The effect of dance therapy on the balance of women over 60 years of age: The influence of dance therapy for the elderly

Abstract

Dance therapy is a physical activity that can lead to balance improvement in older adults. The aim of the study was to evaluate the effects of dance therapy on balance and risk of falls in older women. Twenty-four older women (mean age 66.4 years old) attended dance sessions for three months. Pretest/posttests were completed using the Postural Stability Test, the Limits of Stability Test, and the Fall Risk Test M-CTSIB. Results showed the Limits of Stability Test was significantly higher (17.5%) after dance classes. Regular use of dance therapy shows promise in improving balance by increasing the limits of stability.

Full text

The effect of dance therapy on the balance of women over 60
years of age: The influence of dance therapy for the elderly
Katarzyna Filar-Mierzwa
a
,Małgorzata Długosz
b
, Anna Marchewka
c
, Zbigniew Dąbrowski
c
and Anna Poznańska
d
a
Department of Occupational Therapy, University School of Physical Education in Kracow, Kracow, Poland;
b
University School of Physical Education in Kracow, Kracow, Poland;
c
Department of Clinical Rehabilitation,
University School of Physical Education in Kracow, Kracow, Poland;
d
Sport Institute, University School of Physical
Education in Kracow, Kracow, Poland
ABSTRACT
Dance therapy is a physical activity that can lead to balance improvement in
older adults. The aim of the study was to evaluate the effects of dance therapy
on balance and risk of falls in older women. Twenty-four older women (mean
age 66.4 years old) attended dance sessions for three months. Pretest/posttests
were completed using the Postural Stability Test, the Limits of Stability Test, and
the Fall Risk Test M-CTSIB. Results showed the Limits of Stability Test was
significantly higher (17.5%) after dance classes. Regular use of dance therapy
shows promise in improving balance by increasing the limits of stability.
KEYWORDS
Balance; dance therapy;
older women
Introduction
The process of aging is associated with an increase of neuromuscular deficits (Henderson, Irving, &
Nair, 2009; Latham et al., 2003). This may lead to falls and disorders of balance and gait (Moreland
et al., 2003; Rubenstein, 2006). Exercise is recommended as a way to slow down functional decline
and to improve balance and mobility in older adults (Granacher et al., 2010; Sturnieks, St George, &
Lord, 2008; Tiedemann, Sherrington, Close, & Lord, 2011). Dance movement therapy is a form of
physical activity that may improve balance in older adults. According to the American Dance
Therapy Association, dance therapy is the therapeutic use of movement as a process leading to
emotional and physical integration of a person (Kozłowska, 2002). It means that dance therapy is
multifaceted and affects both the physical and mental spheres. The aim of the study was to evaluate
the effects of dance therapy on balance and risk of falls in older women. We hypothesized that dance
therapy may improve balance in older women.
Falls in older adults
Age-related declines affect all major body systems, including the cardiovascular, respiratory, diges-
tive, nervous, and musculoskeletal systems (Demczyszak, Wrzosek, & Ziółkowska, 2007;
Wieczorowska-Tobis, Kostka, & Borowicz, 2011). Furthermore, aging may functionally affect the
motor and postural systems, which are both linked to postural stability (Błaszczyk & Czerwosz,
2005). It has been shown that loss of static balance; reduced excitability of the peripheral portion of
the vestibular system; and weaker compensatory, psychomotor, and sensory reactions, which are
associated with aging, increase risk for imbalance and falls (Hall & Miller, 2001; Nashner, 1993;
Shumway-Cook & Woollacott, 2001).
CONTACT Katarzyna Filar-Mierzwa, PhD katarzyna.filar@awf.krakow.pl Department of Occupational Therapy, University
School of Physical Education in Kracow, Al. Jana Pawła II 78, Kracow 31-571, Poland.
© 2016 Taylor & Francis
JOURNAL OF WOMEN & AGING
http://dx.doi.org/10.1080/08952841.2016.1194689

Approximately 28%–35% of people aged 65 years and over fall down each year, and this
proportion increases to 32%–42% for those over 70 years of age (World Health Organization,
2007). The causes of falls can be divided into internal (intrinsic) and external (environmental).
Internal factors are directly linked to age-related involution, chronic diseases, pharmacotherapy, or
recent acute illnesses (Kwiatkowska et al., 2011). Environmental factors include all the elements that
are present in the environment of older adults and may have an effect on their balance: They can be
slippery and uneven surfaces; steep stairs; wrapped, thick, and fluffy carpets; movable walkways;
thresholds; uncomfortable shoes; inadequate bathroom lighting, beds, chairs, and shelves; cables;
damaged street surfaces; or high curbs (Kwiatkowska et al., 2011).
The incidence of falls increases with age and can result in injuries leading to total immobility of
older adults or even their untimely death (Czerwiński, Borowy, & Jasiak, 2006; Szpringer,
Wybraniec-Lewicka, Czerwiak, Michalska, & Krawczyńska, 2008; Wieczorowska-Tobis et al.,
2011). Older people living in nursing homes are at increased risk of falling as compared to
community dwellers. It has been reported that approximately 30%–50% of people living in long-
term care institutions fall each year, and 40% of them experience recurrent falls (World Health
Organization, 2007). Ignasiak, Kaczorowska, Katan, and Domaradzki (2009) compared the mobility
of 30 older women from a nursing home and 30 age- and sex-matched community dwellers using
the specialized Fullerton Functional Fitness Test for older adults. The aim of the test, consisting of
six motor attempts, was to assess all the physiological parameters providing independence and safety
during the activities of daily living—namely, aerobic fitness, flexibility, strength, agility, and dynamic
balance. Women from a nursing home were shown to present worse physical fitness and balance
than the controls, which turned out to be associated with different living conditions and lifestyle.
Dance therapy
It has been found that dance therapy improves functioning of the body, coordination, balance,
flexibility, and speed of movements (Czerwiński et al., 2006; Pasek, Pasek, Witiuk-Misztalska and
Sieroń,2011;Żak, 2000). The use of other treatments such as a circuit aerobic step exercise program
(Anek & Bunyaratavej, 2015), aqua aerobic therapy (Kim & O’Sullivan, 2013), Nordic walking
training (Virag et al., 2015), as well as strength training in older adults (Holviala et al., 2014) also
improve balance and functional abilities.
It has been shown that physical exercise, including dance, may exert a beneficial effect on balance
and mobility; thus it can reduce the risk of fall in older adults (Alpert et al., 2009; Federici, Bellagamba,
& Rocchi, 2005; Hamburg & Clair, 2003; Keogh, Kilding, Pidgeon, Ashley, & Gillis, 2009).
Dance therapy is something that older adults enjoy, which in turn is essential in terms of their
motivation. Resnick and Spellbring (2000) showed that the main reasons older adults quit their
exercise programs are boredom and fear; conversely, having fun was the main reason behind the
adherence of older adults to their physical activity programs. The unique potential of dance stems
from the fact that the routine may vary from class to class, and it is often perceived as a fun, rather
than as a standard exercising (e.g., walking on a treadmill) (Alpert et al., 2009).
Granacher et al. (2012) confirmed that dance therapy plays an important role in improving
balance of older adults. They studied the effects of dance classes on static and dynamic postural
control. The study included two groups: 14 individuals who attended 60-minute salsa classes twice a
week for 8 consecutive weeks and 14 controls who did not practice any sports. The participants were
examined using a balance platform. The study showed that participation in salsa classes improved
both static and dynamic balance. Although the salsa classes were demonstrated to be a good way to
improve balance, they turned out to be insufficient for gait improvement and postural muscle
strengthening.
Hackney, Hall, Echt, and Wolf (2013) analyzed a group of visually impaired individuals over 75 years
of age to assess the impact of modified, adjusted forms of tango on their balance and quality of life.
More than half of the participants were women. Balancing skills of the participants were assessed with
2K. FILAR-MIERZWA ET AL.

the Dynamic Gait Index (DGI) and standing up from a chair (how many times a person is able to get up
from a chair in 30 seconds) tests. DGI was developed as a clinical tool to assess gait, balance, and fall
risk. The subjects were examined three times: Prior to the dance therapy, immediately thereafter, and
after one month. The intervention resulted in a significant improvement of balancing skills, which
points to the usefulness of dance therapy in this indication, also in older adults.
Methodology
Participants
The study included 24 women aged between 61 and 74 years (mean 66.4 years). Prior to enrollment,
each woman completed a survey regarding their incidence of balancing disorders and falls during the
two years preceding the study. None of the participants had a history of falls, but three reported
episodes of vertigo and balancing disorders. One of the inclusion criteria of the study was sedentary
lifestyle, i.e., lack of any physical activity aside from that associated with the activities of daily living.
Other inclusion criteria were: Female sex, over 60 years of age, and the lack of physical and/or
psychological contraindications to dance therapy, as certified by a primary care physician. The list of
the exclusion criteria included paralysis and paresis interacting with independent mobility, severe
vertigo, dementia, diabetes mellitus, and cardiovascular disorders.
The subjects were familiarized with all the study procedures and then their written informed
consent was sought. The protocol of the study was approved by the Local Ethics Committee at the
Regional Medical Chamber in Kracow, Poland.
Protocol for dance therapy sessions
The women participated in the dance therapy program for three months, with three 45-minute
sessions weekly. Each dance therapy session included three parts. The first part was a 10-minute
warm-up, including training of an appropriate dancing posture (exercises for a normal body
posture), slow dancing technique evenly improving all muscle groups equally, and dancing-gymnas-
tic exercises (Janowska & Seredyńska, 2006). The second part, a 30-minute proper training, included
basic steps and figures of a folk dance (Kuźmińska, 2002), ballroom dance (Official Board of
Ballroom Dancing, 1968), integration dance, and dances of foreign nations (PSPiA Klanza, 1995),
as well as practicing simple choreographies, including previously learned steps, figures, and dancing
improvisation. The third part, a 5-minute cooling down, included coordination, balance, breathing,
and relaxation exercises (Janowska & Seredyńska, 2006).
The dance therapy, according to the aforementioned protocol, represented a form of moderate
physical activity, corresponding to 50%–70% of maximum heart rate in a given person. For example,
the target heart rate for a 70-year-old person is 75–105 beats per minute, and this value should not
be exceeded at any point of the session. Therefore, heart rates of participating women were
monitored with a cardiac monitor (Polar Sport Tester, Polar Electro Oy, Finland) throughout each
training session.
Standardization of tests
First, the subjects were examined for their postural stability. The aim of this static test was to
evaluate the participant’s ability to maintain balance by means of the angular deflection of her center
of gravity. Selection of an appropriate static measurement scale was based on body height of the
participant (Biodex Medical Systems, 2009; McIlroy & Maki, 1997; Nashner, 1993).
The Limits of Stability (LOS) test was the second test performed by the study participants. The
LOS for balance in a standing position was determined at the maximum angle at which the
subject could deviate from the vertical position without losing her balance. This test verified the
JOURNAL OF WOMEN & AGING 3

subject’s ability to maintain her center of gravity whenever it was outside the plane of support.
When the LOS is exceeded, a person falls or needs to implement corrective strategies to prevent
the fall (place-step, bending the knees) (Biodex Medical Systems, 2009;Clark,Rose,&Fujimoto,
1997).
The last test was the Fall Risk Test –Modified Clinical Test of Sensory Integration and Balance
(FRT M–CTSIB). Researchers selected this test to assess the risk of falls. According to literature, it
accurately identifies persons with moderate to severe balancing disorders. Furthermore, the test can
be used to identify the disorders linked to various systems involved in postural control, i.e., visual
control, and vestibular and somatosensory systems. The test is comprised of four parts. In Part 1, the
ability to maintain a standing position on a solid surface motionless with eyes open (visual control,
vestibular and somatosensory systems) is tested. In Part 2, the same parameter is examined but with
eyes closed. The aim of Part 3 is to determine one’s ability to maintain an upright position on a
dynamic surface with open eyes (evaluation of interaction between visual control and somatosensory
systems). The same parameter is a subject of examination in Part 4 but with eyes closed (assessment
of interaction between somatosensory and vestibular systems). The test is well known in clinical
practice, and its results correlate strongly with the risk of falling (Biodex Medical Systems, 2009;
NeuroCom Int., 2008).
Procedures
Prior to and after dance therapy, subjects were tested on the BioSway balance platform (Biodex),
according to standardization in line with the manufacturer’s instructions (Biodex Medical Systems,
2009). The device consisted of a suitably configured platform and a display. It also provided a foam
surface to create unstable ground conditions. Researchers used the platform because it is convenient
and provides reliable, reproducible, and objective data on the levels of neuromuscular control and
balance on both stable and unstable surfaces. Each subject was examined three times. Prior to each
proper test, a test examination was carried out in order to ensure that each participant understood
the procedure correctly.
Results
The results were analyzed with a specialized software package, Statistica (StatSoft). First, the
outliers were identified and excluded from further analysis. Statistical characteristics of the results
were presented as arithmetic means, standard deviations, medians, lower and upper quartiles,
maximum and minimum values, and coefficients of variation (%). The results are shown in
Table 1.
Normal distribution of the analyzed variables was verified with the Shapiro-Wilk test, a powerful
test that is particularly applicable for examination of small samples. As the values of all three tests
(Postural Stability Test [PST], LOS test, FRT) were distributed normally, a paired t-test was used for
comparison of pre- and postdance therapy values. The results are presented in Table 1.
A statistically significant difference (p< 0.05) was found between the pre- and postdance
therapy results for the LOS test. The mean postdance therapy result of the test was 17.5% higher
than the respective predance therapy value (29.1 ± 11.44 vs. 34.2 ± 11.91; p= 0.0059) (Table 1).
The researchers did not find a significant difference between the pre- and postdance therapy
results for the PST (p= 0.5412). Similarly, no statistically significant differences were observed
between the pre- and postdance therapy values for all the parts of the FRT M–CTSIB (eyes open firm
surface: p= 0.3822; eyes open foam surface: p= 0.5754; eyes closed firm surface: p= 0.1561; or eyes
closed foam surface: p= 0.9236) (Table 1).
4K. FILAR-MIERZWA ET AL.

Discussion
The aim of the study was to analyze the effects of dance therapy on balancing skills in women older
than 60 years. The study showed that a 3-month program of dance therapy resulted in a significant
improvement of balancing skills in older women, as demonstrated by an increase in the values of the
LOS test.
Available studies have suggested that dance therapy may improve balance and reduce the risk of
falls in older women. Most previous studies analyzing the effects of dance classes on balance in older
adults documented a significant improvement of this parameter (Eyigor, Karapolat, Durmaz,
Ibisoglu, & Cakir, 2009; Shigematsu et al., 2002; Sofianidis, Hatzitaki, Douka, & Grouios, 2009).
Alpert et al. (2009) analyzed the effects of a modified form of jazz dance on balancing skills,
cognitive function, and mood in healthy older adult women. The level of balancing skills was
determined with a standardized clinical test, The Sensory Organization Test (SOT). The test was
used to study three sensory activities related to sustainability: Visual aids, proprioception, and
kinesthetic control. Balancing skills of the study participants improved gradually during the dance
classes and were eventually significantly better than at the baseline. Jazz dance improves flexibility of
the locomotor system and exerts a favorable effect on both the balancing and cognitive skills.
Therefore, jazz dance classes constitute an original and attractive option to improve balancing skills
of older women and to prevent falls. In another study, Borges et al. (2012) analyzed the effects of a
dance therapy, including some figures and steps of ballroom dancing, on balancing skills and
autonomy in older adults with a sedentary life. The study included 75 people, among them 39
individuals who attended dance classes for 8 months, three times a week, and 36 controls who did
not undertake any physical activity throughout the analyzed period. Balancing skills of the study
participants were determined on the basis of their posture and with a stabilometer. When compared
to the controls, individuals subjected to dance therapy showed significant improvement in their
balancing skills and functioning.
One explanation for the improvement of balancing skills in our participants is the fact that
dancing involves all three components required to maintain balance, i.e., visual control and the
somatosensory and vestibular systems. The somatosensory system was previously shown to be an
essential component of dance training and to exert beneficial effects on both the motor and sensory
orientation (Simmons, 2005).
Our findings partially supported the hypothesis that dance therapy may improve balancing skills
in older women. However, it should be remembered that the improvement was confirmed with only
one out of the three conducted tests—namely, with the LOS test.
Aging is associated with a decrease in stability limits (Holbein-Jenny, McDermott, Shaw, &
Demchak, 2007). This reflects the influence of multiple factors, among them reduced ankle
Table 1. Pre- and postdance therapy results of the conducted tests and statistical significance of the intervention-related changes.
Test NAverage Median Min. Max.
Lower
quartile
Top
quartile SD
Coefficient of
variation
Paired
t-test
Postural Stability Test Before 23 1.11 1.20 0.30 2.20 0.70 1.30 0.43 38.53 t=−0.62
After 24 1.15 1.20 0.40 1.80 0.80 1.55 0.43 37.11 p= 0.5412
Limits of Stability Test Before 24 29.1 29.0 10.0 54.0 20.5 36.5 11.44 39.28 t=−3.04
After 24 34.2 32.0 15.0 58.0 28.0 42.0 11.91 34.86 p= .0059*
Fall Risk Test CTSIB eyes
open foam surface
Before 24 1.36 1.37 0.82 2.07 1.16 1.58 0.28 21.05 t=−0.57
After 23 1.32 1.33 0.86 2.05 1.06 1.60 0.32 24.27 p= 0.5754
Fall Risk Test CTSIB eyes
open firm surface
Before 24 0.67 0.64 0.32 1.00 0.58 0.76 0.17 25.88 t= 0.89
After 24 0.64 0.62 0.33 1.20 0.46 0.76 0.22 34.00 p= 0.3822
Fall Risk Test CTSIB eyes
closed foam surface
Before 23 2.63 2.52 1.95 3.54 2.26 3.02 0.46 17.50 t=−0.09
After 23 2.45 2.47 1.57 3.52 1.91 2.94 0.59 24.29 p= 0.9236
Fall Risk Test CTSIB eyes
closed firm surface
Before 24 0.73 0.69 0.40 1.28 0.52 0.89 0.23 31.89 t= 1.47
After 24 0.69 0.70 0.28 1.11 0.56 0.83 0.21 30.99 p= 0.1561
Note. *Significantly different from the respective predance therapy value (p< 0.05).
JOURNAL OF WOMEN & AGING 5

muscle strength (Melzer, Benjuya, Kaplanski, & Alexander, 2009) and poor cutaneous mechan-
oreceptor function in the soles of the feet, both resulting in greater instability of older subjects
during the activities of daily living and increased risk of falling (Girardi, Konrad, Amin, &
Hughes, 2001).
Dance therapy puts great emphasis on controlled weight shifting and ankle movement sway,
alternation between a narrow stance and a wide stance to continually change the base of support,
rotational trunk-driven movements, and dorsiflexion and plantar flexion during dance. These
features may impact important sensorimotor elements that contribute to enhanced limits of stability.
Therefore, the increase in the limits of stability may likely be attributed to the improvements in
flexion/extension ankle torques, range of ankle motion, movement recovery strategies, or sensory
integration. All these features are inherent to dance (Fuzhong, 2014).
Due to dance therapy-induced increases in the limits of stability, older women can more
efficiently perform the activities of daily living, which provides them with a stronger sense of
independence and safety. This in turn may result in quality of life improvement.
Participation in dance classes protects older subjects against deterioration of their physical fitness,
a key determinant of both normal body balance and reduced risk of falling. Women in this study
commented that they liked dance therapy and would continue this form of physical activity. Attitude
may protect older women against balancing disorders and falls in the future.
Balancing skills can be assessed with various types of clinical tests, scales, and exams on dedicated
balance or posturographic platforms. In this study, we used the BioSway, a special balance platform.
Importantly, previous studies showed that examination with a balance platform provides highly
reproducible results and is a reliable method to assess static and dynamic balance in people of
various ages (Ocetkiewicz, Skalska, & Grodzicki, 2006).
Aside from the measurement methods, this study also has other strengths. The measurements
with the balance platform were taken immediately after completing the dance therapy program in
order to exclude potential confounding effects of other physical activity on the results. Moreover,
only the data for women who regularly attended the dance therapy classes were included in the
analysis.
Limitations
However, our study is not free from some potential limitations, such as lack of a control group,
small sample size, and that only one out of the three parameters was significant. Future studies
should include women from various age categories, also above 80 years of age, whose balancing
skills usually deteriorate markedly. As dance therapy is multifaceted, the psychological and social
effects of this modality should be further evaluated as a motivational factor for continued
physical activity.
Conclusions
Regular dance therapy seems to be a promising method for improving balancing skills due to
increase in the stability limits. Therefore, this form of physical activity, supervised by qualified
professionals, should be recommended for older women, especially those who have sedentary life-
styles. However, due to potential limitations of this study, verification of this hypothesis requires
further research, including a control group and a larger number of subjects.
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