By Kara Patterson
Every 10 minutes, someone in Canada will have a stroke (1). Stroke can impact all aspects of a person’s functioning, including speech, cognition, mood, and mobility. Currently, there are 426,000 Canadians living with the effects of stroke (1), with balance and gait frequently limited. A longitudinal study I conducted with my colleagues at the Toronto Rehabilitation Institute revealed that, despite gains made with inpatient rehabilitation, balance and gait deficits remain at discharge (2). These persisting deficits can have negative consequences on a person’s independence and quality of life (3,4). In addition, individuals with stroke often report feelings of social isolation (5), lack of confidence in their ability to maintain their balance (6), and declining satisfaction with their mobility function after returning home (7). Clearly, new interventions for balance and gait are sorely needed. Group interventions for gait and balance provide the added benefit of socialization which may decrease feelings of isolation. Dance classes are a novel and promising intervention for people with stroke that may address these needs.
Dance is a worldwide human activity that involves complex whole-body movements synchronized to the rhythmical stimuli found in music (8). Older adults who are regular social dancers have more stable gait, better balance, and faster motor reaction times compared to older adults who do not dance (9,10). Dance also has the same aerobic benefits as jogging and walking programs (11). People who dance recreationally describe it as an enjoyable experience with benefits such as emotional and social well-being and reduced stress (8). Dance has also been used therapeutically for the treatment of gait and balance dysfunction in individuals with Parkinson’s disease (PD). A recent meta-analysis of 13 experimental studies confirmed that older adults with PD who danced showed greater improvements in balance and gait than older adults who did not dance (12). Furthermore, it appears that improvements made with dance may be greater than gains made with traditional group exercise classes (13) or conventional physiotherapy (14).
The advantages associated with dance may be derived from (a) the combination of synchronized movement to the rhythmic cues embedded in music, and (b) the motivating effect of music. Music can enhance motor performance during exercise in healthy adults (15,16), and rhythmic auditory cueing combined with physiotherapy improves gait performance (17), arm function (18), and brain activation patterns (18) in individuals with stroke. Exercising to music is also associated with lower ratings of perceived exertion (19) and improved mood (20), suggesting that it could maintain motivation to exercise. Furthermore, synchronized movement between individuals in group activities, such as marching (21) and limb movements to a musical beat (22), increase prosocial behaviours like cooperation and affiliation. Thus, the reported emotional and social well-being associated with dance may stem from feelings of social connectedness driven by the synchronized movement during dance class. The potential for dance to foster feelings of social connection is a significant advantage over other types of group exercise. Previous work on social isolation after stroke recommended that interventions to address isolation should specifically foster connectedness to others, rather than provide social support alone (23). Finally, dance as therapy has high rates of adherence and patient satisfaction. Several studies of dance for people with PD have reported that no one dropped out of the dance classes (24). In addition, participants in the dance group of controlled studies often attend additional classes once the study is finished, which does not occur in traditional exercise groups (12,13).
Despite the promising results of dance for individuals with PD, comparatively little work has been done to investigate the use of dance for other neurological conditions including stroke. In my lab, the REhabilitation of the Lower Extremities AfteR Neurological Injury, (RELEARN lab), we recently conducted a systematic review on the use of dance for people with neurological conditions (in review (25) and presented at the National Centre for Dance Therapy Symposium last year). We analyzed nine studies that used a dance intervention and reported balance and mobility outcomes in individuals with neurological conditions other than PD. Three of the nine studies investigated dance for people with stroke, with a total sample size of 11 (26-28). We found pre-post changes in balance and gait similar to or greater than those reported in a systematic review of dance for PD (12). Furthermore, the reported pre-post changes in outcome measures, such as the Berg Balance Scale and gait velocity, exceeded published minimally important difference cut-offs, suggesting that these gains made with dance are likely to have an impact on function (29,30). However, it is important to note that none of these studies were randomized controlled trials (RCTs) and the largest sample size was nine. Thus, significant work remains to determine whether dance for people after stroke is feasible and effective.
Last year, the RELEARN lab conducted a study to explore the feasibility of a dance program for community-dwelling people with stroke. We ran two 10-week dance programs that provided two 1-hour classes per week to people with stroke. The dance class was led by a qualified dance instructor with the assistance of four to five volunteers from the dance community. Our measures of feasibility included enrollment and attendance rate, as well as the number of adverse events. We also collected measures of balance and walking before and after the program. Participant satisfaction with the dance program was assessed with a questionnaire at the end of the 10 weeks.
Recruitment for the dance program was successful. Of the 33 individuals approached, 97 per cent expressed interest in participating. Twenty-two people enrolled in the study and underwent the pre-dance assessment. Among the 11 who did not enroll, commonly cited barriers to participation were travel and scheduling. Ultimately, 20 participants took part in the dance classes and retention was high; all 20 people completed the study without serious adverse events. On average, participants attended 93% of all dance classes. This is significant considering that a component of the study was conducted during the winter months (31). At the post-dance assessment, balance as measured with the Mini-Balance Evaluation Systems Test (Mini-BESTest) (32) had improved. On the satisfaction questionnaire, most participants indicated strong agreement with the following statements: “I enjoyed participating”; “my balance has improved”; and “my mood has improved” (31). Participants also reported increased confidence in their balance and walking abilities. Perhaps of more interest was that the participants expressed a strong desire to continue the dance program. At the end of the study, participants independently started a Facebook group to stay in touch and were arranging with the study instructor to schedule more dance classes. These anecdotes led us to believe that the dance program fostered feelings of social connection and motivation for sustained physical activity.
Overall, we are encouraged by these preliminary results and next year the RELEARN lab will start a RCT to determine the effects of a dance program for people with chronic stroke. We anticipate that individuals in the dance group will exhibit gains in balance and gait while the control group will not. We also expect that gains in balance confidence will be observed in the dance group. Finally, we predict that both groups will exhibit decreased social isolation and increased quality of life, but that the changes in the dance group will be larger. If effective, dance classes could be used to improve balance and walking in a fun and social way for people with chronic stroke.
- CorHealth Ontario. Ontario Stroke Network: stroke stats & facts [Internet]. Toronto, Canada: CorHealth; 2017 [cited 2017 Nov 28]. Available from: http://ontariostrokenetwork.ca/information-about-stroke/stroke-stats-and-facts/
- Patterson KK, Mansfield A, Biasin L, Brunton K, Inness EL, McIlroy WE. Longitudinal changes in post-stroke spatiotemporal gait asymmetry over inpatient rehabilitation. Neurorehabilitation & Neural Repair. 2015;29:153-62.
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- Schmid A, Duncan PW, Studenski S, Lai SM, Richards L, Perera S, et al. Improvements in speed-based gait classifications are meaningful. Stroke. 2007;38:2096-100.
- Salter K, Hellings C, Foley NC, Teasell R. The experience of living with stroke: a qualitative meta-synthesis. J Rehabil Med. 2008;40:595-602.
- Pang MYC, Eng JJ. Fall-related self-efficacy, not balance and mobility performance, is related to accidental falls in chronic stroke survivors with low bone mineral density. Osteoporos Int. 2008;19:919-27.
- Pound P, Tilling K, Rudd AG, Wolfe CDA. Does patient satisfaction reflect differences in care received after stroke? Stroke. 1999;30:49-55.
- Quiroga Murcia C, Kreutz G, Clift S, Bongard S. Shall we dance? An exploration of the perceived benefits of dancing on well-being. Arts Health. 2010;2:149-63.
- Verghese J. Cognitive and mobility profile of older social dancers. J Am Geriatr Soc. 2006;54:1241-44.
- Zhang JG, Ishikawa-Takata K, Yamazaki H, Morita T, Ohta T. Postural stability and physical performance in social dancers. Gait Posture. 2008;27:697-701.
- Garber CE, McKinney JS, Carleton RA. Is aerobic dance an effective alternative to walk-jog exercise training? J Sports Med Phys Fitness. 1992;32:136-41.
- Shanahan J, Morris ME, Bhriain ON, Saunders J, Clifford AM. Dance for people with Parkinson Disease: what is the evidence telling us? Arch Phys Med Rehabil. 2015;96:141-53.
- Hackney ME, Kantorovich S, Levin R, Earhart GM. Effects of tango on functional mobility in Parkinson’s disease: a preliminary study. J Neurol Phys Ther. 2007;31:173-9.
- Volpe D, Signorini M, Marchetto A, Lynch T, Morris ME. A comparison of Irish set dancing and exercises for people with Parkinson’s disease: a phase II feasibility study. BMC Geriatr. 2013;13:54.
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- Thaut MH, Leins AK, Rice RR, Argstatter H, Kenyon GP, McIntosh GC, et al. Rhythmic auditory stimulation improves gait more than NDT/Bobath training in near-ambulatory patients early poststroke: a single-blind randomized trial. Neurorehabil Neural Repair. 2007;21:455-9.
- Luft AR, McCombe-Waller S, Whitall J, Forrester LW, Macko R, Sorkin JD, et al. Repetitive bilateral arm training and motor cortex activation in chronic stroke: a randomized controlled trial. JAMA. 2004;292:1853-61.
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- Reddish P, Fischer R, Bulbulia J. Let’s dance together: synchrony, shared intentionality and cooperation. PLoS One. 2013;8:e71182.
- Haun J, Rittman M, Sberna M. The continuum of connectedness and social isolation during post stroke recovery. J Aging Stud. 2008;22:54-64.
- Shanahan J, Morris ME, Bhriain ON, Saunders J, Clifford AM. Dance for people with Parkinson disease: what is the evidence telling us? Arch Phys Med Rehabil. 2015;96(1):141-53.
- Patterson KK, Wong JS, Prout EC, Brooks D. Dance for the rehabilitation of balance, gait and functional mobility in adults with neurological conditions other than Parkinson’s disease: a systematic review. Disabil Rehabil. 2017;in review.
- Demers M, McKinley P. Feasibility of delivering a dance intervention for subacute stroke in a rehabilitation hospital setting. Int J Environ Res Publ Health. 2015;12:3120-32.
- Dureska MD. Beginning ballet as an intervention for gait, balance, and mobility for an individual with post-stroke hemiparesis: a case report. Dissertation Abstracts International: Section B: The Sciences and Engineering. 2008.
- Hackney ME, Hall CD, Echt KV, Wolf SL. Application of adapted tango as therapeutic intervention for patients with chronic stroke. J Geriatr Phys Ther. 2012;35:206-17.
- Tilson JK, Sullivan KJ, Cen SY, Rose DK, Koradia CH, Azen SP, et al. Meaningful gait speed improvement during the first 60 days poststroke: minimal clinically important difference. Phys Ther. 2010;90:196-208.
- Godi M, Franchignoni F, Caligari M, Giordano A, Turcato AM, Nardone A. Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders. Phys Ther. 2013;93:158-67.
- Patterson KK, Wong JS, and Brooks D. The feasibility of a dance program to improve gait and balance in individuals with chronic stroke. Int J Stroke. 2016;11[(2S)],32-3.
- Franchignoni F, Horak F, Godi M, Nardone A, Giordano A. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest. J Rehabil Med. 2010;42:323-31.