ORIGINAL RESEARCH
Effects of dance on upper extremity activities in underserved adults Carolyn J. Murrock, RN, PhD (Associate Professor), Christine Heifner Graor, RN, PhD (Associate Professor), & Annette Sues-Mitzel, RN, CNS, DNP (Director) Nursing Center for Community Health, College of Health Professions, School of Nursing, The University of Akron, Akron, Ohio
Keywords Underserved; nurse-managed clinics; health promotion; exercise; dance. Correspondence Carolyn J. Murrock, RN, PhD, Nursing Center for Community Health, College of Health Professions, School of Nursing, The University of Akron, 209 Carroll Street, Akron, OH 44325-3701. Tel: 330-972-8077; Fax: 330-972-5737; E-mail: [email protected] Received: 18 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12232
Abstract Purpose: This secondary analysis examined the immediate and maintaining effects of a 12-week line-dancing intervention on upper and lower extremity activities in underserved adults who receive care from a nurse-managed clinic (NMC). Data sources: This one-group, repeated measures, feasibility study consisted of 40 participants recruited from an urban apartment complex that housed a NMC. Of the 40 participants, 21 participants completed the 12-week line-dancing intervention. Physical function of the upper and lower extremities was measured with the Late Life Function and Disability Instrument at baseline, 12, and 18 weeks to determine the maintaining effects. Conclusions: Age ranged from 45 to 87 years (M = 63; SD = 7.8), body mass index (BMI) was 33.4 (SD = 7.8), 92% were female, and 75% were African American. At baseline, participants showed limitations in all aspects of physical function. Significant improvements in upper and lower extremity activities were noted at 12 weeks and maintained at 18 weeks. Implications for practice: Although line-dancing mainly involves the lower body, there were significant improvements in upper extremity activities at 12 weeks, which were maintained at 18 weeks. The maintaining effects support line-dancing as an intervention to improve upper and lower extremity activities needed for independent living. NMCs are important settings for health promotion interventions in underserved adults.
Introduction Underserved adults are often defined as those who lack healthcare coverage, have limited access to healthcare resources, experience increased prevalence of comorbidities and logistical barriers, and accrue more out-of-pocket expenses than those who are not underserved (Hill et al., 2012). Underserved adults also do not receive appropriate, effective, and timely care for prevention and treatment of many chronic health conditions (Alverson & Kessler, 2012). To meet these needs, nurse-managed clinics (NMCs) provide primary care with an emphasis on health promotion and disease prevention by serving adults who would otherwise be underserved or not served at all (Coddington & Sands, 2008). The NMCs are operated by advanced practice nurses (APNs) who perform health assessments, prescribe treatments and medications, and coordinate health care. The APNs lead the healthcare team
C 2015 American Association of Nurse Practitioners
in primary care, health promotion, and disease prevention interventions. Health promotion interventions (i.e., exercise, dietary changes, diabetes management, medication management, foot, eye, and skin cancer screenings) are especially important as many chronic health conditions that impact physical function and independent living are more common among underserved adults. Few studies have been conducted at NMCs to examine healthpromoting interventions to improve physical function in underserved adults. Physical function is the performance of activities necessary for independent living, such as walking, climbing stairs, and handling objects (Haley et al., 2002). The ability to perform these specific activities requires gross and fine motor skills of the upper and lower extremities. An important part of physical function is muscle strength, which plays different roles in upper and lower extremity
1
Effects of dance on upper extremity activities
movement. While muscle strength of lower extremities is required for ambulation, muscle strength of upper extremities is required for skillful hand function (Liu et al., 2011). Muscles of the upper extremities are essential for coordinating different positions of the elbows, wrists, and arms to properly position hands and fingers for the performance of dexterous tasks (Kim & Bishu, 2004). Strength of large muscle groups in the upper extremities is vital for carrying, lifting, pulling, and pushing objects. Thus, upper extremity (UE) muscle strength is fundamental to perform everyday tasks necessary for independent living, such as preparing meals, doing housework, shopping for groceries, using transportation, handling finances, managing medications, and using the telephone (Seidel et al., 2009). As muscle strength declines with age, it can become challenging for individuals to live independently. Agerelated loss of muscle strength occurs both in the upper and lower extremities and becomes apparent after middle-age (Goodpaster et al., 2006). The decline of muscle strength can lead to difficulty in performing daily tasks and impact the ability to carry out activities essential for independent living (Szabo et al., 2011). To help individuals overcome muscle strength decline, exercise is frequently recommended. However, most exercise interventions to improve physical function focused on lower extremity activities (Baruth et al., 2011; Chale-Rush et al., 2010; Yorston, Kolt, & Rosenkranz, 2012). As a part of independent living, few studies have reported measuring UE activities in older adults with multiple sclerosis (GucluGunduza, Citakera, Nazlielb, & Irkecb, 2012), stroke patients (Lin et al., 2009), and mastectomy patients (Hayes, Rye, Battistutta, DiSipio, & Newman, 2010). Only one study reported using a simulated bowling video game in long-term care residents to improve UE activities (Hsu et al., 2011). Thus, there is a need to expand exercise interventions to include both upper and lower extremity activities to improve physical function needed for independent living. Dance is a type of exercise defined as a patterned, rhythmic movement in space and time (Pepper, 1984). It is a weight-bearing activity that requires the movement and coordination of large and small muscle groups of the upper and lower body (Hanna, 1995). Dance appeals to a wide range of individuals of all ages and cultures. It can take on many forms (low-impact, ballroom, ballet, etc.), be performed in a variety of settings, and does not necessarily require much expense or equipment (Keogh, Kilding, Pidgeon, Ahsley, & Gillis, 2009). In addition, dance can be altered to accommodate those with physical limitations, such as arthritis, osteoporosis, and neurological conditions (Keogh et al., 2009). Studies show that dance has physical and mental health benefits, such as reduced stress in underserved adults (Murrock & Graor, 2014), decreased 2
C. J. Murrock et al.
risk of falling in elderly (Lee, Tabourne, & Harris, 2010; McKinley et al., 2008), increased bone mineral density in women (Young, Weeks, & Beck, 2007), and increased social interaction in the elderly (Kreutz, 2008). When reviewing the literature, only two studies reported improvement in functional capacity and physical function in adults after completing a line-dancing intervention (Murrock & Gary, 2008; Murrock & Graor, 2014). Other dance studies reported improvements in static and dynamic balance (Sofianidis, Hatzitaki, Douka, & Grouios, 2009), locomotion-related functional abilities (Dewhurst, Nelson, Dougali, & Bampouras, 2014), physical performance (Eyigor, Karapolat, Durmaz, Isisoglu, & Cakir, 2009), and lower body strength and walk speed (McKinley et al., 2008) in older adults. However, no dance studies were found that reported measuring UE activities. Because most individuals have been exposed to dance, it may be more acceptable than other types of exercise programs to improve physical function in the upper and lower extremities. Thus, the purpose of this secondary analysis is to document the immediate and maintaining effects of a line-dancing intervention two times per week for 12 weeks on physical function of both upper and lower extremity activities in underserved adults who received care at an NMC affiliated with a local university.
Theoretical framework The study was based on the theory of Music, Mood, and Movement (MMM) that proposes music as an external time cue with recurring and predictable patterns to coordinate body movements, such as dance steps, hand claps, and finger snaps (Murrock & Higgins, 2009). Music is an impetus for movement and the motivating factor to dance. Dancing to music appeals to diverse groups of people, can occur in group settings, and encourages social interaction. Thus, music is an auditory cue for movement for a dance intervention to improve upper and lower extremity activities that are an important part of physical function.
Methods Design Data for secondary analyses were from a one-group, repeated measures, feasibility study that examined the effects of a dance intervention on depression, physical function, and disability in adults (Murrock & Graor, 2014). The convenience sample was recruited from residents living in an urban neighborhood apartment complex in the Midwest to participate in the one-group, repeated measures feasibility study. Approval for this feasibility study was obtained from the local university Institutional Review Board (IRB).
Effects of dance on upper extremity activities
C. J. Murrock et al.
Setting and sample The NMC, affiliated with a local university, was housed in the apartment complex and provided holistic, integrative primary care through an Interprofessional Primary Care Medical Home model. By providing primary care, the NMC was many residents’ health home. The apartment complex accommodated residents, ages 45– 90+, who were classified as disabled and whose income was at or below 60% of the median income for the county. Guidelines for disabled classification and median income were determined by the fraternal organization involved in nonprofit housing and development for low and moderate-income elderly. Inclusion criteria were (a) ability to read and write English and (b) provision of written medical clearance from their healthcare providers. Most residents had medical insurance (Medicaid, Medicare, or private) and a primary care provider. Exclusion criteria were (a) unstable chronic health conditions (unstable angina, uncontrolled hypertension, etc.), (b) foot ulcers, (c) currently enrolled in a structured exercise program 2– 3 days per week, (d) diagnoses of psychoses or substance abuse, and (e) confinement to a wheelchair. The dance intervention was held on-site in the community room located in the apartment complex.
Sampling and data collection procedures The 4-week recruitment period was held in the community room of the apartment complex right next to the NMC. Advertisements via flyers were posted in the community room, in the nursing clinic, and at the building entrance of the apartment complex. In the community room, potential participants spoke face-to-face with to the coprincipal investigators (Co-Is) and asked questions about the dance study. After the recruitment period, 40 participants expressed interest, volunteered to be in the study, and met inclusion criteria. Written informed consent was obtained by the Co-Is from all participants prior to the beginning of the line-dancing intervention the following week. After consent was obtained, baseline data collection occurred. Data collection consisted of: demographic information, medications, comorbidity, the Late Life Function and Disability Instrument (LLFDI) instrument, weight, body fat, and body mass index (BMI). Data were collected at baseline, 12, and 18 weeks (6 weeks postintervention) in a private area of the community room by the Co-Is. Baseline data collection period took approximately 45–60 min per participant and was collected during the 4-week recruitment period. Data collection at 12 and 18 weeks consisted of the LLFDI instrument, weight, body fat, and BMI and took approximately 30–45 minutes per participant. For all
data collection time points, Co-Is were available to read the LLFDI instruments to the participants if necessary. To convey gratitude and enhance retention, participants who had attended at least half of dance classes at week 6 received a cash incentive of $10. At the week 12 data collection corresponding to the end of the dance intervention, participants who had attended at least half of the classes during weeks 7–12 received a cash incentive of $15. When measuring the maintaining effects of dance at 18 weeks, participants received a cash incentive of $20.
Dance intervention The line-dancing intervention was taught by an experienced dance instructor, who led each line-dancing class two times per week for 12 weeks, for a total of 24 classes. A dance assistant attended each class to help the participants learn line-dancing steps. Each line-dancing class consisted of a 5-min warm-up, 30 min of line-dancing, and a 10-min cool-down period. The line-dancing routines consisted of basic, easy to learn line-dancing steps that involved repetitive movement of the legs, trunk, and arms choreographed to secular and gospel music. For each line-dancing routine, the same secular and gospel music were used during each line-dancing class. Because many participants had physical limitations (bad back, knee/hip discomfort, and arthritis), many line-dancing steps were modified to be lower intensity. As a result, each participant chose either regular intensity or lower intensity line-dancing steps. During each line-dancing class, chairs were available for participants needing to sit and rest and participants rejoined the line-dancing routines typically at the beginning of the next song. The Co-Is attended all line-dancing classes, provided bottled water for hydration, and carried cell phones to access 911 emergency services if needed to ensure participant safety. In addition, a first aid kit, glucose meter, glucose tabs, and blood pressure cuffs were available at all dance classes. None of these safety precautions were needed during the 12-week line-dancing intervention.
Measures Demographics, medications, health history, and comorbidity were assessed at baseline by the Co-Is. Comorbidity was measured with the Charlson scale (Charlson, Pompei, Alex, & MacKenzie, 1987), a weighted sum of comorbid conditions that reflect the functional burden of illness conditions. The NMC’s scale with an attached height rod was used to measure weight (in pounds) and height (in inches). Each participant was weighed wearing light street clothes without shoes. A segmental bioelectrical impedance analyzer (Omron Body Fat Analyzer, Model HBF-306, Bannockburn, IL) was used to calculate 3
Effects of dance on upper extremity activities
body fat and BMI as each participant’s weight, height, gender, and age were entered into the arm-to-arm analyzer. Then, each participant’s hands and fingers gripped the sensor electrodes on the handles of the device while standing with arms extended. The arm-to-arm analyzer is comparable to hydrostatic weighing and has a high validity coefficient (r = .83; Gibson, Heyward, & Mermier, 2000). The LLFDI assessed physical function and disability in community-dwelling older adults (Haley et al., 2002; Jette et al., 2002). The physical function component was a comprehensive assessment of an individual’s ability to perform gross and fine motor skills necessary to perform an assortment of activities relevant to living independently in the community (Haley et al., 2002). Because underserved adults are disproportionally affected with chronic health conditions, comorbidity, and physical limitations, the LLFDI was selected to assess physical function. The LLFDI assessed functional limitations through self-reported difficulty in performing 32 physical tasks. The physical function component consisted of three subscales: UE, basic lower extremity (BLE), and advanced lower extremity (ALE). Seven items assessed UE activities that related to movements of the hands and arms needed for daily activities. Fourteen items assessed BLE activities that primarily involve standing, bending over, and fundamental walking activities; and 11 items assessed ALE that focus on physical activity and endurance (Haley et al., 2002). All questions were phrased: “How much difficulty do you have doing a particular activity without the help of someone else and without the use of assistive devices?” Examples of functional tasks for BLE activities included (a) going up and down a flight of stairs with hand rails and (b) stepping up and down from a curb, while examples of ALE activities included (a) walking several blocks and (b) carrying something in both arms while climbing stairs. The seven items for UE activities included (a) unscrewing the lid off an unopened jar, (b) putting on and taking off long pants, (c) using utensils for preparing meals, (d) holding a full glass of water, (e) reaching behind your back, (f) ripping open a package of snack food, and (g) pouring from a large pitcher. The participants chose their degree of difficulty in performing these 32 physical tasks on a 5-point scale (1 = cannot do, 2 = quite a lot, 3 = some, 4 = a little, and 5 = none) for each item. Total physical function score and the UE, BLE, and ALE subscales scores were computed by summing the item scores to obtain raw scores. Next, raw scores were transformed to scaled scores (0– 100) based on a one-parameter Rasch model (Haley et al., 2002). Higher total and subscale scores indicated higher levels of physical function. For this sample of underserved adults, Cronbach’s alphas for the physical function component was 0.96, UE items was 0.88, BLE items was 0.94, and ALE items was 0.95. This is comparable to a study that re4
C. J. Murrock et al.
ported Cronbach’s alphas of the physical function and the three subscales of 0.83–0.96 in community-dwelling older adults (Hand, Richardson, Letts, & Stratford, 2010). Similarly, another study reported Cronbach’s alphas of 0.92– 0.97 for the physical function and the three subscales in community-dwelling African American women (Murrock & Zauszniewski, 2011). Criterion-related and construct validity of the LLFDI have been reported as well (Hand et al., 2010; Murrock & Zauszniewski, 2011).
Data analysis Prior to entry into the Predictive Analytics SoftWare (PASW, version 19.0), all data obtained from demographics and questionnaires were examined for completeness. Descriptive statistics described the sample and paired t-tests determined the effects of dance on upper, lower, and ALE activities of the physical function component of the LLFDI instrument. Hierarchical regression analyzed the maintaining effects of line-dancing at 18 weeks. Level of statistical significance was set at p values < 0.05.
Results The convenience sample was 92% female and 75% African American. Age ranged from 45 to 87 years (M = 63; SD = 7.9), and mean BMI was 33.4 (SD = 7.8). At baseline, physical function, UE, BLE, and ALE scores showed limitations in all aspects of physical function (see Table 1). Of the 40 participants who volunteered for the study, 28 participants attended at least one dance class. Of these 28 participants, 21 completed the 12-week line-dancing intervention. This supported feasibility of the study as 75% who attended at least one class completed the 12-week line-dancing intervention (Vincent, Pasvogel, & Barrera, 2007). To determine the immediate effects at 12 weeks, paired t-tests revealed that line-dancing significantly increased physical function, UE, BLE, and ALE (see Table 1). Specifically, the mean of each of the seven items that assessed UE activities increased from baseline to 12 weeks. Therefore, participants demonstrated improvement in all aspects of physical function, including UE activities after completing a 12-week line-dancing intervention. At 18 weeks, hierarchical regression determined the maintaining effects of dance for 20 of the 21 participants who completed the 12-week line-dancing intervention. Covariates of age, body fat, BMI, and comorbidity were added in the first step, and the baseline scores of physical function, UE, BLE, and ALE were added in the second step separately for the corresponding dependent variable. For physical function, the overall regression equation was significant (p < .01; F = 7.33) and the variables explained 72% of the change in physical function. Of the covariates,
Effects of dance on upper extremity activities
C. J. Murrock et al.
Table 1 Mean score for each of the seven items of the UE subscale at baseline and 12 weeks Baseline item mean (SD)
12 Weeks item mean (SD)
Change
3.93 (1.27) 4.58 (0.80) 4.53 (0.78) 4.75 (0.63) 4.05 (1.40) 4.18 (1.15) 4.38 (1.01)
4.29 (0.96) 4.62 (0.74) 4.90 (0.30) 4.95 (0.22) 4.52 (1.08) 4.52 (0.75) 4.90 (0.30)
.36 .04 .37 .20 .47 .34 .52
1. Unscrewing lid off an unopened jar 2. Putting on and taking off long pants 3. Using utensils for preparing meals 4. Holding a full glass of water 5. Reaching behind your back 6. Ripping open a package of snack food 7. Pouring from a large pitcher Note. UE, upper extremity.
Table 2 Maintaining effects of physical function, UE, BLE, and ALE activities at 18 weeks
only BMI (β = −2.83) was significant (p = .01). For UE, the overall regression equation was significant (p = .01; F = 5.02) and the variables explained 64% of the change as only baseline UE activities (β = .72) was significant (p < .01). The overall regression equation for BLE was significant (p < .01; F = 7.33) and the variables explained 67% of the change as body fat (β = .61) and BMI (β = −.72) were significant (p = .03 and p = .01, respectively). Finally, the overall regression equation ALE was significant (p < .01; F = 6.71) and explained 71% of the change with only baseline advanced lower extremities (β = .62) as significant (p < .01; see Table 2). Therefore, the changes in physical function, UE, BLE, and ALE were maintained at 18 weeks.
tervention in stroke (Lin et al., 2009) and mastectomy patients (Hayes et al., 2010), which impacted independent living. In addition, findings about the immediate effects of line-dancing on improved lower extremity activity changes are consistent with others (Murrock & Gary, 2008; Murrock & Graor, 2014). The immediate effects of linedancing support the Theory of MMM, which proposes that music is an auditory cue for movement to improve upper, lower, and ALE activities (Murrock & Higgins, 2009). What is vital to note are that the changes in physical function, UE, BLE, and ALE were maintained at 18 weeks. The maintaining effects provide evidence that the linedancing intervention can have a lasting effect on both upper and lower extremity activities. Hence, the results of this study advance understanding about the effect of dance and exercise programs, which have predominately focused on increasing muscle strength of the lower extremities based on the belief that mobility was the most important component of independent living (Liu et al., 2011). Increasing and maintaining muscle strength of the upper extremities can also affect ability to perform functions and tasks needed for individuals to live independently. Reporting both the immediate and maintaining effects of UE activities supports dance as a comprehensive exercise program for improving upper and lower extremity activities in underserved adults.
Discussion
Limitations
Although dancing mainly involves the lower body, this study shows that underserved adults reported significant improvements in UE activities, as well as in lower extremity activities, after line-dancing two times per week for 12 weeks. For the immediate effects, the UE activities that demonstrated the most change was pouring from a large pitcher (.52), reaching behind your back (.47), and using utensils for preparing meals (.37). Thus, the line-dancing routines were helpful in strengthening the UE muscles needed for holding an object, reaching, and manipulating utensils. The results are important as UE activities significantly decreased over time without an in-
Results of this study should be interpreted with caution because of several limitations. First, the potential inferences of the results are limited because of the small sample. Although there was a 75% retention rate for those who completed the 12-week dance intervention (21 of 28 participants), 12 participants never attended. However, 20 of 21 participants returned for the 18-week data collection period (95%). This limitation warrants further investigation to determine reasons for not attending an on-site dance intervention. For example, the apartment complex had a variety of planned activities for the residents, such as cookouts and bus trips during the study period. Also,
R2
R2 adj
Covariate
β
t
p
Physical function UE BLE
.72 .64 .67
.63 .51 .56
ALE
.71
.60
BMI Baseline UE Body fat BMI Baseline ALE
−.65 .72 .61 −.72 .62
−2.83 3.82 2.37 −2.85 3.12
.01
Effects of dance on upper extremity activities in underserved adults Carolyn J. Murrock, RN, PhD (Associate Professor), Christine Heifner Graor, RN, PhD (Associate Professor), & Annette Sues-Mitzel, RN, CNS, DNP (Director) Nursing Center for Community Health, College of Health Professions, School of Nursing, The University of Akron, Akron, Ohio
Keywords Underserved; nurse-managed clinics; health promotion; exercise; dance. Correspondence Carolyn J. Murrock, RN, PhD, Nursing Center for Community Health, College of Health Professions, School of Nursing, The University of Akron, 209 Carroll Street, Akron, OH 44325-3701. Tel: 330-972-8077; Fax: 330-972-5737; E-mail: [email protected] Received: 18 February 2014; accepted: 23 May 2014 doi: 10.1002/2327-6924.12232
Abstract Purpose: This secondary analysis examined the immediate and maintaining effects of a 12-week line-dancing intervention on upper and lower extremity activities in underserved adults who receive care from a nurse-managed clinic (NMC). Data sources: This one-group, repeated measures, feasibility study consisted of 40 participants recruited from an urban apartment complex that housed a NMC. Of the 40 participants, 21 participants completed the 12-week line-dancing intervention. Physical function of the upper and lower extremities was measured with the Late Life Function and Disability Instrument at baseline, 12, and 18 weeks to determine the maintaining effects. Conclusions: Age ranged from 45 to 87 years (M = 63; SD = 7.8), body mass index (BMI) was 33.4 (SD = 7.8), 92% were female, and 75% were African American. At baseline, participants showed limitations in all aspects of physical function. Significant improvements in upper and lower extremity activities were noted at 12 weeks and maintained at 18 weeks. Implications for practice: Although line-dancing mainly involves the lower body, there were significant improvements in upper extremity activities at 12 weeks, which were maintained at 18 weeks. The maintaining effects support line-dancing as an intervention to improve upper and lower extremity activities needed for independent living. NMCs are important settings for health promotion interventions in underserved adults.
Introduction Underserved adults are often defined as those who lack healthcare coverage, have limited access to healthcare resources, experience increased prevalence of comorbidities and logistical barriers, and accrue more out-of-pocket expenses than those who are not underserved (Hill et al., 2012). Underserved adults also do not receive appropriate, effective, and timely care for prevention and treatment of many chronic health conditions (Alverson & Kessler, 2012). To meet these needs, nurse-managed clinics (NMCs) provide primary care with an emphasis on health promotion and disease prevention by serving adults who would otherwise be underserved or not served at all (Coddington & Sands, 2008). The NMCs are operated by advanced practice nurses (APNs) who perform health assessments, prescribe treatments and medications, and coordinate health care. The APNs lead the healthcare team
C 2015 American Association of Nurse Practitioners
in primary care, health promotion, and disease prevention interventions. Health promotion interventions (i.e., exercise, dietary changes, diabetes management, medication management, foot, eye, and skin cancer screenings) are especially important as many chronic health conditions that impact physical function and independent living are more common among underserved adults. Few studies have been conducted at NMCs to examine healthpromoting interventions to improve physical function in underserved adults. Physical function is the performance of activities necessary for independent living, such as walking, climbing stairs, and handling objects (Haley et al., 2002). The ability to perform these specific activities requires gross and fine motor skills of the upper and lower extremities. An important part of physical function is muscle strength, which plays different roles in upper and lower extremity
1
Effects of dance on upper extremity activities
movement. While muscle strength of lower extremities is required for ambulation, muscle strength of upper extremities is required for skillful hand function (Liu et al., 2011). Muscles of the upper extremities are essential for coordinating different positions of the elbows, wrists, and arms to properly position hands and fingers for the performance of dexterous tasks (Kim & Bishu, 2004). Strength of large muscle groups in the upper extremities is vital for carrying, lifting, pulling, and pushing objects. Thus, upper extremity (UE) muscle strength is fundamental to perform everyday tasks necessary for independent living, such as preparing meals, doing housework, shopping for groceries, using transportation, handling finances, managing medications, and using the telephone (Seidel et al., 2009). As muscle strength declines with age, it can become challenging for individuals to live independently. Agerelated loss of muscle strength occurs both in the upper and lower extremities and becomes apparent after middle-age (Goodpaster et al., 2006). The decline of muscle strength can lead to difficulty in performing daily tasks and impact the ability to carry out activities essential for independent living (Szabo et al., 2011). To help individuals overcome muscle strength decline, exercise is frequently recommended. However, most exercise interventions to improve physical function focused on lower extremity activities (Baruth et al., 2011; Chale-Rush et al., 2010; Yorston, Kolt, & Rosenkranz, 2012). As a part of independent living, few studies have reported measuring UE activities in older adults with multiple sclerosis (GucluGunduza, Citakera, Nazlielb, & Irkecb, 2012), stroke patients (Lin et al., 2009), and mastectomy patients (Hayes, Rye, Battistutta, DiSipio, & Newman, 2010). Only one study reported using a simulated bowling video game in long-term care residents to improve UE activities (Hsu et al., 2011). Thus, there is a need to expand exercise interventions to include both upper and lower extremity activities to improve physical function needed for independent living. Dance is a type of exercise defined as a patterned, rhythmic movement in space and time (Pepper, 1984). It is a weight-bearing activity that requires the movement and coordination of large and small muscle groups of the upper and lower body (Hanna, 1995). Dance appeals to a wide range of individuals of all ages and cultures. It can take on many forms (low-impact, ballroom, ballet, etc.), be performed in a variety of settings, and does not necessarily require much expense or equipment (Keogh, Kilding, Pidgeon, Ahsley, & Gillis, 2009). In addition, dance can be altered to accommodate those with physical limitations, such as arthritis, osteoporosis, and neurological conditions (Keogh et al., 2009). Studies show that dance has physical and mental health benefits, such as reduced stress in underserved adults (Murrock & Graor, 2014), decreased 2
C. J. Murrock et al.
risk of falling in elderly (Lee, Tabourne, & Harris, 2010; McKinley et al., 2008), increased bone mineral density in women (Young, Weeks, & Beck, 2007), and increased social interaction in the elderly (Kreutz, 2008). When reviewing the literature, only two studies reported improvement in functional capacity and physical function in adults after completing a line-dancing intervention (Murrock & Gary, 2008; Murrock & Graor, 2014). Other dance studies reported improvements in static and dynamic balance (Sofianidis, Hatzitaki, Douka, & Grouios, 2009), locomotion-related functional abilities (Dewhurst, Nelson, Dougali, & Bampouras, 2014), physical performance (Eyigor, Karapolat, Durmaz, Isisoglu, & Cakir, 2009), and lower body strength and walk speed (McKinley et al., 2008) in older adults. However, no dance studies were found that reported measuring UE activities. Because most individuals have been exposed to dance, it may be more acceptable than other types of exercise programs to improve physical function in the upper and lower extremities. Thus, the purpose of this secondary analysis is to document the immediate and maintaining effects of a line-dancing intervention two times per week for 12 weeks on physical function of both upper and lower extremity activities in underserved adults who received care at an NMC affiliated with a local university.
Theoretical framework The study was based on the theory of Music, Mood, and Movement (MMM) that proposes music as an external time cue with recurring and predictable patterns to coordinate body movements, such as dance steps, hand claps, and finger snaps (Murrock & Higgins, 2009). Music is an impetus for movement and the motivating factor to dance. Dancing to music appeals to diverse groups of people, can occur in group settings, and encourages social interaction. Thus, music is an auditory cue for movement for a dance intervention to improve upper and lower extremity activities that are an important part of physical function.
Methods Design Data for secondary analyses were from a one-group, repeated measures, feasibility study that examined the effects of a dance intervention on depression, physical function, and disability in adults (Murrock & Graor, 2014). The convenience sample was recruited from residents living in an urban neighborhood apartment complex in the Midwest to participate in the one-group, repeated measures feasibility study. Approval for this feasibility study was obtained from the local university Institutional Review Board (IRB).
Effects of dance on upper extremity activities
C. J. Murrock et al.
Setting and sample The NMC, affiliated with a local university, was housed in the apartment complex and provided holistic, integrative primary care through an Interprofessional Primary Care Medical Home model. By providing primary care, the NMC was many residents’ health home. The apartment complex accommodated residents, ages 45– 90+, who were classified as disabled and whose income was at or below 60% of the median income for the county. Guidelines for disabled classification and median income were determined by the fraternal organization involved in nonprofit housing and development for low and moderate-income elderly. Inclusion criteria were (a) ability to read and write English and (b) provision of written medical clearance from their healthcare providers. Most residents had medical insurance (Medicaid, Medicare, or private) and a primary care provider. Exclusion criteria were (a) unstable chronic health conditions (unstable angina, uncontrolled hypertension, etc.), (b) foot ulcers, (c) currently enrolled in a structured exercise program 2– 3 days per week, (d) diagnoses of psychoses or substance abuse, and (e) confinement to a wheelchair. The dance intervention was held on-site in the community room located in the apartment complex.
Sampling and data collection procedures The 4-week recruitment period was held in the community room of the apartment complex right next to the NMC. Advertisements via flyers were posted in the community room, in the nursing clinic, and at the building entrance of the apartment complex. In the community room, potential participants spoke face-to-face with to the coprincipal investigators (Co-Is) and asked questions about the dance study. After the recruitment period, 40 participants expressed interest, volunteered to be in the study, and met inclusion criteria. Written informed consent was obtained by the Co-Is from all participants prior to the beginning of the line-dancing intervention the following week. After consent was obtained, baseline data collection occurred. Data collection consisted of: demographic information, medications, comorbidity, the Late Life Function and Disability Instrument (LLFDI) instrument, weight, body fat, and body mass index (BMI). Data were collected at baseline, 12, and 18 weeks (6 weeks postintervention) in a private area of the community room by the Co-Is. Baseline data collection period took approximately 45–60 min per participant and was collected during the 4-week recruitment period. Data collection at 12 and 18 weeks consisted of the LLFDI instrument, weight, body fat, and BMI and took approximately 30–45 minutes per participant. For all
data collection time points, Co-Is were available to read the LLFDI instruments to the participants if necessary. To convey gratitude and enhance retention, participants who had attended at least half of dance classes at week 6 received a cash incentive of $10. At the week 12 data collection corresponding to the end of the dance intervention, participants who had attended at least half of the classes during weeks 7–12 received a cash incentive of $15. When measuring the maintaining effects of dance at 18 weeks, participants received a cash incentive of $20.
Dance intervention The line-dancing intervention was taught by an experienced dance instructor, who led each line-dancing class two times per week for 12 weeks, for a total of 24 classes. A dance assistant attended each class to help the participants learn line-dancing steps. Each line-dancing class consisted of a 5-min warm-up, 30 min of line-dancing, and a 10-min cool-down period. The line-dancing routines consisted of basic, easy to learn line-dancing steps that involved repetitive movement of the legs, trunk, and arms choreographed to secular and gospel music. For each line-dancing routine, the same secular and gospel music were used during each line-dancing class. Because many participants had physical limitations (bad back, knee/hip discomfort, and arthritis), many line-dancing steps were modified to be lower intensity. As a result, each participant chose either regular intensity or lower intensity line-dancing steps. During each line-dancing class, chairs were available for participants needing to sit and rest and participants rejoined the line-dancing routines typically at the beginning of the next song. The Co-Is attended all line-dancing classes, provided bottled water for hydration, and carried cell phones to access 911 emergency services if needed to ensure participant safety. In addition, a first aid kit, glucose meter, glucose tabs, and blood pressure cuffs were available at all dance classes. None of these safety precautions were needed during the 12-week line-dancing intervention.
Measures Demographics, medications, health history, and comorbidity were assessed at baseline by the Co-Is. Comorbidity was measured with the Charlson scale (Charlson, Pompei, Alex, & MacKenzie, 1987), a weighted sum of comorbid conditions that reflect the functional burden of illness conditions. The NMC’s scale with an attached height rod was used to measure weight (in pounds) and height (in inches). Each participant was weighed wearing light street clothes without shoes. A segmental bioelectrical impedance analyzer (Omron Body Fat Analyzer, Model HBF-306, Bannockburn, IL) was used to calculate 3
Effects of dance on upper extremity activities
body fat and BMI as each participant’s weight, height, gender, and age were entered into the arm-to-arm analyzer. Then, each participant’s hands and fingers gripped the sensor electrodes on the handles of the device while standing with arms extended. The arm-to-arm analyzer is comparable to hydrostatic weighing and has a high validity coefficient (r = .83; Gibson, Heyward, & Mermier, 2000). The LLFDI assessed physical function and disability in community-dwelling older adults (Haley et al., 2002; Jette et al., 2002). The physical function component was a comprehensive assessment of an individual’s ability to perform gross and fine motor skills necessary to perform an assortment of activities relevant to living independently in the community (Haley et al., 2002). Because underserved adults are disproportionally affected with chronic health conditions, comorbidity, and physical limitations, the LLFDI was selected to assess physical function. The LLFDI assessed functional limitations through self-reported difficulty in performing 32 physical tasks. The physical function component consisted of three subscales: UE, basic lower extremity (BLE), and advanced lower extremity (ALE). Seven items assessed UE activities that related to movements of the hands and arms needed for daily activities. Fourteen items assessed BLE activities that primarily involve standing, bending over, and fundamental walking activities; and 11 items assessed ALE that focus on physical activity and endurance (Haley et al., 2002). All questions were phrased: “How much difficulty do you have doing a particular activity without the help of someone else and without the use of assistive devices?” Examples of functional tasks for BLE activities included (a) going up and down a flight of stairs with hand rails and (b) stepping up and down from a curb, while examples of ALE activities included (a) walking several blocks and (b) carrying something in both arms while climbing stairs. The seven items for UE activities included (a) unscrewing the lid off an unopened jar, (b) putting on and taking off long pants, (c) using utensils for preparing meals, (d) holding a full glass of water, (e) reaching behind your back, (f) ripping open a package of snack food, and (g) pouring from a large pitcher. The participants chose their degree of difficulty in performing these 32 physical tasks on a 5-point scale (1 = cannot do, 2 = quite a lot, 3 = some, 4 = a little, and 5 = none) for each item. Total physical function score and the UE, BLE, and ALE subscales scores were computed by summing the item scores to obtain raw scores. Next, raw scores were transformed to scaled scores (0– 100) based on a one-parameter Rasch model (Haley et al., 2002). Higher total and subscale scores indicated higher levels of physical function. For this sample of underserved adults, Cronbach’s alphas for the physical function component was 0.96, UE items was 0.88, BLE items was 0.94, and ALE items was 0.95. This is comparable to a study that re4
C. J. Murrock et al.
ported Cronbach’s alphas of the physical function and the three subscales of 0.83–0.96 in community-dwelling older adults (Hand, Richardson, Letts, & Stratford, 2010). Similarly, another study reported Cronbach’s alphas of 0.92– 0.97 for the physical function and the three subscales in community-dwelling African American women (Murrock & Zauszniewski, 2011). Criterion-related and construct validity of the LLFDI have been reported as well (Hand et al., 2010; Murrock & Zauszniewski, 2011).
Data analysis Prior to entry into the Predictive Analytics SoftWare (PASW, version 19.0), all data obtained from demographics and questionnaires were examined for completeness. Descriptive statistics described the sample and paired t-tests determined the effects of dance on upper, lower, and ALE activities of the physical function component of the LLFDI instrument. Hierarchical regression analyzed the maintaining effects of line-dancing at 18 weeks. Level of statistical significance was set at p values < 0.05.
Results The convenience sample was 92% female and 75% African American. Age ranged from 45 to 87 years (M = 63; SD = 7.9), and mean BMI was 33.4 (SD = 7.8). At baseline, physical function, UE, BLE, and ALE scores showed limitations in all aspects of physical function (see Table 1). Of the 40 participants who volunteered for the study, 28 participants attended at least one dance class. Of these 28 participants, 21 completed the 12-week line-dancing intervention. This supported feasibility of the study as 75% who attended at least one class completed the 12-week line-dancing intervention (Vincent, Pasvogel, & Barrera, 2007). To determine the immediate effects at 12 weeks, paired t-tests revealed that line-dancing significantly increased physical function, UE, BLE, and ALE (see Table 1). Specifically, the mean of each of the seven items that assessed UE activities increased from baseline to 12 weeks. Therefore, participants demonstrated improvement in all aspects of physical function, including UE activities after completing a 12-week line-dancing intervention. At 18 weeks, hierarchical regression determined the maintaining effects of dance for 20 of the 21 participants who completed the 12-week line-dancing intervention. Covariates of age, body fat, BMI, and comorbidity were added in the first step, and the baseline scores of physical function, UE, BLE, and ALE were added in the second step separately for the corresponding dependent variable. For physical function, the overall regression equation was significant (p < .01; F = 7.33) and the variables explained 72% of the change in physical function. Of the covariates,
Effects of dance on upper extremity activities
C. J. Murrock et al.
Table 1 Mean score for each of the seven items of the UE subscale at baseline and 12 weeks Baseline item mean (SD)
12 Weeks item mean (SD)
Change
3.93 (1.27) 4.58 (0.80) 4.53 (0.78) 4.75 (0.63) 4.05 (1.40) 4.18 (1.15) 4.38 (1.01)
4.29 (0.96) 4.62 (0.74) 4.90 (0.30) 4.95 (0.22) 4.52 (1.08) 4.52 (0.75) 4.90 (0.30)
.36 .04 .37 .20 .47 .34 .52
1. Unscrewing lid off an unopened jar 2. Putting on and taking off long pants 3. Using utensils for preparing meals 4. Holding a full glass of water 5. Reaching behind your back 6. Ripping open a package of snack food 7. Pouring from a large pitcher Note. UE, upper extremity.
Table 2 Maintaining effects of physical function, UE, BLE, and ALE activities at 18 weeks
only BMI (β = −2.83) was significant (p = .01). For UE, the overall regression equation was significant (p = .01; F = 5.02) and the variables explained 64% of the change as only baseline UE activities (β = .72) was significant (p < .01). The overall regression equation for BLE was significant (p < .01; F = 7.33) and the variables explained 67% of the change as body fat (β = .61) and BMI (β = −.72) were significant (p = .03 and p = .01, respectively). Finally, the overall regression equation ALE was significant (p < .01; F = 6.71) and explained 71% of the change with only baseline advanced lower extremities (β = .62) as significant (p < .01; see Table 2). Therefore, the changes in physical function, UE, BLE, and ALE were maintained at 18 weeks.
tervention in stroke (Lin et al., 2009) and mastectomy patients (Hayes et al., 2010), which impacted independent living. In addition, findings about the immediate effects of line-dancing on improved lower extremity activity changes are consistent with others (Murrock & Gary, 2008; Murrock & Graor, 2014). The immediate effects of linedancing support the Theory of MMM, which proposes that music is an auditory cue for movement to improve upper, lower, and ALE activities (Murrock & Higgins, 2009). What is vital to note are that the changes in physical function, UE, BLE, and ALE were maintained at 18 weeks. The maintaining effects provide evidence that the linedancing intervention can have a lasting effect on both upper and lower extremity activities. Hence, the results of this study advance understanding about the effect of dance and exercise programs, which have predominately focused on increasing muscle strength of the lower extremities based on the belief that mobility was the most important component of independent living (Liu et al., 2011). Increasing and maintaining muscle strength of the upper extremities can also affect ability to perform functions and tasks needed for individuals to live independently. Reporting both the immediate and maintaining effects of UE activities supports dance as a comprehensive exercise program for improving upper and lower extremity activities in underserved adults.
Discussion
Limitations
Although dancing mainly involves the lower body, this study shows that underserved adults reported significant improvements in UE activities, as well as in lower extremity activities, after line-dancing two times per week for 12 weeks. For the immediate effects, the UE activities that demonstrated the most change was pouring from a large pitcher (.52), reaching behind your back (.47), and using utensils for preparing meals (.37). Thus, the line-dancing routines were helpful in strengthening the UE muscles needed for holding an object, reaching, and manipulating utensils. The results are important as UE activities significantly decreased over time without an in-
Results of this study should be interpreted with caution because of several limitations. First, the potential inferences of the results are limited because of the small sample. Although there was a 75% retention rate for those who completed the 12-week dance intervention (21 of 28 participants), 12 participants never attended. However, 20 of 21 participants returned for the 18-week data collection period (95%). This limitation warrants further investigation to determine reasons for not attending an on-site dance intervention. For example, the apartment complex had a variety of planned activities for the residents, such as cookouts and bus trips during the study period. Also,
R2
R2 adj
Covariate
β
t
p
Physical function UE BLE
.72 .64 .67
.63 .51 .56
ALE
.71
.60
BMI Baseline UE Body fat BMI Baseline ALE
−.65 .72 .61 −.72 .62
−2.83 3.82 2.37 −2.85 3.12
.01
