The Use of Music as Purposeful Activity:

The Use of Music as Purposeful Activity:

A Preliminary Investigation

Annette Bernard, MS, WR/L

ABSTRACT. The purpose of this study was to test the effects of the use of music on exercise repetitions. The subjects were 25 women ranging in age from 65-99 and possessing common characteristics of upper extremity osteoarthritis. Subjects were randomly assigned to two different orders, a music-first group or a non-music-first group. After two preliminary warm up exercises, each subject was asked to do selected repetitive exercises as many times as possible. The difference between each subject's two sessions was the presence or absence of fast paced jazz music. The observed number of completed repetitions was the dependent variable. No order effects were found. Differences in favor of exercising with music approached significance @= .056) according to a one tailed Wilcoxon Matched Pairs test. This suggests that future studies may support the use of music to increase an arthritic patient's motivation to exercise. Suggestions of possible changes for this study to decrease the chances for a Type I1 error and for future research are discussed.

Over 36 million Americans suffer from arthritis, with the majority of these being the elderly. Osteoarthritis, or degenerative joint

Annette Bernard is currently a staff occupational lherapist and program manager in the work hardening department at Good Samaritan Medical Center, 800 Forest Ave., Zanesville, OH 43701. This project was completed as p.mial fulfdlment of the requirements for Ute Master of Science degree in occupational therapy. She wishes to thank her research advisor, Dr. David L. Nelson, for his continued support, encouragement, and friendship.

Physical & Occupational Therapy in Geriatrics, Vol. 10(3) 1992 @ 1992 by The Haworth Press, Inc. All rights reserved. 35

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36 PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS

disease, is the main form of the disease which affects the elderly. Because exercise is essential in the treatment of arthritis, occupational therapists have the skill and knowledge necessary to play a key role in effectively managing this chronic condition (Basmajian, 1980).

Although the importance of exercise with arthritis is easily understood, low exercise adherence rates may hinder the success of an exercise program. Major findings of investigations showed that a participant's self-motivation may influence his or her decision to drop out or adhere to an exercise program (Nagle, 1984).

Nelson and Peterson (1989) stated that rote exercise may not be motivating to many people, especially elderly people. They believe that meaningful, purposeful activities are a natural means of motivating and supporting healthy movement. The purpose of this paper is to detennine if music can be used as a purposeful activity to encourage exercise in elderly people with arthritis.

"Purpose is the goal orientation of the individual and the link between the individual's developmental structure and occupational performance" (Nelson, 1988, p. 636). Nelson and Peterson (1989) discussed the concept of added-purpose activity, or occupation. By embedding therapeutic exercise within a meaningful and purposeful activity, this activity (or occupation) "may enhance the quality of exercise both through increasing the goal orientation of the client and through providing environmental supports guiding the client's attention and strategizing" (p. 19).

Kircher (1984) found that activity with an added purpose may be more motivating to a patientjclient than exercise alone. She compared subject's perceived exertion during purposeful and nonpurposeful activities and found that "a person may not perceive fatigue as readily when his or her attention is focused on an appropriately selected activity. Decreased fatigue perception is assumed to indicate motivation" (p. 168). Kircher stated that purposeful activity has a wide interpretation and offered the following pertinent example: "The use of music and sequencing of range of motion exercises into a graceful routine can direct the mind away from repetitive motion and pain, and toward rhythm and expressive movement, thus increasing motivation.. . " (p. 169).

In another study of perceived exertion in purposeful and nonpur-

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Anrtetre Bernard 37

poseful activities, Steinbeck (1986) also supported the hypothesis that purposeful activity will have a positive effect on performance. He stated that his results "strongly support the intrindic motivational qualities of purposeful activity" @. 532).

Miller and Nelson (1987) provided additional support for added- purpose activity in occupational therapy. They suggested that further research needs to be done studying a variety of added-purpose activities (purpose of exercise as well as purpose of creating an end product or completing a predefined process) to determine their impact on subjects. Often these studies involve a client creating a tangible end product while incorporating the desired exercise movement. Could similar results be obtained without working toward a tangible end product? For example, could the additional support of rhythm and expressive movement increase a person's purpose or motivation to exercise?

In 1917, when the American Occupational Therapy Association was organized, Soibelman (1948) discussed the role of music in occupational therapy as having very little importance. However, in succeeding years, music was introduced as a common modality within many occupational therapy departments. Several authors of the 20's, 30's,40's, for example, Roos (1936) and Korber (1943), introduced papers detailing the use of music and instruments and the qualities which made them beneficial to the patient's exercise program. Most of these reported on the mechanics and physiology involved in playing various instruments (i.e., what movements and muscles were involved). More recently, music therapists have described observations of their programs and conducted a number of studies supporting the use of music in treatment programs.

In his discussion of a music therapy program instituted for residents in a home for the aged, Shapiro (1969) detailed a number of the activities he used within the program and listed the following as benefits received by the patients he observed: increased motivation, improved coordination, decreased tension, elevated mood, relief of stiffness of arthritic hands and muscles, and reactivation and revitalization of larger arm muscles through simulated conducting of music.

Palmer (1977) described her music therapy program in which the use of music enhanced physical functioning in her geriatric patients.

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Using exercise, one stroke victim appeared to gain increased tolerance, strength, and range of motion. Palmer found that the sound of music was usually enough to encourage cooperation from the residents even if it was painful to them.

In a study concerning pain rehabilitation and music therapy, Wolfe (1978) observed the effects of music on exercise frequency and positivelnegative verbalizations. Background music was added during other activity sessions. Wolfe found that exercise frequencies increased and negative verbalizations related to pain decreased. Patients verbalized an acceptance of and liking of the use of music and requested it at other times of the day. However, other tactics, such as staff ignoring negative verbalizations, were also employed. Wolfe indicated that music may hnction "as an effective diversional tool to aid in inhibiting the perception of chronic pain" (p. 176) and that further research which focuses primarily on the relationship between music and the reduction of pain needs to be done.

Olson (1984) studied the effect of a player piano on the cognitive, affective, and motor responses of a group of elderly people. Because the player piano was prominent in the elderly's youth, it provided a unique aspect to this study. Measurement involved observational and subjective verbal feedback. Five sessions were conducted with several songs included in each session. Olson found that the use of music increased physical activity and rhythmic participation within groups, and enhanced positive feelings of well-being. The author suggested a need for more controlled studies to further substantiate her findings.

Using a multiple baseline design across subjects, Confrancesco (1985) studied the effect of music therapy on hand grasp strength and functional task performance in stroke patients. Although the primary dependent variable, hand grasp strength, was measured by a dynamometer, additional tests were used for pretestlposttest measures to test for generalization of treatment effects. Conhancesco introduced a variety of instruments which were appropriate for training in increasing concentration and coordination, improving muscle strength, joint movement, and finger agility, and maintaining balance and grasp techniques, Confrancesco found consistent results in considerable increases over baseline. Although the multiple baseline results appear impressive, a larger sample size with the same results would be even more convincing.

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Annette Bernard

METHODOLOGY

The purpose of the present study was to determine if the presence of music increases the arthritic patient's desire or motivation to participate in an exercise program. The number of repetitions without music was compared to the number of repetitions of exercise with music. The hypothesis was that the patient who exercises with music will perform a greater number of repetitions.

Sample .

The sample was comprised of 25 female residents from two area nursing homes. Subjects were between the ages of 65 and 99, with a mean of 85.52 years (S_D = 7.67). Moskowitz (1986) listed pain and limitation of motion as two of the three most common characteristics of osteoarthritis. Each facility's activity director selected subjects who exhibited one or both of these characteristics in the upper extremity, were not currently experiencing an inflammatory stage, and were capable of following instructions and performing the required movements. The activity director was familiar with the participants and had access to nursing personnel and charts if the eligibility of any resident to participate in the study was in question. The subjects were those who were currently participating in the facility's exercise program. All subjects were their own legal guardians.

Measurement

The activity director administered the tasks to each participant and used a counter to maintain an accurate re.cord of each subject's number of repetitions of the required exercise movement (extending arm in front of their body and bringing it back toward the body). The experimenter was positioned at a distance far enough to avoid distracting the participant and also used a counter and acted as the checker to ensure inter-observer reliability.

Procedure

Each subject experienced the two conditions on separate days to eliminate any fatigue which may affect the results. On one day the .

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experiment took place with music, on the other day without music. To avoid order effects, random assigment was used to determine which subjects would perform the task with music and which would perform the task without music on the first trial. Each participant then received the opposite condition for the second trial.

Each subject performed three exercises for each trial. The first - -

two exercises were treated as warm-up exercises, similar to a normal exercise class. The number of repetitions performed on the third exercise in each trial was recorded, and these numbers were used in the final data analysis. The subject remained seated either in a straight-backed chair, a wheelchair, or in bed, depending on where they were when they were approached for the experiment. Most of the subjects completed the experiment in their room. Each situation was noted so that the subject performed the second trial in the same seated position and the same room.

The activity director administered the instructions as follows: "Today we are going to do three simple exercises. For each exercise you may use whichever arm or leg is more comfortable for you to use. You may stop at any time. Do you have any questions? Let's begin. I would like you to use your arm to reach for the ceiling ten times." If the subject did not initiate the movement, the activity director demonstrated to make sure the subject understood. Once the activity director was sure that the subject understood, the activity director said, "Now you do the movement while I count to ten. Remember to stop if you feel tired. Begin." All of the subjects were able to complete ten repetitions of this exercise movement.

The activity director gave instructions for the second exercise in the same way, except the subject was instructed to do leg kicks. For the third exercise, the subject was instructed in much the same way. However, for this exercise the subject was instructed to complete as many repetitions as possible. The activity director gave instructions as follows: "For this exercise, I would like to see how many you can do without getting too tired. I would like you to reach out in front of you with one hand and pull your hand back toward you. Do the exercise as many times as you can without stopping until you are tired. Make sure you stop when you feel tired. I will count to myself and let you go as long as you are able. Ready? Begin." If the subject stopped, the activity director prompted once with "Can

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Annette Bernard 41

you continue?" The activity director let the subject continue or con- cluded the session.

During the trials with music, all directions were followed exactly except that the music was turned on before starting the third exercise. Each subject used the same extremity they used for the first trial. The experimenter allowed the subjects who participated in a pilot study to add their input for the selection of music to be used in this experiment. The preliminary subjects were given several choices and the overall preference was a selection of music by Benny Goodman, entitled, "One More Time." The music can be characterized as a fast-paced jazz selection with a combination of instrumental and vocal sections. The music was played on a cassette recorder. The activity director made sure that the subject could hear the music clearly before instructing the subject to begin the third exercise.

RESULTS

See Table 1. The data used for analysis consisted of the number of repetitions completed for the third exercise in the music and non- music trials. Mean inter-observer reliability with music was 99.5 % and 99.2% without music. Non-parameuic tests were used to analyze the data due to distributional skewing. Mann-Whitney U Tests com- paring the two orders in terms of both measurements revealed no evidence of order effects. The Wicoxon Matched Pairs Signed Ranks Test approached significance in favor of using music with an exercise activity for elderly people with arthritis, Z= 1.59, one-tailed e= .056. The means of the two groups are closer to each other than the medians because of outliers in the non-music condition. These outliers were.made up of three subjects who completed 95-1 15 repetitions, The other 25 subjects completed 42 or less repetitions.

It may be a popular cultural assumption that the use of music would stimulate the desire and motivation to exercise. This is quite apparent

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TABLE 1

Number of Exercise Re~et i t ions

1

Number o f Exercise R e ~ e t l t i o n s With Wlthout

nusic nusic

MEAN

SP

MEDIAN

in the increased popularity of musically guided aerobics classes. This pilot study failed to support this idea. The data did, however, ap- proach statistical significance, suggesting that a similar study with a few methodological changes may attain the prespecified significance level.

A number of factors may be taken into account to suggest why these particular data were not significant or what changes could have resulted in significance. One factor is the number of participants. Although 25 i s a sufficient number for this type of study, a much higher number, such as 100, may have led to significance. Two of the 25 cases performed far better in the non-music condition than the music condition with no reasonable explanation as to why this oc- curred. Perhaps a greater number of subjects would have helped to offset the impact of these unusual occurrences.

Another factor which may be considered is the subject's interest in the study. Some subjects needed coaxing by the activity director

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Annefre Bernard 43

in order to participate just because of their resentment toward the word "exercise"; some appeared worried about getting to their next group or meal on time; and some appeared to change their attitudes due to how they felt that day, emotionally or physically. Harris (1987) suggested that a subject may be more motivated to participate in a study if it is conducted in the facility's activity room instead of in the subject's personal room. Perhaps if the current study had required the subjects to complete the experiment in the activity room, only those who were truly motivated and interested in the study would have participated.

Another factor which the experimenter noticed was that several of the subjects counted to themselves and appeared to stop when they felt they had completed a sufficient number of repetitions. Their stopping did not appear to be due to fatigue, boredom, or pain. Par- ticipation in exercise groups where the person is told to do 10,20, etc. repetitions appeared to carry over to the experiment. Many subjects did, however, continue when they were prompted to do so. Perhaps in a future study the experimenter could more strongly emphasize the fact that more was better and possibly even instruct the subjects not to count to themselves. This may be difficult to achieve in the without music session, but instructing the subject to think of something else would be a variable which may confound the data. Also, the: fact that only ten repetitions were required in the wann-up exercises may have affected the subject's decision to stop.

One other factor which needs to be addressed is the music itself. Although the music was selected by a group of pilot study subjects, the actual experiment's subjects may have been more interested if they had been given a choice of music. This may have also increased their awareness of the music. Although all subjects stated that they could hear the music, it was not always obvious what it was about the music that was affecting their responses. Especially in the pilot studies, even when the subjects did better with music, they often stated that they redly did not pay attention to the music or that it had no effect on them. On the other .hand, many of these preliminary subjects stated that the music made them feel happy, excited, and reminiscent of their past, as expected.

Another problem was that few of the subjects in the actual study performed their exercises in rhythm to the music. Perhaps subjects

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should be preselected, based on each individual's ability to move . in rhythm to music. Another possibility would be to train subjects to exercise to rhythm. The current subjects were not explicitly instructed to perform the exercise rhythmically. However, this is a natural act and encouraging it may have enhanced the number of exercise repetitions.

It did not always appear as if the subjects were actually concen- trating on the music. This may suggest that music could have been affecting the subjects on a subconscious level. In the majority of the cases, the individual data showed a higher number of repetitions with the music, but the interaction that took place between the music and each subject is unclear.

In addition to increasing subject size, using more objective measures for collecting data may help to obtain significant results in future applications of this study. Several of the observations made by the experimenter were subjective in nature and therefore are difficult to control.

CONCLUSION

The addition of purposefulness to an activity is a key concept upon which many occupational therapists base their treatment. Much research has been conducted supporting this concept and suggesting creative new ways to add this purposefulness. The field of music therapy has shown support for the use of music with exercise. It is hoped that future occupational therapy studies will join in the growing body of literature which supports the use of music as a fonn of purposeful activity and a means of increasing motivation.

REFERENCES

Basmajian, I.V. (1980). 7herapeutic exercise, Snrdent edition. Baltimore: Williams & Wilkins.

Confrancesco, E.M. (1985). The effect of music therapy on hand grasp strength and functional task performance in stroke patients. Journal of Music lherapy, XXU (3), 129-145.

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Annette Bernard 45

Harris, M. (1987). Effects of addedpurpose on activity choice in a nursing home population. Unpublished Master's Project, Western Michigan University, Kalarnazoo.

Kircher, M. A. (1984). Motivation as a factor of perceived exertion in purposeful versus nonpurposeful activity. American Jotortrnal ojOccupatio~1 Therapy, 38, 165-170.

Miller, L. and Nelson, D.L. (1987). Dual-purpose activity versus single-purpose activity in terms of duration of task, exertion level, and affect. Occupationul Therapy in Mental Health, 7, 55-67.

Moskowitz, R. W., and Haug, M. R. (1986). Arthritis and the elderly. NY: Springer Publishing Company.

Nagle, F.J., and Montoye. H.J. (1981). Erercise in health kidisease. Springfield, IL: Charles C. Thomas.

Nelson, D. L. (1988). Occupation: form and performance. American Journal of Occupational Therapy. 42, 633-641.

Nelson, D. L., and Peterson, C. Q. (1989). Enhancing therapeutic exercise through purposeful activity: a theoretical analysis. Topics in Geriatric Rehabilitation, 4 (4), 12-22.

Olson, B. K. (1984). Player piano music as therapy for the elderly. Journal of Music Therapy, X X I (I), 35-45.

Palmer, M.D. (1977). Music therapy in a comprehensive program of treatment and rehabilitation for the geriatric resident. Journal of Music Therapy, XIV (4), 190-197.

Selvin, B, and His Orchestra (1972). Featuring Benny Goodman. "One More Time" (1931).

Shapiro, A. (1969). A pilot program in music therapy with residents of a home for the aged. Gerontologist, 9, 128-133.

Soibelman, D. (1948). l7zerapeutic and industrial uses of music. NY: Columbia University Press.

Steinbeck, T.M. (1986). Purposeful activity and performance. American Journal of Occupational Therapy. 40, 529-534.

Wolfe, D. E. (1978). Pain rehabilitation and music therapy. Journal of Music Therapy, XV (4), 162-178.

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The Use of Music as Purposeful Activity: