Content uploaded by Nawab Ali
Author content
All content in this area was uploaded by Nawab Ali on Jun 28, 2020
Content may be subject to copyright.
Journal of Alzheimer’s Disease 74 (2020) 679–690
DOI 10.3233/JAD-190681
IOS Press
679
Effects of Aerobic Dance on Cognition
in Older Adults with Mild Cognitive
Impairment: A Systematic Review
and Meta-Analysis
Yi Zhua,1, Qian Zhongb,1, Jie Jia,1, Jinhui Mac, Han Wud, Yaxin Gaob, Nawab Aliband Tong Wanga,∗
aDepartment of Rehabilitation, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu,
China
bFirst Clinical Medical College, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu,
China
cDepartment of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
dDepartment of Rehabilitation, Nanjing Drum Tower Hospital, The Affiliated Hospital of the Medical School at
Nanjing University, Nanjing, Jiangsu, China
Accepted 16 January 2020
Abstract.
Background: Regular aerobic exercises could improve global cognition in older adults with mild cognitive impairment
(MCI), such as aerobic dance a type of commonly practiced aerobic exercises. However, its effects remain debatable in
improving the cognitive function in patients with MCI.
Objective: The aim of this systematic review and meta-analysis is to evaluate the effects of aerobic dance on cognitive
function among older adults with MCI.
Methods: We searched articles in the MEDLINE, PubMed, Embase, and The Cochrane Library databases from inception
to 28 February 2019, with the following criteria: 1) randomized controlled trials; 2) older adults with MCI; 3) aerobic dance
intervention.
Results: Five studies of 842 participants were identified. This meta-analysis showed that aerobic dance can significantly
improve global cognition (Mini-Mental State Examination: MD = 1.43; 95%CI:[0.59, 2.27]; p= 0.0009; Alzheimer’s Dis-
ease Assessment Scale-Cognitive Subscale: MD=–2.30; 95%CI:[–3.60, –1.00]; p= 0.0005), and delayed recall ability
(SMD = 0.46;95%CI: [0.30, 0.62]; p< 0.00001) in older adults with MCI. In addition, have positive effects on improving
executive function (Trial-Making Test A: MD= –2.37;95%CI:[–4.16, –0.58]; p= 0.010; Trial-Making Test B: MD= –16.0;
95%CI: [–30.03, –2.11]; p= 0.020) and immediate recall ability (SMD=0.24;95%CI: [0.01, 0.46]; p= 0.04).
Conclusion: Aerobic dance significantly improves global cognitive function and memory in older adults with MCI. In
addition, it also benefits executive function. However, due to the limitations as the review states, more randomized controlled
trials with better study design and larger sample sizes should be conducted in the future research to make it much clearer.
Keywords: Aerobic dance, cognition, executive function, memory, meta-analysis, mild cognitive function, randomized
controlled trials
1These authors contributed equally to this work.
∗Correspondence to: Tong Wang, Rehabilitation Center, The
First Affiliated Hospital of Nanjing Medical University, No.
300 of Guangzhou Road, Nanjing, Jiangsu 210029, China.
Tel.: +86 139 5168 0478; Fax: +86 25 8331 8752; E-mail:
wangtong60621@163.com.
INTRODUCTION
Mild cognitive impairment (MCI) is an interme-
diary phase between the typical aging process and
dementia. MCI includes group of people who suf-
fer from cognitive impairment that occur at the
early stage of dementia [1]. According to two recent
ISSN 1387-2877/20/$35.00 © 2020 – IOS Press and the authors. All rights reserved
680 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
meta-analysis of people aged over 60, the prevalence
of MCI is about 15% [2, 3], while a third, a Chinese
cohort study conducted in Beijing, indicated that the
prevalence of MCI among elders was 16.6% [4]. In
addition, the conversion rates from MCI to demen-
tia and Alzheimer’s disease (AD) are 34% and 28%,
respectively [2, 3]. Reduction of the risk factors could
be an effective measurement against MCI [5], lead-
ing to a drop of the onset of AD at an early age. In
addition, 15% of MCI can be reversed to normal [2].
Although there is no positive evidence supporting
pharmacological interventions in alleviating cogni-
tive function decline of MCI patients [6–9]. However,
several non-pharmacologic interventions, including a
Mediterranean diet [10], social connections [8, 11],
and cognitive training [12–14] have shown promising
results through observational research. In compar-
ison, it has been widely illustrated that physical
exercise plays an important role in slowing down
the progression from MCI to dementia [11, 15–19],
specifically benefiting executive function and mem-
ory [17, 19]. The possible mechanism could be the
fact that physical exercise not only increase blood
flow to the brain and improve function of cardiovas-
cular system as well as it changes the whole metabolic
system. Furthermore, physical exercise also involves
cognitive and social activities, which might enhance
overall brain function [20]. Two recent systematic
reviews and meta-analysis reported that intervention
such as physical activities including aerobic exer-
cises, can improve cognitive function among older
adults with MCI [21, 22]. Aerobic exercises are those
exercises that involve large muscle groups activation,
such as dancing, jogging, swimming and cycling, etc.
[21].
Dance is a very popular community-based activity
and commonly practiced aerobic exercise through-
out the world. That requires emotional expression,
social interaction, sensory stimulation, motor coor-
dination, and bodily movements along with music.
However, the intensity, duration, and frequency of
such exercise may vary, such as in cha-cha, rumba,
waltz, Tai Chi, etc. [23]. As believed, social connec-
tions may improve cognitive functions among older
adults with MCI as a result of dancing [8, 11]. In addi-
tion, another study has indicated that music training
may have a stimulatory effect on sensorimotor and
auditory system, which may enhance cortical plas-
ticity [24]. Since dance training combines all these
factors, it therefore may enhance cognitive functions.
Furthermore, it improves mood, fitness level, and
self-confidence [25]. Although the exact mechanism
of action of this phenomenon is not clear so far, sev-
eral publications have founded possible mechanism,
such as cell and functional magnetic resonance imag-
ing (fMRI) theories [26–28].
Moreover, several recent studies have shown that
aerobic dance could improve global cognition as well
as other specific domains, such as executive function
and memory retention in older adults without cog-
nitive impairment [29–31]. Although few trials have
focused on observing the effects of aerobic dance on
cognitive impairment among older adults with MCI,
the effects of aerobic dance on the global cognition
or specific domain of the patients with MCI remains
unclear. The aim of the current systematic review and
meta-analysis is to determine the effects of aerobic
dance on cognitive function in older adults with MCI
within the published literature.
METHODS
Literature research
This study was conducted according to the
Preferred Reporting Items for Systematic Review
and Meta-analysis (PRISMA) statement [32]. We
searched MEDLINE, PubMed, Embase, and the
Cochrane Central Register of Controlled Trials for
studies on the effects of aerobic dance. The search
items included the combination of Medical Sub-
ject Heading terms (MeSH) and free words. Taking
‘mild cognitive impairment’ as an example: the rele-
vant ‘MeSH’ is [cognition dysfunction], and the free
word including: [Cognitive Impairments] [Mild Neu-
rocognitive Disorder] [Cognitive Declines] [Mental
Deterioration], etc. Firstly, we used ‘or’ to combine
all those items. Secondly, we searched and combined
the ‘MeSH’ and free words of ‘dance’, ‘cognition’,
and ‘RCTs’, respectively. Thirdly, we used ‘AND’ to
combine all items. Finally, we searched ‘All Field’
(search strategies for all databases are presented in
detail in the Supplementary Material). All searches
including MEDLINE, PubMed, Embase, and the
Cochrane Library were performed from database
inception to 28 February 2019.
Inclusion and exclusion criteria
To be eligible for inclusion in this systematic
review, a research work has to satisfy the follow-
ing criteria: 1) Study population over 50 years old,
Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI 681
diagnosed as MCI by neurologists; 2) Aerobic dance
as an intervention, such as cha-cha, rumba, waltz,
and Tai Chi; 3) Participants in the control group
received health education and/or exercise but not
aerobic dance training; 4) Outcome measurements
involved global cognition or other specific domains
such as memory and executive function; 5) Ran-
domized controlled trial (RCTs); 6) Published in
peer-reviewed journals in English language.
Conference abstracts, case reports, and protocols
were excluded from this review. Moreover, studies
including elderly with Parkinson’s disease, stroke,
cardiovascular disease, and other severe illnesses
were also excluded from this study.
Fig. 1. Flowchart for searching and selection of the included studies.
682 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
Study selection and data extraction
Two independent reviewers (ZQ and GYX) eval-
uated eligible studies and then extracted data.
Disagreements were resolved by discussion or judge-
ment from the third reviewer (ZY). The following
information were extracted from each study: authors,
country, age, sex proportion, number of participants,
type of intervention, duration, frequency, intensity,
the cognitive measurements, and their outcomes.
Quality assessments
Two independent reviewers (ZQ and GYX)
assessed the risk of bias in the included trials using
the Cochrane Risk of Bias Tool [33]. Furthermore,
Selection Bias, Performance Bias, Detection Bias,
Attrition Bias, Reporting Bias, and other Biases were
evaluated, then assigned each of the above items as
either high risk, low risk, or unclear according to
the levels of bias. Disagreements between the two
reviewers were resolved by discussion.
Statistical analysis
All the data was analyzed using RevMan V5.3
(Copenhagen: The Nordic Cochrane Centre, The
Cochrane Collaboration, 2014). In the meta-analysis,
we synthesized continuous outcome data using mean
difference (MD) and standard deviation (SD). When
different measurements for the same outcome were
performed in different studies, we used standardized
mean difference (SMD) to obtain the summarized
effect instead.
In addition, according to the difference of fre-
quency and duration between trials, the clinic
heterogeneity was observed; as a consequence,
we used the random-effects model with generic
inverse-variance was used to pool the effect and its
corresponding 95% confidence interval (CI). I2statis-
tic were used to examine the heterogeneity of the
included studies. Large I2(>75%) suggests high het-
erogeneity in meta-analysis [33], therefore we only
pooled studies when I2was below 75%. In addi-
tion, to determine the causes of the heterogeneity,
we conducted a sensitivity analysis by eliminating
the studies one by one to identify the study that is
heterogeneous from the other studies, by examining
whether the I2statistics changed substantially. Other-
wise, we used a sub-group to modify the effects of the
outcomes and the two-side pvalue <0.05 to indicate
that the statistics are significant. Furthermore, Funnel
plot was not used for assessing publication bias since
the number of articles involved in the meta-analysis
was very small.
RESULTS
Identification of studies
The flow chart (Fig. 1) illustrates the search strat-
egy. Thirty-six articles were identified from the three
main electronic databases, while four more arti-
cles were obtained from other sources for further
eligibility screening. These articles were imported
into the Endnote (a common reference manage-
ment software) and thirteen duplicates were removed
through the build-in function of the software.
Subsequently, two reviewers (ZQ, GYX) removed
ineligible articles by reading their titles, abstracts,
and/or full text. Ultimately, only five studies were
included in this systematic review and meta-analysis
[34–38].
Study characteristics
The detailed characteristics of each trial are pre-
sented in Table 1. All the studies were reported
between 2012 and 2018, and were conducted in
four different regions (one from America [34], two
from China [35, 37], one from Japan [36], and one
from Greece [38]). A total of 842 participants were
included in the review out of which 263 (31%) were
male and the rest were female.
In addition, the dance style also varied across dif-
ferent studies, such as salsa, rumba, waltz, cha-cha,
blues, jitterbug, tango, and Tai Chi. Four publications
[34, 36–38] adopted a combination of salsa, rumba,
waltz, cha-cha, blues, jitterbug, and tango, while one
study [35] used Tai Chi only as their intervention. All
the studies described their dance routine and were
divided into three parts: 1) warm up for 5 to 10 min
to reduce the risk of muscle injury and impacts on
the respiratory system; 2) aerobic dance for about
30 min; 3) cool down for 5 to 10 min. Four trials [34,
35, 37, 38] were conducted twice or three times a
week, while the other was once a week [36]. In addi-
tion, the duration of two studies was three month [34,
37], while that of the other was about a year [35,
36, 38]. Only two studies [34, 37] clearly stated their
exercise intensity and both were 60%–80% HR max.
As for as age is concerned, the participants of four
trials [34–37] were about 75 years old whether they
were in the intervention group or control group, while
Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI 683
Table 1
Characteristics of included trials
Dancing Control
Trial Location Age (y) Proportion Intervention Age (y) Proportion Intervention Intervention Outcome measures
mean (SD) of female mean (SD) of female (frequency,
duration,
intensity)
Barnes [34] America 71.7 (5.5) 67.7% (21/31) Dance (traditional
dance-based
aerobic format)
73.9 (6.3) 62.5% (20/32) Stretching 60 min/day, 3
times/week, 12
weeks
1) Delayed recall/RAVLT
(95%CI: [0.30, 0.62];
p< 0.00001)
60%–75%
HRmax
2) Immediately
recall/RAVLT (95%CI:
[0.01, 0.46]; p= 0.04)
3) Executive
function/VFT (95% CI:
[–3.43, 3.88]; p= 0.9),
TMT-A (95% CI:
[–4.16, –0.58];
p= 0.010), TMT-B
(95% CI: [–30.03,
–2.11]; p= 0.020)
Lam [35] Hong Kong (China) 77.2 (6.3) 73.1% (125/171) Tai Chi 78.3 (6.6) 78.9% (172/218) stretching and
tonging exercise
30 min/day,
3 days/week
1 year
Moderate
intensity
1) Global cognitive
function/MMSE (95%
CI: [0.59, 2.27];
p= 0.0009), ADAS-Cog
(95% CI: [–3.60,
–1.00]; p= 0.0005)
2) Delayed recall/10 min
delayed recall (95%CI:
[0.30, 0.62];
p< 0.00001)
3) Immediately
recall/DST, forward
and backward (95%CI:
[0.01, 0.46]; p= 0.04)
4) Executive
function/VFT (95% CI:
[–3.43, 3.88]; p= 0.9),
TMT-A (95% CI:
[–4.16, –0.58];
p= 0.010), TMT-B
(95% CI: [–30.03,
–2.11]; p= 0.020)
(continued)
684 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
Table 1
(continued)
Lazarou [38] Greece 65.89 (10.76) 80.3% (53/66) Dance (Tango,
Waltz,
Viennese,
Waltz, Foxtrot,
Rumba, Cha
Cha, Swing,
Salsa,
Merengue,
Disco-Hustle,
Greek
traditional
ballroom
dancing)
67.92 (9.47) 76.2% (48/63) Non dance 60 min/day,
twice/week
10 months
1) Global cognitive
function/MMSE (95% CI:
[0.59, 2.27]; p= 0.0009),
MOCA
2) Delayed recall/RBMT2
(95%CI: [0.30, 0.62];
p< 0.00001)
3) Immediately
recall/RBMT1 (95%CI:
[0.01, 0.46]; p= 0.04)
4) Executive function/FAS
(95% CI: [0.58,2.88];
p= 0.003)
Doi [36] Japan 75.7 (4.1) 50.7% Dance (Salsa,
Rumba, Waltz,
Cha Cha, Blues,
Jitterbug,
Tango)
76.0 (4.9) 46.3% Playing music
instrumen-
tals/health
education
control
T: 60min/week 1) Global cognitive
function/MMSE (95% CI:
[0.59, 2.27]; p= 0.0009)
C: 90 min/week
40 weeks
Moderate
intensity
2) Delayed recall/20 min
delayed story memory
recall (95%CI: [0.30, 0.62];
p< 0.00001)
3) Executive function/TMT-A
(95% CI: [–4.16, –0.58];
p= 0.010), TMT-B (95%
CI: [–30.03, –2.11];
p= 0.020)
Zhu [37] China 70.3 (6.7) 51.7% (15/29) Aerobic dance
routine, usual
care
69.0 (7.3) 67.7% (21/31) Usual care only 35 min/day,
3 times/week
3 months
1) Global cognitive
function/MOCA
2) Delayed recall/WMSR
60%–80%
HRmax
(95%CI: [0.30, 0.62];
p< 0.00001)
3) Immediately recall/DST,
forward and backward
(95%CI: [0.01, 0.46];
p= 0.04)
4) Executive function/TMT-A
(95% CI: [–4.16, –0.58];
p= 0.010), TMT-B (95%
CI: [–30.03, –2.11];
p= 0.020)
T, Training group; C, Control group; SD, standard deviation; HRmax, maximum heart rate; RAVLT, Rey Auditory Verbal Learning Test; VFT, Verbal Fluency Test; TMT-A, Trial-making Test
part A; TMT-B, Trial-making Test part B; MMSE, Mini-Mental System Examination; ADAS-Cog, Alzheimer’s Disease Assessment Scale-Cognitive Subscale; DST, Digit Span Task; RBMT,
Rivermead Behavioral Memory Test; FAS, F-A-S test; WMSR, Wechsler Memory Scale-Revised.
Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI 685
in the other article their age was around 65 years old
[38].
The outcomes of these trials were global cog-
nition, memory (immediate and delayed recall),
and executive function. These were measured using
different cognitive assessment tools, for example,
Global cognition was assessed using the Mini-Mental
System Examination (MMSE) [35, 36, 38], Mon-
treal Cognitive Assessment (MoCA) [37, 38], and/or
Alzheimer’s Disease Assessment Scale-Cognitive
Subscale (ADAS-Cog) [35]. On the other hand, exec-
utive function was assessed by Verbal Fluency Test
(VFT) [34, 35], FAS (F-A-S test) [38], TMT-A (Trial-
making test A) [34–38], and/or TMT-B (Trail Making
Test B) [34–38]. The common assessed components
of memory were immediate and delayed recall abil-
ity. In addition Digit Span Task (DST) [35, 37], Rey
Auditory Verbal Learning Test (RAVLT) [34], and
Rivermead Behavioral Memory Test 1 (RBMT1) [38]
were used to assess immediate recall ability. Wechsler
Memory Scale-Revised (WMSR) [37], RAVLT [34],
Rivermead Behavioral Memory Test 2 (RBMT2)
[38], and 10 min or 20 min story memory recall tests
[35, 36] were used to assess delayed recall ability.
All the five included studies adopted aerobic dance as
their interventions, with stretching, toning exercise,
health education, and usual care as their controls.
Quality assessment
To sum up, all the 5 studies were of an exem-
plary standard. Regarding the selection bias (i.e.,
randomization sequence generation), all the five arti-
cles tended to have an extremely low risk since they
generated the randomization sequencing numbers by
standard ways such as using number generators on a
computer or algorithm. Two studies [37, 38] clearly
showcased their method for allocation concealment,
and we considered their selection bias (allocation
concealment) as low risk. The other three studies did
not mention allocation concealment and were con-
sidered as ‘unclear’ [34–36]. Due to the nature of the
intervention, blinding the instructor and participants
was impossible in all five studies. However, outcome
assessments were blinded in all the five studies. We
considered their blinding bias as high risk. For the
attrition bias, almost every trial gave the desired out-
comes. Reasons for dropping were clearly stated in
each of the included trial. Therefore, we considered
their risk of attrition bias as low. We considered the
reporting bias for each trial as low risk, since all the
outcomes they intended to study were reported and
Fig. 2. Risk of bias in trials of each item. Green circle: The risk of
bias was low. Red circle: The risk of bias was high. Yellow circle:
The risk of bias was unclear.
discussed in each study. Detailed information about
the bias assessment was shown in Fig. 2.
Effects of aerobic dance intervention on MCI
Global cognition
Figure 3 summarizes the results on global cogni-
tion. All five trials assessed global cognition while
using different assessment tools. To reduce hetero-
geneity, we used subgroups to analyze the outcomes
based on the assessment tools. Results from pooling
of three studies used MMSE to measure cognition
impairment showing that aerobic dance could signifi-
cantly improve global cognition (MD = 1.43; 95%CI:
[0.59, 2.27]; p= 0.0009) [35, 36, 38]. Results from
the subgroup of two studies using MoCA, showed
a high heterogeneity, so we did not pool the effect
[32, 33]. One of the two trials reported that aerobic
dance could improve global cognition by comparing
MoCA scores among experimental and control group
[38], but the other did not find any improvement.
The main difference between those two studies were
686 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
Fig. 3. Forest plot for aerobic dancing on global cognitive ability. MMSE, Mini-Mental State Examination; ADAS-Cog, Alzheimer’s Disease
Assessment Scale-Cognitive Subscale.
Fig. 4. Forest plot for aerobic dancing on executive ability. TMT-A: Trial Making Test-part A; TMT-B: Trial Making Test-part B.
as follows: First, the duration was different. Zhu’s
et al. trial trained participants for 3 months and found
that there was no difference between the groups [32].
While Lazarou et al. with a longer period of study
(10-month) found the effects were significant [33].
Second, the frequency of the two trials were different
(35 min per day three times a week and 60 min per
day two times a week), respectively. Thirdly, the sam-
ple size was different, the trial with 129 participants
reported that MoCA scores improved significantly
through aerobic dance [33], on the other hand, the
other study with 59 participants reported the opposite
result [32]. In addition, results of one study [35] using
ASAD-cog to assess cognition indicated that aero-
bic dance enhanced global cognition in older adults
with MCI (MD = –2.30; 95% CI: [–3.60, –1.00];
p= 0.0005).
Executive function
Figures 4 and 5 shows the effects of aerobic dance
on executive function, which was assessed by using
VFT,FAS, TMT-A, or TMT-B. Results of the analysis
of each subgroup showed that aerobic dance posi-
tively enhance the ability of verbal fluency (VFT:
MD = 0.22; 95%CI: [–3.43, 3.88]; p= 0.9; FAS:
MD = 1.73; 95%CI: [0.58,2.88]; p= 0.003) and exec-
utive function (TMT-A: MD =–2.37; 95%CI: [–4.16,
–0.58]; p= 0.010; TMT-B: MD = –16.07; 95%CI:
[–30.03, –2.11]; p= 0.020).
Memory
Memory was another domain of cognition and
was commonly assessed by a participant’s ability
of immediate and delayed recall. Among the five
included trials, two used Digit Span Task [35, 37],
Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI 687
Fig. 5. Forest plot for aerobic dancing on verbal fluency. VFT, Verbal fluency test; FAS, F-A-S test.
Fig. 6. Forest plot for aerobic dancing on immediately recall ability.
Fig. 7. Forest plot for aerobic dancing on delayed recall ability.
while one employed RAVLT [34] and the other used
RBMT1 [38] to assess the immediate memory recall.
To ensure that the results from different trials could
be synthesized, we calculated the standardized mean
difference for each study first. The pooled results on
SMD (Fig. 6) showed that aerobic dance interven-
tion significantly improve immediate recall ability in
older adults with MCI (SMD = 0.24; 95%CI: [0.01,
0.46]; p= 0.04). Similarly, the pooled results for
delayed recall, were assessed using WMSR, RAVLT,
RBMT2, and 10 min or 20 min story memory recall
tests. Their results showed that aerobic dance sig-
nificantly improve delayed recall ability amongst
elderly with MCI (SMD = 0.46; 95%CI: [0.30, 0.62];
p< 0.00001). Finally, all the detailed data is shown in
Fig. 7.
DISCUSSION
Our systematic review and meta-analysis collected
data from five RCTs freely available in the current
literature. According to the results, aerobic dance
significantly improves global cognition and mem-
ory in MCI patients. Additionally, the results showed
that executive function and memory was slightly
improved by performing aerobic dance.
However, some of the outcomes of these trials
were inconsistent. As prior research indicated that
688 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
changes in some domains of cognitive function may
not be sensitive in a short period [21], different dura-
tions of these trails may lead to inconsistency in their
outcome. For example, Barnes conducted a 3-month
intervention and found that there was no difference
between the experimental and control group in either
global cognitive function and other domains [34]. On
the contrary, other trials of longer duration or follow
up period confirmed that cognitive function could be
improved to some extent [35–38]. Moreover, Lam
et al. reported better delayed recall ability 1 year later,
while surprisingly there was no difference between
experimental and control group after five months of
intervention [35]. While using MoCA as the outcome
of global cognition, one study found that there was no
improvements after three months’ intervention [37];
on the other hand, the study with a 10-month training
showed significant effects [38]. Only two involved
studies clearly mentioned the intensity of aerobic
dancing, with a target peak heart rate of 60%–75%
and 60%–80% of maximum heart rate, respectively
[29, 32]. This suggest that intensity maybe another
factor of getting inconsistent results. Furthermore,
the location, proportion of male and female, and their
respective age were differences between studies. Two
studies were from China [35, 37], one from America
[34], and the remaining two studies were from Japan
[36] and Greece [38], respectively. Sex distribution
is another different characteristic, as two trials had
balanced proportion between male and female and
they were both around 50% [36, 37]. In Lam’s et al.
[35] and Lazarous’s et al. [38] studies, the proportion
of female was 76% and 78%, respectively, meaning
they were almost three times as male. In addition, the
type of aerobic dance intervention was not the same
among five studies. For example, in Takehiko’s [36]
and Lazarou’s [38] studies, the training group per-
formed a mixed type of aerobic dance, while in the
remaining other three trials, only one type of dance
was practiced [34, 35, 37]. Despite the fact that not
all of the factors were the same, they showed positive
effects on improving cognitive function of MCI by
taking part in aerobic dancing activities.
One study with 60 participants conducted in
Greece, which chose specific traditional Greek dance
as their intervention that lasted for 24 weeks with two
times a week for 60 min a session. Their result showed
that dance improve cognitive functions, such as atten-
tion, verbal fluency, and executive function in MCI
[39]. In addition, another similar study with a larger
sample size using eight types of ballroom dance in
Filipinos showed almost the same results [40].
The exact mechanism of how aerobic dance
improves cognitive function in older adults with
MCI remains unclear. However, two studies tried to
find this possible mechanism. One is the changes in
rhythm and the spatial awareness of the body dur-
ing dance movements that activate place cells and
grid cells [26]. The other possible mechanism may
be that aerobic exercise delays the degeneration of
nerve cells [27]. In addition, Qi et al.’s resting state-
fMRI study showed change among cortical activation
after aerobic dance. They found significant increase
in the amplitude of low-frequency fluctuation in the
bilateral frontotemporal, entorhinal, anterior cingu-
late, and parohippocampal cortex after three months
of aerobic dance in MCI patients. As a matter of
fact, many cognitive functions such as memory, exec-
utive function, and learning depend on the frontal
cortex and medial temporal lobe, and activation of
these areas through dance may result in functional
improvements [28].
Strengths and limitations
Our systemic review and meta-analysis focused on
identifying the possible effects of aerobic dance, that
could be used as a treatment option for MCI patients.
All the trials in this review were conducted and pub-
lished within the last 5 years; therefore their results
were the latest and most convincing. Furthermore,
to ensure the quality of our study, we only included
RCTs designed with high quality for this review.
However, there were some limitations of this
review. Firstly, since aerobic dance was an emerg-
ing non-pharmaceutical intervention, very few trials
in the area were available in the literature so far. Sec-
ondly, the sample size in each trial was not too large.
Thirdly, the characteristics of the participants are
quite different across different trials, such as cultural
background, living conditions, social connections,
and level of education. Therefore, the heterogene-
ity of the studies in this review is substantial and
consequently, the obtained results may not be very
convincing. In addition, literature search was only
performed in the English language medium; there-
fore, some trials reported in other language may be
missed.
Implications for future research
As discussed, RCTs with large sample size, longer
intervention and follow-up period are needed to reach
a better conclusion of the possible effects of aerobic
Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI 689
dance on cognitive function in patients with MCI.
Only a few studies used resting state-fMRI and
positron emission tomography to reveal the neural
activities, brain volume, and functional connection
between brain networks in MCI patients [41, 42].
These studies have revealed that aerobic exercise
might increase the thickness of grey matter and hip-
pocampal volume [43, 44]. But the mechanism of
the effects of aerobic dancing on cognitive functions
remains unclear. Therefore, further studies should
include more conventional methods to reveal the cor-
relation between the changes in neural activation,
functional connections, and cognitive improvement
in such patients.
Conclusion
This research review found that aerobic dance sig-
nificantly improves global cognition and memory in
older adults with MCI. In addition, it also benefits
execution function to a large degree. On the other
hand, due to the limitations stated, better design and
large sample size trials are needed to reveal the true
effects of aerobic dance on people with MCI in the
future.
ACKNOWLEDGMENTS
This study was supported by National Natu-
ral Science Foundation of China (NSFC), Youth
Funding, Grant No. 81802244 and the Science &
Technology Department of Jiangsu Province, Grant
No.BE2013724, BE2017734.
Authors’ disclosures available online (https://
www.j-alz.com/manuscript-disclosures/19-0681r2).
SUPPLEMENTARY MATERIAL
The supplementary material is available in the
electronic version of this article: https://dx.doi.org/
10.3233/JAD-190681.
REFERENCES
[1] Petersen RC (2004) Mild cognitive impairment as a diag-
nostic entity. J Intern Med 256, 183-194.
[2] Hu C, Yu D, Sun X, Zhang M, Wang L, Qin H (2017) The
prevalence and progression of mild cognitive impairment
among clinic and community populations: A systematic
review and meta-analysis. Int Psychogeriatr29, 1595-1608.
[3] Xue J, Li J, Liang J, Chen S (2018) The prevalence of mild
cognitive impairment in China: A systematic review. Aging
Dis 9, 706-715.
[4] Hao L, Wang X, Zhang L, Xing Y, Guo Q, Hu X, Mu B, Chen
Y, Chen G, Cao J, Zhi X, Liu J, Li X, Yang L, Li J, Du W,
Sun Y, Wang T, Liu Z, Liu Z, Zhao X, Li H, Yu Y, Wang X,
Jia J, Han Y (2017) Prevalence, risk factors, and complaints
screening tool exploration of subjective cognitive decline in
a large cohort of the Chinese population. J Alzheimers Dis
60, 371-388.
[5] Eshkoor SA, Hamid TA, Mun CY, Ng CK (2015) Mild cog-
nitive impairment and its management in older people. Clin
Interv Aging 10, 687-693.
[6] Feldman HH, Ferris S, Winblad B, Sfikas N, Mancione L,
He Y, Tekin S, Burns A, Cummings J, del Ser T, Inzitari
D, Orgogozo JM, Sauer H, Scheltens P, Scarpini E, Her-
rmann N, Farlow M, Potkin S, Charles HC, Fox NC, Lane
R (2007) Effect of rivastigmine on delay to diagnosis of
Alzheimer’s disease from mild cognitive impairment: The
InDDEx study. Lancet Neurol 6, 501-512.
[7] Cooper C, Li R, Lyketsos C, Livingston G (2013) Treat-
ment for mild cognitive impairment: Systematic review. Br
J Psychiatry 203, 255-264.
[8] Langa KM, Levine DA (2014) The diagnosis and manage-
ment of mild cognitive impairment: A clinical review. JAMA
312, 2551-2561.
[9] Tricco AC, Soobiah C, Berliner S, Ho JM, Ng CH, Ashoor
HM, Chen MH, Hemmelgarn B, Straus SE (2013) Efficacy
and safety of cognitive enhancers for patients with mild cog-
nitive impairment: A systematic review and meta-analysis.
CMAJ 185, 1393-1401.
[10] Roberts RO, Geda YE, Cerhan JR, Knopman DS, Cha
RH, Christianson TJ, Pankratz VS, Ivnik RJ, Boeve BF,
O’Connor HM, Petersen RC (2010) Vegetables, unsatu-
rated fats, moderate alcohol intake, and mild cognitive
impairment. Dement Geriatr Cogn Disord 29, 413-
423.
[11] Horr T, Messinger-Rapport B, Pillai JA (2015) Systematic
review of strengths and limitations of randomized controlled
trials for non-pharmacological interventions in mild cog-
nitive impairment: Focus on Alzheimer’s disease. J Nutr
Health Aging 19, 141-153.
[12] Hong YJ, Jang EH, Hwang J, Roh JH, Lee JH (2015) The
efficacy of cognitive intervention programs for mild cogni-
tive impairment: A systematic review. Curr Alzheimer Res
12, 527-542.
[13] Sherman DS, Mauser J, Nuno M, Sherzai D (2017) The effi-
cacy of cognitive intervention in mild cognitive impairment
(MCI): A meta-analysis of outcomes on neuropsychological
measures. Neuropsychol Rev 27, 440-484.
[14] Gates NJ, Sachdev PS, Fiatarone Singh MA, Valenzuela M
(2011) Cognitive and memory training in adults at risk of
dementia: a systematic review. BMC Geriatr 11, 55.
[15] Strohle A, Schmidt DK, Schultz F, Fricke N, Staden T, Hell-
weg R, Priller J, Rapp MA, Rieckmann N (2015) Drug and
exercise treatment of Alzheimer disease and mild cogni-
tive impairment: A systematic review and meta-analysis of
effects on cognition in randomized controlled trials. Am J
Geriatr Psychiatry 23, 1234-1249.
[16] Vega JN, Newhouse PA (2014) Mild cognitive impairment:
Diagnosis, longitudinal course, and emerging treatments.
Curr Psychiatry Rep 16, 490.
[17] Cui MY, Lin Y, Sheng JY (2018) Exerciseintervention asso-
ciated with cognitive improvement in Alzheimer’s disease.
Neural Plast 2018, 9234105.
[18] Hahn EA, Andel R (2011) Nonpharmacological therapies
for behavioral and cognitive symptoms of mild cognitive
impairment. J Aging Health 23, 1223-1245.
690 Y. Zhu et al. / Aerobic Dancing Improves Cognition in MCI
[19] Teixeira CV, Gobbi LT, Corazza DI, Stella F, Costa JL,
Gobbi S (2012) Non-pharmacological interventions on
cognitive functions in older people with mild cognitive
impairment (MCI). Arch Gerontol Geriatr 54, 175-180.
[20] Gallaway PJ, Miyake H, Buchowski MS, Shimada M,
Yoshitake Y, Kim AS, Hongu N (2017) Physical activity:
A viable way to reduce the risks of mild cognitive impair-
ment, Alzheimer’s disease, and vascular dementia in older
adults. Brain Sci 7, E22.
[21] Zheng G, Xia R, Zhou W, Tao J, Chen L (2016) Aerobic
exercise ameliorates cognitive function in older adults with
mild cognitive impairment: A systematic review and meta-
analysis of randomised controlled trials. Br J Sports Med
50, 1443-1450.
[22] Song D, Yu DSF, Li PWC, Lei Y (2018) The effectiveness of
physical exercise on cognitive and psychological outcomes
in individuals with mild cognitive impairment: A systematic
review and meta-analysis. Int J Nurs Stud 79, 155-164.
[23] Karpati FJ, Giacosa C, Foster NEV, Penhune VB, Hyde
KL (2017) Dance and music share gray matter structural
correlates. Brain Res 1657, 62-73.
[24] Lappe C, Herholz SC, Trainor LJ, Pantev C (2008) Cortical
plasticity induced by short-term unimodal and multimodal
musical training. J Neurosci 28, 9632-9639.
[25] Lakes KD, Marvin S, Rowley J, Nicolas MS, Arastoo S,
Viray L, Orozco A, Jurnak F (2016) Dancer perceptions
of the cognitive, social, emotional, and physical benefits of
modern styles of partnered dancing. Complement Ther Med
26, 117-122.
[26] Doeller CF, Barry C, Burgess N (2010) Evidence for grid
cells in a human memory network. Nature 463, 657-661.
[27] Hafting T, Fyhn M, Molden S, Moser MB, Moser EI (2005)
Microstructure of a spatial map in the entorhinal cortex.
Nature 436, 801-806.
[28] Qi M, Zhu Y, Zhang L, Wu T, Wang J (2019) The effect of
aerobic dance intervention on brain spontaneous activity in
older adults with mild cognitive impairment: A resting-state
functional MRI study. Exp Ther Med 17, 715-722.
[29] Anstey KJ, Sherrington C, Lord SR, Cumming RG, Kosmat
H, Vranic A (2017) The efficacy of a dance intervention as
cognitive training for the old-old. PLoS Med 25, 32-40.
[30] Candidate LJ, Candidate XZ, Manning K, Steffens D, Wang
L (2017) Physical exercise-induced improvement in gait
speed and interoceptive-exteroceptive network synchro-
nization. Am J Geriatr Psychiatry 25, S137-S138.
[31] Kosmat H, Vranic A (2017) The efficacy of a dance inter-
vention as cognitive training for the old-old. J Aging Phys
Act 25, 32-40.
[32] Moher D, Liberati A, Tetzlaff J, Altman DG (2009)
Preferred reporting items for systematic reviews and meta-
analyses: The PRISMA statement. BMJ 339, b2535.
[33] Higgins JP, Green S (2011) Cochrane Handbook for
Systematic Reviews of Interventions. The Cochrane Collab-
oration.
[34] Barnes DE, Santos-Modesitt W, Poelke G, Kramer AF, Cas-
tro C, Middleton LE, Yaffe K (2013) The Mental Activity
and eXercise (MAX) trial: A randomized controlled trial
to enhance cognitive function in older adults. JAMA Intern
Med 173, 797-804.
[35] Lam LC, Chau RC, Wong BM, Fung AW, Tam CW, Leung
GT,Kwok TC, Leung TY,Ng SP, Chan WM (2012) A 1-year
randomized controlled trial comparing mind body exercise
(Tai Chi) with stretching and toning exercise on cognitive
function in older Chinese adults at risk of cognitive decline.
J Am Med Dir Assoc 13, 568.e515-520.
[36] Doi T, Verghese J, Makizako H, Tsutsumimoto K, Hotta
R, Nakakubo S, Suzuki T, Shimada H (2017) Effects of
cognitive leisure activity on cognition in mild cognitive
impairment: Results of a randomized controlled trial. JAm
Med Dir Assoc 18, 686-691.
[37] Zhu Y, Wu H, Qi M, Wang S, Zhang Q, Zhou L, Wang S,
Wang W, Wu T, Xiao M, Yang S, Chen H, Zhang L, Zhang
KC, Ma J, Wang T (2018) Effects of a specially designed
aerobic dance routine on mild cognitive impairment. Clin
Interv Aging 13, 1691-1700.
[38] Lazarou I, Parastatidis T, Tsolaki A, Gkioka M, Karakostas
A, Douka S, Tsolaki M (2017) International ballroom danc-
ing against neurodegeneration: A randomized controlled
trial in Greek community-dwelling elders with mild cog-
nitive impairment. Am J Alzheimers Dis Other Demen 32,
489-499.
[39] Douka S, Zilidou VI, Lilou O, Tsolaki M (2019) Greek
traditional dances: A way to support intellectual, psycho-
logical, and motor functions in senior citizens at risk of
neurodegeneration. Front Aging Neurosci 11,6.
[40] Dominguez JC, Del Moral MCO, Chio JOA, de Guzman
MFP, Natividad BP, Decena JM, Montalvo MJY, Reande-
lar M, Phung KTT (2018) Improving cognition through
dance in older Filipinos with mild cognitive impairment.
Curr Alzheimer Res 15, 1136-1141.
[41] Liang P, Wang Z, Yang Y, Jia X, Li K (2011) Functional dis-
connection and compensation in mild cognitive impairment:
Evidence from DLPFC connectivity using resting-state
fMRI. PLoS One 6, e22153.
[42] Khazaee A, Ebrahimzadeh A, Babajani-Feremi A,
Alzheimer’sDisease Neuroimaging Initiative (2017) Classi-
fication of patients with MCI and AD from healthy controls
using directed graph measures of resting-state fMRI. Behav
Brain Res 322, 339-350.
[43] Colcombe SJ, Erickson KI, Scalf PE, Kim JS, Prakash R,
McAuley E, Elavsky S, Marquez DX, Hu L, Kramer AF
(2006) Aerobic exercise training increases brain volume in
aging humans. J Gerontol A Biol Sci Med Sci 61, 1166-1170.
[44] Erickson KI, Voss MW, Prakash RS, Basak C, Szabo A,
Chaddock L, Kim JS, Heo S, Alves H, White SM, Wojcicki
TR, Mailey E, Vieira VJ, Martin SA, Pence BD, Woods JA,
McAuley E, Kramer AF (2011) Exercise training increases
size of hippocampus and improves memory. Proc Natl Acad
SciUSA108, 3017-3022.
