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AbstractAlthough preliminary evidence supports the psychophysical benefits of dance for adults withParkinson disease, guidelines for community-based dance programs await further scrutiny for safetyand efficacy. This pilot study was designed to assess the feasibility of an intensive trial of group-delivered modern dance for 11 adults with early-to-middle stage Parkinson’s. The Timed ‘‘Up andGo’’ test and the Fullerton Advanced Balance scale were administered to assess balance safety andre-administered at closure along with a self-reported feedback questionnaire. Video recordingswere analyzed for qualitative behavioral change. Pre/posttest comparisons from the Timed ‘‘Up andGo’’ test were not significant, while those from the Fullerton Advanced Balance Scale were signifi-cant at the .05 level for the group as a whole (p ¼ .01) with an average score change of þ3.1 points. Although qualitative results generally concurred with the social benefits associated with an enjoyableform of expressive exercise, important indicators surfaced bearing on future research and commu-nity program designs. These include need for more rigorous stratification of participants and adapt-ing dance class structure to address specific group needs to promote motor learning for sustainedfunctional gains.
Keywordsparkinson, dance, feasibility, balance
Each year, 114.7 adults per 100,000 between the ages of 50 and 99 are diagnosed with degenerative,idiopathic Parkinson disease (Bower, Maraganore, McDonnell, & Rocca, 1999). Clinical signs ofParkinson disease (PD) manifest as bradykinesia, rigidity, resting tremor, freezing episodes, andpostural instability (Morris, Iansek, Summers, & Matyas, 1995). Weak and inflexible posturalresponses and stereotypical movement patterns such as shuffling steps and reduced foot clearance
at swing in gait are associated with high risk of falls (Bloem et al., 2004; King & Horak, 2009; Kim,Horak, Carson-Kuhta, & Park, 2009). As the disease advances, moving spontaneously becomesprogressively more difficult. Movements become slower and halted and are marked by episodes
1 Department of Physical Therapy, Human Performance & Biodynamics Laboratory, Winston-Salem State University,Winston-Salem, NC, USA
Corresponding Author:Glenna Batson, Winston-Salem State University, 601 Martin Luther King Jr Drive, Winston-Salem, NC 27110, USAEmail: email@example.com
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of freezing and other abnormal movements. Robbed of spontaneous expression of normal movementamplitude and timing, persons become habituated to progressively smaller spheres of activity andnonuse (Hirsch, 2009). These deficits lead to forced reliance on conscious attention and cognitivecontrol strategies to sustain the flow of the simplest of automatic everyday actions, such assitting-to-standing, walking, and turning (Smith & Batson, 2010).
Although both the etiology of PD (Olanow & Tatton, 1999) and its cure (Nieuwboer, De Weerdt,
Dom, & Lesaffre, 1998) appear elusive, the more promising non-pharmacological (or nonsurgical)treatments for improving postural stability are those that challenge dynamic balance by demandingcontinual adjustment to changing environmental contexts (Hirsch, Toole, Maitland, & Rider, 2003). Such an overall goal for exercise—especially for people with neurological impairments—should beto provide an environment conducive to solving motor problems leading to acquisition, retention,and transfer of functional capabilities similar to the functional demands of everyday life (Hirsch,2009). Evidence-based examples purporting to test such an approach include Tai Chi (Li et al.,2007) and treadmill aerobic exercise (Skidmore, Patterson, Shulman, Sorkin, & Macko, 2008).
Recently, dance has shown promise as a rhythmic, enjoyable, social, and cost-effective intervention
that helps adults with PD improve mobility and balance, as well as enhance cognitive and psychological
performance (Hackney & Earhart, 2010; Hackney, Kantorovich, & Earhart, 2007; Westheimer, 2008). Dance is ‘‘human behavior composed of purposeful, intentionally rhythmical, and culturally influ-enced sequences of nonverbal body movements and stillness in time and space and with effort’’(Hanna, 2008, p. 492). Modern dance is a subset of 20th-century Western classical dance, whichconstitutes a form of nonverbal communication through bodily gesture. ‘‘Dancers declare or makevisible, thoughts, ideas, and images through patterns of movement and stillness of their body’’(Stevens & McKechnie, 2005, p. 249). Such nonverbal communication occurs through at least threeintersecting ways: (a) action observation—direct perception and experience of physical motion ofthe whole moving body and facial expression through neural mirroring and kinesthetic resonance(Gallese, 2007); (b) recognition and recall of patterns and structures, which call upon both declara-tive and procedural learning (Stevens & McKechnie, 2005); and (c) rhythm as an aid to learning andguiding motor coordination.
Attending to the body as it moves through space enhances motor learning (Baker et al., 2007).
Challenging perception of spatial relations and exploring movement range, allegedly strengthensneural connections in brain regions representing the body schema (Haggard & Wolpert, 2005). Many natural, complex sensorimotor activities (e.g., sports, leisure activities, and select physicaloccupations) also involve integration of spatial patterning, rhythmic synchronization, and coordina-
tion of the whole body (Brown, Martinez, & Parsons, 2006). Although modern dance contains move-ments that could also be called ‘‘functional’’ or task-specific (e.g., bending, walking, and reaching),it is distinguished from both functional and athletic activities in that the ‘‘goal’’ of movement is thedeliberate and purposeful expression of the body itself through movement (Longstaff, 2000; Stevens& McKechnie, 2005).
The therapeutic value of dance has been established for elderly populations (Hui, Chui, & Woo,
2009). Older adults who dance have shown improvements in balance, functional mobility, and moti-vation to choose healthier, more active behaviors (Song, June, Kim, & Jeon, 2004; McKinley et al.,2008). At the same time, dance differs from other complementary therapies in its use of improvisa-tion, musical accompaniment, partnering (intentional touch to lead and follow in movement),
and progression of complexity of coordinative structures (Hackney & Earhart, 2010; Stevens &Mckechnie, 2005).
Although initial reports of the benefits of dance for this population are promising (Earhart, 2009),
moving toward standardized practice guidelines is challenging. PD-related associations endorsecommunity-based programs or commercial videos on their websites, but none of these programs
or tools have been rigorously tested for feasibility, safety, or efficacy (Hirsh, 2009). Exercise
prescriptions of any kind for persons with PD need to take into account multiple intrinsic andextrinsic variables. Participant satisfaction and enjoyment in exercise (O’Brien, Dodd, & Bilney,2008) and in dance classes (Hackney & Earhart, 2010) have been well documented. Yet, issuesaffecting on feasibility such as compliance, teacher-to-participant ratio, group familiarity (with othergroup members as well as with exercise mode), safety in movement choices to reduce fall risk, andlong-term effects on functional and behavioral status, also must be investigated more thoroughly.
This pilot study primarily was designed to assess the feasibility and safety of group delivery of an
intensive trial of modern dance on mobility and balance in adults with early-to-middle stage PD. Feasibility is defined as adherence, cost, ease of attendance and participation, level of risk (adverseoccurrences such as falls or other medical episodes), and potential for long-term follow-up eitherindividually or as a group. A second aim was to explore the value of quantitative measures ofbalance heretofore not researched in studies on dance and PD and to examine qualitative data fortrends toward physical and behavioral change. Such prospective data would assist in designingfuture research on dance protocols that would meet the specific needs of this population. Given thebrief, intense intervention, the research team speculated that the participants would participate fullywithout adverse incidents and that trends toward functional gains would be evident in qualitativeobservation and on select balance measures.
This pilot research (quasi-experimental, single group pretest–posttest) was approved by the Institu-tional Review Board at Winston-Salem State University (WSSU). The study received funding froma Research Initiation Grant awarded by the WSSU Graduate School.
Eligibility included adults between 50 and 85 years old, diagnosed primarily with idiopathic PD,who were dwelling independently in the community and who required minimal assistance in trans-fers and ambulation. Excluded were those diagnosed with additional neurological disorders, historyof head trauma, and cognitive or hearing impairments that would interfere with hearing music and/orhearing or following verbal instructions.
Recruitment proved challenging. Although 28 PD support groups exist in the state of North Car-
olina, this was the first time in the state that research involving a dance protocol was offered to thispopulation. Although there is national recognition of the potential benefits of dance for people with
PD (Westheimer, 2008), little knowledge of these purported benefits had filtered down to the med-ical or lay communities in the region. Due to a variety of reasons, the study had to be rescheduledand relocated several times to recruit a reasonable sample of participants. A convenience sampleultimately was recruited from a wellness center affiliated with a teaching hospital in North Carolina. The wellness center attracted a large number of people with PD, who routinely exercised and/orreceived outpatient therapy, including participating in the ‘‘Big and Loud’’ program run by the staffspeech and physical therapists (LSVTGlobal1, 2010). Located in a shopping mall with free parking,the center provided easy access for a relatively homogeneous sample of active, independent,community-dwelling adults with PD, most of whom already had bonded socially.
Twelve prospective participants met the eligibility criteria and obtained their doctor’s clearance
to participate. One participant cancelled prior to intake testing due to complaints of hot weather. Thestudy was offered free of charge, with a $50 honorarium promised to those completing at least twothirds of the dance classes and the posttest session. The final group of eligible participants included11 adults (5 males and 6 females, mean age 72.7 + 8.7) with early-to-middle stage Parkinsondisease (Hoehn & Yahr score of 1–2.5). All participants were within 1–6 years of diagnosis of
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Table 1. Demographics of Adults with Parkinson Disease in a Modern Dance Class
Note. Dx Yr ¼ Year of diagnosis, MMSE ¼ Mini-Mental State Exam score, MFES ¼ Modified Falls Efficacy Scale (balance confidencescore), Falls ¼ within the last year, freezing episodes, trouble with turning, previous dance training (yes ¼ ballroom only).
idiopathic PD, except one person with non-idiopathic PD. Seventy-five percent had fallen at leastonce in the last year. (See Table 1, for demographic information about the study sample.) Prior tostudy enrollment, most reported overall good health and pursued an active lifestyle of exercise,leisure, and support group activities. Participants were allowed to continue all current activitiesbut were asked not to enroll in any new activities during the study. None of the subjects had previousexperience with modern dance but the two oldest male participants practiced ballroom dance.
At intake, the study coordinator requested that all participants sign informed consent. Additionally,all were requested to complete a medical questionnaire on current and past medical history, fallhistory, freezing episodes, and basic problems with mobility in activities of daily living. Thoseexpressing difficulty in filling out the forms independently could receive the help of a proxy. Threeparticipants required help from their spouses one due to general movement slowness with hypophoniaand hypokinetic speech and two needed help recalling the number and type of prescribed medicationsthey were currently taking.
At intake, the Mini-Mental State Exam (MMSE; Folstein, Folstein, & McHugh, 1975) served as abasic screen of cognitive status for safety. This brief cognitive screening test helped establishwhether potential participants were oriented and able to hear, comprehend, follow, and remembertwo- and three-step commands. A more rigorous cutoff point on the MMSE has been suggestedto detect cognitive deficits (27 of the 30 points, rather than 23–24, established in the original instru-ment; Jefferson et al., 2002). In the current study, none of the participants scored less than 29 of the30 points (Table1), indicating no significant cognitive impairment that alone would jeopardize theirability to participate. The Modified Falls Efficacy Scale (MFES) also was administered as a baselinefor balance confidence (Tinetti, 1986). The MFES is a self-reported scale of 14 items, in which per-sons rate their balance confidence on a scale from 1 (lowest perceived confidence) to 10 (highest) inperforming simple activities of daily living (e.g., walking around the house, walking outside, andcooking). Subjects averaged 8.3 (+1.2), out of a possible 10 points across all 14 items, indicating
good ability to conduct themselves independently in daily activities without assistance or fear of fall-ing (Tinetti, 1986). Determinants of balance confidence and the relationship between balance con-fidence and fall risk are conjectural in people with PD (Mak & Pang, 2009). Nonetheless,administering the MFES helped establish a relative baseline of perceived confidence in daily navi-gation in this group.
Selected measures of balance were administered by two community-based, licensed physical thera-pists with at least 5 years of clinical experience. The physical therapist testers were blind to the ulti-mate aims and outcomes of the study, as well as the movement choices in the dance protocol. Beforeintake screening or testing began, both therapists underwent a 4-hr training session at the testing siteon the mechanics of test administration to ensure standardization and reliability in the testing pro-cedures, as well as emergency procedures to ensure safety.
Selection of balance measures was based on evidence suggesting that no one clinical test is suf-
ficient to fully assess postural stability in this population (Brusse, Zimdars, Zalewski, & Steffen,2005). Two measures were selected on the basis of their clinical utility and comprehensiveness,as well as their validity, sensitivity, cost-effectiveness, and prospective use in future research: (a)the Timed ‘‘Up and Go’’(TUG; Nordin, Rosendahl, & Lundin-Olssen, 2006) and (b) the FullertonAdvance Balance Scale (FAB; Rose, Lucchese, & Wiersma, 2006). The physical therapists adminis-tered the TUG and the FAB across two time periods: first, at intake (along with the MMSE), toobjectively assess participants’ ability to participate safely in an active dance exercise class, andagain within 1 day of the conclusion of the study (posttest). Subsequent pretest–posttest comparisonswere analyzed for trends toward change in balance and mobility in prospectively designing futureresearch. Although statistically significant pre–post differences were not anticipated for either test,the study coordinator speculated that pretest–posttest comparisons on these objective tests wouldshow a trend toward improvement in balance and that video analysis would show discrete alterationsin coordination not commonly captured by clinical tests (Haggard, 1997).
The TUG is a timed test (in seconds) of movement efficiency and is an indirect measure of func-
tional balance and fall risk (Shumway-Cook, Brauer, & Woollacott, 2000). Participants stand upfrom a chair (with arms), walk 3 m at a comfortable pace, turn around to walk back to the chair, andsit down. A TUG score of 13.5 s or longer is predictive of a 90% risk for falls (Shumway-Cook et al.,2000; Morris, Morris, & Iansek, 2001). Here, freezing or episodes of postural instability (near fallsand actual falls) were tracked.
The FAB is a 10-item ordinal scale of dynamic balance designed to reveal possible functional
limitations in visual, somatosensory, and vestibular sensory systems as well as neuro-musculo-skeletal limitations (Rose et al., 2006). The FAB combines elements of several standardized balancetests, such as standing together with eyes closed, turning 360, and functional reach (Berg BalanceScale; Berg, Wood-Dauphinee, Williams, & Maki, 1992), standing on foam with eyes closed (Clin-ical Test of Sensory Interaction on Balance; Shumway-Cook & Horak, 1986), walking with headturns (Dynamic Gait Index; Marchetti & Whitney, 2006), and reactive postural adjustment (Push andRelease Test; Jacobs, Horak, Tran, & Nutt, 2006). Elderly persons who score 25 points or lower (outof a possible 40 points) are deemed at high risk for falls (Hernandez & Rose, 2008).
Both testing sessions took place in the same room as the dance classes and conditions were
kept consistent across time periods. As per standardized guidelines for each test, a mean of twotrials for the TUG was recorded, along with one trial of the 10 items in the FAB. All tests anddance class sessions were video recorded with a camera stationed on a tripod in one corner of theroom.
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Feasibility was assessed by compliance (attendance), attrition rate, administration requirements andcosts, incidence of adverse events, and responses to participation on the feedback questionnaire. Compliance was defined as daily program attendance and was calculated by dividing the numberof person-sessions missed by total person-sessions. Administration requirements included spaceallocation, access to the therapy site, transportation, and personnel costs required to administer thestudy. Adverse events were defined as falls or abnormal physiological responses to exercise, such assyncope, diaphoresis, or long-term muscle pain as monitored by the study coordinator, the danceteacher, and/or the participant himself or herself, or the caregiver. Caregivers also were invited toparticipate as desired but their personal responses to the study were not considered as data.
A large 30 square feet multipurpose room at the back of the wellness facility was offered free ofcharge to the study coordinator. The room was well lit, with adjustable temperature controls for com-fort. The room had no mirrors and the door could be closed for privacy. Stackable, cushioned chairswith armrests were placed in a large open circle to start the class, with other chairs placed at theperimeter of the room for resting as needed. Participants were instructed to wear comfortable cloth-ing and closed-toed, nonslippery or sticky shoes to facilitate ease of movement on the thin industrialcarpet. Caregivers were invited to participate actively in the class but were asked to refrain frommerely observing to allow for those persons with PD to participate freely without scrutiny. All per-sons were asked to participate during the ‘‘on’’ phase of their medication regimen during testing andclass sessions.
The dance classes began 3 days after the second baseline test. The 3-week training schedule con-
sisted of nine classes, scheduled each Tuesday, Wednesday, and Thursday of 3 consecutive weeks. Each class was 85 min in length for a total of approximately 11 hr of instruction. Trained health carepersonnel, water and juice, and bathroom facilities were in close proximity at all times.
A dance teacher with 35 years of teaching experience was hired to teach all classes. Although the
teacher had no prior experience teaching movement to this population, she had extensive experienceteaching movement classes to the well elderly. She was selected not only on the basis of the length ofher teaching experience (mostly at the college level) but also for her knowledge and expertise inteaching older populations fitness classes, modern dance, and folk dance. The teacher was counseledin advance by the study coordinator only on issues of safety in movement choices, such as the needto avoid abrupt transitional movements in standing, and excessive or abrupt movements of the headand neck. Choices for movement content, sequencing, pacing, and musical accompaniment wereentirely drawn from previous experience with the elderly and from observing commercial tapesof exercise classes endorsed by Parkinson disease associations.
The teacher’s rationale for her method was to use three specific modern dance constructs:
(a) awakening and augmenting participants’ sensory perception of their whole body moving witha clear sense of direction through space; (b) maximizing balance perturbations within margins ofsafety; and (c) maximizing a sense of personal efficacy (what the teacher referred to as encouraging‘‘permission to move’’). This latter construct implied challenging participants’ capacity to moveautonomously by improvisational problem solving, rather than merely imitating the teacher. Eachclass was taught with compact discs and taped music consisting of mixed instrumental tunes selectedto complement movement choices. The dance movements mimicked many functional movementscommon to everyday life (walking with swinging arms, bending, and reaching) but were not task-specific. These functional movements, when taught within a dance context, demand more randombalance perturbations and challenge a wider range of motion and variety of dynamics not readily
encountered in daily living. Many of the elements practiced were conducive to motor learning, suchas repetition with variation, part- and whole body coordinated activities, memory and recall, andmental practice of motor imagery (Schmidt & Lee, 2005).
The class was divided into three parts. These three parts progressed from more static activities in
sitting to more dynamic movements both in static standing and crossing the floor in linear and curvi-linear weaving patterns. Part one of the class included a relatively fast, energetic 7- to 10-min warm-up in the chair that emphasized awakening sensory awareness and orienting to the whole movingbody. The teacher spoke loudly, clearly, and authoritatively, so that her verbal guidance could serveas an auditory cue (in addition to the music) in helping participants coordinate breathing with rhyth-mic movement. The teacher’s intentional physical demonstrations also helped reinforce movementlearning and coordination through ample use of visual and verbal cueing. Using words rich in visualand kinesthetic imagery interspersed with counting, the teacher explored three basic movements insitting: slow, sequential, and rhythmic flexion, extension, and rotation of the spine, leg movementsin alternating rhythmic patterns (e.g., marching, Charleston, etc.), and reaching with the arms nearand beyond the base of support. Improvisation was introduced during the chair exercise segment, inwhich the teacher asked for volunteers to create a movement, until three or four movements wereoffered. These gestures were woven into a sequential ‘‘dance.’’
Part two of the class consisted of approximately 30 min of standing and ambulating activities. The
teacher advanced the pace to the level of a low aerobic effort. Participants needed simultaneously tobe mindful not only of their own body movement but of others moving quickly in the group in closeproximity to one another. Lower limb movements were kept simple and functional (free of synco-pated steps). Rather, the teacher emphasized and exploited moving spatial relationships, such as lin-ear, diagonal, and random walking pathways in which participants could practice weaving in and outof the line of progression. The weaving not only was designed to challenge balance but also to facil-itate affect through social interaction. The level of complexity of coordination increased when theteacher asked participants to coordinate the arm movements they had learned in the chair with var-ious walking patterns. This portion of the class also exploited large range trunk and upper bodymovements. Smaller-to-larger body and arm movements were performed in cardinal, diagonal, andrandom spatial pathways with variations in muscular effort (e.g., ‘‘flicking,’’ ‘‘pushing,’’ and‘‘slicing’’ with the arms). Hands-on assistance was kept to a minimum throughout the class unlessa participant appeared at risk of physical harm to self or others. The teacher was alert to changing theclass pace when individuals appeared at risk for fatigue, falling, or other potentially adverse events.
Part three of the class involved an additional 15–20 min of small group improvisation. For exam-
ple, standing in place, participants would invent ‘‘hand dances’’ where one hand ‘‘had a conversa-tion’’ with the other hand. Participants were guided first to ‘‘chatter’’ (quick and small movements)from one hand to another or to ‘‘yawn’’ (big and slow movements). The hand dances graduallyevolved into creative improvised ‘‘conversation’’ among two to four other group members. The last8–10 min of the class involved a slower paced cooldown period that transitioned back to sitting andresting. Participants often stayed 10–15 min after the class ended to socialize and share experiences. At the conclusion of the 3-week study, all participants were given a self-reported feedback question-naire to complete overnight and submit when they returned the next day by appointment for thebalance posttesting session.
SPSS Version 7.0 and Excel 2003 were used to analyze statistics from the FAB, the TUG, and basicdescriptive intake data. Significance for parametric and nonparametric statistics was set at p ¼ .05
(Portney & Watkins, 2008). A Canon 2R65 digital video camcorder was used to record testing andclass sessions. These data were analyzed by the study coordinator and by an objective physical
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therapist observer not connected with the study. Results from items on the feedback questionnaire(Appendix 1) were collated and averaged.
All 11 participants completed the study, both pre- and post-study sessions, and the feedback ques-tionnaire. No adverse events occurred within the class time or nor were noted secondarily to linger-ing effects of the class. The class series was delivered at a low cost of $720, inclusive of dancerteacher’s fee and refreshments. Feedback results from the questionnaire indicated overall satisfac-tion with having attended the class series but select problems were acknowledged with regard toclass pacing and select movement choices.
Pre/posttest comparisons from the Timed ‘‘Up and Go’’ test were not significant (Table 2); Pre/postt-est comparisons from the Fullerton Advanced Balance Scale were significant at the .05 level for thegroup as a whole (p ¼ .01) with an average change in score of þ3.1 points (Table 3).
The primary purpose of this study was to determine the feasibility of modern dance for a small sample ofadults with PD. Although general guidelines exist on appropriate modes of exercise for persons withneurodegenerative diseases, little research has been conducted on the impact of specific componentsof exercise on either short- or long-term mobility in PD (King & Horak, 2009). A second aim, therefore,was to examine both quantitative and qualitative data to help design protocols for prospective studies.
Initial evidence of feasibility in this study is seen in the high level of compliance (attendance), lackof attrition or adverse events, cost-effectiveness, and overall satisfaction and social benefits of
Table 2. Pre- and Posttest Scores on the Timed ‘‘Up and Go’’ Test of Participants With Parkinson Disease in aModern Dance Class
Note. Time in seconds. Minus (À) indicates increased speed (faster performance); Plus (þ) indicates slower speed.
Table 3. Pre- and Posttest Total Scores on the Fullerton Advanced Balance Scale of Participants With Parkin-son Disease in a Modern Dance Class
Note. Pre-study and post-study totals. Top score ¼ 40 points < 25 ¼ 90% fall risk.
participation. Each of these elements will be discussed in turn. Attendance was 91% (n ¼ 11). Oneparticipant joined during the second week of the study but participated fully during the second 2weeks. Another fell at home during the second week and missed four classes midway through thestudy, but attended all remaining sessions, including posttesting. Compliance was 100% for theremaining nine subjects. By the conclusion of the study, most of the participants had forgotten aboutthe prospective $50 gift card honorarium, making it unlikely that this gift constituted an inducementto attendance. The group as a whole was able to sustain attention and follow verbal and musical cue-ing for up to 40 min of progressively complex movements. Rarely did any group members sit out dueto apparent fatigue, pain, or inability to follow.
Total cost of the program was $$720 (inclusive of a $700 fee paid to the dance teacher and $20 for
refreshments. Additional research expenses that would not be budgeted for in a routine communitydance class, included $3600 total paid to the 2 licensed physical therapists for administering the tests,a $50 honorarium offered to each of the 11 participants who completed the study, $100 expenses forthe study coordinator for gas and incidentals, and $60 for recording materials (camcorder mini-tapesand DVDs). The wellness facility space was offered free as a service to the community.
Dynamic balance depends on integration of multi-sensory input, flexible attention (ability to dual-and multi-task), and quick reactive responses to changes in direction and environmental surfaces(King & Horak, 2009). All these are challenged in dance through rapid internal and external pertur-bations with a variety of muscular dynamics and speeds. Participants in this study did not appearto gain in movement efficiency. Pre/posttesting results from the Timed ‘‘Up and Go’’ test werenonsignificant for the group (n ¼ 11; Table 2). Nor was there a trend toward significance. Averagepre- and post-study scores comparatively were 13.9 s (+4.8) and 13.1 s (+ 4.7), respectively. Although movement performance was faster for the group as a whole (9 of the 11 participants), mostparticipants scored within 1–2 s of their pretest value, possibly indicating a learning effect more thanan actual functional gain. Two participants (205 and 209) scored higher (i.e., an increase in seconds,indicating a subsequent decrease in gait speed). The increase in speed (slower performance) for par-ticipant 205 (8.9 s pre vs. 11.1 post), possibly was due to persistent leg pain secondary to falling at
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home several days earlier. For undetermined reasons, participant 209’s posttest scores were sloweron the TUG (18.4 pre- vs. 22.8 s post) as well as on the FAB (a score of 19 pre vs. 16 post; Tables 2and 3). Meaningful change in the TUG has been established (a decrease of 4.09 s) for those withAlzheimer disease (Ries, Echternach, Nof, & Blodgett, 2009) but not for Parkinson disease. Twoparticipants approached ta posttest value of over 3.5 s (Table 2), participants 208 and 202. Partici-pant 208 was the youngest and fittest of the male participants. Conversely, participant 202 was themost impaired in terms of bradykinesia and masked facies. Her posttest TUG score decreased bynearly 4 s, implying increased movement efficiency. Qualitatively, she appeared to show significantgains in her affect, physical and facial expressiveness, and her ability to move and coordinate com-plex movements.
In general, this group of participants appeared to be at a lower functional level than the group with
PD researched in a study on tango (Hackney et al., 2007). The group was slower on average on theTUG at baseline than the experimental tango group (10.7 + 0.4 s pre and 9.8 + 0.4 s post) reportedby Hackney et al. For this group of persons with PD, self-reported number of falls over the last yearand pretest FAB scores suggested a higher risk of falling for more than half of the group. Mean timeon the TUG among the elderly has been reported as higher for those at risk for falling (11.1 vs. 13.0 sfor male non-fallers vs. fallers and 13.0 vs. 13.9 for female; Thrane, Joakimsen, & Thornquist,2007). Although reaction times of persons with PD generally have been shown to decrease (i.e.,movement gets faster) when cues are externally cued (rather than self-initiated; Ballanger et al.,
2006; Siegert et al., 2002), low power and inadequate dosage renders the results of this study insuf-ficient to interpret significance.
Results on the Fullerton Advanced Balance Scale were significant at the .05 level for the group as
a whole (p ¼ .01) with an average change in score of þ3.1 points (Table 3). Of note is that at intake,half of the participants scored at or lower than the baseline score of 25 (high risk for falls). Gainsprimarily were noted in more dynamic or multitasking items, such as changing levels, Item 6 (Stepup and over a 6’’ bench, p ¼ .002), and multitasking with vestibular perturbation, Item 9 (Walkingwith head turns, p ¼ .01). Neither of these movements were practiced during the dance series. Scoresfor the FAB have not been standardized to detect meaningful significant differences—either statis-tically or practically. At the same time, the results of this study are promising. Post-study scoreimprovement implies a trend toward balance improvement after a brief and relatively intense inter-vention, although further research involving larger and more stratified samples, increased control,and long-term retention.
Important factors affecting on design of future studies and classes surfaced from participantresponses on the feedback questionnaire (see Appendix 1 for questionnaire). Participants were can-did in commenting on the organizational structure of the class and their perceived gains (physicaland social). A number of suggestions were offered in regard to pacing and music choices, movementchoices, familiarity and length of the study, and perceived value for continued participation.
Participants generally reported that the pace was too fast, especially in more complex steps such asbraiding (Carioca). Participants further showed mixed responses to class pace and music choices. Suggestions implied that better choices for rhythmic music and pacing could have been made, forexample (a) to better match the movements with the rhythm of the music; (b) to ensure that the musicbe played at a volume for all to hear; and (c) to select a pace that should allow everyone to follow theteacher’s lead.
Table 4. Self-Reported Perceived Difficulty in Performing Movements by Participants With Parkinson Diseasein a Modern Dance Class
Stepping sideways, diagonally, and circle
Likert-type scale—1 ¼ easiest, 10 ¼ hardest.
Evidence supports the use of verbal, visual, and auditory cueing in exercise for correct body pla-
cement and movement timing, both of which enhance movement ease and safety (Nieuwboer et al.,2007). In dance, augmented auditory cues promote movement initiation (downbeat), sequencing(connection and flow of movement), and problem solving in programming body coordination(e.g., walking and clapping). Auditory cueing appears to improve gait initiation, walking speed, andcadence (Howe, Lovgreen, Cody, Ashton, & Oldham,, 2003) and decreases severity of freezing(Siegert et al., 2002). In a study using positron emission tomography, healthy subjects performinga stepping sequence to a tango beat found increased activity in the basal ganglia, especially the puta-men (Brown et al., 2006). Initial speculation purports that auditory cues might bypass defectiveloops from the basal ganglia via other thalamic and cerebellar pathways (Nieuwboer et al., 1997). Yet, it appeared from participant feedback that the kind of music (its rhythm, loudness, and com-plexity) was important in helping sustain motor learning. In this study, an average of five differentrhythmic choices were introduced throughout the study (e.g., waltz, soft rock, Celtic, and otherpopular music), as opposed to the tango (Hackney et al., 2007) where the timing of step patternsis governed by a unified strong, repetitive rhythmic beat.
Of interest were responses to Item 4, which asked participants to rate hallmark movements used inthe class using a Likert-type scale of 1–10 of perceived difficulty (1 being easiest and 10 hardest;Appendix 1). Judging by participant responses, appears that many of the movements challengedthem to nearly the limits of their abilities. Compared to stepping patterns, turning, improvising,or flexing/extending the spine, the most difficult movement option was coordinating arms and legs(mean score 7.3 out of 10, in terms of rated difficulty). These complex patterns of arm-and-leg coor-dination constituted a large portion of class time (Table 4). This finding suggests that a slower andmore individuated progression of movements would be useful in helping participants learn morecomplex movements. This movement progression could begin with orienting perceptually in thespace and warming up more slowly by breathing and moving isolated body parts, before moving intomore coordinated patterns.
Video observation showed a number of improvements in coordination and balance with sponta-
neity of expression and/or movement choice, even among those participants with the highest degreeof hypokinesia, masked facies, or tremor. The participants themselves acknowledged few demon-strable changes in balance, however, suggesting a mismatch between self-perception and actual per-formance. Several remarked that they had entered the study without anticipating any improvementsin balance. Given the diagnosis of PD (a degenerative and ‘‘incurable’’ disease), some expressed thatone should not expect to see improvement, especially given the brevity of the study. Three of the 11
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persons noticed positive improvements while walking (e.g., spontaneous arm swing). A more com-mon response was increased awareness of the degree of deficit (e.g., the need to improve one’s ‘‘pos-ture’’ or ‘‘coordination’’) or increased self-efficacy (‘‘The most important thing I learned was to askfor help when I am confused.’’). Although the study questionnaire captured a number of direct andimplied comments relating to overall participation, future surveys might enhance their sensitivity tochange by querying other psychometric factors. For example, it would behoove researchers toadminister a survey several times during a study to capture subjective perceptions of bodily sensa-tions and feelings related to well-being and movement ease and aspects of self-efficacy (Johnson &Almeida, 2007).
Participants acknowledging the highest degree of satisfaction with the study were those who hadbackgrounds in ballroom dance. These participants were most likely to report spontaneous improve-ments in balance and satisfaction with music and movement choices and class pacing, as well as tonotice positive changes in their movement profile (such as balance improvements, spontaneous armswings with walking, and being faster on their feet). Others felt they needed much more time to‘‘master’’ the steps, with at least three of the participants finding the movements too unfamiliar andcomplex to begin to master. In the latter case, participants varied in their emotional reactions to thischallenge, either by ‘‘joining in the fun’’ regardless or feeling more ‘‘isolated’’ as a consequence.
Despite visible and verbal expressions of group enjoyment and few complaints of physical discom-fort or disease throughout the study, only 1 participant of the 11 stated that she would continue toseek other dance classes offered in the community. Some stated lack of interest in this kind of dance(one participant with 100% attendance remarking that he ‘‘just didn’t like modern dance.’’). Othersclaimed to be too busy to add more activities to their schedule of activities and others expressed awish to avoid participating in unfamiliar groups and settings.
Although feasibility studies can help researchers in gauging the potential clinical utility of an exer-cise class, more controlled studies are needed to improve validity and sensitivity of a number of fac-tors. At the most fundamental level, increased sample sizes with randomized experimental andcontrol groups to test the efficacy of dance as compared with another form of related exercise wouldstrengthen the findings in this study. Selecting among those persons with ‘‘tremor-dominant’’Parkinson disease versus those with ‘‘postural instability-gait-difficulty’’ could better help stratifysubjects. Furthermore, more quantitative testing of postural control and balance would help withstratification and with class design. A retention phase would help consolidate motor learning find-ings through tracking motivation to continue exercising, fall rates, freezing episodes, and otherevents over at least a 3-month period. Other factors needing further scrutiny and control includegroup delivery, teacher training, and dosage (e.g., length or intensity of classes); these will bediscussed below.
Group classes offer a cost-efficient way to deliver ‘‘therapeutic’’ interventions and have beenshown to offer physical and social benefits, including for persons with PD (Earhart, 2009). Com-pliance, lack of attrition, and the general upbeat tenor and camaraderie of the group throughout
the study suggested that the social benefits in this study concurred with previous evidence (Cruiseet al., 2010). Among the elderly, evidence for social benefits of group exercise is robust (Elward& Larson, 1992). Social interaction among people living with the same disease appears to be astronger predictor for continuing to exercise than any individual motivation to improve physicalcapabilities (Allen, Dodd, Taylor, McBurney, & Larkin, 2004). This group, already engaged inphysical activities and/or therapy, appeared to enjoy the movement challenges, and the opportu-nity to participate in a noncompetitive or nonjudgmental atmosphere. Members of the group gen-erally looked out for one another, for example, by assisting others who froze or were havingdifficulty comprehending more complex locomotor movements by holding their hand and guidingthem along.
A question looms large regarding the optimal group size. Given only one instructor, how
large a group with Parkinson’s should be recruited to ensure that individual needs are met andthat the group as a whole can participate safely? Guidelines exist for a feasible patient-to-instructor ratio in exercise classes for adults with diverse deficits post-stroke. In one studyinvolving a slow paced exercise protocol within a tightly controlled environment, researcherssuggest an 8-to-1 ratio (participants-to-trained instructor; Mount, Bolton, Cesari, Guzzardo,& Tarsi, 2005), while in another more vigorous aerobic protocol, a 3-to-1 ratio is suggested(Eng et al., 2003). Implied is these findings is that the greater the type and degree of deficit,the lower the ratio should be of participants to trained personnel (Mount et al., 2005), espe-cially when more dynamic exercises of balance and agility are involved (Eng et al., 2003). No guidelines are evident for participant-to-instructor ratio for group-delivered classes for per-sons with PD. In this study, one teacher was responsible for a class of 11 with no additionalassistance. Instruction was primarily verbal with music accompaniment and any hands-on gui-dance was kept to a minimum to encourage participants to move independently. When partici-pants in this study appeared stuck (frozen) or unable to keep up with the pace, they either satdown, or received some verbal or manual guidance from another class member. This did notappear to affect the overall pace of the class. Future class designs, however, might benefit fromincreased stratification of participants, so that movement choices can better address the needsof each individual within the group context.
With the growing popularity of dance programs for people with PD, caution must be exercised inthat some programs have not been tested scientifically for efficacy (Hirsch, 2009). Participants fromthis study implied the need to adjust pacing, rhythm, and to increase sensitivity to individual needswithin the group. At this point in time, scant information exists on training instructors to teach exer-cise to people with PD. Short-term seminars are being initiated by dance and rehabilitation centers toteach dancers basic skills (Westheimer, 2008), but no medical credentialing or practice guidelinesexist (Hirsch, 2009). It is suggested that community-based teaching programs at a minimum shouldinclude training addressing basic exercise physiology, first aid, and emergency procedures (Hirsch,2009). In this study, the group found the overall pace of the class too fast, preferring a slower paceand progression. More than half the members of the group implied that movement choices were toocomplex and novel in commensurate with levels of learning and gains made.
Because of the multiple psychophysical and intrinsic and extrinsic variables associated with exerciseeffects, determining the exercise prescription (optimal mode, frequency, duration, and intensity) thatwill trigger physiological gains is a complex process (Hirsch, 2009). Dosage for this study was
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determined largely by availability of research team participants and anticipation of participant andcaregiver burden in attending a relatively intensive exercise program. The entire study required 4 hrof research team training prior to the pretest phase, 1 hr of intake and post-study testing per parti-cipant, and 11 hr of class time (exclusive of travel time). This dosage approximated half of that ofprevious studies on tango (1-hr session twice a week for 10 weeks (20 sessions in total; Hackney &Earhart, 2010; Hackney et al, 2007).
Exercise prescription should be evaluated in light of the evidence on brain plasticity. Models of
PD and exercise (both animal and human) suggest that intense sensorimotor training changes thebrain and positively affects a number of other systems (Hirsch & Farley, 2009). Focused, high-intensity exercise may ameliorate the signs and symptoms and neurometabolic pathophysiologyof PD (Hirsch & Farley, 2009). Impact includes slowing the motor deterioration associated withdisease progression; prophylactic protection of dopaminergic neurons and metabolites from toxicevents, decreasing the psychophysical stresses of inactivity and the disease itself (Dibble, Hale,
Marcus, Gerber, & LaStayo, 2009; Ridgel, Vitek, & Alberts, 2009). In this study, small, butsignificant gains were recorded in the posttest FAB scores, but without follow-up, it is impossibleto determine the long-term effects or potential functional gains.
For this sample of adults with early-to-middle stage PD, modern dance appeared to offer a pleasur-able and feasible alternative to other modes of exercise—one that is cost-effective, relatively simpleto administer, and with social as well as potentially functional benefits. Future studies clearly wouldbenefit from larger and more tightly stratified and randomized experimental and control groups. Dosage needs to be specifically determined with long-term retention and functional transfer in mind. Future studies also might include a retention phase that would track fall history, freezing episodes,and quality of life factors (Ravenek & Schneider, 2009). Comparing modern dance with tango ormodern dance with aerobic dance is necessary to determine efficacious variables and contexts. Further studies await analysis on the specifics of the movement protocol that would better supportthe use of modern dance in promoting functional gains in this population.
Please respond to these questions as candidly as possible. All responses are entirelyvoluntary and confidential.
Was this class helpful in finding improved mobility in everyday life?
Please explain why (or why not) and give examples (e.g., increased stamina, easier to do specific activities,etc.)
How? Where you able to keep up with the pace? Follow the steps? Did your coordination improve overtime?
RATE how easy or hard it was for you to perform the movements
1 ¼ easiest, 10 ¼ hardestBending & straightening the spine_______________Turning _______________Stepping sideways, diagonally, or in a circle __________Moving your arms in coordination with your legs ___________Rhythmic stepping ____________Improvising ____________
Which items were ESPECIALLY HELPFUL in keeping pace with the class?
Taped Music _____________Teacher’s verbal cues___________Watching the teacher__________Watching others____________
Did the class help you with creative expression? Give an example.
Did you experience any lingering (prolonged, sustained) unpleasant effects
(e.g., dizziness, muscle soreness, etc.)?
What was the most important thing you learned?
Did the class inspire you to join another dance class in the community? If not, why not?
10 Do you have any recommendations for the research team for designing future studies?
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The author(s) declared no conflicts of interest with respect to the authorship and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research and/or authorship of this
article: The Graduate School of Winston-Salem State University.
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Glenna Batson, PT, ScD, MA, is an associate professor of physical therapy at Winston-Salem State Universitywith more than three decades of involvement in complementary and integrative approaches to self-care. Recentresearch includes validating clinical tools for detecting balance deficits in elite dancers, and the effects ofperceptuo-motor learning on balance, using the Alexander Technique and mental practice of motor imageryin the elderly and Feldenkrais Method1 on adults post-stroke.
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