Complementary Therapies in Clinical Practice 49 (2022) 101662

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Complementary Therapies in Clinical Practice

journal homepage: www.elsevier.com/locate/ctcp

Feasibility, acceptability and effects of dance therapy in stroke patients: A

systematic review
Isabel Ares-Benitez a, b, Maxime Billot c, Philippe Rigoard c, d, e, Fatima Cano-Bravo f,
Romain David c, Carlos Luque-Moreno g, *
a
Faculty of Nursing and Physiotherapy, University of Cádiz, 11009, Cadiz, Spain
b
IntegraSalud (Functional Rehabilitation Center), 11500, Puerto de Santa Maria, Spain
c
PRISMATICS Lab (Predictive Research in Spine/Neuromodulation Management and Thoracic Innovation/Cardiac Surgery), Poitiers University Hospital, 86021,
Poitiers, France
d
Department of Neurospine & Neuromodulation, Poitiers University Hospital, 86021, Poitiers, France
e
Pprime Institute UPR 3346, CNRS, ISAE-ENSMA, University of Poitiers, 86360, Chasseneuil-du-Poitou, France
f
Virgen del Rocio Universitary Hospital, 41013, Seville, Spain
g
Departamento de Fisioterapia, Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, 41009, Sevilla, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: Introduction: Stroke is the leading cause of non-traumatic disability in adults, with balance and gait disturbances
Postural balance representing the main limitations of body functions. Dance therapy (DT) has shown positive effects in older
Dance therapy adults and in patients with neurological pathologies. This systematic review aims to examine the feasibility,
Complementary therapies
acceptability and effects of DT in stroke rehabilitation, specifically on functional gains of gait and balance.
Stroke rehabilitation
Gait Disorders, Neurologic
Methods: A systematic search was carried out for articles published in the MEDLINE, PEDro, Web of Science,
Scopus and CINHAL in February 2021 and updated in April 2021. Results: Eight studies were included (2 clinical
cases, 5 case series and 1 randomized controlled trial), 7 of them in patients with chronic stroke and only 1 in
subacute stroke phase. The most widely used dance modality was tango and ballet, with sessions ranging from 30
to 110 min. DT seems to show positive effects on post-stroke body functions and activities such as gait and
balance. Reported dropout rates are inconsistent, no adverse effects were reported, and participant satisfaction
was high.
Conclusion: Given the heterogeneity and uneven quality of the included studies, strong conclusions cannot be put
forward on the effectiveness of DT in post-stroke body function and activities. Nevertheless, DT seems to be safe
and acceptable therapy for patients, and no adverse effects have been reported. More studies with a high level of
evidence and feasibility are needed to determine the patient profile, the characteristics of the intervention, the
participation rate and the role of the rehabilitation professional most likely to generate optimal benefit.

1. Introduction social reintegration [2,3]. To date, 30% of stroke survivors experience

functional disability associated with paralysis, balance problems, speech
Stroke is currently the leading cause of non-traumatic disability in disorders and cognitive deficits [4]. While some benefits can be obtained
adults, being more frequent in people over 65, although it can also affect through rehabilitation [4], balance and gait disturbances in post-stroke
young people and children [1]. Rehabilitation intervention in patients usually do not disappear completely and represent a significant
post-stroke patients is a process that aims to prevent complications and functional limitation, being associated with a higher risk of falls [5,6].
reduce neurological deficit, the objective being to achieve maximum Conventional rehabilitation, through repetitive exercises, manual
functional capacity, and consequently facilitate personal autonomy and therapy, task-oriented exercises and other techniques, has shown

Abbreviations: DT, Dance therapy; RCT, Randomized control trial; CMSQ, Checklist for measuring study quality; STPW, Spatio-temporal parameters of walking
(STPWs); BBS, Berg Balance Scale; TUG, Time-up and go test; ICF, International Classification of Functioning, Disability and Health.
* Corresponding author. Departamento de Fisioterapia, Facultad de Enfermería, Fisioterapia y Podología, Universidad de Sevilla, c / Avicena s/n, 41009, Sevilla,
Spain.
E-mail address: carloslm@us.es (C. Luque-Moreno).

https://doi.org/10.1016/j.ctcp.2022.101662
Received 25 March 2022; Received in revised form 6 August 2022; Accepted 18 August 2022
Available online 28 August 2022
1744-3881/© 2022 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-
nc-nd/4.0/).
I. Ares-Benitez et al. Complementary Therapies in Clinical Practice 49 (2022) 101662

benefits in the functional recovery of stroke survivor patients [7]. 2.2. Search strategy
However, the proposed activities may sometimes be unmotivating [8]
and the frequency and intensity of conventional rehabilitation are usu­ A systematic electronic search of articles published in the PEDro, Web
ally insufficient to achieve maximum possible recovery [7]. Further­ of Science, Scopus, MEDLINE and CINHAL databases was carried out in
more, motor learning is sustained by positive interaction with the February 2021 and updated in April 2021. Two evaluators (IAB and
external environment [9] and high-variable training seems to favor CLM) independently conducted the research in the databases and the
balance confidence in post-stroke patients with severe impairments selection of eligible papers. A third evaluator (MB) was consulted in case
[10]. For this reason, in recent years complementary therapies have of disagreement.
been developed to optimize post-stroke rehabilitation [11,12], one of The terms used in the search strategy were “Stroke” and “Dance
them, being Dance Therapy (DT), because of its close relationship with Therapy” (as MeSH terms) and “cerebrovascular accident” and “Dance” (as
balance. a colloquial language term). Table 1 describes the search process and the
Dance is an activity that involves the performance of movements of results found.
the whole body, through space and synchronized with music [13]. Some Due to the scarcity of articles that met our inclusion and exclusion
of the most widely used dance modalities are the Argentine tango, ballet criteria, a search was conducted through the grey literature (reference
and ballroom dancing in older adults, and in the neurological population lists of included articles and relevant systematic reviews were hand
[14–17]. In a recent systematic review and meta-analysis, Fong Yan searched in google scholar, as well as doctoral theses in the DART-
et al. [18] highlighted that DT can be considered as an effective alter­ Europe, Dialnet-thesis repositories)".
native exercise modality to improve physical health and outcomes
associated with sedentary and inactive behavior in several pathological 2.3. Inclusion and exclusion criteria
populations. DT also offers aerobic benefit similar to physical activity
programs, as well as to a sense of social well-being [18]. In addition, In the present review, different study designs (randomized control
dance in older adults has improved gait stability, reaction time and trials (RCTs), case studies, case series and case-control) were accepted,
balance compared to control an age-matched control group [19,20]. due to the small number of RCTs to answer the research question. The
DT has previously been used for rehabilitation in neurological pa­ PICO question [24,25] was asked: For a post-stroke patient, is DT
thologies such as Parkinson’s disease and has shown benefits at car­ feasible for improving limitations of body function and/or activities
diovascular, cognitive and social levels along with improvements in (balance and gait)?
balance and gait [14,16,17,21]. Recently, a systematic review investi­
gating the effects of dance on neurological conditions other than Par­ (P) Patients with post-stroke hemiparesis.
kinson’s disease (stroke (only 3 studies included), multiple sclerosis, (I) DT understood as any intervention or treatment that uses the
spinal cord injury and Huntington’s disease) have reported improve­ performance of movements coordinated with music using any
ments in general health, walking and balance similar to those obtained dance modality or style.
in Parkinson’s disease patients [14]. To date, there is no evidence of DT (C) Comparison with other types of intervention or non-intervention,
effects specifically dedicated to the post-stroke patients. Despite the fact or no comparation.
that post-stroke patients present some clinical manifestations common (O) Effects on limitations of body functions/activities (balance and
to other neurological pathologies, their specificity (marked asymmetry, gait).
common gait patterns, balance alterations, etc.) can determine specific
aspects of the best DT for these patients. In addition, it is necessary to The search filter was used: “articles published in English or Spanish”.
discuss particular aspects, such as the stage of chronicity of the patients Studies that measured the feasibility and acceptability of DT in this
(post-stroke time), which is not as decisive in other neurological pa­ type of population were also included.
thologies, and it may be critical to analyze the feasibility and effects of As exclusion criteria: qualitative, descriptive or non-objective eval­
treatment based on spontaneous recovery at each stage. uation of study variables.
The aim of this study was to provide a systematic review of the
literature on DT interventions specifically applied to post-stroke pa­
tients, with the objectives: (i) to describe the types of DT interventions 2.4. Evaluation and methodological quality
performed (type of dance, individual/group, intensity, frequency), tak­
ing into account the chronicity of the patients; (ii) to investigate the The evaluation of the methodological quality of the studies included
feasibility (in terms of participant dropout, occurrence of adverse in the systematic review was carried out through the Checklist for
events, adherence) and acceptability (in terms of perceived effectiveness Measuring Study Quality (CMSQ) [26] (Table 4), an instrument with
and satisfaction) of DT interventions; (iii) to evaluate the effectiveness of proven validity and reliability in different types of studies, obtaining the
DT interventions on motor impairments (balance) and functional ac­ respective correlation values for criterion validity and intra- and
tivity limitations (gait), in accordance with the International Classifi­ inter-examiner reliability (r = 0.90, 0.88 y 0,.5) [26] and currently
cation of Functioning , Disability and Health (ICF) model [7,22]; and recommended in systematic reviews that include different types of
(iv) to determine the role of the rehabilitation professional in DT for experimental design.
post-stroke patients.
Table 1
2. Material and methods Search strategy for the different databases.
Database Search Strategy Results
2.1. Study design PEDro Stroke AND dance 3
Web of TI=((stroke OR “cerebrovascular accident”) AND 24
A systematic review of the literature was carried out according to the Science (dance OR “dance therapy”))
Preferred Reporting for Systematic Reviews and Meta-Analyses (PRISMA) Scopus TITLE((stroke OR “cerebrovascular accident”) AND 10
(dance OR “dance therapy”))
[23] and the systematic review registration number CRD42020193668 CINAHL TI((stroke OR “cerebrovascular accident”) AND (dance 7
(PROSPERO). complete OR “dance therapy”))
MEDLINE TI((stroke OR “cerebrovascular accident”) AND (dance 18
OR “dance therapy”))
Total 62

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The level of evidence and grade of recommendation was evaluated series [27–31], 2 clinical cases [32,33] and 1 randomized controlled
through the proposed classification of the Centre for Evidence –Based trial [34]. Only the latter presented a good grade of recommendation
Medicine de Oxford (OCEBM) [26] (Table 3), which is one of the most and level of evidence (A, 1b).
widely used systems of evidence hierarchy in the health field, due to its All studies had a poor level of evidence and grade of recommenda­
high degree of specialization according to the type of clinical scenario tion, showing favorable results, but not conclusive due to insufficient
[27]. sample size and lack of randomized control groups. The characteristics
of the studies show a poor level of internal and external validity as
3. Results measured by the CMSQ. However, all obtained similar positive results
on the variables of interest.
Based on our inclusion and exclusion criteria, 8 studies were The most relevant characteristics of the studies included in this
included. Fig. 1 shows an outline of the article selection process, de­ systematic review are presented in Table 2.
tailing the reasons for exclusion.

3.2. Participant characteristics

3.1. Synthesis of results
With regard to participant characteristics, the total number of pa­
The 8 studies selected for the systematic review were analyzed by tients was 111, of whom 56 were men and 55 women. Patient age ranged
extracting the most relevant information (Table 2) for their evaluation: from 47 to 73 years. All were post-stroke patients in different phases of
author and year, grade of recommendation, level of evidence and study evolution (the inclusion criteria for determining subacute or chronic
design, characteristics of the sample (number of participants, age and phase was “having suffered a stroke 1–6 months ago or >6 months
post-ictus time), characteristics of the intervention (duration and mo­ ago”). Patients in the subacute phase reported a post-stroke time ranging
dality), variables of interest and their respective measurement tools and from 1 to 6 months (2.44 months on average), and those in the chronic
the results obtained. Table 3 shows the synthesis of results on the phase from 1 to 13 years. Patients with severe cognitive deficits, recent
feasibility of the DT intervention. surgeries, serious health status or who did not tolerate a certain amount
The included studies were very heterogeneous with a low level of of daily physical activity were excluded. Most studies exclude patients
methodological evaluation (between 11 and 21) (Table 4), with 5 case who are not able to walk independently (with or without technical aids),

Fig. 1. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flowchart.

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Table 2
Synthesis of results.
Author and year. De- SampleAge Post-Stroke Intervention Variables of interest Results
(LE, GR) sign (years) x (sd) time and measurement tools

Dureska 20071 CC n = 1; 48 5 years 90 min, 3 d/w, 8s. (24 sessions) Balance (BBS, DGI, ↑ Balance (pre/post 4 points BBS) and
Chronic Ballet. Individual ABC) STPW and TUG (pre/4s)
(C,4) STPW (GAITRite®)
Functional mobility
(TUG)
Hackney et al. CC n = 1; 73 13 years 90 min, 20 d, 11w. (20 sessions) Balance (BBS, FRT, ↑ Balance (8 points BBS pre/post and 0.19
20122 (C,4) Chronic Tango. Couples ABC) STPW m in FRT pre/follow-up)
(GAITRite®)
Functional mobility
(TUG)
Demers et al. 20153 CS n = 9; 2.44 m (1,66) 45 min, 2 d/w, 4w. (8 sessions) Balance (BBS) ↑ Balance (15,66 points more on average in
(C,4) 63.7(11.7) Subacute Jazz dance and merengue. Group BBS)
n = 11;
Subramaniam et al., CS 9.72 years 85–100 min, 6w. (20 sessions) Balance (BBS) ↑ Balance (Significant differences in BBS)
20154 (C,4) (3.32) Voluntary balance
control (LOS)
60,75(5.12)
Chronic (1◦ : 5 d/w/2w; 2◦ : 3 d/w/2w; 3◦ : 2 Reactive balance Significant differences in CoP response
d/w/2w.) Just Dance 3 (Kinect). control (MCT) RF time, movement velocity and maximum
Individual (TUG) excursion.↓ RF (Significant differences in
TUG)
26
Dursun E. et al. RCT T= T: 38.96 m 30 min, 5 d/w,3w. (15 sessions) Balance (BBS) Significant differences in BBS and TUG
20165 (C,4) (35.29) Tango. Couples between T and control group
47.15(15.5) Control: T: BTX-A + 45min CPT+ 30min Functional mobility
41.87 m Tango (TUG)
(31.68).
Control = 19 Chronic Control: BTX-A + 45 min CPT+
49.21(12,7) 30min CPT
Patterson et al. CS n = 20; 6.4 years 60 min, 2 d/w,10w. (20 sessions) STPW (Zeno Walkway, ↑ WS (pre/post 3.7 cm/s), no significant
20186 (C,4) (6.0) Ballet, contemporary, jazz, folk and ProtoKinetics) differences STPW (p > 0.05). ↑ Balance
62.4 (10.5) Chronic Ballroom dancing. Group Balance (Mini (p<0.05)
BESTest)
Subramaniam et al. CS n = 13; 9.72 years 85–110 min, 6w. (20 sessions) Balance: (FRT) ↑ paretic UL movement and ↓RF (ABC and
20197 (C,4) 60.75(5.12) (3.32) (1◦ : 5 d/w/2w; 2◦ : 3 d/w/2w; 3◦ : 2 RF (ABC, TUG) TUG)
Chronic d/w/2w.) Just Dance 3 (Kinect).
Individual
Micheli Rochetti CS n = 11; + 1 year 50 min, 2d/w, 6w. (12 sessions) Balance (BBS, FRT) ↑ Balance (Significant differences in BBS
et al. 20218 (C,4) 54.3(15) Chronic Bolero basic steps and stretching Functional mobility and FRT)↑ Functional mobility (Significant
exercises. Individual (TUG) differences in TUG)

ABC (Activities specific Balance Confidence Scale); BBS (Berg’s balance scale); BTX-A (Botulinum Toxin A); CC (clinical case); CoP (centre of pressure); CPT (con­
ventional physical therapy); CS (case series); d (day); DGI (dynamic gait index); FRT(Functional Reach Test); GR (Grade of recommendation); LE (level of evidence);
LOS (Limits of Stability test); m(months); MCT (Motor Control Test); min (minutes); RCT (randomized control trial); RF (risk of falls); STPW (spatio-temporal pa­
rameters of walking); sd (standard deviation); T (tango group); TUG (Time-up and go test); UL (upper limb); w (week); WS (walking speed).

except for Demers et al. [27], in which some patients were professional with knowledge and experience in the discipline of dance
wheelchair-bound and could do part of the intervention sitting down. In could adapt any step to the needs of his patients, providing one more
the two studies of Subramaniam et al. [29,30], it was absolutely tool to add to the wide range of techniques used in neurological
essential to maintain independent standing without technical aids for at rehabilitation.
least 5 min, as it was impossible to perform the intervention in any other Group therapy has shown beneficial effects at the psychosocial and
way. community integration levels [35]. 4 studies use the individual modality
Only 1 out of the 8 studies reviewed carried out the intervention in [29–32], 2 in couples [33,34] and 2 do the intervention in groups [27,
patients with subacute stroke phase [27]. 28].
Only 2 studies [27,28] determined previous dance experience As regards the DT programs mentioned in the studies included in this
through questionnaires; 60% of the patients in the Patterson et al. [28] review, 2 were provided by interdisciplinary health care staff [27,34], 1
study had previous experience. One study mentioned [31] “previous by a physiotherapist student with 10 years of practice in dance and 3 by
contact with dancing” as non-inclusion criteria. Demers et al. [27] dance instructors with previous experience working with elderly people
defined having received formal dance training before the stroke as or those with functional limitations [28,32,33]. Finally, 2 studies did not
“having received dance classes for more than one year as an adult”. indicate who performed the intervention [29,30].
Participants reported that DT was challenging but fun (3 patients out of
7 who dropped out did so because they did not like the intervention). 3.4. Dance therapy feasibility and acceptability

3.3. Dance intervention characteristics These results are detailed in Table 3. Five studies [27–29,31,34]
reported on participants who dropped out, with a mean rate of 18%.
Total duration of the DT program of ranged from 3 to 11 weeks, with Common reasons were another disease, did not like the intervention or
an average of 6.75 weeks. The dance sessions were provided with a difficulty of attendance. Four studies [28,30,32,34] reported atten­
frequency of 2–5 sessions a week, with an average of 2.6 sessions a week. dance, and only 2 [28,32] reported absences, and the reasons for missed
Furthermore, duration of the dance sessions ranged from 30 to 110 min classes commonly included scheduling conflicts, bad weather, personal
(including the corresponding breaks), with an average of 69.4 min. issues, or illness.
All dance modalities followed basic principles such as rhythm, None of the studies report adverse events. On some occasions,
coordinating movements, weight changes and balances. A rehabilitation reference was made to fatigue (“I worked hard, I’m tired” and also “I feel

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Table 3 Table 3 (continued )

Synthesis of results (Feasibility). Author and Adverse Adherence Participant Compliance
Author and Adverse Adherence Participant Compliance year. (LE, GR) events (dropout and perception and (attendance)
year. (LE, GR) events (dropout and perception and (attendance) reasons) satisfaction
reasons) satisfaction
classes were
Dureska 2007 Not N = 0/1 Not reported Lapses in missed across
reported duration of eight
study. participants.
Vacation or The average
sick leave. attendance
Hackney et al., Not N = 0/1 Exit Not reported rate was
2012 reported questionnaire: 92.5% of
He wanted the dance classes
program across all
to continue participants.
because of Subramaniam None N = 2/13 (1 Not reported Not reported
perceived et al., 2019 difficult to
benefits for his commute to
mobility, the laboratory
balance, and and 1 technical
QOL. problem
Demers et al., None N = 7/9 (4 Challenging, Not reported during data
2015 discharged enjoyable collection)
from activity and it Micheli Not N = 6/12 (3 Not reported Not reported
rehabilitation was great to Rochetti reported other diseases,
before complement to et al., 2021 2 did not
completion of their usual accept to stop
eight dance therapies. conventional
sessions and 3 7 dropped out physiotherapy
they did not and did not and 1 missing
like the enjoy the sessions)
intervention) intervention.
IMI: Intrinsic Motivation Inventory; QOL: quality of life.
Subramaniam None N = 0/11 IMI Scale. Most of the
et al., 2015 Significant participants
main effect of were adherent as tired as after a good session of physio” [27]; “not very intense” [31])
training on to the but in no case was it a problem for the participants, who could rest if
motivation [F rehabilitation
(2, 20) = paradigm in
they needed it or had scheduled breaks. Participants reported that DT
36.677, (p < this study was challenging but fun (3 patients out of 7 who dropped out did so
0.01)]. (98% for because they did not like the intervention) [27]. Falls were not reported
vigorous first and, in general terms, the patients felt more confident to move and less
two weeks,
in fear of falls.
consisting of 5
sessions/week Participant perception and satisfaction was assessed by Exit ques­
and 100% for tionnaire [28,33], Intrinsic Motivation Inventory (IMI) Scale [30] or by
two weeks of 3 subjective questions [27,34]. The main results were positive, except for
sessions/week 3 participants did not like dance intervention [27]. The participants felt
and last two
weeks of 2
more confident, and they enjoyed meeting other people with similar
sessions/ conditions (Table 3). Some wished to continue or lengthen DT [27,28,
week). 33].
Dursun et al., None N = 0/26 “All the It was
2016 participants observed that
were very none of our
3.5. Outcomes according to the ICF
proud for their participants
achievements”. had to The results reported in the different selected studies refer to the body
discontinue functions/activities levels of the ICF [22], specifically those corre­
tango class or
sponding to gait and balance.
additional
conventional 3 of the selected articles [28,32,33] objectively studied
rehabilitation spatio-temporal parameters of walking (STPWs) in chronic post-stroke
sessions patients, without significant differences in these parameters after the
because of DT intervention. 2 of them investigated gait with the GAITRite® system
extreme
fatigue.
[32,33] and another through pressure measurement system (Zeno
Patterson Not N = 2/20 Exit The median Walkway™, ProtoKinetics) [28]. The latter study [28] evaluated gait at
et al., 2018 reported (before questionnaire: number of the self-pace walking speed, and reported an improvement of 0.027 m/s
starting the “I loved it. It classes from pre to post-intervention. However, STPWs were not improved
intervention. 1 helped me be attended out
significantly after the dance intervention. Hackney et al. [33] also
would not be confident in of a maximum
able to attend walking of 20 was 19 evaluated gait speed during the 6-min walking test in three conditions,
the dance without my (Q1 = 18, Q3 normal gait speed, reverse gait and fast gait, and they obtained changes
classes cane. I enjoyed = 20). of +0.20 m/s, +0.10 m/s and 0.00 m/s, respectively. Dureska’s study
regularly and 1 being in a Throughout [32] evaluated STPWs with and without technical aids (such as a cane).
was no longer group with the entire
interested) others with study period a
The improvement in walking speed was similar with or without a cane
stroke.” total of 10 (0.104 m/s and 0.116 m/s, respectively). They also highlighted that
greater improvement was observed after 4 weeks (halfway through the
intervention), and they attributed the lack of results during the final 4

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Table 4
Methodological evaluation of selected studies according to the Checklist for Measuring Study Quality (CMSQ). Source: Downs SH, Black N. The feasibility of creating a
checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community
Health. 1998; 52(6):377-8432.
Cheklist/ítems Dureska Hackney Demers Subramaniam Dursum Patterson Subramaniam Rochetti
200735 et al., 201236 et al. 201537 et al., 2015 et al. 201638 et al. 201839 et al., 2019 et al., 2021

Quality of the study: 6 6 6 7 7 7 7 6

1. Hypothesis/objective 1 1 1 1 1 1 1 1
2. Results 1 1 1 1 1 1 1 1
3. Inclusion/exclusion criteria 1 1 1 1 1 1 1 1
4. Intervention 1 1 1 1 1 1 1 1
5. Confounding factors 0 0 0 0 0 0 0 0
6. Conclusions 1 1 1 1 1 1 1 1
7. Random variability 0 0 0 0 0 0 0 0
8. Adverse effects 0 0 1 0 0 1 0 0
9. Losses in follow-up 0 0 0 1 1 1 1 0
10. Values of probability 1 1 0 1 1 0 1 1
External validity: 1 1 1 1 1 1 1 1
11. Patient Participation Request 0 0 0 0 0 0 0 0
12. Patients’ representative of 0 0 0 0 0 0 0 0
the population
13. Staff, place and facilities 1 1 1 1 1 1 1 1
representative
Internal validity 4 4 4 8 8 4 8 5
14. Blinded subjects 0 0 0 0 0 0 0 0
15. Blinded examiners 0 0 0 0 0 0 0 0
16. Filtration of clear 0 0 0 0 0 0 0 0
information
17. Tracking length adjustments 0 0 0 1 0 0 1 0
18. Test statisticians appropìate 0 0 0 1 1 1 1 1
19. Compliance with the 1 1 1 1 1 1 1 1
intervention
20. Outcomes measures precise 1 1 1 1 1 1 1 1
21. Recruitment subject of study 1 1 1 1 1 1 1 1
22. Subject recruitment period 1 1 1 1 1 1 1 1
23. Radonmization groups 0 0 0 1 1 0 1 0
24. Assignment randomized 0 0 0 0 1 0 0 0
intervention (subjects and
examiner)
25. Correction confounding 0 0 0 0 0 0 0 0
factors
26. Losses of subjects in follow- 0 0 0 1 1 1 1 0
up
Statistical power 2 0 2 5 5 5 5 2
27. Sufficient power to detect 2 0 2 5 5 5 5 2
clinical effects in sizes sample
Total score 13 11 13 21 21 17 21 17
Percentage (%) 40,62% 34,37% 40,62% 65,62% 65,62% 53,12% 65,62% 53,12%

weeks to numerous absences. performance improvement of 1s from pre to post- DT intervention and
All the studies included in this review evaluated balance directly or 1.7s from pre to 1-month follow-up. In the case-control study [34] an
indirectly, and the most widely used scale to objectify such changes was average TUG change was obtained in the DT and the control group of
Berg’s balance scale (BBS) [27,30–34], Time-up and go test (TUG) 4.98 ± 7.1s and 2.65 ± 5.3s, respectively (p = 0.421). Furthermore, the
[29–34], the Functional Reach Test (FRT) [29,31,33] and the Mini­ clinical case with ballet [32] intervention showed an improvement of 5s
BESTest [28], with general significant results in favor of the DT on the TUG.
intervention.
Demers et al. [27] obtained a significantly improved balance 4. Discussion
outcome (BBS) with an average of 15.7 points of difference from the
initial assessment. Hackney et al. [33] obtained an 8 points improve­ DT was performed as complementary rehabilitation approach in
ment of the BBS score, while Dureska [32] reported a 4 points benefits. post-stroke patients in subacute or chronic phase. From the 8 included
In the same line, Dursun [34] found significant improvement in the studies in this systematic review, DT showed feasibility and accept­
balance outcome in the tango group compared to the control group in ability for post-stroke patients who are able to stand or using a wheel­
subacute post-stroke patients [27] (<6 months). The study by Patterson chair, through individual, couple or group sessions. The most common
et al. [28] showed significant improvement in balance evaluated with DT program was offered 2–3 times a week (1 h/session) for 6–7 weeks
the MiniBESTest [36] (p = 0.0005). [37], and interventions close to 1 h could be more highly recommended
Subramaniam et al. [29] showed that the TUG changes after DT to achieve motor engagement [39]. While DT showed promising but not
intervention were significantly correlated with changes in the flexion significant improvement for gait speed, significant benefits were re­
angle of the shoulder joint in the functional stand-reaching test (R2 = ported on balance after DT intervention.
0.52, p < 0.05), highlighting the importance of the upper limb in balance
reactions in post-stroke patients. In addition, Subramaniam et al. [30]
and Micheli Rochetti et al. [31]. showed significant TUG improvement 4.1. Participant characteristics
from pre to post DT intervention. Hackney et al. [33] reported TUG
Demers et al. [27] used DT in subacute post-stroke patients and

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showed a greater capacity of recovery than chronic post-stroke patients. valuable tool in the wide range of techniques used in stroke
The authors suggested that this finding was due to the greater sponta­ rehabilitation.
neous neuroplasticity that has been previously observed in subacute
rather than chronic post-stroke patients [40,41]. Interestingly, the pro­ 4.3. Dance therapy feasibility and acceptability
posed approach of these authors was to include patients with severe
functional limitations, such as being wheelchair-bound, to benefit from Dropout rates (18%), when reported, are in line with neurological
early intervention through DT, in line with other qualitative studies conditions other than Parkinson’s disease [14], and significantly lower
[39]. It is essential to determine the benefits in subacute and chronic than in Parkinson’s disease [50,51]. The low drop-out rates reported in
phases, and to identify whether the improvement in patients in the the studies by Subramaniam et al. [29,30] could suggest that the use of
subacute phase is due to spontaneous recovery [42] or to the interven­ virtual reality, which provides extra motivation, could be the key, as
tion itself. In this review, due to the heterogeneity of the experimental reported by participants. Losses due to patients not liking the inter­
design we were unable to compare changes in balance without any vention could be related to preferences for other activities as a com­
distinction between stroke phases. Nevertheless, all studies reported plement to conventional rehabilitation. However, the adverse effects
significant improvement in balance, which could indicate, in line with were null, so DT has been shown to be shown as a safe intervention, as
the literature [42], that response to DT is independent of post-stroke long as it meets the standards described in the studies. Future studies are
phases, as long as an individualized treatment plan is designed with necessary to determine the profile of patients who most likely to benefit
realistic objectives. from this intervention.
Previous experience in DT activity could significantly influence the The perception of improvement and satisfaction was, in general
level of therapeutic adherence, as well as the motor skill memory of terms, very positive in all five studies in which they were reported, and
movements [17]. However, patients, regardless of their previous expe­ shows high acceptability of the DT intervention by the patients.
rience of dance, enjoyed practicing DT, showing the feasibility of DT in a
population with subacute and chronic stroke. While DT could be 4.4. Outcomes according to the ICF
intimidating for people who have not previously participated in dance
classes [16], Demers et al. [27] reported that DT was challenging and The loss of mobility and gait in stroke survivors still represents a
fun for the patients. Previous dance experience could nevertheless be major challenge in rehabilitation [65], and it is associated with alter­
taken into account by adjusting the level of the DT programs proposed to ation of independence, social engagement and quality of life [66–68]. A
post-stroke patients, in addition to their functional capacities. All in all, qualitative study reported beneficial effects in physical, emotional and
DT could be considered as a good complement to conventional reha­ social aspects of the post-stroke patient [69] and, although none of the
bilitation to ensure motivation and adherence to the rehabilitation studies have directly evaluated participation as an outcome, these re­
program. Three of the studies [27,28,30] also report no adverse effects, sults might be influenced by the level of the ICF, and future studies need
which supports DT feasibility. to be more thoroughly documented [70]. A walking speed of 1 m/s or
less is associated with limitations in daily life activities and community
4.2. Dance intervention characteristics life, and a speed less than 0.6 m/s is associated with a higher probability
of hospitalization [71]. Although it has been recommended in order to
All dance modalities follow basic principles such as rhythm, coor­ eliminate error and inter-patient variability to observe an improvement
dinated movements, weight changes and balances. More specifically, the of 0.3 m/s [72] after rehabilitation program, a change in 0.1–0.2 m/s
Tango or adapted Tango, which is practiced by two people [15], pro­ can also be considered as clinically relevant [73]. The three studies that
vides great safety and allows the patients to perform the DT rehabili­ assessed gait reported limited benefits from no change to an increase of
tation program without technical aids. This condition also helps patients 0.20 m/s. Furthermore, Hackney et al. [33] assessed backward walking
to safely explore their functional limit capacities. In another way, when speed and reported an improvement of 0.10 m/s. While limited, these
DT is administrated in a group, it should be small in order to control the results suggest that Tango exercises, and more broadly, DT rehabilita­
needs of each individual and to provide more individualized attention. tion programs, could help to improve gait in different directions and
To increase safety, the collaboration of volunteers could be of help [43, should be evaluated in ecological situations in future studies.
44], and an adapted dance intervention (including ludic-inclusive It has been clearly established the literature that stroke-induced
components in addition to the functional aspect) [45] could be carried balance disorders are associated with various somatosensory impair­
out with patients seated on chairs, favoring the participation of those in ments, motor dysfunction, and perceptual and visual disturbances
a subacute stage [39]. The greatest strength of group DT in subacute [52–55]. The 8 studies included in this systematic review showed
post-stroke rehabilitation is that it has a perceived positive impact on improvement in balance after DT intervention performed individually or
mental functions, personal factors, motivation, and interpersonal and in groups [28,32]. It is worth noting that the greatest clinically relevant
social interactions. This type of intervention represents an innovation (>6) [56] balance improvement (>15 points in BBS) [27] was observed
for patients and could help to intensify their mobility [10], functional in a subacute post-stroke patients. Even with no evidence, we can sug­
recovery, perceived effort [39] and endurance, with only minimal ef­ gest that an early stage of stroke DT intervention might result in an
fects on fatigue [38]. A rehabilitation professional (usually physical or optimal rehabilitation program associated with neuroplasticity [40].
occupational therapists) [45] with knowledge and experience in the DT is a global therapy involving the whole body. To date, it is unclear
discipline of dance [31] or collaborating with dance artists [46], could which mechanisms could be mainly involved in balance rehabilitation
therefore adapt the steps to patient needs, guiding and assisting the with DT. However, it has been reported that post-stroke patients were
upper hemiparetic side. He/She could also use different types of dance, more receptive to visual information compared to healthy counterparts
individual or by pair, to meet individual patient preference [47] and [55,57]. While some evidence of rehabilitation efficacy could emerge
ultimately optimize attention/concentration and therapy adherence. In with therapy directly related to visual information such as virtual reality
this sense, some descriptive studies on the use of DT in post-stroke pa­ [57–61], future studies are needed to investigate sensory reweighting
tients highlight the importance of the characteristics of the dance after DT intervention in post-stroke patients, and its influence on body
instructor carrying out an adjusted intervention [37] and planning the awareness [62].
intervention in virtual environments [29,30,48]. Positive results at the Subramaniam et al. [29] showed that improvement of upper limb
level of the autonomic nervous system through aerobic training in vir­ flexion angle of the shoulder and reaction time after 10 DT training
tual environments suggest that a more aerobic intervention [48] would sessions was correlated with changes in TUG test in 13 post-stroke pa­
entail distinct advantages [49]. DT could be considered as one more tients. It was also previously reported that improved reaction time and

7
I. Ares-Benitez et al. Complementary Therapies in Clinical Practice 49 (2022) 101662

functional capacity of the upper limbs is helpful for stability recovery better established. The most widely used dance modality was tango and
and fall avoidance [63]. ballet, with sessions ranging from 30 to 110 min. The tango modality
Although most of the studies have focused their evaluation on bal­ seems to achieve better results due to the performance of steps in a
ance and gait, assessment of upper limb performance of DT rehabilita­ couple. Therapeutic dance can be considered as a complementary tool
tion of stroke can be considered as clinically relevant to maintain for rehabilitation in stroke survivors, in both subacute and chronic
equilibrium in dynamic conditions, as in reaching and grasping tasks. phases. Nevertheless, future high-quality studies are needed to deter­
From a case report, Hackney et al. [33] reported that 20 sessions of mine the dose-response characterization and to standardize the clinical
Tango led to improved TUG. It has been shown that dynamic balance approach.
measures [63] (such as the TUG) are greater predictors of the risk of falls
than walking speed or static balance test. The authors also found
increased TUG performance with dual cognitive task (count backward) Declaration of interest
and suggested that the multitask nature of the tango involving music,
current and future step patterns, partnering with other dancers, could be Authors have nothing to disclose.
related to the dual task benefit. All in all, these findings suggested that
DT can improve cognitive interference treatment in motor tasks in stroke Acknowledgement
survivors, notably while walking [33,64].
We thank Jeffrey Arsham for his proofreading of the manuscript and
4.5. Limitations and perspectives his suggestions regarding medical writing.

While our review has objectives related to feasibility that are part of Appendix A. Supplementary data
a scoping review (clarify key concepts and definitions; examine how
research is carried out in a field; identify key characteristics and factors; Supplementary data related to this article can be found at https://do
identify and analyze knowledge gaps), it also has objectives related to i.org/10.1016/j.ctcp.2022.101662.
DT effects (such as determining, as much as possible, the incipient evi­
dence on the effectiveness of this discipline in post-stroke patients) that
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