Dance to Improve Mobility and
Reduce Falls
Marie McNeely, PhD
Instructor in Physical Therapy
and Neurology
Washington University in St. Louis
Locomotor Control Laboratory
Program in Physical Therapy
Disclosures
• No conflicts of interest to declare
Program in Physical Therapy
Outline
• The importance of being physically active
• Findings from dance studies
• Future directions for dance research
• Implementation of a dance program
Program in Physical Therapy
The State of Physical Activity in the U.S.
• 39.6 million people in the United States over the age of 65
in 2009, and this is expected to grow to 72.1 million by
2030 (19% of the population)1
• Approximately 60% of Americans over age 65 do not meet
physical activity recommendations2
• Physical activity is particularly reduced in people with
chronic conditions like Parkinson disease (PD)3,4
Program in Physical Therapy
Why Exercise?
• Improvements in
• Circulation
• Mood
• Lung capacity
• Cognition
• Muscle strength
• Stress response
• Energy
• Quality of life
• Self-esteem
• Neuroprotection
AND MORE!
Program in Physical Therapy
Why Exercise is Important for Older Adults
• Falls are a leading cause of morbidity and mortality in older
adults5-7, and exercise may prevent falls8
• Frailty may be delayed or reversed with exercise9
• Exercise is important for preventing and managing
diabetes, cardiovascular disease, and other health
conditions10,11
• Cognition function improves with exercise12,13
• Exercise improves measures of walking speed, time, and
distance, which are powerful predictors of mortality and
morbidity14
Program in Physical Therapy
Barriers to Exercise15,16
• Physical discomfort
• Fear of falling
• Comorbidities
• Competing priorities
• Lack of time
• Apathy
• Discomfort in social situations
• Dependence on an instructor
• Affordability
• Belief exercise is not needed
• Belief exercise would not be
beneficial
Program in Physical Therapy
Why Choose Dance?17
• Accessible
• Appealing
• Socially engaging
• Challenges balance
• Complex movements and multitasking
• Targets strength, flexibility, and endurance
• Task-specific training of difficult movements
• Includes music
• Supportive class environment
• Trained instructors
• Evidence supports a wide variety of benefits
Program in Physical Therapy
Dance Intervention Studies in Older Adults18,19
• Controlled studies have evaluated many dance styles
•
•
•
•
Tango
Salsa
Greek traditional
Caribbean
traditional
•
•
•
•
•
Thai traditional
Turkish folkloristic
Aerobic
Ballroom
Line
•
•
•
•
Creative
Contemporary
Adapted
Video game
• Program durations were 4 weeks – 18 months
• Sessions were 1 – 7 times per week for 10 – 90 minutes
Program in Physical Therapy
Dance Programs are Safe, Feasible, and Fun
• No adverse events or no increase in adverse events in
older adults, even in vulnerable populations such as
chronic heart failure20, stroke21, and Parkinson disease22-24
• “During the dance class, the participants did not want to
stop even if they were becoming fatigued.”21
• “Following 12 months of participation, 11 of the 16
individuals in the Tango group chose to continue attending
classes even though they had formally completed all study
requirements and were no longer expected to attend.”25
Program in Physical Therapy
Dance Improves Balance
•
•
•
•
Improved performance in clinical balance tests
Improved static balance and dynamic postural control
Increased balance confidence
Reduced falls
Single Limb Stance
40
35
Time (s)
30
25
20
Pre
15
Post
10
5
0
Aerobic Dance Wait List Control
Graph created with data from Hopkins et al. 1990.26
Program in Physical Therapy
Dance Improves Walking
Stride Length
200
200
180
180
160
160
140
140
120
100
80
1
0.8
100
80
60
40
40
20
20
0
1.2
120
60
0.6
Pre
Post
0.4
0.2
0
Salsa Dance No Intervention
Control
Stride Time
Time (s)
Length (cm)
Velocity (cm/s)
Stride Velocity
0
Salsa Dance
No Intervention
Control
Salsa Dance
No Intervention
Control
Graphs created with data from Granacher et al. 2012.27
Program in Physical Therapy
Dance Improves Endurance, Strength, & Flexibility
• Endurance
• Lower limb functional strength
• Flexibility
5x Sit to Stand
Sit and Reach
20
20
450
18
18
400
16
16
350
14
14
300
12
250
200
Distance (cm)
500
Time (s)
Distance (m)
6 Minute Walk Test
10
8
12
10
8
150
6
100
4
4
50
2
2
0
0
Thai Dance
Home Exercise
Instructions
Pre
Post
6
0
Thai Dance
Home Exercise
Instructions
Thai Dance
Home Exercise
Instructions
Graphs created with data from Janyacharoen et al. 2013.28
Program in Physical Therapy
Dance Improves Functional Mobility
Timed Up-and-Go
40
35
Time (sec)
30
25
20
Pre
15
Post
10
5
0
Ballroom Dance
RCF Activities Control
Graph created with data from Holmerova et al. 2010.29
Program in Physical Therapy
Dance Is
More Than a Movement Intervention
Program in Physical Therapy
Dance Improves Cognition
• Task-switching
• Attention
• Memory
• Visuospatial skills
• Reaction time
• Information processing
Scale of Elderly Cognitive
Function
Score (points)
140
120
100
80
Pre
60
Post - 6m
40
Post - 12m
20
Post - 18m
0
Square Dance
No Intervention
Control
Graph created with data from Zhang et al. 2014.30
Program in Physical Therapy
Dance Improves Mood
• Reduction in anger
• Reduction in depressive symptoms
• Improvements in anxiety
Geriatric Depression Scale
10
Score (points)
9
8
7
6
5
Pre
4
Post
3
2
1
0
Ballroom Dance
Wait List Control
Graph created with data from Vankova et al. 2014.31
Program in Physical Therapy
Dance Effects on Quality of Life
• Quality of life
•
•
General health
Physical functioning
•
•
Mental health
Body pain
• Life satisfaction
Score (points)
Quality of Life - Short Form Health Survey-36
120
120
120
120
Pre
100
100
100
100
Post
80
80
80
80
60
60
60
60
40
40
40
40
20
20
20
20
0
Turkish
No
folkloristic Intervention
Dance
Control
General health
0
Turkish
No
folkloristic Intervention
Dance
Control
Physical functioning
0
0
Turkish
No
folkloristic Intervention
Dance
Control
Mental Health
Turkish
folkloristic
Dance
No
Intervention
Control
Pain
Graph created with data from Eyigor et al. 2009.32
Program in Physical Therapy
Future Directions in Studying Dance
• Determine the ideal intervention parameters
•
•
•
•
Dance style
Frequency
Duration
Intensity
• Examine rates of acquisition and maintenance of benefits
• Direct comparisons between dance interventions
• Investigation of mechanisms of benefits
• Bringing these programs into the community and reaching
more people
Program in Physical Therapy
How Dance May Be Working
• Plasticity-related changes33
• Music may reduce stress and enhance social relationships34
Program in Physical Therapy
Current Dance Studies in Our Laboratory
• Exercise study comparing three different exercise types
and examining the neural mechanisms of benefits in
people with Parkinson disease
• Teletango study evaluating remote dance instruction in
people with Parkinson disease
Program in Physical Therapy
Considerations for Developing Dance Programs
• Who are your participants?
• Participant characteristics
• Special populations
• Satisfaction
• Safety/Risk
• Recruitment
Program in Physical Therapy
Considerations for Developing Dance Programs
• What are your goals for the class
• Aerobic benefits
• Improved movement and mobility
• Cognition
• Mood
• Community
• Social support
Program in Physical Therapy
Considerations for Developing Dance Programs
• Who will teach and assist with classes?
• Instructors
• Staff
• Volunteers
• Family members
Program in Physical Therapy
Considerations for Developing Dance Programs
• Where and will the classes take place?
• Space/facilities
• Accessibility
Program in Physical Therapy
Considerations for Developing Dance Programs
• When and will the classes take place?
• Frequency of classes
• Duration of classes
• Duration of program
Program in Physical Therapy
Considerations for Developing Dance Programs
• How will the classes be conducted?
• Size
• Music
• Syllabus/Content
• Pace
• Progression
• Adaptability
Program in Physical Therapy
Case Study: Adapted Tango35
• Developed for Parkinson disease and older adults
• Composed of simple step elements
• Movement initiation and cessation
• Multi-directional perturbations
• Varied speeds and rhythms
• Focus on
• Foot placement
• Whole body coordination
• Attention to partner
•
• Path of movement
• Aesthetics
Successfully implemented in the community
• participants 36-95 years old
Program in Physical Therapy
Summary: Why to Consider a Dance Program?
• Provides exercise
• Wide range of benefits for health and well-being
• Feasibility of implementing high-quality programs in a
community setting
Program in Physical Therapy
References
1) A.f.C.L. U.S. Department of Health and Human Services, "Administration on Aging (AoA) Aging Statistics,"
http://www.aoa.acl.gov/Aging_Statistics/index.aspx.
2) C.A. Macera, S.A. Ham, M.M. Yore, et al., "Prevalence of physical activity in the United States: Behavioral Risk Factor Surveillance
System, 2001," Prev Chronic Dis, vol. 2, no. 2, p. A17, 2005.
3) M. van Nimwegen, A.D. Speelman, E.J. Hofman-van Rossum, et al., "Physical inactivity in Parkinson's disease," J Neurol, vol. 258, no.
12, pp. 2214-2221, 2011.
4) L. Rochester, D. Jones, V. Hetherington, et al., "Gait and gait-related activities and fatigue in Parkinson's disease: what is the
relationship?," Disabil Rehabil, vol. 28, no. 22, pp. 1365-1371, 2006.
5) R.A. Kenny, L.Z. Rubenstein, M.E. Tinetti, et al. “AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons.” J Am
Geriatr Soc 59(1):148-57. 2011.
6) S. Deandrea, E. Lucenteforte, F. Bravi, R. Foschi, C. La Vecchia, and E. Negri, "Risk factors for falls in community-dwelling older
people: a systematic review and meta-analysis," Epidemiology, vol. 21, no. 5, pp. 658-668, 2010.
7) B. Stubbs, T. Binnekade, L. Eggermont, A.A. Sepehry, S. Patchay, and P. Schofield, "Pain and the risk for falls in community-dwelling
older adults: systematic review and meta-analysis," Arch Phys Med Rehabil, vol. 95, no. 1, pp. 175-187 e179, 2014.
8) C. Sherrington, A. Tiedemann, N. Fairhall, et al.Exercise to prevent falls in older adults: an updated meta-analysis and best practice
recommendations NSW Public Health Bull, 22 (3–4) (2011), pp. 78–83
9) J.P. Michel, A.J. Cruz-Jentoft, and T. Cederholm, "Frailty, Exercise and Nutrition," Clin Geriatr Med, vol. 31, no. 3, pp. 375-387, 2015.
10) A.H. Abdelhafiz and A.J. Sinclair, "Diabetes, Nutrition, and Exercise," Clin Geriatr Med, vol. 31, no. 3, pp. 439-451, 2015.
11) P.D. Neufer, M.M. Bamman, D.M. Muoio, et al., "Understanding the Cellular and Molecular Mechanisms of Physical Activity-Induced
Health Benefits," Cell Metab, vol. 22, no. 1, pp. 4-11, 2015.
12) J. Rodakowski, E. Saghafi, M.A. Butters, and E.R. Skidmore, "Non-pharmacological interventions for adults with mild cognitive
impairment and early stage dementia: An updated scoping review," Mol Aspects Med, 2015.
13) S. Ballesteros, E. Kraft, S. Santana, and C. Tziraki, "Maintaining older brain functionality: A targeted review," Neurosci Biobehav Rev,
vol. 55, pp. 453-477, 2015.
14) B.A. Franklin, J. Brinks, R. Sacks, J. Trivax, and H. Friedman, "Reduced Walking Speed and Distance as Harbingers of the Approaching
Grim Reaper," Am J Cardiol, vol. 116, no. 2, pp. 313-317, 2015.
15) M.R. Franco, A. Tong, K. Howard, et al., "Older people's perspectives on participation in physical activity: a systematic review and
thematic synthesis of qualitative literature," Br J Sports Med, 2015.
16) T. Ellis, J.K. Boudreau, T.R. DeAngelis, et al., "Barriers to exercise in people with Parkinson disease," Phys Ther, vol. 93, no. 5, pp.
628-636, 2013.
17) G.M. Earhart, "Dance as therapy for individuals with Parkinson disease," Eur J Phys Rehabil Med, vol. 45, no. 2, pp. 231-238, 2009.
18) M.E. McNeely, R.P. Duncan, and G.M. Earhart, "A comparison of dance interventions in people with Parkinson disease and older
adults," Maturitas, 2015.
Program in Physical Therapy
References
19) M.E. McNeely, R.P. Duncan, and G.M. Earhart, “Impacts of dance on non-motor symptoms, participation, and quality of life in
Parkinson disease and healthy older adults,” Maturitas, In press.
20) M. Gomes Neto, M.A. Menezes, and V. Oliveira Carvalho, "Dance therapy in patients with chronic heart failure: a systematic review
and a meta-analysis," Clin Rehabil, vol. 28, no. 12, pp. 1172-1179, 2014.
21) M. Demers and P. McKinley, "Feasibility of delivering a dance intervention for subacute stroke in a rehabilitation hospital setting," Int J
Environ Res Public Health, vol. 12, no. 3, pp. 3120-3132, 2015.
22) L.M. Blandy, W.A. Beevers, K. Fitzmaurice, and M.E. Morris, "Therapeutic Argentine Tango Dancing for People with Mild Parkinson's
Disease: A Feasibility Study," Front Neurol, vol. 6, p. 122, 2015.
23) S. Rios Romenets, J. Anang, S.M. Fereshtehnejad, A. Pelletier, and R. Postuma, "Tango for treatment of motor and non-motor
manifestations in Parkinson's disease: a randomized control study," Complement Ther Med, vol. 23, no. 2, pp. 175-184, 2015.
24) D. Volpe, M. Signorini, A. Marchetto, T. Lynch, and M.E. Morris, "A comparison of Irish set dancing and exercises for people with
Parkinson's disease: a phase II feasibility study," BMC Geriatr, vol. 13, p. 54, 2013.
25) R.P. Duncan and G.M. Earhart, "Randomized controlled trial of community-based dancing to modify disease progression in Parkinson
disease," Neurorehabil Neural Repair, vol. 26, no. 2, pp. 132-143, 2012.
26) D.R. Hopkins, B. Murrah, W.W. Hoeger, and R.C. Rhodes, "Effect of low-impact aerobic dance on the functional fitness of elderly
women," Gerontologist, vol. 30, no. 2, pp. 189-192, 1990.
27) U. Granacher, T. Muehlbauer, S.A. Bridenbaugh, et al., "Effects of a salsa dance training on balance and strength performance in older
adults," Gerontology, vol. 58, no. 4, pp. 305-312, 2012.
28) T. Janyacharoen, M. Laophosri, J. Kanpittaya, P. Auvichayapat, and K. Sawanyawisuth, "Physical performance in recently aged adults
after 6 weeks traditional Thai dance: a randomized controlled trial," Clin Interv Aging, vol. 8, pp. 855-859, 2013.
29) I. Holmerova, K. Machacova, H. Vankova, et al., "Effect of the Exercise Dance for Seniors (EXDASE) program on lower-body
functioning among institutionalized older adults," J Aging Health, vol. 22, no. 1, pp. 106-119, 2010.
30) X. Zhang, X. Ni, and P. Chen, "Study about the effects of different fitness sports on cognitive function and emotion of the aged," Cell
Biochem Biophys, vol. 70, no. 3, pp. 1591-1596, 2014.
31) H. Vankova, I. Holmerova, K. Machacova, L. Volicer, P. Veleta, and A.M. Celko, "The effect of dance on depressive symptoms in
nursing home residents," J Am Med Dir Assoc, vol. 15, no. 8, pp. 582-587, 2014.
32) S. Eyigor, H. Karapolat, B. Durmaz, U. Ibisoglu, and S. Cakir, "A randomized controlled trial of Turkish folklore dance on the physical
performance, balance, depression and quality of life in older women," Arch Gerontol Geriatr, vol. 48, no. 1, pp. 84-88, 2009.
33) M.A. Hirsch and B.G. Farley, "Exercise and neuroplasticity in persons living with Parkinson's disease," Eur J Phys Rehabil Med, vol. 45,
no. 2, pp. 215-229, 2009.
34) M. Boso, P. Politi, F. Barale, and E. Enzo, "Neurophysiology and neurobiology of the musical experience," Funct Neurol, vol. 21, no. 4,
pp. 187-191, 2006.
35) M. Hackney and K. McKee, "Community-based adapted tango dancing for individuals with Parkinson's disease and older adults," J Vis
Exp, no. 94, 2014.
Program in Physical Therapy
Questions?
Program in Physical Therapy