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Learn more: PMC Disclaimer | PMC Copyright Notice J Music Ther . Author manuscript; available in PMC: 2026 Apr 16. Published in final edited form as: J Music Ther. 2024 Sep 12;61(3):288–310. doi: 10.1093/jmt/thae011 Search in PMC Search in PubMed View in NLM Catalog Add to search Telehealth Engaged Music for Pain Outcomes: A Music and Imagery Proof-of-concept Study with Veterans Kristin M Story Kristin M Story 1 Department of Veterans Affairs (VA), Richard L. Roudebush VA Medical Center; Center for Health Information and Communication, Indianapolis, IN, USA 2 Indiana University School of Medicine, Indianapolis, IN, USA Find articles by Kristin M Story 1, 2 , Sheri L Robb Sheri L Robb 3 Indiana University School of Nursing, Indianapolis, IN, USA Find articles by Sheri L Robb 3 , Dawn M Bravata Dawn M Bravata 1 Department of Veterans Affairs (VA), Richard L. Roudebush VA Medical Center; Center for Health Information and Communication, Indianapolis, IN, USA 4 Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA Find articles by Dawn M Bravata 1, 4 , Teresa M Damush Teresa M Damush 1 Department of Veterans Affairs (VA), Richard L. Roudebush VA Medical Center; Center for Health Information and Communication, Indianapolis, IN, USA 2 Indiana University School of Medicine, Indianapolis, IN, USA Find articles by Teresa M Damush 1, 2 , Matthew J Bair Matthew J Bair 1 Department of Veterans Affairs (VA), Richard L. Roudebush VA Medical Center; Center for Health Information and Communication, Indianapolis, IN, USA 2 Indiana University School of Medicine, Indianapolis, IN, USA Find articles by Matthew J Bair 1, 2 Author information Copyright and License information 1 Department of Veterans Affairs (VA), Richard L. Roudebush VA Medical Center; Center for Health Information and Communication, Indianapolis, IN, USA 2 Indiana University School of Medicine, Indianapolis, IN, USA 3 Indiana University School of Nursing, Indianapolis, IN, USA 4 Departments of Medicine and Neurology, Indiana University School of Medicine, Indianapolis, IN, USA Author Contributions All authors participated in study conception,data analysis, writing and /or reviewing and editing for this manuscript. ✉ Correspondence concerning this article should be addressed to Maya Story, Richard L. Roudebush VA Medical Center, HSR&D Mail Code 11H, 1481 West 10th Street, Indianapolis, IN 46202, USA. [email protected] PMC Copyright notice PMCID: PMC13081651 NIHMSID: NIHMS2156168 PMID: 38787579 The publisher's version of this article is available at J Music Ther Abstract Music therapy interventions target biopsychosocial outcomes and are a non-pharmacological option for integrated pain management. To date, most music and pain studies have focused on acute pain, passive music experiences, and in-person delivery. The purpose of this study was to examine feasibility and acceptability and determine proof-of-concept for a newly developed telehealth music imagery (MI) intervention for Veterans with chronic pain. A single-group proof-of-concept pilot study was conducted with Veterans with chronic pain (n = 8). Feasibility was assessed through examination of recruitment, retention, and session/measure completion rates; acceptability through participant interviews; and whether the intervention resulted in clinically meaningful change scores (pre- to post-intervention) on measures of pain, anxiety, and depression at the individual level. For Veterans who passed eligibility screening, we had an enrollment rate of 89%, with good retention (75%). Overall, participating Veterans found the intervention acceptable, identified specific challenges with technology, and recommended an increased number of sessions. Preliminary outcome data for pain, anxiety, and depression were mixed, with some Veterans reporting clinically meaningful improvements and others reporting no change or worsening symptoms. Findings informed modifications to the telehealth MI intervention and the design of a larger pilot randomized controlled trial to assess feasibility and acceptability of the modified intervention in a larger population of Veterans with chronic pain using additional measures and a control condition. Keywords: music and imagery, chronic pain, telehealth, feasibility, Veterans Improving chronic pain management and access to care are priorities for the U.S. Department of Veterans Affairs (VA). Chronic pain, a common problem for U.S. Veterans, has a reported prevalence as high as 65.5% and is associated with limitations in mobility and daily activities, dependence on opioids, anxiety and depression, and poor perceived health ( Dahlhamer et al., 2018 ; Nahin, 2017 ). The VA recognizes chronic pain as a complex biopsychosocial condition and recommends an integrative approach to pain management, including non-pharmacological interventions ( Department of Veterans Affairs, 2009 ; Vallerand, 2015 ). Music therapy interventions target biopsychosocial outcomes and are a non-pharmacological option for integrated pain management. Music therapists use a variety of active music-making and receptive music-listening interventions to address pain management, with music listening having the most robust body of research to date ( Bradt et al., 2016 ; Fredenburg & Silverman, 2014 ; Homel et al., 2017 ; Koenig et al., 2013 ). Several meta-analyses indicate significant reductions in self-reported pain, emotional distress, and opioid use resulting from music listening; however, some of these studies lacked scientific rigor and focused primarily on acute pain ( Bradt et al., 2021 ; Hole et al., 2015 ; Lee, 2016 ; Lin et al., 2020 ; Yangoz & Ozer, 2019 ). In addition, most studies included in meta-analyses have been classified as music medicine studies. For example, in Lee’s (2016) meta-analysis 90% of included studies were categorized as music medicine. Studies classified as music medicine involve listening to music administered by healthcare professionals in a hospital or home setting without interaction from a credentialed music therapist ( Bradt et al., 2021 ). Receptive music therapy interventions, however, involve interactive approaches to music listening, provide education about the therapeutic potential of music, and integrate other tools (e.g., lyric discussion, drawing, or journaling) to address biopsychosocial factors that contribute to chronic pain. The Bonny Method of Guided Imagery and Music (GIM) is a music-centered approach that uses carefully selected classical music, corresponding imagery responses, and verbal processing for personal growth and transformation ( Bonny, 2002 ). Therapists trained in GIM have adapted and modified the original method to make it more accessible to clinical populations and individuals from varied cultural backgrounds ( Beck et al., 2017 ; Story & Beck, 2017 ). Individuals with post-traumatic stress disorder (PTSD), depression, fibromyalgia, cancer, and rheumatoid arthritis who participated in GIM sessions improved in health-related quality of life and well-being ( Jerling & Heyns, 2020 ; McKinney & Honig, 2017 ). Case studies of music therapy virtual delivery have described Veterans’ endorsement of telehealth sessions and patient-reported benefits ( Vaudreuil et al., 2020 ). Although these studies have provided compelling preliminary data, additional research is needed to develop telehealth music interventions for chronic pain. Given the growth and availability of music therapy services across the VA, research on telehealth delivery of a music intervention to manage chronic pain is timely and holds promise for improving clinical outcomes and access to pain management services. The purpose of the T elehealth E ngaged M usic imagery for chronic P ain O utcomes (TEMPO) study was to examine feasibility and acceptability and determine proof-of-concept for a newly developed telehealth Music and Imagery (MI) intervention for chronic pain. A proof-of-concept study sets out to determine if an intervention can produce clinically meaningful change in a small, select sample before investing resources in a larger randomized pilot study ( Czajkowski et al., 2015 ). Primary and secondary aims were as follows: Aim 1: Examine feasibility (recruitment, retention, and sessions/measures completion) and acceptability (Veteran’s experience) of a telehealth MI intervention. Aim 2: Examine whether the MI intervention produces pre- to post-intervention change in outcomes at the individual level and whether Veterans perceive a change or improvement since starting MI sessions. Methods Design TEMPO was a single-arm feasibility/acceptability and proof-of-concept study that examined a brief four-session intervention to explore the use of telehealth MI in Veterans with chronic pain. As a proof-of-concept study, we examined feasibility/acceptability of telehealth MI and whether the intervention produced clinically meaningful change scores in participants at the individual level. Findings inform changes that may be needed to the intervention, study design, or measures prior to conducting a larger randomized controlled trial (RCT) pilot study ( Czajkowski et al., 2015 ). After providing informed consent and completing baseline measurements, Veterans were invited to participate in four individual therapist-directed MI sessions delivered using Microsoft Teams video platform. Following completion of the intervention (Session 4), Veterans completed post-intervention assessments and were then invited to participate in a semi-structured interview about their experiences with the intervention. Institutional Review Board approval was obtained from Indiana University IRB# 11598 and the Richard L. Roudebush Veterans Medical Center Research and Development Committee to conduct this research. Participants Veterans with chronic pain receiving care at the Richard L. Roudebush Veterans Medical Center who had access to a computer, tablet, or smart phone, internet access, and had attended at least one video visit appointment in the past 6 months were invited to participate in four weekly Telehealth MI sessions. Veterans were excluded if they had serious or unstable medical or psychiatric illness (e.g., unmanaged psychosis, manic episode) or psychosocial instability (e.g., homelessness) that could compromise study participation, suicidal ideation with current intent or plan, hearing impairments (participant would not be able to hear well enough to enjoy the auditory benefits of music-listening), or cognitive Impairments (participant may not be able to engage in the abstract thinking required for imagery work). Because the goal was to conduct a rapid assessment of feasibility and acceptability to inform a larger pilot RCT, the study was time-limited, and our recruitment goal was up to 10 Veterans. Recruitment occurred from July 2021 to September 2021 through referral from one of the author’s primary care practice. Measurements Feasibility and acceptability were the primary study outcomes. Feasibility was assessed using descriptive statistics to examine recruitment and retention rates, and completion rates for MI sessions and outcome measures. Acceptability was assessed through semi-structured interviews that followed completion of final assessments. The interviews focused on perceptions of technology, benefits, challenges to participating in the telehealth MI intervention, and recommendations for future use of MI (see Supplementary Material for interview guide). Interviews were conducted by the first author who also led the sessions. Measurements to explore changes in pain, depression, and anxiety were administered at baseline and post-intervention. The Patient Global Impression of Change (PGIC) was administered post-intervention to explore participants’ perception of how much they had improved since starting the treatment. The study therapist screen shared the measurement forms with the participant during a telehealth meeting and recorded responses in the study-specific VA REDCap database. To explore changes at the individual level we used established thresholds for clinically meaningful change that have been published for the corresponding measures. Here we report psychometric properties for each measure and corresponding thresholds for clinically meaningful change. Pain Severity and Intensity The 3-item scale (PEG), derived from the Brief Pain Inventory, is a brief measure of pain severity and pain interference. The items assess pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Individuals respond to each item on a scale of 0–10 with higher scores representing more severe pain. The PEG score is calculated as the mean of the three individual item scores. A mean PEG score of four or greater (out of 10) represents moderate pain. The PEG has shown reliability (internal consistency) of 0.73–0.89 and construct validity of 0.60–0.95 ( Krebs et al., 2009 ). A two-point decrease on the PEG is considered a clinically meaningful change in pain ( Krebs et al., 2010 ). Depression and Anxiety The PROMIS ® short form depression 8a, version 1.0 (8 items) and the PROMIS ® short form anxiety 7a, version 1.0 (7 items) are comprised of patient self-reported items that assess how often the patient has been bothered by symptoms during the past 7 days ( Cella et al., 2019 ; Pilkonis et al., 2011 ). Each item has five response options ranging in value from 1 to 5 with higher scores representing more depression, or anxiety. The total raw score range is 8–40 for depression and 7–35 for anxiety. The total score is converted to a T -score, which rescales the raw score into a standardized score with a mean of 50 and a standard deviation of 10 (general U.S. population). PROMIS ® depression and anxiety short forms have shown high internal consistency ranging from 0.96 to 0.98 ( Bartlett et al., 2015 ) and good construct validity of 0.72– 0.83 ( Cella et al., 2010 ; Pilkonis et al., 2011 ). Minimal important change (MIC) was used for PROMIS measures. MIC is a measure of clinically meaningful change and is defined as the threshold for within-person change above which patients perceive themselves as importantly changed. For individuals with chronic pain, a change of 2.3–3.5 points for anxiety is considered MIC; for depression, a change of 1.5–3.7 points is considered MIC ( Terwee et al., 2021 ). Global Improvement in Pain The PGIC is a single-item 7-point scale that was administered post-intervention. The PGIC measures participants’ perception of how much they have improved since starting treatment. For this study, Veterans were asked to complete the sentence, “Since the start of the MI sessions, my pain is ________.” The wording of the response options is simplified from the original published PGIC (which included longer definitions with each response) and mirror response options in published pain studies ( Dworkin et al., 2008 ; Geisser et al., 2010 ). Patient global impression of improvement has shown to be highly correlated with changes in well-established measures of pain intensity and pain interference ( Perrot & Lanteri-Minet, 2019 ). In previous pain studies, “much improved” and “very much improved” ratings are considered moderately important and substantial improvement ( Dworkin et al., 2008 ). Intervention GIM is one of the five international models of music therapy practice, and the only receptive music therapy model of the five ( Trondalen, 2012 ). There is a continuum of methods used in GIM that range from supportive only to intensive therapy. One of the adaptations frequently used with clinical populations is referred to as MI. Guided Imagery and Music (GIM) and Music Imagery Methods for Individual and Group Therapy ( Grocke, 2015 ) details some of the many MI methods derived from GIM. TEMPO used two supportive MI methods from the continuum model: MI for regulation, and resource-oriented MI ( Story & Beck, 2017 ; Story et al., 2022 ; Summer, 2015 ). For ease of description, we refer to these as “supportive MI,” or MI. The components of MI follow the same structure as GIM (prelude, induction, music-listening, and postlude), but the components are modified for a more structured, focused experience ( Story & Beck, 2017 ). Examples of the modifications are: The prelude is focused on the here and now. An image is identified to represent the current state and desired state. The Veteran and therapist choose music together. The induction is focused to enhance one image. Music listening contains no interactive guiding and is from the Veteran’s music collection. Theoretical Framework of MI for Chronic Pain Supportive MI is a process that uses the individual’s relationship to music to develop strategies for self-care, build trust with the music therapist, and connect or deepen inner resources ( Summer, 2015 ). Inner resources (creativity, serenity) connect an individual to their ability to be resilient in the face of conflict, or to overcome some adversity (e.g., pain). The images that hold these resources come in various forms such as visual, kinesthetic, and emotional. An example may be a visual image of a supportive person, a sense of the music being holding in a nurturing way, or colors that represent strength or a sense of peace ( Story & Beck, 2017 ). Acceptance Commitment Therapy is a third-generation approach to cognitive behavioral therapy that uses mindfulness, acceptance, and experiential change strategies. The focus of MI resonates with components of Acceptance Commitment Therapy where the aim is to identify and accept the present condition and then to identify goals and a commitment to the desired condition ( Hayes et al., 2006 ). In this supportive MI method, the first objective is to learn to use MI for self-regulation. Self-regulation refers to regulation of emotions (e.g., sadness, anger) or physiological responses (e.g., tension, breathing). The process to reach that objective is: (1) identify and accept one’s current state/condition, (2) articulate a desired state/condition, and (3) through engagement in the MI process shift perspective, mood, or physiological factors (such as breathing, heart rate, and tension) to help manage pain or accompanying psychosocial symptoms. The music also serves as a reminder and reinforcer of the desired condition (goal) and is used between sessions. MI has a strong educational component that is partly met through self-directed practice (e.g., listening to the music used in the session throughout the week). The overarching goal is to teach individuals how to use the music they already listen to as a coping tool they can access on their own. Once the participant has demonstrated success in using music for self-regulation, sessions shift to the objective of enhancing and deepening a connection with inner resources. The process to reach that objective is: (1) identify a known inner resource (often discovered during a previous session), (2) choose an image for that inner resource, and (3) through engagement in the MI process observe, deepen, and enhance the inner resource. The primary aim of MI for chronic pain is to change a patient’s relationship to pain, their ability to interact with chronic pain, and provide accessible tools to manage pain and related psychosocial symptoms (e.g., anxiety, depression). This process proceeds in small manageable pieces, identifying an easily accessible and desired condition (e.g., decreased pain or tension in the moment) that the therapist and Veteran can work towards during a 45–60-min session. The conceptual framework for MI for Veterans with chronic pain is illustrated in Figure 1 . Figure 1. MI and Chronic Pain Conceptual Framework. Open in a new tab Session Description Participants were offered four individual therapist-directed MI sessions delivered using Microsoft Teams video platform. The music therapist who delivered the intervention was a Fellow of the Association for MI (the designation following completion of advanced GIM training). An MI session series can be 6–10 sessions, depending on the clinical needs of the patient population ( Frohne-Hagemann et al., 2015 ). We chose a four-session series to rapidly evaluate the feasibility and acceptability of this telehealth-delivered intervention for Veterans with chronic pain. The MI session has four steps: Verbal check-in : To create rapport, foster a therapeutic alliance, and help the Veteran identify current state/condition (i.e., pain, mood) and their desired state/condition. During the check-in, the Veteran identifies an image to represent the current state/condition and an image to represent the desired state/condition. Choosing music : Therapist and Veteran choose music together from Veteran’s preferred, familiar music to enhance the desired condition/image. Portions of 2–4 music selections are listened to in the moment and discussed as an educational process to choose the one musical selection that is the best fit to the desired condition/image. Listening to music : The music therapist and Veteran listen to music together. There is optional engagement with other creative modalities (e.g., artwork, writing, movement) during music listening to further explore the desired condition/image. Brief verbal processing : To connect the experiences from the music listening to Veteran’s everyday life and to identify ways to work with MI between sessions through repeated music listening. Figure 2 depicts a linear example of one session. A series of sessions unfold in a more cyclical process ( Figure 3 ) as the patient may return the following week and (1) describe a changed image that is then brought into new music, or (2) engage with a different symptom and use new images and music. Figure 2. MI Single Session. Open in a new tab Figure 3. Cyclical Process of MI Sessions. Open in a new tab For optimal music listening through telehealth delivery, the music therapist uses their computer and music subscription service of choice to retrieve the music selected by the Veteran. The therapist’s computer sound is shared with the Veteran so that the music sounds as if it is being played through their device. The Veteran participants were provided with over-ear headphones and drawing supplies to use during the MI sessions. Data Analysis Primary Aim Feasibility. We used descriptive statistics to examine recruitment and retention rates, and completion rates for MI sessions and outcome measures. Recruitment rate was defined as the proportion of eligible Veterans approached who passed eligibility screening and agreed to participate. Retention rate was defined as the number of participants who enrolled and completed post-session intervention measures. We also looked at the percentage of sessions and planned measures participants completed during the study. Acceptability. Veteran interviews about perceived barriers and benefits of MI sessions were recorded, transcribed, and de-identified for analysis. For analysis we followed a 6-phased approach to thematic analysis ( Braun & Clarke, 2012 ). Transcripts were read several times to become familiar with the data and to generate initial codes. Transcripts were initially coded broadly by one research team member to gain a general understanding of the data variation across participants and interview questions. Then each line of data was coded and examined to identify emergent themes. To ensure credibility, three members of the research team met to review and discuss these interpretations and finalize the themes. Any discrepancies among the team were examined and resolved by consensus. Secondary Aims To examine whether the MI intervention produced clinically meaningful change in participant-reported outcomes we looked at changes in participants’ scores from baseline to post-intervention at the individual level. We used published criteria for what constitutes meaningful change for each measure to interpret changes in scores (see measures). We also compared Veterans’ perception of change in their pain (post-intervention PGIC scores) with pre- to post-intervention change scores in self-reported pain (PEG scores) at the individual level. Results Primary Aim: Feasibility Over a 3-month enrollment period, July–September 2021, 62 recruitment letters were mailed, and we were able to reach 22 Veterans by phone to discuss the study. Sixteen Veterans (73%) expressed interest in the study, however, seven did not follow through with phone appointments to determine their eligibility. A total of nine Veterans were assessed for eligibility. Of those screened, only one participant was ineligible (no computer, tablet, or smart phone/internet access) resulting in an enrollment rate of 89%. Our goal was to recruit 10 Veterans but due to time constraints of the trial, we ended recruitment after eight Veterans were enrolled (80% of desired enrollment goal). Six of the eight enrolled participants completed post-session intervention measures indicating a retention rate of 75%. The two participants who did not complete the study were lost to follow-up at different time points. One participant was lost to follow-up after completing their first session and the second participant never started the study and was unable to be reached for scheduling. Despite multiple attempts we were unable to reach these participants to determine reasons for their decision to not complete the study. The six retained participants completed all four sessions and all planned measures, and five completed an interview (see Figure 4 CONSORT diagram). Table 1 provides the Veterans’ baseline characteristics. Figure 4. Flow Diagram. Open in a new tab Table 1. Sample Characteristics Characteristic N = 8 Age median (range) 65 (44–83) Sex N (%) Male 7 (87.5) Race/ethnicity N (%) American Indian or Alaska Native 0 Asian 0 Black or African American 2 (25.0) White or Caucasian 6 (75.0) Hispanic or Latino 0 Marital status N (%) Married 5 (62.5) Clinical characteristics median (range) N = 7 Pain severity (PEG) 4.0 (1.0–9.3) PROMIS depression 50.9 (47.5–61.2) PROMIS anxiety 56.3 (48.4–66.4) Open in a new tab PEG, pain intensity (P), interference with enjoyment of life (E), andinterference with general activity (G); PROMIS, Patient-ReportedOutcomes Measurement Information System. Primary Aim: Acceptability Five Veterans participated in brief interviews that asked about their experience with the MI intervention including technology and telehealth, perceived benefits and challenges, and suggestions regarding future use of MI. 1 Ease of technology: Despite technology issues, Veterans appreciated the convenience of telehealth MI sessions when they are unable to meet in person. Most Veterans (4/5) were able to connect independently; however, one Veteran reported needing assistance from a spouse. Audio issues were frequently mentioned (3/5 participants), either for poor music quality or having to use the phone for audio when Teams was not working. Veterans appreciated the ability to connect via telehealth when they lived far from a VA medical facility (1/5 participants) or were unable to leave home (1/5 participants), but some (2/5) expressed a preference to meet in person if possible. 2 Perceived benefits and challenges of the MI sessions: Veterans experienced MI sessions as an enjoyable relational process that built on something familiar to support management of their pain and related symptoms. Distraction was often mentioned as one of the ways that MI was helpful, but there was also a heightened awareness of music’s interaction with psychological well-being. Veterans described the MI intervention as both novel and familiar, acknowledging that they already listened to music but were learning through the MI sessions how to listen in a new way. As one Veteran said, “ It made me think about music more and its effect on psychology. It made me be more conscious and pay more attention. I was doing this unconsciously, but you don’t think about what impact it has on you. That maybe I should search out music intentionally .” (ID 2) Veterans commented on the social aspect with the music therapist, “ It was really enjoyable listening to music together, it was peaceful and easy to talk to you .” (ID 7) Veteran participants also commented on trust in the therapeutic relationship, “ It was challenging drawing because I didn’t think I could do it, but I trusted you enough to try it .” (ID 8) Veterans also shared individual challenges, such as the above quote about the challenge of drawing, that did not emerge as a common theme among participants. Other challenges related to theme one, ease of technology, were brought up when asked about technology. One Veteran mentioned that the audio was “ blurred out ” at times. (ID 3) When asked if it affected their experience of the music, they said that it did not. One Veteran stated about the technology, “ It was difficult for us because we are not used to doing it, but it got easier each week. ” (ID 8) Veterans appreciated being able to meet virtually, but for some (2/5) it was not their preferred mode of delivery. 3 Veterans’ suggestion for future MI use: Veterans suggested participation in more than four MI sessions and expressed that it may be beneficial to other patient populations. One Veteran commented, “ I would recommend this for emotional or physical pain. There is so much that Veterans can gain by just stopping and engaging with something creative .” (ID 8) Secondary Aims: Individual Change in Clinical Outcomes To address our secondary aims, we visually inspected change scores for pain, anxiety, and depression at the individual level, and then compared Veterans’ perception of change in their pain post-intervention (PGIC scores) with their change scores for pain ( Table 2 ). Participants A and B had clinically meaningful changes in pain, anxiety, and depression post-intervention. However, the change in pain was not reflected in their PGIC score which indicated “little” or “no change.” Participant C had no change in pain, but clinically meaningful change in anxiety and depression post-intervention. On the PGIC, they indicated that their pain was a “little better.” Participants D and E had no change in pain, with D reporting a clinically meaningful increase in depression and E reporting a clinically meaningful increase in anxiety. On the PGIC, Participant D reported “no change” in pain which was consistent with their PEG change scores, and Participant E reported their pain was “a little worse” which was not consistent with PEG change scores. Participant F reported an increase in pain and clinically meaningful increases in anxiety and depression. However, scores indicating increased pain were not consistent with the participant’s PGIC score which indicated their pain was “moderately better.” Table 2. Pre and Post Telehealth MI, and Veteran Perception of Change Pain (PEG) PGIC PROMIS anxiety PROMIS depression ID Pre Post Change a Pre Post Change b Pre Post Change c A 5.3 1.3 −4.0 No change 47.5 44.7 −2.8 66.4 49.9 −16.5 B 2.7 0.7 −2.0 A little better 50.9 47.5 −3.4 48.4 42.1 −6.3 C 4.0 4.0 0 A little better 56.8 52.1 −4.7 48.4 46.7 −1.7 D 2.7 3.0 0.3 No change 60.3 62.1 1.8 60.0 62.6 2.6 E 1.0 1.3 0.3 A little worse 50.9 55.1 4.2 56.3 57.6 1.3 F 7.3 9.0 1.7 Moderately better 47.5 54.1 6.6 51.3 65.1 13.8 G 9.3 – – – 61.2 – – 65.1 – – Open in a new tab Note : PEG = pain intensity and interference scale; PGIC = Patient Global Impression of Change; PROMIS = Patient-Reported Outcomes Measurement Information System. Lower scores indicate less pain, anxiety, and depression. a 2-point change is clinically meaningful (PEG). b ≥2.3 change is clinically meaningful (PROMIS Anxiety). c ≥1.7 change is clinically meaningful (PROMIS Depression). In summary, two participants reported clinically meaningful decreases in pain, and three reported clinically meaningful decreases in anxiety and/or depression. Three participants reported no change in pain, and one reported an increase in pain that did not reach the clinically meaningful threshold for pain. Two participants reported clinically meaningful increases in either anxiety or depression, and one participant reported clinically meaningful increases in anxiety and depression. For the majority of participants (4/6) their PGIC responses were inconsistent with their PEG pain scores. Discussion This study examined a MI intervention delivered through telehealth for Veterans with chronic pain. Among Veterans who completed eligibility screening we had a strong enrollment rate (89%), coupled with good retention (75%), Although this is a small sample, enrollment/retention rates are good compared with other chronic pain trials, where recruitment and retention are especially challenging due to the complex issues with chronic pain ( Kennedy et al., 2022 ). Session and measurement completion rates were also high which suggests that our systems for session reminders and completing measures immediately after sessions worked well. Two patients were lost to follow-up and unfortunately, we do not have information about why these participants chose not to complete the study. Due to the virtual nature of the study, all study activities, including recruitment were done with no in-person contact. This allowed a greater volume of initial contact through bulk mailings and follow-up phone calls but did not guarantee that we would be able to reach potential Veterans to screen for eligibility. VA research regulations require us to send a letter as first point of contact, adding to the importance of strong and compelling recruitment letters and study brochures. Prior to our next study, it will be important to work with Veterans to refine recruitment strategies to increase the number of potential participants who complete eligibility screening. This would include the use of a Veteran Engagement Panel to help improve our recruitment letters, study brochures, and phone scripts. Participant interviews suggest the intervention was acceptable to Veterans with chronic pain who participated in this study and facilitated identification of three challenges specific to intervention delivery that warrant modification. Based on Veteran feedback, needed modifications include: (1) Increase the number of MI sessions and track dosage to inform future recommendations; (2) Implement technology screening to assess level of comfort and skill with needed technology to engage in sessions; and (3) Check and adjust audio settings at the beginning of each session to ensure good audio quality. Results from preliminary outcome data for pain, anxiety, and depression were mixed with some Veterans reporting clinically meaningful improvements and others reporting no change or worsening symptoms. These findings suggest that the Telehealth MI intervention was beneficial for some and not for others. In subsequent studies it will be important to measure other comorbidities, social support, and self-efficacy so that we can begin to identify Veterans most likely to benefit from MI interventions for pain, and factors that would suggest the intervention is contraindicated. Chronic pain is complex with implications for physical and psychological well-being as well as family and social relationships. Unlike independent music listening, MI is coupled with a therapeutic relationship that provides an opportunity for Veterancentered meaningful experiences that emerge from shared music listening. Beginning with the Veteran’s familiar music helped to build trust and foster the therapeutic relationship by acknowledging the Veteran’s previous experience and knowledge they bring to the session. Similar to previous MI research, Veterans acknowledged that they were learning how to use their already existing relationship to music as a coping tool for symptom management ( Story & Beck, 2017 ). As a proof-of-concept study, the primary purpose was to determine whether the MI intervention could be delivered via telehealth and whether the delivery format was acceptable to this patient population. Our secondary aim was to explore whether the intervention resulted in clinically meaningful change at the individual level. Though we saw some improvements in pain, anxiety, and depression, there were also participants who experienced no change or an increase of symptoms. The three participants who experienced increases in pain, also experienced increases in depression, and anxiety, which highlights the complexity of chronic pain and its relationship with psychological comorbidity. Also of note, only one Veteran’s perception of change in pain, as recorded on the PGIC, matched the pre, post change in pain, as recorded on the PEG outcome ( Table 2 ). This differs from larger studies where the PGIC was highly correlated with changes in well-established measures of pain intensity and pain interference ( Perrot & Lanteri-Minet, 2019 ). In the interviews, we asked about Veterans’ experience in the MI sessions and whether there were specific benefits or challenges. None of the five Veterans interviewed mentioned increases in pain, anxiety, or depression, but the interviews did not specifically ask about symptom change. Findings warrant a future study to better examine comorbidities that might explain for whom the intervention works, and for whom it does not work. The duration and length of the MI intervention may have contributed to the absence of clinically meaningful change for some participants. In clinical practice MI sessions often have a duration of 60–90-min and are provided weekly for 6–8 weeks; a dosage that is similar to other therapies for chronic pain ( Veehof et al., 2016 ). Veterans interviewed from this study endorsed wanting more than four MI sessions and based on these preliminary findings we plan to adjust the frequency to eight MI sessions. Limitations to this study include the small sample from a single clinician’s practice and lack of a control group. Included Veterans had previously engaged in a telehealth visit, but results may be different for Veterans who have no previous telehealth experience. The post-study interviews were also limited to people who agreed to participate and who remained for the full study. Despite efforts to reach participants, we were unable to obtain further feedback from participants who declined the interview or were lost to follow-up. The therapist who delivered the MI sessions was also the person who conducted the assessments and interviews, which may have biased the Veterans’ responses to be more positive. Finally, findings for patient-reported outcomes are highly preliminary and are not considered generalizable. In the present study of six Veteran participants, some improved, some stayed the same, and some got worse. A pilot RCT with a larger sample of participants will allow us to better identify “for whom” the intervention is working or not working. Although we will not be powered to examine between group differences in the pilot RCT, it is important to develop an acceptable control condition for use in subsequent trials should we find adequate evidence that the refined MI intervention is beneficial for a large enough subset of Veterans. To address identified limitations we recommend the following modifications for a subsequent pilot study: (1) the addition of a control group; (2) multiple therapists deliver the intervention; (3) other team members (masked to group assignment) administer measures and conduct interviews, and (4) additional measures to explore outcomes and potential mediators illustrated in the conceptual framework ( Figure 2 ). Conclusion Telehealth MI was feasible and acceptable to Veterans with chronic pain enrolled in this preliminary study and warrants further research as a non-pharmacological intervention to support pain management, and associated symptoms of depression and anxiety. Findings from this study will inform modifications to the telehealth MI intervention and design of a larger pilot RCT to assess feasibility and acceptability of the modified recruitment strategies, modified intervention, control condition, and added measures. Supplementary Material Supplementary material is available online at Journal of Music Therapy ( Journal of Music Therapy | Oxford Academic (oup.com) ). Funding: This work was supported in part by the United States (U.S.) Department of Veterans Affairs (VA) Health Services Research & Development Service (HSRD), Expanding expertise Through E-health Network Development (EXTEND) Quality Enhancement Research Initiative (QUERI) (QUE 20–010). This work was supported in part by the U.S. Department of Veterans Affairs Health Services Research & Development Service. The content does not represent the views of the Veterans Affairs Health Services Research & Development Service. Footnotes Conflicts of interest : None declared. 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