Interaction Effects of Visual Distractions,

Auditory Distractions and Age

on Pain Threshold and Tolerance
Timothy Wright and Bryan Raudenbush
Wheeling Jesuit University

Past research has examined the effects of music and visual distractions on
pain; however, no study has ever assessed the interactive effects of the
two stimuli. Considering that these past studies have all used college-
aged students as their samples, and that the older population is the main
sufferer of pain, new research is required in order to make externally
valid conclusions. The present study obtained 75 participants, 23 of
which who were 35 years of age and above. Each participant completed a
cold pressor task, while watching different combinations of music and
video genres. Pain threshold and tolerance, mood, and workload were
assessed. The pain intensity ratings were analyzed with a 3 within
(music) x 10 within (time) x 3 between (video) x 2 between (sex) analysis
of variance for the subsample of people 35 years of age and above.
Participants 35 years of age and above reported the least pain in the
romantic/classical condition, and, over time, the pain ratings increased
less severely for this condition. An independent samples t-test showed
that the older subsample preferred classical music significantly more than
the younger subsample, which may account for the greater effects of
classical music. Thus, it appears that perceived pain is closely associated
with the presence of preferred stimuli, and such information can be used
as a non-pharmacological adjunct to pain management.

The differential effects of visual distractions on pain tolerance have

been examined throughout numerous studies. One of the first
experiments to consider this question sampled 60 college-aged females
who participated in a cold-pressor task while watching pleasant or
unpleasant slides (Greenstein, 1984). A cold pressor task involves
submerging a hand and forearm in 3 degrees Celsius water, during which
participants rated the intensity of their pain over time. It was found that
the unpleasant slides increased pain tolerance. It was believed that
unpleasant slides had this effect due to their affective quality; however,
the author concluded that future studies would be necessary to confirm
this. Another study showed that tasks with a higher workload
significantly decreased pain intensity when compared to tasks with a
lower workload (Veldhuijzen, Kenemans, de Bruin, Oliver & Volkerts,
Author info: Correspondence should be sent to: Dr. Bryan Raudenbush, Wheeling
Jesuit University, Department of Psychology, 316 Washington Avenue,
Wheeling, WV 26003. e-mail: raudenbc@wju.edu
North American Journal of Psychology, 2010, Vol. 12, No. 1, 145-158.
NAJP
146 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

2006). Finally, Felbaum, Chamberlin, Nolan, Hunker and Raudenbush

(2007) used different genres of videos (sad, comedy, adventure, or
romantic) to study their effects on pain tolerance and pain intensity.
College students participated in a cold-pressor task while watching the
different genres, and it was discovered that the adventure genre displayed
the greatest pain distraction, meaning that the participants in this
condition reported the least amount of pain intensity.
Music and its effects on pain distraction have an equally established
body of research. One study examined the effects of choice and
preference in music and pain perception, with the volunteers (college
students) experiencing a finger-pressure pain test (Perlini & Viita, 1996).
The students in the condition with their favorite music experienced pain
reductions when compared to the participants in the conditions with their
least favorite or no music. Also, annoying and relaxing qualities of music
were found to be moderate predictors of the change in pain experienced.
Additional studies examined the effects of music therapy on various
types of patients. One study, specifically addressing pediatric burn
patients, found through analyzing both qualitative and quantitative data
that music therapy was effective in alleviating pain, anxiety, and
behavioral stress (Whitehead-Pleaux, Zebrowski, Baryza & Sheridan,
2007). Another study used live musicians as a means of reducing the pain
of children experiencing venipuncture, and it was found that children in
the music group experienced significantly lower levels of pain and
distress than children in the control group (Caprilli, Anastasi, Grotto,
Abeti & Messeri, 2007).
Some studies have also examined the effects music and visual stimuli
have on physiological measures. For example, Krumhansl (1997) had 40
college students listen to musical pieces that represented each of the
emotions fear, happiness, and sadness. Physiological measures, which
included heart rate and respiratory functions, were taken. It was
discovered that happy pieces were associated with the largest increases in
respiratory measures, while sad music was associated with the largest
increases in pulse and blood pressure.
Considering that pain is such a costly and widespread problem in
America -- in fact, it is reported by the NINDS (2000) to be the most
costly health problem -- new cost-effective ways of relieving pain are
readily embraced. For example, 20 million Americans suffer from
arthritis, and these individuals lose over 4 billion dollars a year because
of this painful ailment. Ninety-three million workdays a year are lost due
to incidents of lower back pain, and this epidemic costs nearly 5 billion
dollars. Factoring in all the expenses of pain, such as legal charges, direct
medical expenses, lost income, lost productivity, compensation
 Wright & Raudenbush PAIN TOLERANCE 147

payments, a total of approximately 50 billion dollars a year is lost

(NINDS, 2000).
While pain is a universal problem affecting all age groups, older
people are more likely than younger people to experience pain. Pain is
reported by 78%-80% of the elderly population (Martinez, 2008). In fact,
64% of healthy people between the ages of 80-89 reported chronic pain.
Among older individuals in nursing homes or other assisted living areas,
71% to 83% report pain that interferes with their daily lives.
While musical and visual stimuli have each accumulated an extensive
history with regard to their effects on pain distraction, a study has never
attempted to examine their interactive effects on pain distraction and
perceived pain intensity. Considering that the two stimuli are often found
together in social and entertainment settings, examining the combined
effects of musical and visual stimuli on pain threshold and pain tolerance
seems even more appropriate. Also, considering that pain is a more
prevalent problem for the older population, and that no previous study
has dealt with a sample representative of this demographic, it is
worthwhile to examine the effects of age on pain tolerance as well. As
pain is such a widespread epidemic, and visual and musical stimuli are
available for many people (even those of low socioeconomic status)
breakthrough research in this area could potentially save billions of
dollars by at least providing a more cost-effective treatment. Finally,
through the inclusion of multiple genres of music and video, this area of
research will be further expanded.
Based on the results of Felbaum, et al. (2007), it is expected that
participants in both age groups will produce lower pain ratings and
increased pain tolerance in the heavy metal/action adventure condition.
In addition, based on the work of Veldhuijzen, et al. (2006), it is expected
that participants in the conditions that produce increased pain tolerance
and lower pain ratings will indicate that they perceive decreased work
load while participating in the cold pressor task.

METHOD
Participants
Seventy-five volunteers (32 males and 43 females) participated in the
study. These participants were obtained through convenience sampling
with an advertisement in a local paper. They were given $20 as a
compensation for the time spent in the laboratory, in addition to course
credit if such a desire was indicated. The participants ages ranged from
18 to 74. In addition, a subsample was formed of the participants that
were 35 years of age and above. This subsample had a median age of 54
and a standard deviation of 9.08 years. In this subsample, there were 23
participants (6 males and 17 females), and these participants were the
148 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

primary focus of the study. The remaining participants below 35 years of

age were obtained in order to accurately compare music and video
preferences, as well as music listening and video watching habits of the
two age groups. Both subsamples participated in the entire procedure
designed for this study.

Instruments
The Profile of Mood States (POMS; McNair, Lorr & Droppleman,
1971) and the NASA-Task Load Index (NASA-TLX; Hart & Staveland,
1988) were used in this study. The POMS, containing subscales
associated with anger, confusion, depression, fatigue, tension and
anxiety, measured the mood of the participants. The NASA-TLX
measured the workload of the tasks in which the participants were
involved, dividing the workload into categories including mental,
physical, and temporal demand. The scale also measures effort,
frustration, and performance that the participant experienced in relation
to the task. Additional surveys were used for the participants to indicate
their preferred video and music genre on a scale of 1-10 upon the
participants arrival during the first condition, as well as a rating of how
well the video and music presented during the experiment represented
their respective genres on a scale of 1-10 upon the completion of the
participants final condition. The questionnaire regarding video and
music preference was used in order to obtain preferred music and video
types that could be used to correlate with perceived pain and pain
threshold in each respective genre. The other questionnaire gave an
indication as to how well the video and music represented their
respective genres and allowed the experimenter to draw more accurate
conclusions regarding the different genres as a whole.

Stimuli
The heavy metal song used in the study was Drag the Waters by
Pantera, and the classical song used in the study was Stabat Mater
Movement XII, Quando Corpus-Amen by Giovanni Pergolesi. The
videos were played on a computer monitor. The adventure video
contained short clips from the Spiderman Trilogy, Terminator 3, Star
Wars Episode III, Live Free or Die Hard, the Lord of the Rings Trilogy,
Mission Impossible 3, and the Matrix Trilogy. The romantic video
contained short clips from the Spiderman Trilogy, How to Lose a Guy in
10 Days, Sleepless in Seattle, Hitch, Stardust, The Wedding Singer, and
50 First Dates.
This study used a 3 within (classical, heavy metal, no music) x 3
between (adventure, romantic, no video) x 2 between (male, female)
 Wright & Raudenbush PAIN TOLERANCE 149

design and made use of 9 conditions consisting of the different

combination of videos, music, and the control groups:
Adventure Video/ Classical Music
Adventure Video/ Heavy Metal Music
Adventure Video/ No Music
Romantic Video/ Classical Music
Romantic Video/ Heavy Metal Music
Romantic Video/ No Music
No Video/ Classical Music
No Video/ Heavy Metal Music
No Video/ No Music
These nine conditions were presented in a randomly assigned order to
control for the possibility of order effects.
For each respective genre of video and music, the same video or
music was used for that particular genre, and each video and music ran a
total of five minutes. In each of the conditions where no music was
played, the participant wore the headphones, and in the conditions with
no videos, the participant viewed a black screen on the monitor. Also, in
all nine conditions, the participant placed his or her hand and forearm in
an Ecoline RE 106 cold pressor device that maintained the water
temperature at 3 degrees Celsius. The amount of time the participant was
able to keep the hand in the water was recorded, and pain intensity
ratings were taken at 30-second intervals by the experimenter.

Equipment
Participants used Sony Noise Canceling Headphones MDR-NC6
headphones via the headphone port on the tower of the Dell Dimension
XPS T450 computer, and it remained at 75 dB for each type of music.
The operating system used for the computer was Windows 98. A Lauda
Ecoline RE 106 Circulating Water Bath was used. This involves
submerging a hand and forearm in water at 3 degrees Celsius.
Participants were asked to rate the intensity of their pain on a scale from
0 (no pain) to 10 (unbearable) for a maximum of 5 minutes.

Procedure
The first time the participants arrived at the laboratory, the risks and
benefits of the research were explained to them and they were given a
consent form that outlined the procedure of the study. After the
participant gave informed consent, basic demographic information was
obtained, such as age and sex. Then, each participant filled out a survey
regarding his or her favorite video type and favorite music type, asking
them to rate each video and music type that would be presented on a
scale of 1-10. A maximum of five minutes was allotted for the participant
150 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

Partial
Mean Eta
Source SS df Square F p Squared
Music 40.68 2 20.34 3.63 .04* 0.18
Music * Sex 6.86 2 3.43 0.61 0.55 0.04
Music * Video 63.19 4 15.8 2.82 .04* 0.25
Music * Sex * Video 36.9 4 9.23 1.64 0.19 0.16
Error (Music) 190.75 34 5.61
Time 75.04 9 8.34 2.85 .00** 0.14
Time * Sex 18.2 9 2.02 0.69 0.72 0.04
Time * Video 41.04 18 2.28 0.78 0.72 0.08
Time * Sex* Video 59.49 18 3.31 1.13 0.33 0.12
Error (Time) 447.46 153 2.93
Music * Time 12.39 18 0.69 2.21 .00** 0.12
Music * Time * Sex 11.76 18 0.65 2.1 .01** 0.11
Music * Time * Video 32.76 36 0.91 2.93 .00** 0.26
Music * Time * Sex *
Video 14.06 36 0.39 1.26 0.16 0.13
Error (Music * Time) 95.17 306 0.31
TABLE 1 ANOVA Table for the 3 Within (music) x 3 Between (video)
x 10 Within (time) x 2 Between (sex) ANOVA

**Indicates significance at the .01 level.

to submerge their hand in the water. Additionally, the POMS and NASA-
TLX surveys were administered after each condition.

RESULTS
The pain intensity ratings for the subsample of participants 35 years
of age and older were analyzed with a 3 within (music) x 10 within
(time) x 3 between (video) x 2 between (sex) analysis of variance. See
Table 1. A main effect for music was found. Participants 35 years of age
and older who listened to classical music reported significantly less pain
than those who listened to heavy metal. Classical music had a mean of
8.37 (SD =.43), while heavy metal music and control had means of 9.08
(SD = .32) and 8.64 (SD=.35) respectively. Also, an interaction between
music and video was found. Tukey post hoc contrasts show that
participants 35 years of age and older reported the least pain while
watching the romantic video with classical music. See Table 2. Two
additional interactions were found between time and music and among
time, music, and sex. Tukey post hoc contrasts indicate that in general,
 Wright & Raudenbush PAIN TOLERANCE 151

pain increased over time. However, this increase was less when
participants 35 years of age and above listened to classical music. See

TABLE 2 The Interaction Between Music & Video with the Pain
Intensity Ratings
None Classical Heavy Metal
M (SD) M (SD) M (SD)
Romantic 7.70 (.70) 7.28 (.86) 9.15 (.64)
Action 9.29 (.56) 9.40 (.69) 9.18 (.51)
None 8.91 (.56) 8.43 (.68) 8.90 (.50)

TABLE 3 The Trend Between Sex & Video with the NASA-TLX Effort
Ratings
Romantic Action None
M (SD) M (SD) M (SD)
Male 39.83 (18.91) 26.00 (18.91) 93.33 (18.91)
Female 21.00 (18.91) 61.91 (10.11) 59.21 (9.46)

MUSIC AND TIME INTERACTION

10
PAIN RATING

6
30 60 90 120 150 180 210 240 270 300
Time (seconds)

NONE CLASSICAL HEAVY METAL

FIGURE 1 Line Graph Showing the Interaction Between Music & Time
With the Pain Intensity Ratings

Figure 1. The Tukey post hoc contrasts show that among time, music,
and sex, females 35 years of age and older who listened to classical
music reported a less severe increase in pain over time. See Figure 2.
Finally, an interaction was found among music, time, and video. The
Tukey post hoc contrasts indicate that the pain intensity ratings of
participants 35 years of age and above showed a less severe increase over
152 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

time when the romantic video was accompanied by classical music. See
Figure 3.

FEMALES: MUSIC and TIME

10
PAIN RATING

6
30 60 90 120 150 180 210 240 270 300
TIME (seconds)

NONE CLASSICAL HEAVY METAL

MALES: MUSIC and TIME

10
PAINRATING

6
30 60 90 120 150 180 210 240 270 300
TIME (seconds)

NONE CLASSICAL HEAVY METAL

FIGURE 2 (a,b) Line Graphs Showing the Interaction among Sex,

Music, & Time with the Pain Intensity Ratings

TABLE 4 Age Group Comparisons Performed with the Independent

Samples t-Test.
Question < 35 > 35 t p
M (SD) M (SD)
On average, how many hours per week 18.05 15.63
-.59 .56
do you listen to music in general? (19.82) (13.23)
On a scale of 1-10 (1 is completely
9.24 8.93
dislike, 10 is completely like), how much -.83 .41
(1.43) (1.90)
do you enjoy music in general?
On average, how many hours per week 2.50
.18 (.48) -2.14 .04
do you listen to heavy metal music? (5.70)
On a scale of 1-10 (1 is completely
3.96 1.96
dislike, 10 is completely like), how much -3.22 .00*
(2.90) (2.15)
do you enjoy heavy metal music?
 Wright & Raudenbush PAIN TOLERANCE 153

On average, how many hours per week 1.07 2.70

2.42 .02
do you listen to classical music? (1.89) (4.22)
On a scale of 1-10 (1 is completely
dislike, 10 is completely like) how much 4.91 5.96
1.60 .12
do you enjoy classical music? (2.65) (3.21)
On average, how many hours per week
15.11 19.98
do you spend with visual entertainment 1.66 .10
(9.90) (16.91)
(including television and movies)?
On a scale of 1-10 (1 is completely
7.89 6.61
dislike; 10 is completely like), how much -3.1 .00*
(1.71) (1.93)
do you enjoy videos in general?
On average, how many hours per week
do you spend watching romantic videos 2.35 3.20
.84 .40
(including television and movies)? (2.82) (6.41)
On a scale of 1-10 (1 is completely
dislike; 10 is completely like), how much 5.22 5.93
1.07 .29
do you enjoy romantic videos? (2.83) (2.89)
On average, how many hours per week
5.75 6.64
do you spend watching action/adventure .52 .61
(5.09) (10.59)
videos (including television and movies)?
On a scale of 1-10 (1 is completely
dislike; 10 is completely like), how much 7.16 5.82
-2.5 .01*
do you enjoy watching action/adventure (2.00) (2.83)
videos?
* Indicates significance at the .01 level.

The NASA TLX scores for the subsample of participants 35 years of

age and above were analyzed using a 3 within (music) x 3 between
(video) x 2 between (sex) analysis of variance. A main effect for video
was found (F(2, 22)= 4.20, p<.05). The Tukey post hoc contrasts indicate
that participants 35 years of age and above watching the romantic video
reported significantly less effort than when in the control condition. The
romantic video had a mean of 30.42 (SD = 13.37), while the action video
and control had means of 43.95 (SD = 10.72) and 76.27 (SD = 10.57)
respectively. Finally, a trend between sex and video was found (F(2,
22)= 2.90, p<.10). This trend indicated that females over 35 years of age
and above watching the romantic video reported the least effort. See
Table 3.

TABLE 5 Sex Comparisons Performed with Independent Samples t-Test

Question Males Females t p
M (SD) M (SD)
On average, how many hours per week do 15.54 18.47
-.74 0.46
you listen to music in general? (14.00) (20.22)
On a scale of 1-10 (1 is completely dislike,
9.03 9.21
10 is completely like), how much do you -0.5 0.62
(1.65) (1.57)
enjoy music in general?
154 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

On average, how many hours per week do 2.71

.98 (3.16) 1.65 0.1
you listen to heavy metal music? (6.26)
On a scale of 1-10 (1 is completely dislike,
4.31 2.54
10 is completely like), how much do you 2.95 .00*
(3.05) (2.42)
enjoy heavy metal music?
On average, how many hours per week do 1.24 1.90
-.99 0.33
you listen to classical music? (2.23) (3.41)
On a scale of 1-10 (1 is completely dislike,
4.94 5.50
10 is completely like) how much do you -.87 0.39
(2.71) (3.00)
enjoy classical music?
On average, how many hours per week do
17.51 16.20
you spend with visual entertainment .46 0.65
(10.46) (14.37)
(including television and movies)?
On a scale of 1-10 (1 is completely dislike;
7.54 7.40
10 is completely like), how much do you 0.35 0.73
(2.13) (1.69)
enjoy videos in general?
On average, how many hours per week do
1.23 3.66
you spend watching romantic videos -2.6 .01*
(1.61) (5.35)
(including television and movies)?
On a scale of 1-10 (1 is completely dislike;
3.91 6.58
10 is completely like), how much do you -4.7 .00*
(2.27) (2.73)
enjoy romantic videos?
On average, how many hours per week do
7.69 4.86
you spend watching action/adventure videos 1.75 0.09
(5.96) (8.09)
(including television and movies)?
On a scale of 1-10 (1 is completely dislike;
10 is completely like), how much do you 7.94 5.81
4.47 .00*
enjoy watching action/adventure videos? (1.68) (2.43)
*Indicates significance at .01 level.

Independent samples t-tests were performed to compare the sub-sample

that was below age 35 and the sub-sample that was age 35 and above in
regard to their preference ratings for video and music and their reported
amount of time spent with each. The results showed that the older
subsample liked heavy metal music and videos in general significantly
less than the younger subsample. In addition, the older subsample liked
action videos significantly less than the younger subsample. See Table 4.
 Wright & Raudenbush PAIN TOLERANCE 155

ROMANTIC: MUSIC AND TIME

PAINRATING 10

6
30 60 90 120 150 180 210 240 270 300
TIME (seconds)

NONE CLASSICAL HEAVY METAL

ACTION: MUSIC AND TIME

10
PAINRATING

6
30 60 90 120 150 180 210 240 270 300
TIME (seconds)

NONE CLASSICAL HEAVY METAL

NONE: MUSIC and TIME

10
9.5
PAINRATING

9
8.5
8
7.5
7
6.5
6
30 60 90 120 150 180 210 240 270 300
TIME (seconds)

NONE CLASSICAL HEAVY METAL

FIGURE 3 (a,b,c) Line Graphs Showing the Interaction Among Video,

Music, and Time with the Pain Intensity Ratings

Independent samples t-tests were performed to compare males and

females music and video preferences and habits. The results showed that
females liked heavy metal music significantly less than males. In
addition, females liked romantic videos significantly more than males
and watched romantic videos significantly more than males. Finally,
when comparing males and females preferences towards action videos,
females liked action videos significantly less than males. See Table 5.
156 NORTH AMERICAN JOURNAL OF PSYCHOLOGY

DISCUSSION
The interaction among age, music, and video was the most important
finding in this study, especially when putting this finding in context with
the differences in music and video preferences among the older and
younger age groups. This interaction indicated that with an older sample,
a combination of classical music and romantic video produces the least
severe pain increase over time. Considering that the older age group did
not like heavy metal music or action videos as much as the younger
group, it appears that preferences are tied into pain perception. When
considering that females disliked heavy metal music compared to males
and preferred romantic videos, this theory upholding the importance of
preferred stimuli in pain distraction is supported further with the
evidence that females reported a less severe increase of pain over time
with the presence of classical music, and perceived less effort while
watching the romantic video. Also, bearing in mind that less effort was
reported while watching the romantic video, this preferred genre may
relax participants and enable them to perceive less pain when paired with
a less upbeat musical genre (such as classical).
The outcome of this study is consistent with the research of Perlini &
Viita (1996), as preferred music in the present study was related to lower
ratings of pain tolerance. Although the results of this study appear to be
contradictory to the findings of Felbaum et al. (2007) in that action
videos led to increased pain tolerance and decreased perceived pain
intensity, it must be considered that their sample consisted of college
students. Consequently, their samples preferences in video may have
been different from that of an older age group, as was discovered in the
present study. In fact, with the younger group in the present study
reporting that they liked action videos significantly more than the older
group, it appears that preferences once again were the underlying factor
in pain distraction in the study conducted by Felbaum et al. (2007).
The external validity of this study is greater than most pain studies, as
a subsample of 23 older individuals was examined in order to draw
conclusions. As the older population is more likely to deal with pain, this
makes the findings of the study more likely to be relevant to the target
population when compared to the past pain studies mentioned where
children or college students were examined.
While replicating the results with the use of an older sample might
prove to be useful, future studies could also examine the effects of the
presence of preferred stimuli and increasing mobility and physical
rehabilitation. These areas of physical therapy are very closely related to
pain tolerance, as patients undergoing physical rehabilitation often suffer
chronic pain. If their perception of the intensity of the pain were to
decrease, it is likely that the rehabilitation process would speed up,
 Wright & Raudenbush PAIN TOLERANCE 157

allowing for a faster recovery time. This potential study may also benefit
from an older sample, as the older population reported more chronic pain
that interferes with their daily activities (Martinez, 2008). This makes it
likely that they are more prone to need physical rehabilitation.
In summary, this study demonstrates a cost-effective way of reducing
pain through the presence of preferred stimuli (music and video).
Through the examination of a subsample that is representative of the
target population, it further supports the importance of personal
preferences in pain management considering the studys external validity.
Finally, it provides information on how these preferences can be applied
as a non-pharmacological adjunct to pain management, and paves a road
for future studies to look at preferred stimulis usefulness in physical
rehabilitation.

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