Dance and Health
Dance and Health
Dance and Health
ABSTRACT
Background • Physical inactivity is commonly observed medical conditions. The average age of participants ranged
among individuals aged >60 y. Identified barriers to from 52-87 y. Researchers used a variety of measures to
sedentary older adults beginning activity include low self- assess effectiveness; (1) 3 of 5 (60%) that used measures to
efficacy, pre-existing medical conditions, physical assess flexibility showed significant positive results;
limitations, time constraints, and culture. Dancing has the (2) 23 of 28 (82%) that used measures of muscular
potential to be an attractive physical activity that can be strength and endurance showed significant positive
adjusted to fit a target populations age, physical limitations, changes; (3) 8 of 9 (89%) that used measures of balance
and culture. showed significant positive changes; (4) 8 of 10 (80%) that
Objectives • This review examined the benefits to physical used measures of cognitive ability showed significant
health of dance interventions among older adults. positive changes; and (5) the one that measured
Methods • Following the Preferred Reporting Items for cardiovascular endurance showed significant positive
Systematic Reviews and Meta-Analyses (PRISMA) changes. Only 6 studies reported participation, and they
guidelines, a systematic search using the PubMed database found low attrition.
was conducted. Eighteen studies m et the inclusion and Conclusions • The findings suggest that dance, regardless
exclusion criteria and were analyzed for type of of its style, can significantly improve muscular strength
intervention, the study’s design, participants’ and endurance, balance, and other aspects of functional
demographics, and outcomes, including attrition. fitness in older adults. Future researchers may want to
Results • The 18 articles reported on studies conducted in analyze the effects of dance on mental health and explore
N orth America, South America, Europe, and Asia. O f the ways to make this intervention attractive to both genders.
styles of dancing, 6 studies used ballroom , 5 used Standardizing outcome measures for dance would
contemporary, 4 used cultural, 1 used pop, and 2 used facilitate m eta-analysis. (Altern I her Health Med.
jazz. Two studies targeted older adults with pre-existing 2015;21(5):64-70.)
Phoebe Woei-Ni Hwang, MS, is a DrPH candidate. Kathryn alleviating some health conditions. Studies have demonstrated
L. Braun, D rP H , is a professor and chair of the Office of that physical activity has positive effects on depression,
Public Health Studies. Both are located at the University of anxiety,7 dementia,8 heart failure,9 stroke,10 cognition,11 and
Hawai’i at Manoa in Honolulu. sleep.12,13 The harmful effects resulting from physical inactivity
and the positive effects of physical activity suggest that further
efforts are needed to encourage physical activity, with an
Corresponding author: Phoebe Woei-Ni Hwang, MS emphasis on populations at high risk for inactivity.14
E-mail address: pwnhwang@hawaii.edu Physical inactivity is com m only observed among
individuals aged 60 y and older.15 Although many older
adults have positive attitudes toward physical activity and its
P
hysical inactivity contributes to many health conditions, benefits, factors such as the person who is recommending
including obesity,1 cancer, coronary heart disease,2 physical activity, the older adult’s environment, costs of
sarcopenia,3 cerebrovascular disorders,4 circulatory activities, and safety concerns affect their behaviors regarding
diseases,5 and frailty.6 Fortunately, adding physical activity to physical activity.16 Identified barriers to sedentary older
one’s life is an effective method of preventing, controlling, and adults beginning activity include low self-efficacy,
64 ALTERNATIVE THERAPIES, SEP/O CT 2015 VOL. 21 NO. 5 Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health
pre-existing medical conditions, physical limitations, time METHODS
constraints, and culture.17 Databases
The United States’ older adult population has been Guidelines from the Preferred Reporting Items for
steadily increasing since the 1900s. It is predicted that 92 Systematic Reviews and Meta-Analyses (PRISMA) were used
million older adults will live in the United States in 2060, to develop the current systematic review.30 PubMed was
compared with 30 million in 2000.18 Therefore, creative, searched using the keywords dance, aged, and older adults. In
appealing, and effective methods of physical activity need to addition, the term dance therapy was used as a medical
be investigated to accommodate this growing population. subject heading and used in searching as text words. The
Dance therapy is a creative arts therapy that has been search was conducted from September 2013 through October
defined by the American Dance Therapy Association as 2013. Citation chasing was also used by searching the
“the psychotherapeutic use of movement to further the reference sections of other papers that pertain to the topic.
emotional, cognitive, physical, and social integration of the
individual.”19Cross-sectional studies have shown that older Inclusion and Exclusion Criteria
adults who dance on a regular basis have greater flexibility, To be included in the current review, a study had to
postural stability, balance, physical reaction time, and evaluate the benefits of a dance intervention to the physical
cognitive performance than older adults who do not dance health of older adults lacking prior dance experience, within the
on a regular basis.20 age limits defined by a reviewed study’s authors. Studies had to
Unlike other holistic approaches used to increase present results in a quantitative format. Dance was defined as a
physical activity, dance includes an aesthetic form of artistic form of artistic expression through rhythmic movement to
expression.21 Dancing can produce physical results music, which does not include aerobic fitness classes taught to
comparable with those of formal exercise training, and it also music, such as Zumba and step-aerobics. The authors placed no
has been found to improve social and behavioral factors, limitations on the location of the research, intervention, or year
such as self-motivation.22 In addition, it can improve the the study was published. However, publications reviewed had to
emotional, psychological, and physical well-being of be peer reviewed and written in English.
individuals.
Qualitative studies have shown that aesthetic forms of Data Extraction and Coding
expression build passion and can contribute to older adults’ Upon availability, the following information on each
physical, intellectual, and social development.23,24 Dancing has intervention and study was abstracted from each publication:
the potential to be a versatile activity that can be adjusted to fit (1) the mean age and gender of participants, (2) the dance
a target population’s age, physical limitations, and culture. style studied, (3) the program’s implementation strategy,
Two previously compiled literature reviews have (4) the study’s results, (5) the researchers’ decision about the
examined the health benefits of dance.25'26 However, one effectiveness of the intervention, (6) the study’s attrition
review focused on the effectiveness of dance for healthy rates, and (7) the researchers’ conclusions. Effectiveness
people regardless of age. The other specifically examined decisions were coded in the following manner: A plus (+)
dance in older adults but excluded studies with elders who was used for significant results in positive health improvement,
had health conditions as well as studies that did not specify a 0 for null results, and a minus (-) for significance results in
the health status of the older adult. In addition, those 2 the negative direction.
literature reviews focused on the effectiveness of dance as a
substitute for physical activity rather than the feasibility of Quality Analysis
and adherence to the dance programs. Common reasons for The scientific rigor of each study was evaluated using 6
the demise of interventions related to physical activity for criteria adapted from Sackett31 and Megens and Harris.32
older adults are poor adherence and high dropout rates.27 Specifically, studies were assessed for the presence of
Therefore, additional research is needed to identify an (1) clearly stated inclusion and exclusion criteria for
intervention’s ability to be individualized and tailored to participants, (2) an adequate description of the dance
populations of older adults in ways that maintain participants’ program, (3) reliable outcome measures, (4) valid outcome
involvement in the activity. The current study is meant to measures, (5) assessors who were blinded to the participants’
further scientific knowledge on this issue. groups, and (6) participants’ attendance, retention, and
Given that many of older adults have cognitive and dropout rates.
sensory motor impairments28 and that 45.3% of older adults
aged 65 years and older have 2 or more chronic conditions,29 RESULTS
studies of interventions for older adults should not exclude The article selection process is illustrated in Figure 1.
those with chronic conditions. Thus, the purpose of the Specifically, 268 articles were identified based on search
current review was to examine the effectiveness of dance terms. Of those articles, 173 were excluded by title; 28
programs in improving the physical health of all older adults, duplicates were removed; 51 were excluded based on the
both those with health conditions and those considered article’s content; and 2 were included from citation chasing.
healthy. Remaining were 18 articles published from 2004 to 2013.3350
Woei-Ni Hwang-Dance Interventions for Older Adults’ Physical Health ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 65
Figure 1. Article selection process. Intervention Designs
Regarding styles of dancing, of the 18 interventions
examined, 6 used ballroom, 5 used contemporary, 5 used
cultural, and 2 used jazz (Table 1). Ballroom interventions
included foxtrot, salsa, tango, bolero, swing, polka, cha-cha,
waltz, and merengue. Two of the studies that used ballroom
interventions used more than 1 style of ballroom dance in
the program . C ontem porary interventions included
improvisation and the Lebed method. Cultural dance
interventions included Greek, Turkish, Korean, Cantonese,
and line dancing.
Eleven studies reported on the location of interventions.
Two were implemented in the United States; 6 were in Europe;
2 were in Asia; and 1 was in South America. The frequency of
the interventions ranged from 1 to 4 times per week. The
duration of the interventions ranged from 6 weeks to 8 months.
The length of each session ranged from 45 minutes to 2 hours.
Participants
Two of the 18 studies examined the effectiveness of
dance interventions for older adults who had been diagnosed
with specific health conditions (Table 2). Those conditions
included visual impairm ent33and metabolic syndrome.48 The
Table 1 . Intervention Design and Physical Outcomes
a+, significant positive change; 0, no significant change. Each represents the results of a specific measure used to indicate a physical outcome.
66 ALTERNATIVE THERAPIES, SEP/O CT 2015 VOL. 21 NO. 5 Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health
Table 2. Studies’ D esigns and P articipants’ D em ographics3
rem aining 16 studies targeted the general population of 4 criteria33,35,43'45'46’50; an d 2 m et 3 criteria.37,39 All 18 studies
older adults. G roups ranged in size from 13 to 97 participants. specified the inclusion and exclusion criteria for participants
In 8 studies, m ore th an o n e-h alf o f the participants were and em ployed valid and reliable outcom e m easures in their
females, and in 5 studies, all the participants w ere females. evaluations. Fifteen studies adequately d escrib ed the
The rem aining 3 studies did not specify the gender o f their intervention. However, only 6 used blinded assessors, and
participants. The average age of participants ranged from 52 only 6 provided inform ation on participants’ attrition.
to 87 years.
Outcomes
Study Designs The studies’ authors used a variety o f m easures o f health
O f the 18 interventions, 10 were random ized controlled outcom es. For the cu rren t review, each physical health
trials (RCTs),34’36'39'40'42,44'46'48 4 used a quasiexperim ental outcom e of dance m easured by studies’ investigators was
design,37,43,49,50 and 4 included only 1 group using pre- and g ro u p ed into 1 o f th e 6 m e asu rem en t categories:
posttest designs33'38'41,45 (Table 2). O f the 14 RCTs and (1) flexibility—the flexibility o f an older adult’s u p p er and
quasiexperim ental designs com bined, 4 had control groups lower body; (2) m uscular strength an d end u ran ce m easures—
that engaged in another activity, such as walking,42 line the general functional fitness o f an older adult using tests
dancing,50 t’ai chi,37 and a fall prevention program .35'37 The such as get up and go, chair squats, o r gait speed;
other 10 did not provide their control groups with alternate (3) balance—the ability o f an older adult to stand on 1 or 2
activities. legs w ith o u t sw aying or w ith no cen ter-o f-p ressu re
displacem ent; (4) cardiovascular en d u ran ce—the m axim um
Quality Analysis volum e o f oxygen intake; (5) cognitive fu n ctio n —the older
Scientific rigor was assessed by th e 6 criteria provided adult’s m em ory and organizational ability; an d (6) body
by Sackett31 and M egens and H arris.32 As show n in Table 3, co m position—the older adult’s body mass index an d body
none m et all 6 criteria; 10 m et 5 criteria34'36'38’40'42'44-47'49; 6 m et fat percentage.
Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 67
Table 3. Evaluative Criteria for Studies
Inclusion and Intervention Reliable Outcome Valid Outcome Blind Assessment of Accounted Total No.
Study Exclusion Criteria Adequately Described Measures Measures Outcome Measures for Attrition Criteria Met
Granacher et al34 / / / / 5
Krarape et al36 / / / / / 5
Krampe et al38 / / 5
/ / /
Sofianidis et al40 / / / 5
Alpert et al41 / / / / 5
McKinley et al43 / / / / 5
Eyigor et al44 / / / 5
Holmerova et al47 / / / / 5
Kim et al48 / / / / / 5
Song et al49 / / / / / 5
Hackney et al33 / / / / 4
Ferrufino et al35 / / / / 4
Hui et al43 / / / 4
Wallman et al45 / / / 4
Borges et al46 / / / / 4
Young et al50 / / / 4
Coubard et al37 / / / 3
Marmeleira et al39 / 3
Note: / indicates criteria were met; blank indicates criteria were not met.
Across the 18 studies, 59 measurements were reported studies ranged from 6 weeks to 2 months. No correlation
(Table 1). These measurements include 5 measurements of existed between a programs length and the attrition rate.
flexibility, 28 of muscular strength and endurance, 9 of
balance, 1 of cardiovascular endurance, 10 of cognitive Older Adults With Health Conditions
ability, and 6 of body composition. Studies employed Although most the 18 studies focused on improving
approximately 3 measures on average. O f the 18 studies, 6 health among older adults in general, 2 studies limited their
used m easurements from 1 category.35'37’39,41,45'49 All other interventions to older adults with specific health conditions
studies used measurements from multiple categories. or statuses (Table 2). Conditions examined were visual
All but 1 study showed significant improvement in at im pairm ent33 and metabolic syndrome.48 Both studies
least 1 of their measures of physical health, and no change in demonstrated an improvement in the constructs measured.
measurem ent was significant in the negative direction. For example, the dance program for visually impaired older
Specifically, 3 of 5 (60%) measurements of flexibility showed adults used a self-reported visual function test, covering
significant positive results, and 2 showed no significant measures of muscular endurance, strength, and balance.
changes. Twenty-three of the 28 (82%) measurements of Significant positive increases were observed in all 3 tests. The
muscular strength and endurance showed significant positive study that examined older adults with metabolic syndrome
changes, and 5 showed no significant changes. Eight of the 9 found a significant positive increase in older adults’ cognitive
(89%) measurements of balance showed significant positive functioning, although no change in body composition
changes, and 1 showed no significant change. One study occurred.
m easured cardiovascular endurance, showing significant
positive change. Eight of the 10 (80%) measurements of DISCUSSION
cognitive ability showed significant positive changes, and 2 Eighteen studies that fit the search criteria were assessed
showed no significant changes. Finally, for the 2 studies that on each study’s quality, its design, the intervention design,
used a measure of body composition, neither showed a physical health outcomes, and attrition. The results for the
significant change. current review have shown that dance is a promising method
for improving older adults’ physical health. In addition,
Attrition studies show that dance interventions may address older
Only 6 of the 18 studies examined rates of attrition from adult barriers to being physically active such as cultural
their interventions (Table 3). Three reported completion preferences, pre-existing medical conditions, and physical
rates of 100%34,38,40; 1 reported a completion rate of 81%48; 1 limitations.
reported a completion rate of 93%41; and 1 reported a
completion rate of 86%.36 The programs’ lengths for these 6
68 ALTERNATIVE THERAPIES, SEP/O CT 2015 VOL. 21 NO. 5 Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health
Dancing to Improve Overall Physical Health Limitations
Every study except for 1 showed an improvement in a Limitations of this review of research studies include
measure of physical health among older adults. With the imbalanced demographics for participants, inconsistent
exception of body composition, improvements were seen for outcome measures, and lack of process evaluations. More
60% to 90% of measurements in the other categories of specifically, all examined studies reported samples with more
physical health measurement—flexibility, muscular strength than 50% female. In fact, several studies had only female
and endurance, balance, cardiovascular endurance, and participants. Future investigations should identify gender-
cognitive function. Lack of improvement in body composition related barriers in recruitment, retention, program design, and
is perhaps not surprising. Older adults on average increase study objectives. Further, research should explore if dance is a
7.5% of their body fat mass and decrease 2% of the fat-free gender-oriented activity or can be used across all demographics.
body mass per decade, even with moderate sports or The wide variety of measures used to test outcomes limited
recreational activity.51 In addition, dietary intake affects the comparisons across studies and precluded a meta-analysis.
lean mass of older adults and should be considered as a Finally, only 6 studies reported attrition data.
confounding factor when measuring body composition.52 The review was limited in that the only database searched
However, because no significant negative changes were was PubMed. This choice was made because of the review’s
observed, perhaps dance can be seen as a method to maintain focus on physical health outcomes. Researchers who want to
body composition. Body composition may not be a realistic examine mental health outcomes of dance should expand the
evaluation measure for dance, because many variables search to databases such as PsycNET.
contribute to body composition.
A majority of the studies tested muscular strength and Recommendations
endurance and balance, showing a significant positive effect After reviewing the 18 studies that met the search criteria,
for dance on older adults’ functional fitness. These measures the authors propose the following recommendations. First,
are significant when identifying the physiological parameters dance interventions that aim to affect body composition
that support physical mobility and independence in older should either incorporate a nutritional component into the
adults53 and are also commonly used in basic tests of intervention or document the participants’ dietary intakes.
functional fitness for older adults. Therefore, dance Second, the research community should broaden study
interventions increase the functional fitness of older adults, parameters to include dance styles other than the popularly
which strengthens their bodies, allowing them to perform used contemporary and ballroom styles. Third, dancing should
day-to-day tasks independently. be used as a medium to promote older adults’ physical health.
Dance programs should provide a minimum of 1 45-minute
Intervention Design session per week for a total duration of 6 weeks. Program
All types of dance reviewed in this article showed completion and reasons for attritions should be tracked.
significant positive changes. Because the effectiveness of Last, a majority of the studies in the current review
dance as an intervention was observed across a wide range of tested muscular strength and endurance and balance. Those
dosages, the dosage may be modifiable for participants as measures are useful in measuring physiological parameters
long as dance occurs at least once per week, for at least 6 that support physical mobility and independence in older
weeks, with a minimum of 45-minute sessions. adults.53 The measures are also commonly used in basic tests
The current review included a focus on attrition because of functional fitness for older adults. Therefore, future studies
a common downfall of physical activity interventions for should include measures that examine the functional fitness
older adults is poor adherence and high dropout rates.27 of older adults. Standardizing outcome measures for dance
Unfortunately, only 6 of the 18 interventions reported would facilitate future meta-analyses.
program completion rates. However, these 6 reported low
attrition rates. CONCLUSIONS
To the authors’ knowledge, no systematic literature
Dancing to Improve Health Conditions reviews have occurred that document how dance affects the
Two studies specifically examined the effects of dance physical health of older adults. Strong evidence suggests that
interventions on populations of older adults with health dance, regardless of style and dosage, significantly improves
conditions. This preliminary evidence suggests that dance older adults’ functional fitness. However, dance may not be
interventions should not automatically exclude older adults sufficient to change body composition significantly. Although
with pre-existing medical conditions from participating. dance interventions have low attrition rates, a majority of the
Rather, dance interventions can be offered to older adults older adults participating in the dance interventions were
with a variety of conditions. Additional research is needed to female. Additional studies are needed to investigate the
confirm the efficacy of dance to improve specific health physical effects of dance coupled with nutritional education,
conditions. the psychological impacts of dance, and rates of and reasons
for adherence to dance as a physical activity.
Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health ALTERNATIVE TH ERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 69
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70 ALTERNATIVE THERAPIES, SEP/OCT 2015 VOL. 21 NO. 5 Woei-Ni Hwang—Dance Interventions for Older Adults’ Physical Health
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