Can Dance contribute to Physical, Emotional and

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Silvia Susana Wolff; Marcela dos Santos Delabary; Aline Nogueira Haas*. Federal University of Rio Grande do Sul – Rua Felizardo, 750- CEP 90690-200 ...
IJTRR 2017; 6 (1): 70-75

Original Research Article

doi: 10.5455/ijtrr.000000223

International Journal of Therapies & Rehabilitation E-ISSN Research 2278-0343 http://www.scopemed.org/?jid=12

Can Dance contribute to Physical, Emotional and Social Aspects of the Stroke Patient? Silvia Susana Wolff; Marcela dos Santos Delabary; Aline Nogueira Haas* Federal University of Rio Grande do Sul – Rua Felizardo, 750- CEP 90690-200 - Bairro Jardim Botânico, Porto Alegre, Rio Grande do Sul, Brazil. *Corresponding Author ABSTRACT The goal of this study was to analyze whether dance lessons can contribute to physical, emotional and social aspects of a group of stroke patients in Porto Alegre, Rio Grande do Sul, Brazil. This study is characterized as a case study with a qualitative analysis, that consists of the detailed observation of an individual or context. Four chronic stroke patients, tree male and one female, that had a stroke more than six months before the intervention, ranging in age from 50 to 86 years old, took dance lessons for one hour peer week for a period of three years. The activities used a series of different dance techniques to focus on gait, balance, weight transfer, and bearing and movement of the legs and arms with precision and coordination. Open-ended individual semi-structured interviews were audio recorded and transcribed. The interviews took 90 minutes, were facilitated by dance instructor and started as an informal conversation, which led to specific questions, addressed themes related to participants perception in relation to their body and any changes in physical, social or emotional aspects of their being after dance practice. The participants of this study reported perceived improvement in their physical, emotional and social aspects. Results suggest that dance could be an additional efficient resource for the rehabilitation process of stroke patients. Keywords: dance, dance/movement therapy, rehabilitation, stroke.

INTRODUCTION Having a stroke can lead to a radical change in the life of a human being requiring a long, hard, and complex rehabilitation process. The characteristic sequelae are: memory deficits, fatigue, reduced initiative, spatial disorientation, impaired motor function, impaired eye-hand coordination and depth perception, speech (articulation) and language dysfunction (receptive and expressive), in addition to diverse emotional reactions1. Strokes are affecting an increasing number of Brazilians at a young age, placing Brazil with the highest indexes of the disease. Approximately 68,000 deaths by stroke are registered each year, representing the primary cause of death and disability in Brazil2. Hence, more and more therapeutic intervention programs are necessary for this type of population. Traditional therapeutic interventions derived from physiotherapy are known to be tedious, strenuous, and non-social3. In contrast, interventions proposing the use of artistic practices such as dance present an experience of a playful, social, integrative, and potentially fun outlet4.

The main deficits observed in stroke patients are in muscle tone, movement amplitude, and postural alterations, balance difficulties, body organization, perception, sensitivity, and muscle weakness deficits, lack of coordination during gait, and other functional activities. The functional consequences of primary neurologic deficits usually predispose stroke patients to a sedentary life pattern, with restrictions on daily life activities, limiting independency and the quality of life of the individual, contributing to low self-esteem, depression, and social isolation and reduced cardiac reserve5. Thus, it is believed that the deficit improvement and therapeutic approaches through dance can be applied to other dance types and different groups, as is done specifically in this study, which is for stroke patients. According to Wolff 3, dance can be a means for social reintegration and physical rehabilitation for stroke patients. In addition, dance can improve common deficits in stroke patients such as balance and mobility3,6. According to these authors, in a dance lesson, patients are stimulated to move coordinately as

IJTRR 2017; 6 (1): 70-75 a whole, attending to multiple stimuli, thereby improving vocabulary. After the transcription of the interviews they patients’ mobility within their home and the community. were given back for checking and approval by the In this sense, the main goal of this study was to interviewee. analyze whether dance can contribute to physical, The data collection phase occurred in November emotional and social aspects of four stroke patients. 2013, after tree years of project activities. The Toward that goal, the following research questions interviews took 90 minutes, were facilitated by dance were: Can dance be used as a complementary instructor and started as an informal conversation, therapeutic intervention for stroke patients? What which led to specific questions. The questions contribution can dance make to physical, emotional and addressed themes related to participants’ perception in social aspects of the stroke patient? relation to their body and any changes in physical, social or emotional aspects of their being after dance METHODS practice. The interviews occurred naturally without any This study was conducted in outpatient clinic of El- This difficulty of understanding among the interviewees, all study is characterized as a case study with a qualitative of whom turned out to be very accessible and open analysis. According to Bogdan and Biklen7, a case when answering questions about their perception of study consists of the detailed observation of an themselves in the activities proposed. individual or context. This research was approved by Data analysis. The gathered information was the ethics committee of the Federal University of Rio classified, categorized, and interpreted to analyze their Grande do Sul, Brazil. In addition, all participating content. The results collected in the interviews were subjects have signed consent forms. analyzed through the technique for content analysis proposed by Bardin8. Thus, the analysis was carried out Participants. The participants of this research through the elaboration of tree categories: physical, study were four chronic stroke patients, tree male and emotional and social contributions of dance to the one female, that had a stroke more than six months stroke patient. These categories were elaborated before the intervention, ranging in age from 50 to 86 considering the finality and goals of the study as well as years old. Each participated one hour a week for three by looking for patterns and connections among the data years of the extension project “Dance as a as well as reading and re-reading it9. Complementary Rehabilitation Method for Stroke At the final stage of the research, data analysis Patients.” This project was also linked to an was completed, and closed data were discussed and Undergraduate course in dance at the Federal related to the literature, leading to the final University of Rio Grande do Sul (UFRGS) and considerations of this study. Research Group of Art, Body and Education. In the following section, the interviewees are Recruitment of subjects was done through contacts and cited by their initials, in order to maintain their advertising of the project in stroke support groups within confidentiality. hospitals and Health Centers in Porto Alegre. Intervention. The activities were planned RESULTS taking a somatic approach as the starting point, which Physical. In relation to changes in physical directs practices from a series of different dance aspects, the subjects of this research perceived techniques, including exercises for gait, balance, weight improvements in different parts of the body, varying transfer and bearing and the movement of legs and from individual to individual. According to one arms with precision and coordination. The structure of participant that we will identify as “G” an improvement the classes focused on the following: individual was perceived mainly in the hand (which could not be movement quality, progressing from simple to more opened before, and now, can), in the foot (related to complex movements, from slow movements to balance), and in the cognitive aspect: “Yes, the hand, progressively faster, in addition to building body the foot, head” (individual G). This same individual also awareness. Repetition was used with caution and perceived change in the abdominal region: “Yes, attention, with the focus on each individual’s needs, and difference in the abdomen, with the rolling like a ball the idea of bilateralism, where movements performed exercise” (individual G). Now, individual PN did not on one side must then be performed on the other side notice a lot of change in the affected hand, but a lot of it was an important focus to support symmetry for a in the leg: “Because . . . and I . . . in the affected hand, . hemiplegic patient, considered that hemiplegia is a . . not. But the leg, yes” (individual PN). These common deficit in stroke patients. The content of the differences were perceived in balance and gait, due to lessons were divided into three parts and are outlined in the protocol we used in our classes, as described in Table 1. table 1. Data collection. Open-ended individual semiNonetheless, all individuals felt improvements structured interviews were audio recorded and in determined aspects referring to their physicality, such transcribed. The interviews were taped and later as in their agility, walking pattern, limbs’ functionality, transcribed with fidelity, without altering the used speaking, as we can perceive in the following

IJTRR 2017; 6 (1): 70-75 Table 1 – Structure of the lessons for the stroke patients Part of the lesson First Part

Time 30 min

Content a) body awareness exercises; b) barre work: adapted ballet exercises (leg movement, weight transference and bearing, control of knee extension and flexion, laterality awareness, gait), first using the barre for support; c) center work: gait in different rhythms, balance exercises, body symmetry work; floor work: Pilates method exercises and stretching.

Second Part

10 min

a) dancing with partners: modified/simplified waltz and salsa basic steps; b) creative play: playing with each other in situations that include social interaction, problem solving or creating movements within a specific theme (for example: Halloween and Carnival) c) group improvisation: free dancing in couples or group, using movements done during the class or any other movements they might want to create and include.

Third Part

10 min

a) group discussion (this is an opportunity for the participants to share their sensations and feelings toward the lesson: what they liked and disliked, fears, anxieties, what felt good, bad, or uncomfortable).

statements: “Yes, I feel lighter [. . .] I am more agile, right?” (individual PN); “Yes, I feel [. . .]. Look, there is this, right? More agility [. . .] improvements, look . . . everything, leg arm [. . .] I left my cane” (individual PR); “I am very well, I walk, I talk [. . .]” (individual C); “Leg, arm, foot [. . .] and better speaking [. . .] the exercises helped me a lot. [. . .] sweeping, dusting, fixing the bed” (individual G). Emotional. When analyzing responses referring to perceptions related emotional aspects, the interviewees’ opinions were not unanimous. Three participants felt that their emotions and feelings remained the same: “For me, it is the same” (individual C); “Also, normal!” (individual PR); “[. . .] emotions stayed the same” (individual G). However, one participant felt better and happier: “of course . . . yes it is . . . for the better, right? [. . .] I feel happier” (individual PN). Nevertheless, all subjects stated they felt very well in class and that the activities provided integration and wellness moments: “[. . .] I feel good in class” (individual PN); “[. . .] I feel good!” (individual G). However, we perceive a contradiction in relation to the emotional aspect of the interviewees’ answers, because, while at a given moment one perceived change in the emotional status, there are other moments when he feels lonely at home, and even thinking about suicide, which constitute depressive symptoms. This subject affirmed that he feels much better when in a group and developing dance activities and now feels much better than earlier on: “[. . .] at home for me it is bad, because I don’t have anyone to

talk to; I live alone . . . ok. Then I have to go out. [. . .] I am well, my mother dies, my wife left me, so, it all happened at once, so, now I have a group [. . .]” (individual C). In this statement we perceive can the value of group work and the social aspect of the formation of community. Social. In relation to changes in social aspects, the interviewees perceived that they have an active social life and that these dance project activities provided more friends and a possibility to have better group contact: “I feel [. . .] ah, they contributed!” (individual PR); “Yes, making friends” (individual G). In addition, we perceived that all participants in the study have good social integration, because they participate in other activities of daily life, as we can see in the following words: “Yeah, birthday, weekend barbeque [. . .] And when I go out I talk a lot in the street, I even talk too much . . .” (individual PR); “[. . .] Monday I have activity . . . , Tuesday physical therapy, Wednesday computers, . . . Friday here, ah and Wednesday I, for the girlfriend” (individual PN). Besides, all subjects mentioned they enjoy the lessons and the developed activities very much, highlighting the floor work and also adaptive ballet: “I didn’t know how to dance, then I learned” (individual G); “Ok, well, enjoyed it a lot, well” (individual PR); “The floor part is good, which I prefer, ah more . . . It demands more” (individual PN); as I told you, I would like to . . . stay longer, a bit of time to do ballet [. . .]” (individual C). As well, the activities manifested a lot of desire that the project would continue, as G relates: “please, next year continue classes here” (individual G).

IJTRR 2017; 6 (1): 70-75 dance as therapy been recommended for people with varying disabilities as a way of maintaining their In this study, similarly to Wolff research3, we observed movement amplitude, as occurred in this study. that all of the participants perceived improvements in Calil, Santos, Braga and Labronici12, while relation to their physical, emotional, and social comparing two groups of stroke patients, one practicing wellbeing, after three years of participation in the dance dance and the other physiotherapy, also found more for stroke patients project, even though these benefits in the muscle tone of the subjects that perceptions were different from one individual to practiced dance. The authors believe that dance another, as perceived by each participant who express demands more motor mobility than physiotherapy, plus in their own way how the dance project improved some it awakens sensations that give rise to emotions, aspects of their wellbeing. However, we highlight that favoring muscle relaxation and making movement more improvements in the physical status were the ones that effective. These data are compatible with Bertoldi13, were most perceived, and which were given a lot of who described that 75% of the physically impaired emphasis in the answers. These improvements were participants in their study believed dance developed probably due to the emphasis given in the practice of muscle groups not previously worked in other activities. movements with precision and the use of repetition. Based on the above-mentioned studies, we In addition to this study’s results, other believe dance can help the development of cognitive research has shown that dance may be an appropriate abilities such as dual tasking and compensatory and effective strategy to ameliorate functional mobility 10,11 activities for stroke patients, as well as the improvement in elderly people and with Parkinson’s disease , with of balance deficits, changes of direction, and movement the ability to bring benefits to more traditional initiation and termination during movement activities. rehabilitation programs. The authors also suggest that Wolff, Vittielo, Haas and Gonçalves6 affirm that dance dance may be used as therapeutic intervention with an can contribute to the functional competence of stroke effective focus on balance and complex gait tasks. The patients, meaning, “in gait, balance, pivot, weight first part of the study, single dance lessons were taught transference and bearing, change of direction in space, to 45 stroke patients at Towson University, Johns movements in different rhythms and leg movement Hopkins Bayview Medical Center, and Kernan Hospital, precision” (p. 5). in Baltimore. All participants filled out an optional Post-stroke depression is very compromising to questionnaire utilizing a Likert Scale from 1 to 5 points, the patients’ recovery. Although, in a rehabilitation unit, where 1 meant “fully agree” and 5, “fully disagree”; post-stroke depression patients present a similar when questioned about whether they would participate evolution to those without depression. In this sense, the in dance as lessons for rehabilitation, only three said use of therapies focused on problem resolution is no. shown to be effective in reducing depression symptoms Subsequently, in the Zentrum fur Ambulante and in the improving the performance of daily life Rehabilitation at the University of Zurich, Wolff3 activities, which make it an important therapeutic conducted a series of dance workshops. Each group of 14 alternative for the remaining symptomatic population . subjects who took dance lessons together built up a Loss in functional mobility, in general, can lead strong social bond with the other participants in the to low self-esteem, poor mood, exclusion of activities, class. Thus, the data obtained demonstrated and diminished quality of life. Post-stroke depression improvements in mobility, speed, and gait agility, as may be associated with a negative effect on wellness, well as in the mood status of the participants, who increasing disability, functional limitation degree and proved to be more self-confident and willing to pursue cognitive decline. This may be strongly associated with their rehabilitation after four weeks of dance lessons. patients’ low quality of life in a period of one to three Macko et al16 investigated the effects of an 12 years post stroke . adaptive physical activity (APA) in the mobility function 15 Demers and Mackinley proposed a dance and quality of life in chronic stroke patients, intervention for individuals post-stroke and 75% of the demonstrating that mobility, participation, and participants enjoy the classes, because “the dance rehabilitation improved with the program. The results intervention promoted social interaction and was found in our study indicate that a one-hour-long dance performed in a group format” (p. 3129). The authors lesson per week demonstrated its effectiveness in conclude that a “dance is a promising treatment obtaining results similar to those found by Macko et intervention that can be used as an innovation adjunct al16, providing improvements at the physical, emotional, therapy to target multiple impairments in individuals in and social levels. the subacute stage of post-stroke recovery, in a According to Duncan, Lai, Bode, Perera and hospital setting” (p. 3130). DeRosa5, limitations in physical function after a stroke Data previously collected by Wolff3 indicate an have a huge impact on the quality of life and contribute interest of stroke patients in dance lessons, in Baltimore to the economic burden of the disease. For these (USA) and Zurich (Switzerland), as well as benefits authors, none of the evaluation instruments used in resulting from these lessons for these patients. In the research in the area, to date, are applicable to the

DISCUSSION

IJTRR 2017; 6 (1): 70-75 whole spectrum of the severity of stroke. We have willingness to participate in the treatment, among other found the interview to be a valuable instrument to get a things, are truly important, and is where dance can be a more subjective and a deeper view on the perception of complementary activity to the whole process. Even though this study had a small group of the patient in relation to his or her own physical, participants, this study may serve as a starting point for emotional, and social status. reflections on the approached theme. We know individuals with stroke sequelae need frequent longConclusion term rehabilitation. Therefore, dance may be one more In conclusion, we perceive that dance as efficient resource to be used in this process, because therapy could be successful in minimizing not only the besides the physical contribution, it has been shown to physical but also the emotional and social aspects of provide improvements in the patients’ emotional and social aspects. individuals with different disabilities 3,6,10,11,12. Stroke rehabilitation is a long and complex Conflict of Interest: None. process. Therefore, family and caregiver support, in addition to physical therapy treatments and the patient’s

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