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Disability and Rehabilitation
ISSN: 0963-8288 (Print) 1464-5165 (Online) Journal homepage: http://www.tandfonline.com/loi/idre20
Effects of line dancing on physical function and
perceived limitation in older adults with self-
reported mobility limitations
Crystal G. Bennett & Madeleine E. Hackney
To cite this article: Crystal G. Bennett & Madeleine E. Hackney (2017): Effects of line dancing
on physical function and perceived limitation in older adults with self-reported mobility limitations,
Disability and Rehabilitation, DOI: 10.1080/09638288.2017.1294207
To link to this article: http://dx.doi.org/10.1080/09638288.2017.1294207
Published online: 25 Feb 2017.
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ORIGINAL ARTICLE
Effects of line dancing on physical function and perceived limitation in older
adults with self-reported mobility limitations
Crystal G. Bennett
a
and Madeleine E. Hackney
b,c
a
School of Nursing, University of West Florida, Pensacola, USA;
b
Atlanta VA Medical Center, Center for Visual & Neurocognitive Rehabilitation,
Atlanta, USA;
c
Department of Medicine, Division of General Medicine and Geriatrics, Emory University School of Medicine, Atlanta, USA
ABSTRACT
Introduction: Older adults with mobility limitations are at greater risk for aging-related declines in phys-
ical function. Line dancing is a popular form of exercise that can be modified, and is thus feasible for
older adults with mobility limitations.
Purpose: The purpose of this study was to assess the effects of 8 weeks of line dancing on balance,
muscle strength, lower extremity function, endurance, gait speed, and perceived mobility limitations.
Methods: An experimental design randomly assigned older adults to either an 8-week line dancing or
usual care group. The convenience sample consisted of 23 participants with mobility limitations (age
range: 65–93 years). The intervention used simple routines from novice line dance classes. At baseline and
at 8 weeks, balance, knee muscle strength, lower extremity function, endurance, gait speed, and mobility
limitations were measured. ANCOVA tests were conducted on each dependent variable to assess the
effects of the intervention over time.
Results: Results found significant positive differences for the intervention group in lower extremity func-
tion (p<0.01); endurance (p<0.01); gait speed (p<0.001); and self-reported mobility limitations
(p<0.05).
Conclusions: Eight weeks of line dancing significantly improved physical function and reduced self-
reported mobility limitations in these individuals. Line dancing could be recommended by clinicians as a
potential adjunct therapy that addresses mobility limitations.
äIMPLICATIONS FOR REHABILITATION
Line dancing may be an alternative exercise for older adults who need modifications due to mobility
limitations.
Line dancing incorporates cognitive and motor control.
Line dancing can be performed alone or in a group setting.
Dancing improves balance which can reduce risk of falls.
ARTICLE HISTORY
Received 12 July 2016
Revised 7 February 2017
Accepted 8 February 2017
KEYWORDS
Exercise; dance; muscle
strength; gait; endurance
Introduction
With aging, mobility tasks frequently become increasingly difficult
and may result in activity limitations, participation restrictions and
ultimately, the loss of independence. Two-thirds of those over
65 years report serious difficulty walking and climbing a flight of
stairs [1]. Exercise has been found to delay progression of disabil-
ity [2] and decrease the risk for mobility limitations [3,4] in com-
munity-dwelling older adults. However, many older adults have
limitations, which make exercise challenging. Fear of falling or
injury, lack of time and enjoyment, and lack of social support are
also significant barriers to exercise participation [5]. However,
dance is an aerobic exercise that may be acceptable to older
adults because it involves group socialization and [6], is often
accessible to older adults in their communities [7].
Dance is a complex motor activity that involves cognitive con-
trol. Dance, like walking, balance training, and strength training,
requires the integration of sensory, motor control and musculo-
skeletal systems and uses lower extremity large muscle groups [8].
In contrast to walking, dance involves multi-directional changes,
attention and movement to musical beats, and engages memory
with a complex motor pattern [8–10]. Further, dance involves
dynamic balance control while coordinating a movement in
response to music and with other dance participants [11]. Dance
requires constant feedback from the visual system to guide body
movements in relation to visual objects such as other dancers [8].
Dance also actively and intensively uses the auditory system to
synchronize movement to music and verbal commands from the
instructor [12].
Research into dance’s benefits have reported improved static
and dynamic balance [11–16], knee extensor muscle strength [17],
lower extremity function [10,11,13,18–22], endurance
[10,11,13,15,16], and gait speed [11,13,16]. Adults who perceive
having difficulty with mobility activities may restrict their partici-
pation in activities such as exercise and thus placing them at risk
for further declines. One small study of contemporary dance
revealed significant reductions in perceived degree of difficulty
with performing activities of daily living after dance participation
[23]. Line dancing is a simple aerobic exercise that can be modi-
fied specifically for those with mobility limitations. Group dance,
such as line dancing, increases social interaction and exercise
adherence among participants [6,24]. Further, line dancing does
CONTACT Crystal G. Bennett cbennett@uwf.edu UWF, Department of Nursing, 11000 University Parkway, Pensacola, FL 32514, USA
ß2017 Informa UK Limited, trading as Taylor & Francis Group
DISABILITY AND REHABILITATION, 2017
http://dx.doi.org/10.1080/09638288.2017.1294207
not require a partner and can be modified to meet the individual
needs of the participant. Whether line dancing would have a simi-
lar effect on strength, balance, endurance, and perceived mobility
limitations is uncertain. This study addresses an important gap in
knowledge regarding the effects of dance on participants’percep-
tions of limitations with mobility tasks, as well as knowledge
related to the effects of line dancing on mobility. Gathering this
information will aid the development of therapies that address
issues stemming from mobility limitations as well as the percep-
tions related to mobility limitation.
The purpose of this study was to assess the effects of 8 weeks
of line dancing on balance, muscle strength, lower extremity func-
tion, endurance, gait speed, and perceived mobility limitations.
We hypothesized that the line dance intervention group would
improve in balance, knee muscle strength, lower extremity func-
tion, endurance, and gait speed compared with a usual care
group. In addition, reductions in perceived mobility limitations
were expected for the dance intervention group.
Methods
This study was approved by the Institutional Review Board at the
University of Florida. All participants provided written informed
consent prior to participation.
An experimental design randomly assigned older adults to
either an 8-week line dancing or usual care group. In a preliminary
study, eight weeks of line dancing was sufficient to observe sig-
nificant improvements in balance and lower extremity function in
10 older adults [22]. At pretest and immediately after the 8-week
intervention, measures were collected for balance, muscle
strength, lower extremity function, endurance, gait, and perceived
mobility limitations.
Inclusion/Exclusion Criteria. The convenience sample was seden-
tary, non-disabled community-dwelling adults, age 65 years and
older. Inclusion criteria included: exercising fewer than 90 min a
week, self-reported difficulty walking 1
=
4mile or climbing a flight
of stairs, ability to follow and understand directions and willing-
ness to be randomized. Exclusion criteria included: use of an
ambulatory assistive device; neurological conditions (e.g.,
Parkinson’s disease or stroke); use of portable oxygen, internal car-
diac defibrillator, or myocardial infarction within the previous
6 months.
Recruitment. Participants were recruited from the Northwest
Florida community through advertisement via local senior centers,
healthcare clinics, and church organizations. Participants from the
pilot study were not invited to participate in this study. Interested
potential participants contacted the Principal investigator (PI) by
phone and were screened by the PI for eligibility using a pre-
approved script. For eligible and interested persons, an appoint-
ment was made to obtain written consent and collect baseline
data. The PI used a randomized block design of 4 to randomize
participants by a computer following collection of written
informed consent and prior to testing. At the baseline visit, sub-
jects were screened again for eligibility and information about
health history. Prior to starting the intervention, the line dancing
participant obtained written approval from their healthcare pro-
vider to participate in the dance classes. Testing and line dancing
took place at a community center located in a rural community in
Northwest Florida, with adequate space and flooring suitable for
line dancing and testing.
Because there were no dance intervention studies that exam-
ined perceived mobility limitations as an outcome, estimations for
sample were based on other outcomes. Sample size was based
upon a preliminary line dance study that used single leg standing
balance [22]. In a preliminary line dancing study, an effect size of
1.17 was found for one leg standing balance in older adults with
mobility limitations [22]. The effect size from this study was used
in power analysis. Using the POWER procedure in SAS software
(version 9.2, Cary, N.C.) and assuming a level of significance of
0.05, a two-sided test, and power of 0.80, the detectable effect
size was 0.91 for 20 subjects per group that also allowed for 20%
attrition.
Dance intervention
The 8 week line dancing intervention was a low impact dance
program (i.e., one foot was always in contact with the floor), previ-
ously considered appropriate for older adults with mobility limita-
tions [22]. Line dancing classes met 1 h twice a week for 8 weeks.
The classes were taught by a dance instructor with more than
15 years of experience teaching line dancing to older adults, who
had taught line dance classes in the pilot study and assisted in
the design of the dance intervention for the present study. The
line dance intervention used simple routines from novice line
dance classes. The dance routines varied with each class and new
movements were added with each routine, recommended for
community dance classes for older adults [11,14]. Line dancing
involved continuous integrated movements of the legs and trunk,
weight transfers and postural control. Choreographed movements
included walking forward/backward, side to side, turns, pivots,
grapevine patterns, shuffles, knee flexion, stepping and stomping.
The line dancing session included 8 specific choreographed dance
routines performed to music. The dances were taught by pro-
gressing from easy to more complex dance movements.
Previously learned dances were repeated the following week.
Participants learned and performed the dances at a slower tempo
prior to performing the choreography at a moderate pace.
Modifications
The dance steps were modified so all participants could engage
[11,25]. Modifications were documented each session on a partici-
pant log. The instructor and the PI observed participants for diffi-
culty with the movements and introduced a similar but less
challenging movement as a replacement. For example, one partici-
pant had difficulty performing the grapevine pattern of the feet
(alternate stepping across and behind other foot in successive
steps) and the movement was changed to side to side steps to
allow the participant to safely continue dancing. Although three
participants needed modifications, nine participants were able to
perform the steps without difficulty.
Procedures
Each group class included 10 minutes of warm-up, 40 minutes of
dancing and 10 minutes of cool-down. The warm-up session
included seated stretching. The line dancing portion included
learning new dances, practice time, a break and reviewing dances
learned in previous classes. During dancing, the Borg Rating of
Perceived Exertion Scale (RPE) [26] was used to monitor safety.
Participants were instructed to self-monitor and taught to rate
exertion of line dancing on a scale range of 6 (no exertion) to 20
(maximum exertion). None of the participants reported a Borg rat-
ing of 15 or higher indicating heavy to maximal exertion.
The line dance instructor gave verbal instructions and visual
cues (e.g., pointing finger to left to indicate traveling left) while
demonstrating the movements. When teaching new steps, the
instructor demonstrated facing the participants before facing the
opposite direction. The instructor and her assistant were always
2C. G. BENNETT AND M. E. HACKNEY
visible to the participant during the dancing. Participants were
asked to wear supportive and comfortable shoes for the classes.
Safety monitoring
For safety, participants were told that if at any time they felt light-
headed, dizzy, weak or tired, short of breath or had chest pains,
they should stop dancing and sit to rest for 5 min. One participant
complained of being tired halfway through a line dance class, but
after resting for 10 min was able to resume dancing. The PI, a reg-
istered nurse, was on site and an automatic external defibrillator
(AED) was available for each dance class. The investigator and line
dance instructor had cell phones for immediate access to emer-
gency services if needed during the classes. The participants were
asked to provide emergency contact information.
Adherence
Adherence to line dancing was essential to ensure the participant
received an adequate amount of the intervention. Attendance was
monitored and recorded for each dance class. The investigator
greeted the participants at each dance session and offered an
opportunity for questions. Those participants who did not inform
the investigator of their absence were contacted by telephone to
let them know they were missed at class and to ascertain if bar-
riers to participation can be addressed. Participants in the usual
care group were called at start of intervention and every 2 weeks
to provide an opportunity to ask questions and be acknowledged
for their continued participation in the study.
Usual care group
Participants in the usual care group were instructed to continue
their normal daily activities during the study period but not begin
regular exercise program while in the study. Participants were
instructed to complete a daily activity log. The usual care group
was offered free line dance classes for 8 weeks after the study
ended.
Testing protocol
The PI administered all of the tests. The tests were administered
within 4 weeks of intervention starting (pre) and within 1 week of
completion of intervention (post). Balance was measured by the
14-item Berg Balance Scale (BBS) [27] that evaluates performance
on common balance tasks. Participants were rated on a 5-point
scale for the ability to perform the task. These ratings were
summed for a total score ranging from 0 to 56 with higher scores
indicating better performance. The BBS has been found to have
high inter (ICC ¼0.98) and intra-rater reliability (ICC ¼0.98) in a
community dwelling elderly population [28].
Muscle strength of knee extensors and knee flexors of domin-
ant side were measured because adequate knee strength is essen-
tial for mobility tasks [29]. The Nicholas Manual hand-held
dynamometer (Model: BK-7454) measured muscle strength and
was zeroed prior to each measurement following manufacturer
instructions. The participant sat in a chair and was tested with
knee at an 80flexion for assessing knee extensors and at 90
flexion for knee flexors. The dynamometer was placed at the front
lower leg proximal to ankle for knee extensors and to the poster-
ior of the lower leg proximal to ankle for knee flexors. Participants
were shown a demonstration of the movements prior to testing.
Participants were instructed to increase their effort gradually using
maximum effort to move their lower extremity while the dyna-
mometer was held in place for 5 s as this has shown to be
adequate to achieve maximum effort [30]. The force of each
muscle group in kilograms was measured twice and the mean of
the tests were used. Muscle strength was normalized for partic-
ipant’s body weight where the muscle strength in kg is divided
by the participant’s weight in kilograms. Test-retest reliability was
high for knee extensors (0.99–1.00) and knee flexors (0.98–0.99) in
community dwelling older adults with a history of falls [31].
The Short Physical Performance Battery (SPPB) is a valid and
reliable measure of lower extremity function and has been used
in multi-center RCTs of older adults. Tasks of the SPPB include
5XSTS, a tandem, a semi-tandem, and side by side stance held for
max of 10 s, and timed 4 m walk. Scores of 1 to 4 for each test
(5XSTS, balance stances, and timed 4 meter walk) were assigned
based on time (quartiles) of performance [32]. A summary score
(0–12) was calculated by adding the scores of each test.
Test–retest correlations were 0.97 for balance, 0.89 for gait speed,
and 0.73 for time to get up from chair [33].
The 400 m walk has been used as an objective measure of
endurance in large studies such as the Lifestyle Interventions and
Independence for Elders (LIFE) study with community dwelling
older adults. Test–test reliability for inability to complete the 400
m walk is high (0.91–0.93). Older adults who stopped to rest dur-
ing the 400 m walk were found to be five times more likely to
develop mobility limitations than those who did not stop [34].
Participants who are unable to complete the 400 m walk within a
15 min time period or who are unable to complete it without rest
periods or assistance are considered to have major mobility limita-
tions [35]. Participants were instructed to walk the 400 m distance
at their usual pace. The number of minutes needed to complete
the 400 m walk (a measure of endurance) and the ability to com-
plete the walk in 15 minutes was recorded (dichotomous variable).
Gait speed (meters/second) was computed using data from the
400 m walk. In the current study, one participant in the usual care
group at pretest did not complete the 400 m walk in 15 min due
to stopping to rest. Since 15 min is the maximum time allowed for
the test, the participant was instructed to stop walking and
15 min was recorded. The distance walked in meters was also
recorded.
Perceived mobility limitation was assessed by asking partici-
pants to rate difficulty performing mobility tasks listed on the
Fried Preclinical Disability (PCD) Screening [36]: “getting out of a
car”,“getting out of bed”,“walking down a flight of stairs”,
“walking around home”,“walking one-half mile”,“walking a 1
=
4
mile”, and “climbing a flight of stairs”. Participants rated difficulty
from (0) “no difficulty”to (5) “extreme difficulty”. Scores were
summed for mobility tasks. The individual ratings for these tasks
were used to determine mobility limitations. As such, a participant
with a rating of difficulty (a score of 4) for either difficulty walking
a quarter of a mile of climbing a flight of stairs was considered to
have mobility limitations.
Covariates
Depression, balance confidence, and balance were used as covari-
ates in analyzes. Depressive symptoms were assessed using the
15-item Geriatric Depression Scale-Short Form (GDS-S) [37]. The
GDS long form and the GDS-S have been found to be highly cor-
related (r¼0.89) in assessing depressive symptoms supporting the
use of the GDS-S [38]. Respondents provided “yes”and “no”
responses to whether they have symptoms of depression. There
are 10 items which when answered “yes”and 5 items when
answered “no”indicate depressive symptoms. Participants are
asked how they have felt in the past week only. Those with a
EFFECTS OF LINE DANCING 3
score of greater than 5 were referred to their healthcare provider
as this indicates clinical depression [39].
Balance confidence was assessed using the Falls Efficacy Scale
(FES) [40] that is based on self-efficacy theory. The FES has 10
items that asks subjects to rate their level of confidence in per-
forming common everyday activities such as “walking around
house”, and “getting in and out of bed”without falling. Subjects
rated confidence from (1) “very confident”to (10) “not confident
at all”. Higher scores indicate low balance confidence that has
been associated with higher risk of preclinical disability [41].
Test–retest reliability was good at 0.71. Reliability and validity has
been established in community dwelling older adults [40].
Data analysis
Data were entered into the Statistical Package for the Social
Sciences (SPSS Ver. 21) for analysis. Descriptive statistics were
used to describe the characteristics of the sample. Analysis of
covariance (ANCOVA) with the pretest as a covariate was used to
assess the effects of line dance intervention over time. The inde-
pendent variables were dance or usual care group. Significance
was determined using an alpha of 0.05.
Assumptions for ANCOVA were tested and included normal dis-
tribution of data, homogeneity of variance, and sphericity.
Assumption of homogeneity of variance was determined by a
non-statically significant Levene’s test. Assumptions of normal dis-
tribution and sphericity were determined by a non-statistically sig-
nificant Shapiro–Wilks test and Mauchley’s test.
An evaluation of the utility of the covariates (depressive symp-
toms and balance confidence) and the dependent variables were
tested by correlation coefficients between the covariates and the
dependent variables at posttest. If the correlation coefficient was
significant between the covariate and the dependent variable,
then the covariate was included in the analysis.
Analysis of variance (ANOVA) with pretest as a covariate was
used to assess the effects of line dancing on balance, muscle
strength, lower extremity function, endurance, gait, and perceived
mobility limitations. Prior to this analysis, assumptions of normality
and homoscedasticity were assessed. The Levene’s test was not
significantly different for any of the outcomes that indicated that
the assumption of homoscedasticity was met. Normality was
assessed by examining the dependent variables for skewness, kur-
tosis, and a non-significant Kolmogorov–Smirnov (K–S) test.
The K–S tests were significant for the BBS. Thus, the BBS was
included as a covariate. In addition, Pearson’s correlations were
used to examine the efficacy of potential covariates (depressive
symptoms and balance confidence) with the outcomes. In spite of
violations of normality, ANCOVA was used to assess the effects of
the line dance intervention because this statistic is robust against
violations of normality. ANCOVA was used to assess the effects of
dance while controlling for the effects of depressive symptoms,
balance confidence, and the BBS.
Results
Forty-five older adults were screened for eligibility to participate
but twenty-two were excluded because they reported use of
assistive devices (n¼4), having a pacemaker or MI within past six
months (n¼1), or exercising 90 min or more per week (n¼17).
Twenty-three community dwelling older adults who met inclusion
criteria, and signed a consent form were enrolled in the study and
randomized to either the usual care group (n¼11) or the dance
group (n¼12). The sample consisted of 3 males and 20 females
whose age ranged from 65 to 93 years (M ¼73.4, SD ¼8.4). There
were no significant differences in the demographic (Table 1) and
health status characteristics (Table 2) between groups at baseline.
In this study, there were no drop-outs and no line dance partici-
pants missed more than 2 dance classes. Thus, all dance partici-
pants received at least 80% of the dance sessions. Each
participant recorded the type of activity and minutes spent doing
the activity on a daily activity log form kept in a folder. The usual
care group reported spending an average of 28 min per week
engaging in physical activity. When controlling for time spent
dancing, the dance group reported spending 32 min per week
engaging in physical activity, per week.
The line dancing group had significantly greater knee extensor
strength but not knee muscle flexor strength. Intraclass correla-
tions for knee flexor strength at pretest were ICC ¼0.790, knee
flexor strength at posttest ICC ¼0.903, knee extensor strength at
pretest ICC ¼0.822 and at posttest ICC ¼0.758. The line dancing
group had significantly greater SPPB scores, endurance, and gait
speed (Table 4). The line dancing group had significantly greater
gait speed (Table 4). When balance confidence and BBS was con-
trolled, the line dancing group had lower perceived mobility limi-
tations trending toward significance (Tables 3 and 4). The line
Table 1. Demographics.
Total
frequency (%)
(n¼23)
Usual care
frequency (%)
(n¼11)
Dance
frequency (%)
(n¼12)
Chi
Square
Gender
Female 20 (87) 10 (90.9) 10 (83.3) 0.590
Male 3 (13) 1 (9.1) 2 (16.7)
Race
Caucasian 21 (91.3) 11 (100) 10 (83.3) 0.156
Black 2 (8.7) 0 (0) 2 (16.7)
Marital status
Married 9 (39.1) 4 (36.4) 5 (41.7) 0.404
Widowed 7 (30.4) 3 (27.2) 4 (33.3)
Divorced 6 (26.1) 4 (36.4) 2 (8.3)
Never married 1 (4.4) 0 (0) 1 (8.3)
Education
Grade 8 1 (4.3) 0 (0) 1 (8.3) 0.579
Grade 9 1 (4.3) 1 (9.1) 0 (0)
Grade 10 1 (4.3) 0 (0) 1 (8.3)
Grade 11 9 (39.1) 4 (36.4) 5 (41.7)
Grade 12 5 (21.7) 3 (27.3) 2 (16.7)
Post HS 1 (4.3) 1 (9.1) 0 (0)
Associate degree 1 (4.3) 1 (9.1) 0 (0)
College grad 3 (13) 1 (9.1) 2 (16.7)
Master’s degree 1 (4.3) 0 (0) 1 (8.3)
Doctoral degree 0 (0) 0 (0) 0 (0)
Living status 0.305
Lives alone 13 (56.5) 5 (45.5) 8 (66.7)
Lives with someone 10 (43.5) 6 (54.5) 4 (33.3)
Table 2. Health status characteristics.
Total
frequency (%)
(n¼23)
Usual care
frequency (%)
(n¼11)
Dance
frequency (%)
(n¼12)
Chi
square
High blood pressure 17 (73.9) 8 (72.3) 9 (75) 0.901
Peripheral vascular disease 5 (21.7) 4 (36.4) 1 (8.3) 0.104
Diabetes 7 (30.4) 5 (45.4) 2 (16.7) 0.134
Neuropathies 7 (30.4) 4 (36.4) 3 (25) 0.554
Respiratory disease 4 (17.4) 3 (27.3) 1 (8.3) 0.231
Osteoporosis 6 (26.1) 3 (27.3) 3 (25) 0.901
Arthritis 15 (65.2) 8 (72.3) 7 (58.3) 0.469
Depression 6 (26.1) 2 (18) 4 (33.3) 0.408
Joint replacement 6 (26.1) 4 (36.4) 2 (16.7) 0.283
Other conditions not listed 15 (65.2) 7 (63.4) 8 (66.7) 0.879
4C. G. BENNETT AND M. E. HACKNEY
dancing group had significantly reduced self-reported difficulty
climbing a flight of stairs but not a significant difference for diffi-
culty walking a quarter of mile (Table 4). A moderate effect size of
0.54 was noted for the SPPB and an effect size of 0.46 was noted
for perceived mobility limitations.
Discussion
Interestingly, dance improved knee extensor but not knee flexor
strength. Body weight was not significantly different from pre- to
post-test, thus the gains in knee extensor strength may not have
been influenced by decreased body weight. The knee extensors
were more involved in the line dancing movements than the knee
flexors and may account for differences in strength of the muscle
groups [20]. In a 12-week study of Korean dance, significantly
greater strength in the knee extensors also was found but not
knee flexor strength [17]. Similar patterns in muscle strength have
been found for aerobic and balance training where knee extensors
and knee flexors were likewise involved [42–46]. Line dancing sig-
nificantly improved lower extremity function and was consistent
with findings of a pilot study that also used the SPPB [23].
Because line dancing is aerobic in nature, improvements in
endurance were expected. Line dancing significantly improved
endurance. In fact, those in the line dancing group had improved
endurance while it declined for the usual care group. Similar find-
ings were found when the distance in the six min walk was used
to assess endurance [10,11,15,16], in contrast to the 400 m walk
used in the present study. The finding of improved endurance is
of clinical importance, as those with greater endurance may lower
their risk of having a new mobility limitation [4,34,47].
After the 8 week intervention, the mean gait speed of the
dance group was 1.00 m/s –placing these participants at risk of
mobility limitations, yet they were above the major disability
threshold of 0.6 m/s [48]. In contrast, the usual group had a lower
mean gait speed of 0.72 m/s at post-test placing them at a higher
risk of mobility limitations.
Line dancing may have reduced perceived mobility limitations.
Similar improvements in disability were found in a 12-week dance
study that included a greater number of mobility tasks [23].
Despite, faster times to complete the 400 m walk (1/4 mile), line
dancing did not significantly reduce perceived difficulty walking
this distance. In contrast, line dancing did significantly reduce per-
ceived difficulty in climbing a flight of stairs.
Limitations
The small sample size limits the generalizability of these findings
to other older adults with mobility limitations. In spite of not
achieving our sample size, we did detect significant findings,
which do speak to the potential robustness of the intervention’s
effects. However, the impact of not achieving our sample size
means our study was underpowered to detect the expected
effects, undermining the reliability of our study findings. Low
power also reduces the likelihood that a statistically significant
result reflects a true effect, resulting in the potential overestimates
of effect size and low reproducibility of the results. Improving
reproducibility is in fact a priority of rehabilitation research. Future
studies must be adequately powered to achieve this goal. This
study had few male participants which again limits the generaliz-
ability to other older males. Those who chose to participate may
be healthier and may perceive line dancing to be more beneficial
compared with those who did not participate. For this feasibility
study, it was important to maximize the safety of the intervention
for all, and explore ways to modify the program to suit minor
mobility problems, so it was considered prudent not to include
those with more severe impairments. Future studies will address
the needs of individuals with greater mobility difficulties. There
were a greater number of participants in the dance group that
were living alone compared with the usual care group, which may
have impacted findings in unknown ways, given that studies have
shown older adults living independently are healthier than those
who are not. Because the data collector was not blinded to group
a subject was randomized to, there may be potential bias in the
assessments of study outcomes. A greater weekly frequency or
number of weeks for line dancing may potentially increase the
effects on outcomes that were not found to be significant in this
study. Regarding scalability, a moderate effect size (r¼0.46) was
found for the primary outcome of perceived mobility limitations.
To improve the scalability of this intervention, a horizontal
approach is needed for expansion of the program. Using this
approach, the intervention can be implemented with diverse
groups of older adults in various settings. The amount of regular
physical activity was not impacted by this short term dance pro-
gram. Future studies with longer term interventions should exam-
ine the impact on physical activity.
Clinical implications
Line dancing is feasible and appropriate modifications to the
movements can enable the older adult with mobility limitations to
Table 3. Differences between the groups for the BBS.
Pretest Post test
Usual Care
Mean (SD)
Dance
Mean (SD)
Usual Care
Mean (SD)
Dance
Mean (SD)
Berg Balance Scale 48.6 (5.62) 48.1 (7.94) 47 (6.18) 50.4 (4.56)
Table 4. ANCOVA differences between groups.
Pretest Post Test
Usual Care Mean (SD) Dance Mean (SD) Usual Care Mean (SD) Dance Mean (SD) Ftest
Knee extensor strength (kg) 0.09 (0.03) 0.11 (0.03) 0.09 (0.03) 0.14 (0.04) 6.44
Knee flexor strength (kg) 0.07 (0.03) 0.09 (0.04) 0.08 (0.03) 0.11 (0.06) 1.42
SPPB Score 7.73 (1.90) 6.75 (2.37) 7.18 (2.08) 9.17 (2.32) 9.38
Gait speed during 400 m walk (m/s) 0.75 (0.19) 0.86 (0.27) 0.72 (0.13) 1.00 (0.25) 18.03
Endurance (Minutes needed to complete the 400 m walk) 9.53 (2.57) 8.63 (3.17) 9.64 (2.09) 7.05 (1.96) 12.53
Perceived mobility limitations 10.64 (6.00) 8.25 (6.67) 9.27 (5.31) 4.17 (4.43) 4.06
Perceived difficulty walking 1
=
4mile 1.00 (1.18) 0.58 (0.79) 0.55 (0.82) 0.17 (0.39) 0.23
Perceived difficulty climbing stairs 3.64 (1.12) 3.08 (1.93) 3.27 (1.00) 1.75 (1.42) 8.20
Table 4 presents ANCOVA differences between groups.
p<0.05, p<0.01, p<0.001.
EFFECTS OF LINE DANCING 5
perform the dance. However, several factors must be considered
for implementation of the intervention. The line dance instructor
must plan for modifications as part of the line dance choreog-
raphy and observe participants for difficulty during the line dance
classes so that another movement can be substituted. In this
study, the line dance instructor was experienced at monitoring
participants for difficulty and introduced a new movement when
indicated. This will allow the participants to continue to dance
and may prevent participant drop-out. Another factor to consider
is the location of the intervention. In a rural setting there are
often few community centers and little to no public transporta-
tion. Whereas, in the urban setting, the barriers may be adequate
and safe parking, increased distance from parking lot or transit
stop to the class. It is recommended that the location of the
dance program be on site of a community or senior center,
rehabilitation center, or faith-based community center as these
settings often have adequate lighting, accessible parking, and
nearby transit stops. If conducting the intervention in a rural set-
ting, it is recommended that a centralized location where older
adults may receive services such as congregate meals, be consid-
ered to improve adherence. In order to improve sustainability of
the dance class, funding sources will need to be explored to cover
expenses and support from community stakeholders and organi-
zations will be needed.
Conclusion
In conclusion, eight weeks of line dancing improved knee muscle
strength, lower extremity function, gait speed, endurance, and
perceived mobility limitations. Current recommendations are for
older adults to participate in at least 150 min per week of moder-
ate intensity aerobic exercise [49]. In spite of this recommenda-
tion, many older adults do not achieve the minimum
recommended amount of exercise. Line dancing involves socializa-
tion that may increase enjoyment and promote adherence while
incorporating dynamic balance control and the use of lower
extremity large muscle groups to improve physical function, and
reduce perceived mobility limitations that threatens the independ-
ence of older adults.
Acknowledgements
We acknowledge Dr. Beverly Roberts for study design and statis-
tical consultation.
Disclosure statement
There are no apparent conflicts of interest in terms of honoraria
received, speaker forums, consultant roles, stocks, royalties, expert
testimony, board memberships, patents, or personal relationships
of any of the authors.
References
[1] He W, Larsen LJ. U.S. Census Bureau, American Community
Survey Reports, ACS-29. Older Americans with a Disability:
2008–2012. Washington, DC: U.S. Government Printing
Office, 2014.
[2] Berk DR, Hubert HB, Fries JF. Associations of changes in
exercise level with subsequent disability among seniors:
a 16-year longitudinal study. J Gerontol A Biol Sci Med Sci.
2006;61:97–102.
[3] Boyle PA, Buchman AS, Wilson RS, et al. Physical activity is
associated with incident disability in community-based
older persons. J Am Geriatr Soc. 2007;55:195–201.
[4] Life Study Investigators. Effects of a physical activity inter-
vention on measures of physical performance: results of
the lifestyle interventions and independence for elders pilot
(LIFE-P) study. J Gerontol A Biol Sci Med Sci. 2006;61:
1157–1165.
[5] Forkan R, Pumper B, Smyth N, et al. Exercise adherence fol-
lowing physical therapy intervention in older adults with
impaired balance. Phys Ther. 2006;86:401–410.
[6] Lima M, Vieira A. Ballroom dance as therapy for the elderly
in Brazil. Am J Dance Ther. 2007;29:129–142.
[7] Verghese J. Cognitive and mobility profile of older social
dancers. J Am Geriatr Soc. 2006;54:1241–1244.
[8] Brown S, Martinez MJ, Parsons LM. The neural basis of
human dance. Cereb Cortex. 2006;16:1157–1167.
[9] Blasing B, Calvo-Merino B, Cross ES, et al. Neurocognitive
control in dance perception and performance. Acta Psychol
(Amst). 2012;139:300–308.
[10] Hackney ME, Hall CD, Echt KV, et al. Application of adapted
tango as therapeutic intervention for patients with chronic
stroke. J Geriatr Phys Ther. 2012;35:206–217.
[11] Hackney ME, Earhart GM. Effects of dance on gait and bal-
ance in Parkinson's disease: a comparison of partnered and
nonpartnered dance movement. Neurorehabil Neural
Repair. 2010;24: 384–392.
[12] Hackney M, Kantoravich S, Levin R, et al. A study on the
effects of Argentine tango as a form of partnered dance
for those with Parkinson disease and the healthy elderly.
J Neurol Phys. 2007;31:173–179.
[13] Eyigor S, Karapolat H, Durmaz B, et al. A randomized con-
trolled trial of Turkish folklore dance on physical perform-
ance, balance, depression and quality of life in older
women. Arch Gerontol Geriatr. 2009;48:84–88.
[14] McKee KE, Hackney ME. The effects of adapted tango on
spatial cognition and disease severity in Parkinson's disease.
J Mot Behav. 2013;45:519–529.
[15] Hackney ME, Earhart GM. Effects of dance on movement
control in Parkinson's disease: a comparison of Argentine
tango and American ballroom. J Rehabil Med. 2009;41:
475–481.
[16] Duncan RP, Earhart GM. Randomized controlled trial of
community-based dancing to modify disease progression in
Parkinson disease. Neurorehabil Neural Repair. 2012;26:
132–143.
[17] Jeon MY, Choe MA, Chae YR. Effect of Korean traditional
dance movement training on balance, gait and leg strength
in home bound elderly women. J Korean Acad Nurs.
2000;30:647–658.
[18] Mckinley P, Jacobson A, Leroux A, et al. Effect of a commu-
nity-based argentine tango dance program on functional
balance and confidence in older adults. J Aging Phys Act.
2008;16:435–453.
[19] Hackney ME, Byer C, Butler G, et al. Adapted tango
improves mobility, motor-cognitive function, and gait but
not cognition in older adults in independent living. J Am
Geriatr Soc. 2015;63:2105–2113.
[20] Young CM, Weeks BK, Beck BR. Simple, novel physical activ-
ity maintains proximal femur bone mineral density, and
improves muscle strength and balance in sedentary, post-
menopausal Caucasian women. Osteoporos Int. 2007;18:
1379–1387.
6C. G. BENNETT AND M. E. HACKNEY
[21] Hui E, Chui B, Woo J. Effects of dance on physical and psy-
chological well-being in older persons. Arch Gerontol
Geriatr. 2009;49:45–50.
[22] Bennett CG, Roberts BL. Effects of line dancing on physical
performance in older adults with mobility difficulty. Poster
session presented at: Gerontological Society of America
Scientific Conference; Boston, MA, 2011 Nov 5.
[23] Keogh JW, Kilding A, Pidgeon P, et al. Effects of different
weekly frequencies of dance on older adults' functional
performance and physical activity patterns. Eur J Sport Sci
2012;1:14–23.
[24] Cress ME, Buchner DM, Questad KA, et al. Exercise: effects
on physical functional performance in independent older
adults. J Gerontol A Biol Sci Med Sci. 1999;54:242–248.
[25] Emory SL, Silva SG, Christopher EJ, et al. Stepping to stabil-
ity and fall prevention in adult psychiatric patients.
J Psychosoc Nurs Ment Health Serv. 2011;49:30–36.
[26] Borg G. Borg’s Perceived Exertion and Pain Scales.
Champaign, IL: Human Kinetics; 1998.
[27] Berg K, Wood-Dauphinee S, Williams JI, et al. Measuring
balance in the elderly: preliminary development of an
instrument. Physiother Can. 1989;41:304–311.
[28] Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory
measures of postural balance in an elderly population.
Arch Phys Med Rehabil. 1992;73:1073–1080.
[29] Manty M, Mendes de Leon CF, Rantanen T, et al. Mobility-
related fatigue, walking speed, and muscle strength in
older people. J Gerontol A Biol Sci Med Sci. 2012;67:
523–529.
[30] Bohannon RW. Testing isometric limb muscle strength with
dynamometers. Crit Rev Phys Rehabil Med. 1990;2:75–86.
[31] Wang CY, Olson SL, Protas EJ. Test-retest strength reliability:
hand-held dynamometry in community-dwelling elderly
fallers. Arch Phys Med Rehabil. 2002;83:811–815.
[32] National Institute on Aging. 2011. Assessing physical per-
formance in the older patient. (CD-ROM).
[33] Guralnik JM, Ferrucci L, Simonsick EM, et al. Lower-extrem-
ity function in persons over the age of 70 years as a pre-
dictor of subsequent disability. N Engl J Med. 1995;332:
556–561.
[34] Vestergaard S, Patel KV, Walkup MP, et al. Stopping to rest
during a 400-meter walk and incident mobility disability in
older persons with functional limitations. J Am Geriatr Soc.
2009;57:260–265.
[35] Rejeski WJ, Fielding RA, Blair SN, et al. The lifestyle inter-
ventions and independence for elders (LIFE) pilot study:
design and methods. Contemp Clin Trials. 2005;26:141–154.
[36] Fried LP, Bandeen-Roche K, Williamson JD, et al. Functional
decline in older adults: expanding methods of ascertain-
ment. J Gerontol A Biol Sci Med Sci. 1996;51:206–214.
[37] Sheikh JI, Yesavage JA. Geriatric Depression Scale (GDS):
recent evidence and development of a Shorter Version.
Clin Gerontol. 1986; 5:165–173.
[38] Lesher EL, Berryhill JS. Validation of the geriatric depression
scale-short form among inpatients. J Clin Psychol.
1994;50:256–260.
[39] Greenberg SA. The geriatric depression scale (GDS). Try
this: Best practices in nursing care to older adults, Issue 4,
The Hartford Institute for Geriatric Nursing, New York
University, College of Nursing, 2012. Available from: http://
consultgerirn.org/uploads/File/trythis/try_this_4.pdf
[40] Tinetti ME, Richman D, Powell LE. Falls efficacy as a meas-
ure of fear of falling. J Gerontol. 1990;45:239–243.
[41] Higgins TJ, Janelle CM, Naugle KM, et al. Role of self-effi-
cacy (SE) and anxiety among pre-clinically disabled older
adults when using compensatory strategies to complete
daily tasks. Arch Gerontol Geriatr. 2012;55:611–624.
[42] Goodpaster BH, Chomentowski P, Ward BK, et al. Effects of
physical activity on strength and skeletal muscle fat infiltra-
tion in older adults: a randomized controlled trial. J Appl
Physiol. 2008;105:1498–1503.
[43] Lu X, Hui-Chan CW, Tsang WW. Effects of Tai Chi training
on arterial compliance and muscle strength in female
seniors: a randomized clinical trial. Eur J Prev Cardiol.
2013;20:238–245.
[44] Kalapotharkos VI, Michalopoulos M, Strimpakos N, et al.
Functional and neuromotor performance in older adults:
effect of 12 wks of aerobic exercise. Am J Phys Med
Rehabil. 2006;85:61–67.
[45] Talbot LA, Gaines JM, Huynh TN, et al. A home-based ped-
ometer-driven walking program to increase physical activity
in older adults with osteoarthritis of the knee: a preliminary
study. J Am Geriatr Soc. 2006;51:387–392.
[46] Wu G, Zhao F, Zhou X, et al. Improvement of isokinetic
knee extensor strength and reduction of postural sway in
the elderly from long-term Tai Chi exercise. Arch Phys Med
Rehabil. 2002;83:1364–1369.
[47] Simonsick EM, Newman AB, Visser M, et al. Mobility limita-
tion in self-described well-functioning older adults: import-
ance of endurance walk testing. J Gerontol A Biol Sci Med
Sci. 2008;63:841–847.
[48] Cummings SR, Studenski S, Ferrucci L. A Diagnosis of dis-
mobility—giving mobility clinical visibility: a mobility work-
ing group recommendation. JAMA. 2014; 311:2061–2062.
doi:10.1001/jama.2014.3033
[49] Physical Activity for Everyone Fact Sheet [Internet]. Atlanta,
GA: Centers for Disease Control and Prevention; 2013 [cited
2014 Jan 5]. Available from: http://www.cdc.gov/physicalac-
tivity/everyone/guidelines/olderadults.html
EFFECTS OF LINE DANCING 7
