarbiatModares University 2008.[Persian]

26. RostamiM,AbazariF,PouraboliB,JahaniY,ShirzadiF.The effects of huko point massage with ice on intensity of pain due of phlebotomy in children with thalassemia in Kerman SamenAlhojaj Medical Ceneter,Iran.Medical-Surgical Nursing Journal,2014;3(3):157-16[Persian]

27. D.L Wong,C.MBaker.Pain in children:comparison of assessment scales.Pediatric Nursing1998;14(1):9-17

28. LuffyR,GroveSK.Examining the validity and preference of three pediatric pain measurement tools in African-American children.pediatric Nurse.2003 Jun- Feb;29(1):54-9.

29. AlhaniF,ShadH,AnooshehM,HajizadehE.The effect of programmed distraction on the pain caused by venipuncture among adolescents on hemodialysis.PainManag Nurs.2010;11(2):85-91

30. NikfaridL,GhamarYousefiR,NamaziyanM,Namdar F,Nezami5 M.[comparison of EMLA cream versus local refrigeration for reducing venipuncture-related pain in pediatric patients of children's Medical center].Nurse Research2008;5(16):32- 37.[Persian]

31. BalamR,BavdekarSB,JadhavS.Can Indian classical instrumental music reduce pain felt during venipuncture? Indian J Pediatr.2009may;76(5):469-73

32. Cooke H.Musictherapy,concerted action for complementary and alternative medicine assessment in the cancer field ,(camcancer) consortium 2014 ;December9

33. MokE,WongKY.Effect of Music on Patient Anxiety.AORN Journal.2003,77(2):396- 410

34. ZamanzadeV,SeyyedrasooliA,ParvanK,Aghakeshizade.The effect of music on anxiety and pain in patients undergoing cholecystectomy.Medical-Surgical Nursing Journal,2015;3(4):203-209[Persian]

35. C.DanhauersS,VishnevskyT,R.campbellC,P.MccoyT,A.ToozeJ,N.KanipeK,etal.Musi c for patients with hematological malignancies undergoing bone marrow biopsy:a randomized controlled study of anxiety, perceived pain,and patient satisfaction.JsocIntgr oncol.2010;8(4):140-147.

36. Nilsson U,LindellL,ErikssonA,KellerthT.The effect of music intervention in relation to gender during coronary angiographic procedures:A randomized clinical trial .European Journal of cardiovascular Nursing,2009(8):200-206

37. Tabarsa, M. ., Roshangaran, F. ., fakhreazizi, S. ., Khaloobagheri, E. ., &Hekmati Pour, N. . (2021). The Effect of Extended Parallel Process Model on Sexual Self- Control of Female Adolescents in Aliabad Kotoul in 2020. Indian Journal of Forensic Medicine & Toxicology, 15(3), 495-499. https://doi.org/10.37506/ijfmt.v15i3.15352