Introduction

The therapeutic impact of music on health and well-being has gained significant attention in contemporary research. Music has been shown to divert individuals from unpleasant experiences and facilitate physical movement, social interaction, and communication [1]. Positive music experiences have been associated with increased emotional well-being and dopamine activity in the brain, leading to reduced anxiety, worries, and agitation [2]. Additionally, music’s influence on the sympathetic systems of the autonomic nervous system has physiological effects, including modulation of heart rate variability, reduction in heart rate and blood pressure, and enhancement of immune system function [3–6].

In rehabilitation, music intervention has become a vital component, extending beyond traditional therapy. It involves the strategic use of musical elements, integrated with standard exercises and treatments [2, 7, 8]. The therapeutic effects of music-based interventions have been extensively studied, particularly in relation to neurorehabilitation, where such interventions have demonstrated efficacy in improving motor and cognitive functions [9, 10]. Our focus on lower extremity conditions arises from the observation that rehabilitation of these conditions, such as stroke-related gait impairments, often necessitates interventions that are both motivating and conducive to sustained engagement. While lower extremity conditions encompass a wide range of impairments, including those affecting balance, gait, and overall mobility [11], this diversity underscores the need for innovative and versatile rehabilitation tools capable of addressing various challenges within this category. Music-based interventions, particularly those that incorporate rhythm and movement coordination, have shown promise in enhancing rehabilitation outcomes for these impairments, making them a compelling area for further research [12–14].

Several studies supported the role of music intervention in lower limb rehabilitation. For instance, a randomized controlled trial demonstrated that music intervention coupled with rehabilitation exercises significantly alleviated pain and improved mobility and gait in children with lower limb burns [15]. Another study [16] investigated the effects of self-selected versus motivational music on muscle endurance and affective state in middle-aged adults. The study employed a within-subject design where 26 healthy middle-aged males (average age 50.8±8.4 years) performed maximal and endurance isometric strength tests under three different conditions: self-selected music (SSM), motivational music (MM), and a control condition (CC) with no music. The results showed that mean force during the isometric endurance test was significantly higher in the SSM condition (507.3±132.2 N) compared to both MM (476.3±122.4 N, p<0.01) and CC (484.6±119.2 N, p = 0.03). Additionally, participants reported a higher Felt Arousal Scale (FAS) score and Feeling Scale (FS) in the SSM condition, indicating a more positive affective state. These findings suggest that self-selected music can enhance muscle endurance and positively influence mood during strength exercises in middle-aged adults. These findings underscore the potential of music intervention to divert attention from discomfort and reduce perceived exertion levels. For instance, Magill-Levreault [17] highlighted the role of music therapy in pain management, where it was shown to decrease pain perception by altering affective and cognitive processes. Similarly, Mohammadzadeh et al. [18] found that music significantly reduced the rate of perceived exertion (RPE) during progressive exercise, especially among untrained individuals, while Potteiger et al. [19] demonstrated that various types of music, including self-selected music, were associated with lower RPE during moderate-intensity exercise. These studies collectively highlight the prospective utility of music in rehabilitation settings, where managing discomfort and perceived exertion is crucial.

Amid the growing use of musical instruments in rehabilitation interventions, this study explored a novel area: the use of organ pedal training for lower extremity rehabilitation. Evidence supporting the use of organ pedaling as an effective intervention for lower extremity rehabilitation comes from various domains where music and movement are integrated into therapeutic practices. Organ pedal training, which involves coordinated lower limb movements similar to those required in other rhythmic and music-based therapies, has shown promise in enhancing motor functions and overall rehabilitation outcomes. For instance, music therapy has been widely recognized for its positive impact on motor recovery in neurological conditions such as stroke and Parkinson’s disease, where rhythmic auditory stimulation significantly improves gait and mobility [20, 21]. This suggests that the rhythmic and repetitive nature of organ pedaling could similarly benefit lower extremity rehabilitation. Moreover, the physical demands placed on organists, who frequently engage in complex foot movements, are comparable to those seen in athletic training. This has led to observations that organists develop enhanced lower limb strength, endurance, and coordination, further supporting the potential of organ pedalboard as a rehabilitation tool [22]. Additionally, music’s ability to serve as a motivator during physical activity, reducing perceived exertion and increasing endurance, has been well-documented in exercise settings [18, 19]. These findings are indicative of the broader applicability of music-integrated physical exercises in promoting lower limb functions. Although direct studies on organ pedaling are limited, the extrapolation from related music and movement therapies strongly supports its potential effectiveness in treating lower extremity conditions. The unique combination of rhythmic movement and cognitive engagement in organ pedaling makes it a promising area for further research and application in rehabilitation settings.

The selection of the organ pedalboard as a rehabilitation tool is grounded in its unique ability to engage the lower extremities in a musically and rhythmically structured environment. Unlike many other musical instruments, the organ pedalboard requires precise, coordinated foot movements to produce sound, thereby directly targeting motor control and coordination in the lower limbs [23]. This makes it particularly well-suited for rehabilitation applications. The repetitive, goal-oriented nature can improve functional outcomes through tasks that mimic daily activities. Despite limited research in this specific domain and the recognized need for more musical interventions for lower extremity rehabilitation, organ pedal training holds potential as a non-invasive and possibly beneficial approach.

To explore the therapeutic potential of organ pedaling for lower extremity rehabilitation, this study retrospectively applied the Biopsychosocial Model [24] as a guiding conceptual framework. The Biopsychosocial Model proposed by Engel (1977) posits that health outcomes result from the intricate interplay between biological, psychological, and social factors. This framework is particularly apt for understanding how organ pedaling might influence lower extremity conditions, as it addresses not only the physical rehabilitation of muscles and joints but also the psychological and social dimensions of recovery. From a biological perspective, organ pedaling engages multiple lower limb muscle groups, promoting range of motion, flexibility, and strength, which are critical for rehabilitation [20]. Psychologically, the rhythmic and musical nature of pedaling can enhance patient motivation and adherence to rehabilitation protocols by reducing the perception of effort and increasing overall engagement [19]. Socially, the use of music-based interventions such as organ pedaling may facilitate social interaction, improving the overall well-being of patients through shared musical experiences [25]. By incorporating the biopsychosocial model, this study aims to provide a comprehensive understanding of the potential benefits of organ pedaling for lower extremity rehabilitation. This framework guides the research process, ensuring that the investigation remains focused on the interconnected biological, psychological, and social factors that contribute to successful rehabilitation outcomes.

Method

Organ pedalboard description

A standard 32-key radiating concave American Guild of Organists-approved pedalboard was demonstrated. The organ pedalboard used in this study spanned a range from C2 to G4, encompassing 32 musical notes on a standard organ. The lowest note was C2, while the highest reached G4, covering approximately two and a half octaves. This extensive range enabled a variety of foot movements and exercises targeting diverse muscle groups in the lower extremities.

The pedalboard was equipped with a MIDI (Musical Instrument Digital Interface) function, a standard technology that allows electronic musical instruments, computers, and other equipment to communicate and synchronize with each other. In this study, the MIDI function connected the pedalboard to a laptop and an external sound module, enabling it to produce sounds through speakers that mimicked a traditional pipe organ. This feature was crucial in facilitating a realistic musical experience during the rehabilitation exercises. Fig 1 presents the modified pedalboard used in this study.

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Fig 1. The modified pedalboard with a MIDI function.

https://doi.org/10.1371/journal.pone.0314147.g001

Findings

A total of 17 healthcare providers who agreed to participate in the study attended one of the four focus groups. No participant was dropped out. The focus groups were composed as follows: three groups included one music therapist, one occupational therapist, one physiotherapist, and one sports trainer. One group included two occupational therapists in addition to the other three disciplines, resulting in a total of 17 participants. This composition ensured the representation of a variety of perspectives from different healthcare disciplines were represented.

Nine participants were males. The median age of participants was 32.5 years, with an interquartile range (IQR) of 21 (50–29) years, indicating a relatively broad age distribution. Similarly, the median years of professional practice were 5 years, with an IQR of 6.5 (9.5–3) years. This distribution suggests a diverse range of experience levels among participants, with both early-career and more experienced professionals represented.

Most participants (n = 15, 88.2%) held a Master’s degree or higher level of education. The majority of the participants (70%, n = 12) were employed full-time across a variety of healthcare settings, including hospitals (n = 6), elderly care homes (n = 6), private clinics (n = 2), and other facilities (n = 3). The participants primarily served older adult (n = 10), adult (n = 5), and paediatric (n = 2) patient populations. Table 1 presents the demographic characteristics of the focus group participants.

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Table 1. Demographic characteristics of the participants (N = 17).

https://doi.org/10.1371/journal.pone.0314147.t001

The analysis of the focus group data revealed three higher-order themes that provide a structured framework to better categorize and clarify the sub-themes that emerged. These higher-order themes enhance the readability and understanding of the research findings.

The first higher-order theme is "The Multifaceted Role of Music in Rehabilitation," which encapsulates the overarching influence of music within the rehabilitation context. It includes sub-themes that explore the role of music as a key motivator, encouraging sustained patient engagement and natural movement. Additionally, this theme examines how the organ pedalboard is perceived not only as a therapeutic tool but also as a musical instrument, making the rehabilitation process more engaging and less clinical for patients.

The second higher-order theme is "Benefits of Organ Pedalboard," which brings together various benefits of using the organ pedalboard in rehabilitation. Sub-themes under this category include physical benefits, such as improvements in range of motion, flexibility, balance, and coordination; cognitive benefits, including enhancements in memory, attention, and cognitive processing; as well as the psychosocial benefits, where the pedalboard boosts patient confidence, provides a sense of accomplishment, and facilitates social interaction.

The third higher-order theme is "Modifications of Organ Pedalboard," which addresses the logistical and safety aspects of incorporating the organ pedalboard into rehabilitation settings. This theme includes sub-themes that discuss the unique requirements and adaptations necessary for effective use of the pedalboard across different patient populations, the importance of safety features and modifications to prevent injury, and the need for programming and customization to make the pedalboard a more accessible and effective tool for rehabilitation settings.

Discussion

We addressed the research objectives outlined in the introduction and successfully identified healthcare providers’ perceptions of using organ pedalboards as a rehabilitation tool for lower extremity conditions. The findings revealed that healthcare providers view music as a motivator that enhances patient engagement and supports natural movement, particularly in lower limb rehabilitation. Additionally, the study highlighted key barriers and facilitators influencing the adoption of organ pedalboards in clinical practice, such as safety concerns and the need for customized training programs. Importantly, the healthcare providers provided specific recommendations on how organ pedal training could be integrated into existing rehabilitation protocols, emphasizing its potential to improve physical, cognitive, and psychosocial outcomes. These insights contribute significantly to the development of targeted rehabilitation strategies and underscore the need for further research to optimize the use of organ pedalboards in clinical settings.

The findings of this study provide valuable insights into healthcare providers’ perceptions and attitudes towards the use of organ pedalboards as a rehabilitation tool for lower extremity conditions. The healthcare providers’ views generally align with previous research on the role of music in rehabilitation. Music has been widely recognized as a motivating factor for patients during rehabilitation activities [32, 33]. It allows patients to move naturally by following the inherent rhythm and beats of the music, encouraging sustained engagement [34].

Researchers have extensively studied and documented the therapeutic role of music in rehabilitation. It has been shown to motivate patients to participate in rehabilitation activities and facilitate natural movements [35]. Music has also been found to stimulate the brain and trigger physiological responses, aiding in physical and cognitive rehabilitation [36]. Furthermore, the use of familiar music can trigger patients’ memories and associations, potentially enhancing the overall rehabilitation experience [37]. These findings emphasize the potential of music intervention in diverting attention from discomfort and reducing perceived exertion levels, highlighting its prospective utility in rehabilitation settings [38].

The use of the organ pedalboard was perceived as an innovative approach to rehabilitation, offering an alternative to traditional methods. This aligns with the growing body of literature advocating for the integration of creative and engaging methods in rehabilitation to enhance patient adherence and outcomes [39]. The participants thought that patients may positively perceive training on the organ pedalboard as a music activity, potentially leading to increased participation and sustained engagement in rehabilitation [40]. The participants suggested that the organ pedalboard could be used to train a variety of physical aspects, including range of motion, flexibility, balance, and coordination. This is consistent with previous research that has demonstrated the effectiveness of music-based interventions in improving these physical attributes [41, 42]. Moreover, the pedalboard can facilitate social participation and engagement, as patients can engage in rehabilitation activities with their caregivers or family members. This collaborative activity can strengthen social relationships and enhance the quality of life [25]. However, individual preferences and sensitivities to music should be considered, as the sound produced from the pedalboard may be perceived as ’noise’ by some patients, leading to frustration [43].

Interestingly, the participants also identified the potential of the organ pedalboard as a cognitive rehabilitation tool. This is a novel finding that warrants further investigation. The use of the organ pedalboard could potentially enhance cognitive processes such as attention and memory, which are crucial for successful rehabilitation [44–46]. The potential benefits are not only limited to adults but also to other patient groups, including children with special educational needs such as ADHD and MR [47]. This finding suggests a promising avenue for future research.

The organ pedalboard has been identified by the participants as a potential psychosocial tool for rehabilitation in patients with upper or lower limb problems. The ability to create music using the pedalboard can provide a sense of accomplishment and confidence, which can be beneficial for patients’ mental health and overall well-being [25]. Accumulating evidence shows that music interventions have a significant effect on patients by reducing their level of pain [48], anxiety [49], and stress [50].

However, the study also identified potential challenges in implementing organ pedal training, such as the need for specific adaptations to target certain movements and the potential for patients to adopt compensatory movements. These findings highlight the importance of careful planning and individualized programming in the implementation of organ pedal training. Furthermore, it is essential to address the safety considerations associated with using the organ pedalboard as a rehabilitation tool. The current design of the organ bench is not optimal for rehabilitation use. Adjustments to the chair height and position, as well as the addition of armrests, back support, and a seatbelt or pelvic belt, can prevent patients from slipping from the chair [51]. Additionally, the level of supervision and manpower required for patients practicing movements on the pedalboard should be carefully considered, along with the implementation of safety measures such as back support, straps, and handlebars to prevent slips and falls [52]. Furthermore, the programming of the organ pedalboard for rehabilitation purposes is crucial, with the need for cueing methods, signal displays, and song and sound selection to meet the diverse needs and abilities of patients [53]. Programming the organ pedalboard can make it a feasible tool for rehabilitation training. Simple cueing systems, such as lighting on the pedal keys or signal cues on a screen monitor, can guide the rehabilitation movements in creating music. Visual feedback has been largely used in rehabilitation interventions, as it has been shown to be effective [54, 55].

This study highlights the importance of aligning healthcare professionals’ perspectives with the proposed theoretical framework for the use of organ pedalboards in rehabilitation. The findings reveal that professionals’ insights generally support its key components, particularly in relation to the biopsychosocial model. This model emphasizes the interplay of biological, psychological, and social factors in health, which are also reflected in the perceived benefits of organ pedal training. The professionals agreed that the organ pedalboard could effectively address the biological aspects of rehabilitation by improving range of motion, flexibility, and coordination. These practical insights align with the framework’s biological dimension, affirming its relevance in real-world applications. Additionally, the psychological and social benefits of using the organ pedalboard, such as enhanced patient motivation, cognitive engagement, and social participation, also resonate with the framework’s focus on these areas. However, some discrepancies between theoretical expectations and practical challenges were identified. For example, while the framework posits that music-based interventions could universally enhance emotional well-being, the professionals noted that patient preferences for music vary significantly, which could impact the tool’s effectiveness. This feedback suggests a need for further refinement of the framework to account for individual differences and responses to music. Incorporating these practical experiences into the framework would enhance its applicability and credibility, ensuring it addresses real-world challenges while maintaining theoretical rigor. Aligning the framework with the insights of regular users increases the likelihood of its successful adoption and effective use in rehabilitation settings, ultimately leading to better patient outcomes.

The cost of implementing organ pedalboards in rehabilitation is indeed a critical factor that must be acknowledged. While our study focused on the potential benefits of this tool, the oversight of not emphasizing the high cost, as highlighted in the interview guide, should be addressed. The participants’ primary focus was on the therapeutic advantages rather than the financial barriers. It was because most of the participants worked for an organization. They used tools provided by the organization to manage their patients. Understanding the therapeutic effects of pedalboards for patients enabled participants to recommend this tool to the decision makers of their workplace. However, the modification and programming costs associated with adapting the pedalboard for rehabilitation could pose significant challenges, particularly in resource-limited settings. To mitigate these concerns, it is important to clarify that the pedalboard is not intended for individual patient ownership but rather should be purchased and maintained by institutions or clinical settings, such as hospitals and research institutes, where patients would undergo training. Future research could investigate the feasibility of this institutional ownership approach. This strategy is anticipated to enhance accessibility and alleviate individual financial burdens, allowing the primary focus to remain on the clinical benefits of this rehabilitation tool.

The cultural context must be carefully considered when evaluating the adoption of the organ pedalboard as a rehabilitation tool. However, we did not discuss any cultural factors influencing its adoption during this exploratory study due to time constraints. In the Hong Kong settings where the study was conducted, the organ (pedalboard) is not a popular musical instrument. This lack of familiarity may create cultural barriers, as patients may prefer to work with instruments they are more accustomed to, such as the piano or traditional Chinese instruments. These cultural preferences could impact the effectiveness of the intervention, as patient engagement is closely linked to their comfort and familiarity with the therapeutic tools used. However, it is important not to make assumptions that patients would be unwilling to try the pedalboard. In fact, the novelty of this “new instrument” may actually create a sense of intrigue and interest, potentially facilitating greater patient engagement. The current unpopularity of the pedalboard might be due to factors such as its availability, personal interest, or lack of exposure and training, rather than inherent cultural aversions. We recommend that future research assess the potential effectiveness of integrating the organ pedalboard into rehabilitation settings under institutional ownership, along with the implementation of ’train-the-trainer’ programs for healthcare professionals. By offering the pedalboard as an option, patients can explore this unique tool as part of their rehabilitation, potentially enhancing their overall experience and outcomes. Importantly, future research should also explore patients’ perceptions, attitudes, and experiences with the organ pedalboard directly. Understanding the target population’s perspectives, preferences, and cultural considerations will be crucial in developing effective strategies for the successful integration of this rehabilitation tool.

The findings offer valuable insights, but they should be interpreted within Hong Kong’s sociocultural context. We believe that the findings of the study can also be applicable to the regions with sociocultural contexts similar to Hong Kong. Generalizability to communities with different cultural backgrounds or healthcare systems may be limited, as Hong Kong is a developed region where Western therapies are widely accepted. However, future research should explore the applicability in diverse cultural settings to better understand the broader potential and limitations of this approach. Such cross-cultural investigations will provide crucial insights into how the organ pedalboard intervention may need to be tailored or adapted to ensure its effectiveness and acceptability in varied settings.

Our study has the strength of having four different types of healthcare professionals involved. They provided detailed expert comments and opinions about the study topic comprehensively. A notable limitation is that the interview guide lacked pilot testing before implementation. This could have a missed chance to refine questions or structure, potentially affecting data quality and depth. Future studies should pilot the interview guide to identify and address issues prior to full data collection. Another limitation of the current study is the absence of comprehensive field notes taken by a dedicated note-taker during the interviews. While the researchers made brief notes throughout the discussions, these did not capture the level of detail and contextual observations that formal field notes would have provided. The lack of a dedicated note-taker may have resulted in the loss of valuable insights into the non-verbal cues, interactions, and nuances of the interview process. Meanwhile, member checking was not conducted due to time constraints. This may limit the ability to confirm whether our interpretations and findings accurately reflect participants’ viewpoints.

Other limitations are that we did not apply modifications to the organ accessories, such as chairs and lights for cueing, and pilot them on lower-limb patients.

We also did not gather voices and opinions from the perspectives of patients and organizations. While patients are the end-users, we are uncertain how they perceive this novel tool adopted in their rehabilitation. We are also concerned about the acceptability of policymakers regarding the use of musical instruments for rehabilitation purposes. In the future study, we aim to modify the organ accessories and software program and test its feasibility through a pilot study on patients with particular lower limb problems. We will also conduct qualitative studies, collecting the perceptions of patients, healthcare providers, and policymakers on the implementation and actual use of the tool (instrument) in rehabilitation settings.

Conclusion

Our study is the first to explore the feasibility of using a pedalboard as a rehabilitation tool. The introduction of the organ pedalboard as a rehabilitation tool presents a promising avenue for lower extremity rehabilitation. Its potential to improve the physical, cognitive, and psychosocial aspects of rehabilitation underscores its significance in the field of healthcare. However, further research and development are necessary to address safety concerns and program the pedalboard for rehabilitation. This will assist in the development of a lower extremity training protocol that can accommodate all the physiological hip, knee, ankle, and foot movements in the future.

Supporting information