A music‐with‐movement exercise programme for community‐dwelling older adults suffering from chronic pain: A pilot randomized controlled trial

Abstract Aim This study developed, implemented and tested the effectiveness of a music‐with‐movement exercise programme in improving the pain situations of older adults with chronic pain. Design A pilot randomized controlled trial. Methods This was a pilot randomized controlled trial. The intervention was an 8‐week music‐with‐movement exercise (MMEP) programme for older adults with chronic pain recruited in elders’ community centres. The control group received the usual care and a pain management pamphlet. Outcome variables were pain intensity, pain self‐efficacy and pain interference, depression and loneliness. Results Seventy‐one participants joined this study. Pain intensity was significantly reduced between the experimental group compared to the control group. The experimental group participants reported significant improvements in pain self‐efficiency, pain interference and reduced loneliness and depressive symptoms. However, no significant difference was observed between groups.


| INTRODUC TI ON
Chronic non-cancer pain is a prevalent condition affecting 37% of community-dwelling older adults who live in the community (Abdulla et al., 2013;Ickowicz et al., 2002). Pain is associated with significant physical and psychosocial incapacities, and interferes with older adults' daily and social activities (Abdulla et al., 2013;Ickowicz et al., 2002). Poorly controlled and persistent pain is associated with various adverse outcomes, including functional impairment, cognitive failure, depression, anxiety, falls, sleep and appetite disturbances, reduced social interaction and unnecessary healthcare use and expenditures (Eggermont et al., 2012;Zis et al., 2017). The common pain sites for older adults are the back, arms, hips and legs (Fouladbakhsh et al., 2011). produces physiological responses to establish and keep up physical activity in managing health conditions. Music interventions based on the theory of pain, providing both adequate analgesia and minimal side effects (Good, 1998), have led to a decrease in surgical pain (Good et al., 1999;McCaffrey & Good, 2000;Tse et al., 2005), labour pain (Chuang et al., 2019;Simavli et al., 2013) and chronic knee pain (McCaffrey & Freeman, 2003) in previous studies. Garza-Villarreal et al. (2017) conducted a systematic review and meta-analysis on music as an intervention for the management of chronic pain. Music was often delivered in recorded tapes, as live music or choir singing. The reviewed studies, however, did not include any music-with-movement elements (Garza-Villarreal et al., 2017). Clark et al.'s (2016) systematic review and narrative synthesis showed that music can help to promote behavioural changes in people who exercise. Listening to music increases participation in exercise, improves the performance and experience of exercise and promotes adherence to exercise (Clark et al., 2016). In a separate systematic review and meta-analysis, Clark et al. (2012) examined the effectiveness of music interventions in engaging older adults in physical activities. Participating in exercise programmes while listening to music improved the physical activity levels of older adults. In particular, greater improvement is observed in groups with music than in groups without music.
Music-with-movement programme also demonstrated positive outcomes on cognitive functions and moods for older adults with dementia (Cheung et al., 2018). The programme involved batting balloons, waving ribbons, foot tapping, playing musical instruments (hand bells, drums, triangles, etc.) and mimicking movements demonstrated by the facilitator. Participants were encouraged to move their bodies and use any props freely without any restrictions.
Family members suggested music to accompany the sessions, which were mainly songs that had been popular when the participants were young, religious music and nursery rhymes (Cheung et al., 2018). The study demonstrated that music with movement is a suitable intervention for older adults. Unfortunately, the study did not examine pain intensity as an outcome measure.
It is believed that the music-with-movement programme can help older adults develop physical exercise habits and improve their pain situations. People with healthy habits live longer, are happier and utilize less healthcare resources, paving the way for healthy ageing. The music-with-movement exercise programme (MMEP) was developed in consultation with a music therapist and a physiotherapist. They chose five songs and integrated the exercise from an exercise book into the music. The steps, intensity and appropriateness for older adults were reviewed by the physiotherapist. The effectiveness of exercise guidebook was validated in a pilot randomized controlled trial involving 64 community-dwelling older adults with chronic pain (Li et al., 2020). The present study tested the effectiveness of a MMEP. The objectives were as follows: (1) to develop and implement a MMEP for older adults suffering from chronic pain; (2) to evaluate the effects of this MMEP on improving pain intensity, pain self-efficacy, mood and quality of life of community-dwelling older adults with chronic pain when comparing to those with usual pain and received a pain pamphlet.

| ME THODS
This study tested the effectiveness of a MMEP in mitigating pain intensity, pain self-efficacy and pain interferences, as well as reducing loneliness and depressive symptoms in a sample of communitydwelling older adults in Hong Kong.

| Study design
A pilot randomized controlled trial was conducted to test the effectiveness of a MMEP. The trial has been registered on the Clini calTr ials.gov platform (NCTXX). Research Ethics Committee approval was obtained from The Hong Kong Polytechnic University and the participating centres.

| Sample and procedure
Older adults were recruited from a District Elderly Center (DEC) subsidized/run by the Social and Welfare Department of Hong Kong.
Since this was a pilot randomized controlled trial, a sample size of 30 participants from each experimental group and control group was adopted (Browne, 1995). A total number of 60 participants was required for the study.

| Inclusion and exclusion criteria
Potential participants were invited to participate in this study if they were aged 60 or above, could understand Cantonese, had a history of non-cancer pain in the past 3 months, had a pain score of 2 or above as measured by the Numeric Rating Scale (on an 11-point numeric scale), were able to take part in an exercise and stretching programme and owned a smartphone and can access the Internet at the time of the study. Exclusion criteria include: having severe visual and/or auditory deficits, having a serious organic disease or malignant tumour, having a mental disorder as diagnosed by neurologists or psychiatrists, had surgical treatments in the past 2 months and had drug addiction.

| Recruitment procedure
The research team collaborated with local elders' community centre to recruit older members to join the MMEP. Older members of the centre who expressed interest in participating were randomized into either the experimental or control group using a computer-generated list generated in Microsoft Excel by a research assistant who did not involve in data collection. The participating elder centre was not informed of individuals' membership in the two groups. Older members served as the unit of allocation, intervention and analysis. Written informed consent was obtained from all participants before checking the inclusion and exclusion criteria.

| Music-with-movement exercise programme for the experimental group
The MMEP is an 8-week programme composed of centre-based face-to-face activities and home-based digital-based activities.

The making of music videos
A music therapist, in consultation with the physiotherapist, chose five songs that are popular among older adults and integrate them into the exercise from an exercise guidebook. The exercise guidebook was developed and validated by five experts in pain management, including three university professors whose research focus was pain management, and two Registered Nurses from hospital pain clinics who had tremendous experience in pain management.
The effectiveness of the exercise guidebook was tested out in a pilot randomized controlled trial involving 64 community-dwelling older adults with chronic pain. Improvements were observed in the pain intensity, pain interference, pain self-efficacy, mood and quality of life of the participants in the experimental group (Li et al., 2020). The physiotherapist then reviewed the MMEP and checked the musicwith-movement exercise for its steps, intensity and appropriateness for older adults.

The centre-based programme
The centre-based programme was delivered face to face, twice a The home-based and digital-based activities were delivered via a WhatsApp group over the 8 weeks. Participants received an exercise logbook in the first centre-based face-to-face session. The logbook contained a graphic step-by-step guide of the music-with-movement exercise and a record sheet for participants to record the frequency with which they practiced the programme. Participants were encouraged to practice the MMEP for 30 min at least twice a week at home. They were given the five songs and videos of the physical exercises they have learned in class via WhatsApp. The research assistant sent reminders to the participants via WhatsApp twice a week to encourage and remind them to practice MMEP at home.

| Control group
The participants in the control group received the usual care and a pain management pamphlet distributed by the healthcare professions. Usual care refers to the participant receiving their routine care. The pain management pamphlet included introduction to pain and pain management strategies. The pain pamphlet can still help older adults manage their pain situations but the effect would be lesser than the MMEP.

| Outcome measures
Validated and reliable measurement scales were used to assess the various outcomes in the present study. A research assistant was trained to conduct data collection and blinded to the group allocation of the participants.

| Pain intensity
Pain intensity was measured using the 4-item Brief Pain Inventory-Chinese version (BPI-C) (Wang et al., 1996). Items are rated from 0 = 'no pain' to 10 = 'pain as bad as you can think'. The scale demonstrated good internal consistency with Cronbach's alpha of 0.894 (Wang et al., 1996). A higher score indicates greater pain intensity.

| Pain self-efficacy and pain interference
The 10-item Pain Self-Efficacy Questionnaire-Chinese version (PSEQ-C) was used to assess participants' confidence in performing specific tasks or their confidence in facing more general situations such as coping with chronic non-malignant pain (Lim et al., 2007). The PSEQ-C is a reliable measure with Cronbach's alpha of 0.93 (Lim et al., 2007). Validity has been demonstrated with its significant correlation of −0.413 with Pain Catastrophizing Scale (Lim et al., 2007). Participants responded on a 7-point scale, with 0 = 'not at all confident' and 6 = 'completely confident'.
A higher score reflects greater pain-related self-efficacy (Lim et al., 2007).
Pain interference was measured using the 7-item Brief Pain Inventory-Chinese version (BPI-C) (Wang et al., 1996). Participants responded to each item on a 10-point scale from 0 = 'does not interfere' to 10 = 'completely interfere'. The scale demonstrated good internal consistency with Cronbach's alpha of 0.915 (Wang et al., 1996). A higher score indicates greater pain intensity (Wang et al., 1996).

| Depression
The Chinese version of the 15-item Geriatric Depression Scale (GDS) was used to measure depression. The scale has been widely used and has demonstrated good internal consistency with Cronbach's alpha of 0.82 (Boey & Chiu, 1998). A higher score indicates more depressive symptoms.

| Loneliness
The Chinese version of the 6-item De Jong Gierveld Loneliness Scale (DJGLS) was used (Leung et al., 2008). The DJGLS comprises an emotional subscale and a social subscale, each consisting of three items. The scale has demonstrated good internal consistency with Cronbach's alpha of 0.76 (Leung et al., 2008). A higher score indicates more depressive symptoms. Higher scores indicate higher levels of loneliness.

| Statistical analysis
Data were analysed using SPSS version 25. Descriptive statistics and frequency distributions were calculated for sample characteristics.
Chi-square tests and t-tests were used to identify any differences in demographics between the experimental and control experimental groups. A p value of <0.05 was considered statistically significant.
Generalized estimating equations (GEE) with the identity link and first-order autoregressive (AR(1)) working correlation matrix were used to evaluate the effect of the intervention on primary

TA B L E 1 Participants' characteristics.
(pain intensity as measured by BPI) and secondary (pain self-efficacy as measured by PSEQ, pain interference as measured by BPI, de-  Figure 1 shows the consort flow diagram. A total of 71 participants who satisfied the inclusion criteria participated. Forty-one participants were allocated to the experimental group and 30 to the control group. Table 1 presents demographic characteristics of the participants. Participants were predominantly female (71.8%) and widows (62%), aged between 60 and 100 at the study. More than half of the participants were uneducated. Nearly 86% of the participants lived with others. Hypertension was the most commonly reported chronic disease in this sample (62.0%). No statistically significant differences in demographic characteristics were found between the experimental and control groups. Except for the pain interference, there were no statistically significant differences in outcome measures found between the experimental and control groups.

| Demographic results
Tables 2 and 3 present the GEE results. between-comparison revealed that the experimental group reported lower pain intensity (p = 0.001) than the control group, with a medium effect size (d = 0.54).

| DISCUSS ION
The present study examined the effectiveness of an 8-week MMEP in a sample of 71 community-dwelling older adults with chronic pain.
Some participants in the control group dropped out after randomization and caused the discrepancy in the number of participants when comparing the experimental group with control group. Our results showed that pain intensity was significantly reduced over the 8-week period for participants who received the MMEP. The same improvement was not observed in the control group who received an information pamphlet but no music-with-movement exercise.
Participants in both experimental and control groups reported statistical improvements in pain self-efficiency and pain interference as well as reduction in loneliness and depressive symptoms. Also, the control group would receive a pamphlet with pain relief strategies. It is believed that it will be less efficient than the MMEP, yet, still provide some information for those suffering from chronic pain.
Ageing population places high demands on the public health system, including medical and rehabilitation and social services.
Chronic diseases including degenerative arthritis and osteoporosis, commonly reported in older adults, result in chronic pain and disability. Chronic pain, defined as ongoing pain felt in the bones, joints and tissues of the body that persists longer than 3 months, is a major cause of pain and disability (Booth et al., 2017). Pain limits functional mobility and activities of daily living, such limitations are particularly apparent in older adults. Various consequences of persistent pain, such as fear of movement, anxiety and pain catastrophizing, further contribute to disability and pain in the older population. The present study recruited community-dwelling older adults with a pain score of 2 or above as measured by the Numeric Rating Scale (on an 11point numeric scale). These older adults stayed in the community and lived independently. An increase in pain intensity would possibly

TA B L E 3 Estimated marginal means
and standard error at each measurement time point for GEE models that showed significant Group × Time interaction.