Title

DRUMBEAT© for arthritis “ a shared purpose” rather than a “lonely struggle”

Date of Award

2021

Degree Type

Thesis

Degree Name

Master of Medical Science by Research

School

School of Medical and Health Sciences

First Advisor

Amanda Devine

Second Advisor

Leesa Costello

Third Advisor

Stephen Bright

Fourth Advisor

Ros Sambell

Abstract

Australia is regarded as a healthy nation, with life expectancy one of the highest in the world. Yet the latest National Health Survey tells a very different story. Almost 50% of Australians are now living with one or more chronic conditions, with arthritis and other musculoskeletal (MSK) conditions representing the most expensive chronic disease group in Australia. As the leading cause of chronic pain and second most common cause of disability and early retirement due to ill health in Australia, Arthritis is costing the economy over $7 billion a year, in addition to over $1.1 billion in extra welfare costs and lost tax revenue. Although personal, social and economic burdens of arthritis are immense they tend to be poorly recognised, with government investment considerably lower than for any other major disease group, with the exception of asthma.

While very common, arthritis is not well understood. Prevailing myths inaccurately portray arthritis as an old person's disease and an inevitable part of aging. More than 150 types of arthritis and related MSK conditions have been described; classified as either inflammatory, or non-inflammatory. Osteoarthritis (OA) is the most common type of non-inflammatory, characterised by progressive damage to cartilage and other joint tissues. Rheumatoid arthritis (RA) is the prototypical inflammatory arthritis, followed by gout, psoriatic arthritis (PsA), ankylosing spondylitis (AS), juvenile idiopathic arthritis (JIA) and systemic lupus erythematosus (lupus), among others. Classified as chronic autoimmune disorders, the symptoms of inflammatory arthritis (IA) are not localised to the damaged joint, and individuals may also experience fever, weakness, and organ damage, in addition to the stiffness and pain in the joints. As the sample size of this pilot study is small, it was decided to not recruit from the entire target population but rather to focus on those individuals living with IA.

The measure of prevalence of arthritis and other MSK conditions in Australia poses a challenge as there are wide variations in condition specific data. A snapshot from the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS) indicates almost 4 million Australians, 1 in 6 people, live with some form of arthritis – this number has almost doubled since the 1950’s and is expected to significantly increase by 2030. Limited national statistics and publications show an estimated 456,000 Australians (1.9% of the total population) with RA; JIA as affecting around 1 child in every 1,000 aged 0–15; PsA occurring in up to 30% of people who have psoriasis, a common skin disorder that affects approximately 2% of the population; and suggest AS affects one in 200 Australians. The limited data relating to incidence, treatment, costs and outcomes of the many types of arthritis is seen as a major barrier to recognition of the impact and potential severity of the disease group by the general public, clinicians and policymakers.

statistics and publications show an estimated 456,000 Australians (1.9% of the total population) with RA; JIA as affecting around 1 child in every 1,000 aged 0–15; PsA occurring in up to 30% of people who have psoriasis, a common skin disorder that affects approximately 2% of the population; and suggest AS affects one in 200 Australians. The limited data relating to incidence, treatment, costs and outcomes of the many types of arthritis is seen as a major barrier to recognition of the impact and potential severity of the disease group by the general public, clinicians and policymakers.

The study investigated whether individuals living with various forms of IA could improve levels of self-management by participating in a drumming intervention based on the Holyoake DRUMBEAT (Discovering Relationships Using Music -Beliefs, Emotions, Attitudes, & Thoughts) format, that uses hand drumming to allow participants to explore and engage connections between making music together as a group and development of emotional skills, such as self-regulation and self-confidence.

The initial aim of the study was to help understand the unique experiences of those individuals living with IA, as expressed by research participants in this study. The subsequent and overarching aims of the research were to investigate what benefits persons living with IA might derive through their participation in innovative and novel hand-drumming programs such as DRUMBEAT.

Seven participants with varied forms of IA were invited to take part in a 6-week hand-drumming intervention based on the Holyoake DRUMBEAT program. The 2.5hour weekly sessions were held in 2019 at the headquarters of AOWA. Each session consisted of playing djembe drums and/or percussion, and discussions to facilitate effective interaction between participants. Additionally, the inclusion of breaks before, after and during the sessions was an important consideration to encourage social interaction with others possibly facing similar challenges in life. Ad hoc adaptations led to change in peripheral delivery components of the program so as to suit the participants’ abilities, rather than their disabilities. Modification was about flexibility and this is inherent in the way the sessions were delivered. The core content of the program remained the same. Exclusion criteria included presence of a major depressive disorder, or a previously diagnosed depressive disorder that had not been stabilised through treatment; or presence of any co-existing musculoskeletal conditions that prevented participation.

A sequential mixed-methods action research design was adopted for this exploratory health promotion intervention. The integration of mixed methods and action research allowed for various research tools to be used: researcher observations; weekly transcripts; one-on-one interviews; final focus group transcripts; and pre, interim, and post – program questionnaires. Depression, anxiety and quality of life (QoL) were assessed using the RAND 36-Item Health Survey 1.0 and the Hospital Anxiety and Depression scale (HADS). In analysing the results, each participant’s general self-efficacy was assessed using the Rheumatoid Arthritis Self-Efficacy (RASE) questionnaire and the Locus of Control of Behaviour Scale (LoCBS). The UCLA Loneliness Scale (Version 3) was utilised to measure loneliness and social support, together with a simple, four-item Session Rating Scale (SRS) administered, scored and discussed at the end of each session, to get real-time feedback from participants. The Visual Analogue Scale (VAS) was also completed at the end of each session to help capture any differences in pain intensity and / or severity, pre- and post-drumming.

Quantitative results show depression was significantly lower from baseline to follow up. Depression had decreased from a mean (Median; SD; IQR) of 6.29 (7.0; 3.15; 5.0) to 4.42 (5.0; 2.82; 5.0) during the 6-week intervention. Anxiety reduced from a mean (Median; SD; IQR) of 7.86 (7.0; 4.98; 10.0) to 7.14 (7.0; 4.91; 9.0). Statistically significant improvements in QoL scores were observed in physical functioning from a mean (Median; SD; IQR) of 55 (65; 20.41; 30) to 65 (75; 18.26; 25). Trends in improvement in role physical / role emotional scale was noted, together with reduced bodily pain. There were smaller non-significant improvements in energy / fatigue, emotional wellbeing and general health. All QoL measures appeared to improve, though all but physical did not reach statistical significance due to small sample size and inadequate exposure to the intervention for some participants. The study encountered poor participation rates, with fatigue and lack of confidence identified as the main reasons for non-attendance. Only 28.57% (n=2) of the participants completed the full 6-week DRUMBEAT program, with 57.14% (n=4) completing four, or more sessions. Social function and differences in loneliness, as measured by UCLA scale (version 3) were the only scales to remain unchanged. The degree of change was also not significant in self‐report measures of locus of control. The majority of participants (n=6) indicated small non-significant improvements in self-efficacy. Qualitative analysis revealed a significant sense of community and by week two there was a noticeable sense of bonding within the group. In addition to community features the qualitative analysis revealed some positive signs of improvement in multiple domains of social-emotional behaviour.

We conclude that the drumming intervention may have a beneficial effect on both mental and physical self-reported health, in the short term, in an IA population. These findings add to the growing evidence on how engagement in a group drumming intervention, such as DRUMBEAT may influence participants to utilise experiences drawn from their own lives to find solutions to challenges, and promote healthy behaviour changes.

To support these results, further studies are needed to measure outcomes and the potential usefulness of incorporating DRUMBEAT into a successful management strategy of IA. This will allow for the opportunity to produce more evidence and determine the effects of outside factors.

While appreciating the role of medications to alleviate symptoms, clearly the current approach to the management of chronic conditions, such as IA, is not working and therein presents an opportunity for innovative interventions such as DRUMBEAT. Based upon the findings and recommendations of this study, DRUMBEAT appears to be an easily accessible, fun, sustainable program that may help participants gain the social support and skills necessary for them to thrive, learn, work, earn and participate in community life.

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