BACKGROUND AND PURPOSE
Balance training and therapeutic exercise have been used in physical therapy for the treatment of aging adults with recurrent falls. Aging adults undergo age-related changes in joint range-of-motion, strength, sensory processing, and sensorimotor integration, which contribute to balance impairments with increasing age. The incidence of falling increases with age, and it may result in a substantial loss of function as people become older than 65 years.1 A fall can be defined as an unintentional loss of balance that leads to failure of postural stability.2 In addition, falls represent the most common mechanism of injury,3 and the leading cause of death from injury, in people older than 65 years.4 Furthermore, falls are associated with pain, loss of confidence, functional decline, and institutionalization.5–7 The 2008 American Academy of Neurology fall guidelines suggested that people with diagnoses of stroke, dementia, walking and balance problems, history of recent falls, and people who use walking aids, are at the highest risk of falling.8 Fear of falling may lead to more sedentary lifestyle with subsequent deconditioning that creates an ongoing downward spiral leading to frailty and increased risk of future falls. Based on these trends, older people with multiple impairments and comorbidities are at an increased risk for falls and functional decline.
Physical therapy interventions for the sedentary and deconditioned adult who sustains frequent falls often involve flexibility, strengthening, balance activities, and endurance training. The focus of this case report utilizes dance therapy to complement traditional interventions and meet the patient's rehabilitation goals. Physical therapists have expressed moderate to high agreement that dance could positively impact clients' physiological and psychological states, thus, facilitating long-term participation and corresponding health benefits.9 Several studies have explored the effects of dance on mental health, balance, fall risk, and function.9–13 Individuals with serious mental illness showed significant improvements in Timed Up and Go (TUG) scores and nonsignificant improvements in anxiety, depression, and balance confidence after regular 1-hour dance lessons once a week for 10 weeks.10 In addition, music therapy may reduce therapeutic doses of some psychotropic medications; improve mood and self-expression; stimulate speech, organization, and mental processes; promote sensory stimulation and motor integration; help achieve overall rehabilitation goals,11 and increase the level of participation in nursing home residents.12
Specific outcome measure improvements have been documented with dancing such as decreased risks of falls in community-dwelling, independent older adults;13 and sustained bone mass, improved static and dynamic balance, and improved lower limb functional strength in healthy white postmenopausal women.14 Significant changes were attained in resting heart rate, 6-Minute Walk Test (6-MWT), TUG, lower limb endurance, and some SF-36 domains in community-dwelling older adults.15 When evaluating gait benefits alone, musical motor feedback and rhythmic auditory stimulation improved some gait parameters in older adults with acute hemiparesis following stroke, even when the auditory stimulus is removed.16,17 Musical motor feedback consists of sensor insoles that detect ground contact of the heels and a portable music player in which music is played at an adjustable speed that is estimated from the time interval between 2 consecutive heel strikes.16 Rhythmic auditory stimulation is an adjusted regular metronome sound that has been shown to affect walking rhythm in patients with Parkinson disease, Huntington's chorea, and hemiparesis due to stroke.17
Cultural dance is a practical form of physical activity that promotes physical and mental health among subgroups of populations that often have lower amounts of participation in physical activity and who may find cultural dance as a more acceptable alternative.18 Traditional Greek dance has shown benefits for improving static and dynamic balance control in healthy community-dwelling older adults.19 Also, a Turkish folklore dance-based exercise treatment resulted in improvements in 6-MWT, chair rise, stair climbing, Berg Balance Scale (BBS) score, and some SF-36 subscales in healthy physically active older women.20 Another study promoted traditional dance movement programs as a means of health promotion and falls prevention for the aging adult in the community, after finding the benefits of Korean traditional dance movement on balance, depression, and decreased medical costs in older women.21 Healthy, community-dwelling, older women who dance jazz have demonstrated improvements in balance using the sensory organization test, which suggests jazz dancing as an effective fall prevention strategy.22,23 Likewise, healthy, community-dwelling older women who performed dance-based aerobic exercises improved selected components of balance and locomotion agility, thus reducing fall risks.13 Other forms of cultural movements such as Tai Chi Chuan, use martial arts to improve balance control in healthy community-dwelling older adults24 as well as improved cardiopulmonary function, immune capacity, mental control, flexibility, muscle strength, and fall reduction in older adults.25
Dancing also has improved outcomes for persons with Parkinson disease. Tango dancing, for example, improved measures of balance, falls, gait, and confidence in community-dwelling healthy individuals and older adults with Parkinson disease when compared with traditional exercise.26 The aforementioned studies compared the effects of partnered and nonpartnered dance movement on gait and balance in women with mild-to-moderate stages of Parkinson disease, and both groups significantly improved on the BBS, comfortable and fast walking velocity measures, and cadence.27 Tango and Waltz/Foxtrot dancing significantly improved the BBS score, 6-MWT distance, and backward stride length in community-dwelling individuals with mild to moderate Parkinson disease; although Tango may be superior when targeting the deficits.28 Dance provides sensory cueing for older adults with Parkinson disease, which appears to be a powerful means of improving gait in these individuals.29 In addition, a case study that applied Tango as the therapeutic intervention for a community-dwelling, African American older adult male with chronic stroke resulted in improvements in balance, mobility, endurance, and dual-task ability.30
Limited research has explored the effects of Salsa dance on clinical outcomes in the aging adult. Salsa is a syncretic dance form with origins in Cuba, a major crossroad of Spanish (European) and African cultures. The patient population where this case report was performed is predominantly of Latin, particularly Cuban descent, many of whom have been exposed to Salsa music and dancing at some time of their lives. The purpose of this case report is to examine the effects of a 12-week Salsa dance therapy program on balance, gait, and fall risk in a sedentary woman with Alzheimer's disease, late effects of a cerebral hemorrhagic aneurysm, arthritis, and recurrent falls.
Patient History and Systems Review
The patient was an 83-year-old Hispanic woman referred to outpatient physical therapy for functional decline, unsteady gait, right knee pain due to degenerative joint disease, and frequent falls within home. The patient's chief complaint was left anterior shoulder pain and right knee pain sustained in a fall 1 month ago, with a total of 8 major falls in the past year without significant injuries. As a result of the most recent fall, the patient became more sedentary due to fear of falling, showed overall decreased balance, and consequently had more difficulty walking. Her past medical history included Alzheimer's dementia, depression, generalized arthritis, peripheral vascular disease, brain aneurysm (18 years ago) with hemiparesis of mainly the right lower extremity and frequent falls. Her medications included Aricept (donepezil hydrochloride) for the dementia, sertraline (Zoloft) for anxiety and depression, cilostazol (Pletal) for peripheral vascular disease, Aspirin (acetylsalicylic acid) or Tylenol (acetaminophen) for pain relief, and supplements such as vitamin B and omega 3 amino acid for nutritional supplementation.31 The patient and legal surrogate were informed that the data collected would be submitted for publication and written consent was obtained.
The patient lives in her own house with 2 steps to enter, along with a caregiver who spends most of the day with her and assists with activities of daily living and administering medication. The patient used a 5-year-old 4-wheeled rolling walker with swiveling wheels (4WRW) for ambulation, which was unsteady and had poorly functioning breaks. In addition, after the brain aneurysm episode, the patient was issued an ankle-foot orthosis to wear on the right hemiparetic lower extremity, but the patient had been noncompliant with the wearing schedule for years and refused the use of a new ankle-foot orthosis. At the time of admission, the patient had activity limitations at home such as difficulty transferring from different surfaces; difficulty walking, showering, dressing, grooming, or standing long periods which impaired the ability to cook, do laundry, or perform housekeeping tasks. In addition, the recent functional decline had hindered her social interaction (participation restriction) by not being able to attend family events, go shopping with a caregiver, nor enjoy leisure activities outdoors.
Based on the patient's history and review of systems, the patient was a good candidate for a falls prevention program that focused on Salsa dance intervention. The patient and caregiver goals were to improve balance, safety, gait quality, walking distance, and to decrease the risk of falls. Although the patient had dementia, she was able to follow 1- to 2-step commands and perform a familiar task like Salsa dancing, due to her cultural background. At the same time, this activity would assist in regaining muscle strength, balance, and functional endurance through active and dynamic standing exercises. In addition, dancing with music could be perceived as an enjoyable activity by the patient and increase her participation and compliance with therapy.
Examination and Evaluation
On initial examination, baseline measurements were obtained for mental orientation (person, time, place, situation), observational postural assessment, skin integrity, and presence of pain using the Visual Analog Pain Scale (1 = least amount of pain; 10 = most amount of pain). The range of motion was measured using standard goniometry, motor strength of lower extremity through manual muscle testing, muscle tone using the Modified Ashworth Scale, and light touch sensation of lower extremity. Scales and definitions from the Functional Independence Measure (FIM) were used to rate bed mobility, transfers, walking, and stair-climbing ability. In addition, standardized functional measures were utilized to further investigate the patient's mental status, balance, endurance, and gait quality. These included the Saint Louis University Mental Status (SLUMS), the Tinetti Assessment Tool known as the Performance-Oriented Mobility Assessment (POMA), BBS, TUG, gait speed, and 6-MWT.
The SLUMS Test is a 30-point screening questionnaire that tests orientation, memory, attention, and executive functions. Lower scores indicate a higher level of dementia.32 The SLUMS Test was normalized on a large (N = 702) group of primarily white, male veterans older than 60 years. Scoring differs according to the educational level of the subject. Individuals with a high school education who score 27 to 30 are considered to have normal mental functioning, whereas scores of 21 to 26 could indicate mild neurocognitive disorder, and scores 20 and below could indicate dementia. In individuals with less than a high school education, scores ranging from 25 to 30 are indicative of normal mental functioning, whereas scores of 20 to 24 could indicate mild neurocognitive disorder, and scores less than 19 could indicate dementia. Sensitivity and specificity for the cutoff values for mild neurocognitive disorder (23.5) and dementia (19.5) in patients with less than high school education (the relevant category for our patient) were 0.92/0.81 and 1.0/0.98, respectively.32
The Tinetti Assessment Tool (POMA) is an easily administered task-oriented observational test that measures an older adult's gait and balance abilities.33 Scores lower than 19 of possible 28 indicate high risk for falls. Studies indicate that the POMA has a concurrent validity of 0.64 to 0.70, predictive validity: sensitivity of 61.5% and specificity of 69.5%, the interrater reliability of 0.75 to 0.90, and test-retest reliability from 0.88 to 0.97.33–36
The BBS examines standing and dynamic standing in older adults,37 and predicts the risk of falls.38 A score of 36 or less indicates a nearly 100% chance of falling in the next 6 months in older adults.39 The BBS is both inter- and intratester reliable and has concurrent and construct validity.40,41
The TUG Test is a gait-based functional mobility test that is easy to administer, reliable, and has high sensitivity (87%) and specificity (87%) for predicting falls.42 This test also correlates well with balance, gait speed, and functional capacity;43–45 and demonstrates excellent intra- and interrater reliability with intraclass correlation coefficients of 0.97 and 0.99.44,46 Individuals taking 13.5 seconds or longer to perform the TUG Test were classified as participants with history of falls with the overall correct prediction rate of 90%.42
Walking speed, measured through the 10-Meter Walk Test, is considered a functional vital sign in the assessment of older adults, and it is useful to collect both self-selected and fast gait speed capabilities.47 Self-selected walking speed, also termed gait velocity, correlates with functional ability, balance confidence, potential for rehabilitation, and aids in prediction of falls and fear of falling.47 This measure also predicts hospitalization and mortality rate.48 Although walking speed varies with age, gender, and arthropometrics, the range for normal walking speed in community-dwelling older adults has been reported to be 1.2 to 1.4 m/s.49 A change in gait speed of approximately 0.05 m/s represents a small but clinically meaningful change, and a change greater than approximately 0.10 m/s represents a substantial meaningful change in gait performance.50,51
The 6-MWT measures submaximal aerobic capacity in older adults using walked distance as the primary measure. The 6-MWT has excellent test-retest reliability (intraclass correlation coefficient = 0.95−0.97)46,52 and correlates well with other measures of functional performance.43,46,52,53 A change in 6-MWT distance reflects a change in aerobic capacity with intervention, with a 20-m increase representing a minimal clinically important change and a 50-m increase, a substantial change.51
The physical therapy examination revealed decreased cognition and signs of dementia according to the SLUMS score of 7/30. The patient's cognitive impairments did not permit accurate completion of the Falls Efficacy Scale to measure fear of falling nor accurately rate the amount of pain present using the Visual Analog Scale. However, she demonstrated decreased general safety with ambulation such as poor posture/body mechanics and decreased use of brakes with a 4WRW, poor consistency using the 4WRW during transfers, and a perceived fear of falling. Observing her posture, shoulders were rounded and her right knee hyperextended in stance position. Pain had been present since her last fall in the left shoulder during active elevation and in the right knee during ambulation. The patient also demonstrated decreased bilateral ankle dorsiflexion passive range of motion (right 0°, left 0° to 5°), decreased strength of right lower extremity (hip 3−/5, knee flexion 2+/5, knee extension 3+/5, ankle plantar/dorsiflexion 3−/5, ankle eversion 1/5). Motor performance results were noted via the modified Ashworth with a 1+/4 on the right lower extremity. Functionally, the patient required supervision with bed mobility, minimal assistance during transfers with a 4WRW, moderate assistance to walk 15.25 m (50 ft) with a 4WRW, and was not able to climb stairs. Analyzing her gait pattern, she demonstrated increased ankle inversion and decreased hip and knee flexion, which limited right foot clearance during the swing phase of gait. As a result, she compensated with right hip circumduction and short step length. In addition, she walked using a flexed forward trunk posture and hyperextended her right knee due to instability in the stance phase of gait.
During functional balance and walking tests, the patient consistently scored in the high fall risk category for all outcome measures. The Tinetti (POMA) score was 9/28(<19/28 indicates high falls risk33), BBS 13/56(<45/56 indicative of high fall risk38), the TUG Test was 93 seconds (adults who took $13.5 seconds were classified as participants with history of falls with an overall correct prediction rate of 90%42), walking speed 0.27 m/s (1.2−1.4 m/s is considered normal range for safe community ambulation49), and 6-MWT distance of 140.2 m (460 ft) using a 4WRW and requiring 4 standing breaks (80–89-year-olds walked 292.1 m [6112.7 m] or 958.3 ft [6369.8 ft]43). Based on the examination data, the patient could benefit from familiar functional exercises, such as dancing Salsa, which could challenge her flexibility, strength, balance, endurance, and decrease risk of falling during functional tasks.
The patient was seen in the outpatient clinic for a total of 24 sessions of 1-hour duration over a period of 12 weeks. A physical therapist in a postgraduate geriatric physical therapy residency program performed all patient care, including leading the Salsa dancing program and assigning the patient with an updated home exercise program every 4 weeks, which addressed physical impairments. In addition, the therapist had previous experience with Salsa dancing steps and instruction. The therapy sessions were divided into two halves: The first half addressed functional activities, and the second half involved Salsa dancing. Functional activities consisted of gait training, transfer training, bed mobility training, and stair climbing. Additional interventions targeting impairments included hip/knee/ankle stretching and strengthening as well as core strengthening. Salsa dance interventions were performed inside the parallel bars and in front of a mirror to improve visual feedback for both the patient and the therapist. The dance consisted of performing 4 basic Salsa steps while holding on to the bar with both hands. Manual cues were provided at the pelvis to direct movement and timing. The steps used in the intervention form part of the Cuban casino style Salsa dancing and are commonly called “Para Abajo,” “Guapea,” “Side-stepping,” and “Back Rocks.” Basically, these steps consist of a combination of stepping forward, stepping backwards, stepping sideways, and rocking backwards using alternating feet movements. Sequencing of steps involves weight shifting side to side, moving in diagonal patterns, and coordinating each step position and length. Initially, therapy sessions focused on learning each step sequence using verbal, visual, and tactile cues.
Owing to memory deficits, the patient had to be cued on the steps each session. However, the ease of movement and motor performance improved with each subsequent session. Repeated motor practice has been identified as crucial for motor recovery through neuroplasticity and motor learning.54 The practice pattern used for this patient consisted of part to whole practice for each step (eg, 1, 2, 3...1, 2, 3 progressing to 1, 2, 3, 4, 5, 6) in a blocked sequence of consecutive steps and was progressed each therapy session to facilitate skill acquisition. Once the patient achieved competence on the steps sequence, music was introduced using 1 earpiece for the patient's ear and 1 for the therapist's ear, which facilitated the therapist's feedback while the patient coordinated the movement with the rhythm played. Timing of the patient's steps to the music is important to achieve a fluid movement. Strong evidence suggests that rhythmic auditory stimulation significantly improves gait and upper extremity function and has been shown to be more effective than other sensory cues and techniques in physical rehabilitation.55 In this case, the rhythmic auditory stimulation provided feedback for the patient to time her stepping in this higher balance activity task of dancing. To decrease confusion and facilitate learned task recall from 1 session to the next, only 1 slow tempo instrumental Salsa song was utilized in the therapy sessions.
Initially, the 4 dance steps were practiced 10 times each in a blocked schedule to gain acquisition of skill. When the patient's confidence and dance coordination improved, she was encouraged to use only 1 hand on the parallel bar for support and the step frequency was increased to 20 repetitions of each basic step (again in blocked sequence), with rest breaks when appropriate. The time required to finish each basic step 20 times was recorded with music and without music to compare performance speeds (Figures 1 and 2). Every therapeutic session emphasized safety during transfers, proper walker use, and a home safety checklist was provided to address environmental safety problems that could be contributing to falls.
Functional measures improved from baseline to 6 weeks; and to a lesser extent, from 6 weeks to 12 weeks, as portrayed in Table 1. Her ankle flexibility improved in the left ankle more than the right, the muscle tone in the lower extremity remained the same, and the lower extremity strength improved mostly at the knees. In terms of functional mobility, using the Functional Independence Measure scale, bed mobility improved from supervision to modified independence, transfers from minimal assistance with a 4WRW to supervision with a 4WRW, gait score improved from moderate assistance for 15.25 m (50 ft) using the 4WRW to supervision for 182.9 m (600 ft) using a 4WRW, and stair climbing score improved from total assistance to close supervision for 14 to 16 steps using bilateral hand rail support.
Functional balance tests improved from baseline to week 6 and week 12, although she remained in the high-risk categories for falls. The POMA score improved 5 points (Figure 3), but scores lower than 19/28 indicate risks for falls. The final BBS was 32/56 (Figure 4). While this score is still in a high-risk group, the 19-point gain constitutes a significant clinically meaningful change.56 TUG performance time decreased by 63 seconds (Figure 5), a marked improvement, but remains above 13.5 seconds, which indicates risks for falls.42 Gait speed nearly doubled in both self-selected (a 0.21 m/s gain) and fast speeds (a 0.29 m/s gain) during the 10-Meter Walk Test (Figure 6), which is well above the 0.10 m/s gain needed for a substantial meaningful change.50,51 Finally, the 6-MWT distance improved by 41.5 m or 136 ft (Figure 7), indicating clinically important improvements in aerobic capacity.51
At the time of discharge, the patient continued to receive assistance from her aide at home. The caregiver also facilitated the home exercise program 3 to 5 times a week. The patient required minimal assistance to supervision for most activities of daily living at home due to her level of dementia and decreased safety awareness. Also, the family and aide noticed a significant increase in activity and function at home. The patient experienced 1 fall at week 5 of therapy, with no significant injuries, and she did not report any other falls at the time of discharge. During a 6-month follow-up phone call to the patient's daughter, she reported no significant falls since the termination of therapy and a recent decline in walking endurance was likely due to arthritis-related pain and swelling in both knees.
This case report describes the effects of a 12-week physical therapy program, which consisted partly of a Salsa dancing intervention in a sedentary patient with Alzheimer's dementia, late effects of a cerebral hemorrhagic aneurysm with right hemiparesis, arthritis, and recurrent falls. The patient demonstrated improvements in a range of motion, strength, functional activities, POMA, BBS, TUG Test, gait speed, and the 6-MWT.
At the time of initial assessment multifactorial causes led to frequent falls and functional decline. Her symptoms of dementia, assessed by the SLUMS, were a factor in decreased safety awareness during mobility, compliance with safety instructions, and home exercises. Impaired cognition has a strong correlation to falls,57,58 as it is often difficult for the cognitively impaired person to recognize “risky” situations and make prudent choices that would prevent a fall. Environmental hazards at home, such as slippery walking surface, loose rug, poor lighting, and obstacles in the walking path can increase the risk of falling, particularly in individuals with compromised balance. In addition, issues of pharmacologic interactions and adverse effects can add substantially to impaired balance and risk of falls. Antidepressants, antianxiety drugs, sedatives, tranquilizers, diuretics, and sleep medications are all related to increasing the risk of falling in older adults.59 In this case, the use of multiple medications, specifically sertraline for anxiety and depression, could have increased the risk of falling.
Several studies have explored the effects of dance on mental health, balance, fall risk, and function.10–16,18–23,26–28 Particularly, Tango dancing improved measures of balance, falls, gait, and confidence, in healthy individuals and the older adults with Parkinson disease when compared with traditional exercises.26 Dance provides sensory cueing for the Parkinson's patient, which appears to be a powerful means of improving gait in these individuals.29 This case study used sensory cueing to challenge standing balance through the task of dancing, which resulted in balance gains at the time of discharge.
Information about the effectiveness of Salsa dancing in healthy or nonhealthy older adults as an intervention for improving postural control is limited in the literature. This patient had multiple comorbidities, and the task of dancing Salsa was familiar to her due to her cultural background. At the time of discharge, functional outcomes greatly improved from baseline scores. BBS increased by 19 points, which could demonstrate a decreased risk for falls.60 Berg score changes of 6.5 indicate 95% confidence that a genuine change has occurred for older adults who have reported falling.56 Likewise, gait speed and 6-MWT distance increases were clinically significant. Walking speed changes of 0.1 m/s are considered clinically significant.61 In this case, the patient improved normal walking speed by 0.21 m/s and the fast walking speed by 0.29 m/s, which decreased the risk of hospitalization and mortality.48 A change of 20 m in the 6-MWT represents a minimal clinically important change, and a change of 50 m represents a substantial change.51 At the time of discharge, the 6-MWT score improved from 140.2 m (460 ft) at baseline to 181.7 m (596 ft) at 12 weeks, achieving and clinically significant change of 41.5 m and approaching her age and gender norm of 281.8 m, according to Lusardi et al43 in a study of community dwelling older adults with and without assistive devices. It is possible that with increased adherence to the home exercise program the patient could have attained greater improvements at the time of discharge. Also, the Salsa dance intervention likely could not be progressed further with faster music rhythms, decreased level of support, and variation of step order due to her decreased memory and dependence on cues to perform the specific steps.
This case study adds support to the benefits of dance as a therapeutic intervention in the aging adult. It would be beneficial to design future studies that evaluate the effects of dance therapy on individuals with specific impairments and compare functional outcomes to conventional therapy. The identification of reliable predictors of exercise adherence will allow health care providers to effectively intervene and change patterns of physical activity in sedentary aging adults.62 Dance is promising as an efficient, effective, and exhilarating physical therapy intervention, with inherent sources of motivation for long-term neurological and orthopedic patients in a hospital or community settings.63 It could be beneficial to develop programs that promote dancing as a form of exercise in aging adults to increase activity level, exercise compliance, and possibly increase function.
This case study documents clinically significant improvements across a variety of functional measures in a sedentary patient with multiple comorbidities after receiving Salsa dance as a therapeutic intervention. Further studies are needed to investigate the effects of this form of therapy on different conditions. In addition, culturally sensitive dance forms could increase activity levels and exercise compliance in sedentary aging adults.
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