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Effect of Bharatnatyam-based Dance Therapy in Children and Adolescents with Down Syndrome.

INTRODUCTION

Down Syndrome (DS) is a genetic condition characterised by presence of one extra chromosome in 21st pair, resulting in physical growth delays, mental and social impairments [25]. Despite many co morbidities, life expectancy has increased by more than 80% of individuals with DS above 30 years of age. They become more vulnerable to lifestyle diseases such as diabetes mellitus, obesity etc. leading to low fitness and sedentary behaviour, thereby increasing potential health risks [18].

Exercise capacity in individuals with DS is extremely low due to high rates of sedentary behaviour [12]. People with DS show reduced levels of cardiovascular fitness than rest of community [19]. This can be enhanced by aerobic exercise training program[4]. Reduced muscle strength and ligament laxity are common musculoskeletal impairments present along with hypotonia, which has a negative effect on proprioceptive feedback from muscle and joint sensory units. This can lead to low force production, motor delay resulting in poor postural reaction and balance [15]. Cerebellar hypoplasia i.e. smaller size of cerebellum is also reported to affect postural control contributing to increased reaction time, thus reducing motor performance [6]. All this cumulatively causes individuals with DS to present peculiarities such as "clumsiness", i.e., having a movement profile characterized by slow movements and impaired coordination [17]. There is evidence that individuals with DS present deficits in performing tasks that have predominance in perception requirements, mainly in tasks that demand time synchronization because of atypical patterns of brain organization that can be partially attributed to structural characteristics of brainstem and cerebellum [27]. Owing to risk of cardiovascular health concerns, regular physical activity is essential for individual with DS. Alternative interventions programs have a potential to improve physical skills, promote socialization, exhibit health benefits and provide a pathway that leads towards a better quality of life for individuals with DS [24].

Dance can provide a total body workout and may influence flexibility, muscle strength, cardio respiratory fitness, balance [16]. It is a form of aerobic exercise which integrates creativity and self-expression into learning process, so that participants become more active and physically fit [10].

Simultaneous use of different body parts along with music induces a dynamic and temporal variability in the execution of whole-body movements which is provided with dance therapy. Previous literature suggests the use of dance therapy to enhance neuroplasticity in comparison with tradition therapy programs as training involves more conscious control [22].

In addition, literature review suggests that community-based dance is beneficial for typically developing individuals [23]. A study demonstrated improvement in balance outcomes in young adults with and without DS using dance movement therapy for 18-week intervention [14]. Dance movement therapy is proven to be effective in children with attention deficit hyperactivity disorder suggesting significant improvement after three weeks intervention program [26]. Another case study using dance therapy was found to have positive effect on 21-year-old male with DS, having social, physical, and psychological benefits [23]. However, these studies limit their application due to a smaller sample size and short duration of dance protocol. Moreover, they do not comment on overall effect on physical fitness.

Bharatanatyam, an Indian classical dance form, is a recreational form of physical activity performed by individuals of all ages. It is a sequence of rhythmic and dynamic body movements. In this study, Bharatanatyam was selected as a dance form due to its nationwide popularity. This dance form demands strong lower extremity work in Araimandi (Half squat), Modita (full squat), Tattavadu (squat and tap) and Ekapadam (one leg stand) along with postural stability and coordination which makes it a perfect workout. This is accompanied by verbal commands and music influencing motivation and relaxation. These movement patterns are proven to influence strength and cardio respiratory fitness [1, 20].

Purpose of the present study was to evaluate the effect of 12-week Bharatnatyam based dance therapy protocol on body composition, cardio respiratory system, muscle strength and postural control in children with DS.

METHODS

Participants:

Study commenced after approval by Research Committee, Mahatma Gandhi Mission (MGM) School of Physiotherapy, Navi Mumbai. Five special schools were approached out of which three schools agreed to participate in this study. Formal permission was taken from school authorities. Seventy-four children with DS were shortlisted, out of which 30 subjects were selected based on inclusion and exclusion criteria. Total of 20 males and 10 females with mean age 11 [+ or -] 4 years participated in the study. Inclusion criteria was children and adolescents in age group of 5-18 years diagnosed with DS, not enrolled in any other form of aerobic exercise and should be able to follow commands. Children and adolescents with behavior problems that would prevent them from participating in organized classes, health problems that preclude them from participating in moderate physical activity programs and any other co-existing diagnosis were excluded from the study. Written informed consent was obtained from each parent/guardian. Physical fitness certificate was obtained from medical practitioner.

Procedure:

Each participant was evaluated for height (meters) and weight (kilograms) for deriving Body Mass Index (kg*[m.sup.2]) as measure of body composition as described by American College of Sports and Medicine, 2000. Dynamic balance was evaluated using Four Square Step Test and functional balance using Paediatric Berg's Balance scale in individuals with DS [4,13]. Reaction time was measured using ruler drop test [2] Lower Limb isometric muscle strength was tested using Commando dynamometer [11]. Explosive muscle power was tested using standing broad jump test [8]. Cardio respiratory endurance was tested using 6-minute walk test, while respiratory muscle function was checked by Maximum Inspiratory Pressure and Maximum Expiratory Pressure device [7,9]. Pre and post evaluation was performed by physical therapist. Each participant underwent one-week pre-training for acclimatization to protocol considering that participants had lower levels of physical activity. Bharatnatyam based dance movements were selected and they were taught by the person who was both a physical therapist and certified classical dance trainer. The 12-week protocol for 3 sessions/week for 60 min/session was then started. Table 1 demonstrates Bharatnatyam based dance movements protocol. This protocol was administered in a group session with five therapists assisting the participants. Bharatnatyam based dance therapy was administered using fusion music with low to moderate intensity with beats of 10 counts for each step. Dance movements were aimed to increase abilities mainly in balance, strength, endurance, physical fitness and thus movement control. These movements were initially demonstrated to participants by trained therapist, following which they were assisted during one-week pre-training for acclimatization to enable them to perform in continuous sequence of movements during intervention. Bharatnatyam based dance therapy protocol was implemented such that it would involve the use of aerobic energy systems by maintaining the intensity and duration of exercise protocol. A progressive sequence from lesson to lesson and week to week was employed, that gradually developed participant's skill and fitness. Heart rate and blood pressure was recorded for before commencing the session.10 minutes of warm up and cool down was given. Five-minute rest pause was given after 20 minutes. After completion of 60 minutes dance session heart rate and blood pressure was recorded for safety concerns. Evaluation was conducted at two data points which includes post six weeks and post twelve weeks by same therapist who performed pre evaluation using the outcome measures mentioned above.

Statistical analysis:

Statistical analysis was performed using SPSS software (version 23). Demographic details are descriptive, and expressed as mean [+ or -] SD. Level of significance was set at p < 0.05 for all inferential statistics. Data was tested for normality using Shapiro-Wilk test. Outcomes were analysed using 1 (group) x 3 (data point) analysis of variance (ANOVA) with Repeated measures. An alpha value of 0.05 was used as level of significance. Bonferroni post hoc tests were performed for comparisons across data points.

RESULTS

Twenty males and 10 females within the age group of 5-18 years with mean age 11 [+ or -] 4 years participated in the study. There were no dropouts reported during course of study. No participants missed sessions due to fatigue or any other adverse effect.

Post Bharatnatyam based dance therapy protocol, assessment indicated 2% reduction in BMI, 18% reduction in skin fold thickness of triceps and 13% reduction in gastrocnemius indicating improvements in body composition (p < 0.05). On measures of cardio respiratory fitness we found that MIP increased by 59% and MEP by 47%. Distance on 6-minute walk test increased by 27% (p < 0.05). Distance on standing broad jump test improved by 34.6% lower extremity isomeric strength improved by 44% to 86% (p < 0.05). With maximum gains in hip muscles followed by knee flexors and then ankle plantar flexors, with least gains reported in knee extensors which was about 44% to 54% (p < 0.05). Scores of paediatric BBS improved by 18% and time taken to complete four square step test reduced by 39% (p < 0.05). Descriptive statistics are reported in Table 2.

No significant changes were demonstrated on waist-hip ratio and reaction time (p > 0.05).

DISCUSSION

The present study evaluated the effect of Bharatnatyam based dance therapy in children and adolescents with DS. We hypothesized that this 12-week Bharatnatyam based dance therapy protocol will influence body composition, cardiorespiratory system, muscle strength and postural control in children with DS. Findings of present study suggest that Bharatnatyam based dance therapy has a positive outcome on body composition, cardiorespiratory fitness, lower extremity isometric muscle strength, static and dynamic balance in children and adolescents with DS. Dance therapy as a form of rehabilitation, engages multiple body system and can be performed in varied setting, economical in terms of equipment used and appeals to wide range of individual's right from children to the elderly. This form of therapy brings in elements of fun and enjoyment, social interaction along with physical activity which can potentially improve adherence to therapy.

Postures and movements used in Indian Classical dance forms are representatives of Hindu deities and are based on half squatting postures (Aramandi) or a full squat (Muzumandi) which also comprises of rhythmic stamping of feet and multitude of fine and meaningful hand gestures. Half squat position (Aramandi) involves squatting while keeping back erect while feet together in V-formation, legs rotated outwards and knees spread apart. Full squat position (Muzumandi), similar position is achieved but heels are raised as individual performs a full squat. Certain dance postures adopted in Indian classical dance form resemble postures from western dance forms. Literature suggests analogy between postures performed in Bharatanatyam and Ballet dance form [3]. Semi-squat (Aramandi) position performed in Bharatanatyam involves closed chain knee flexion with hip abduction and external rotation. Muscles used in these postures include hip extensors, adductors, quadriceps, hamstrings, tibialis anterior, medial and lateral gastrocnemius muscles [28]. As lower extremity muscles are engaged more heavily due closed chain knee bending postures and movements, we were able to appreciate strength improvement in lower extremity muscles in present study.

Movements in dance involve integration of cutaneous, proprioceptive, visual and vestibular inputs along with other environmental stimuli. In order to accomplish integration of these sensory inputs, brain creates a schema with respect to space and context of movement. Dance has been proved to increase this mapping capability in turn promoting clarity and relationship between body segments for resulting in improvements in postural control [5]. Experts in motor learning field refer to this as "internal focus of attention" along with external focus of attention" cues, which facilitate connection between body and space [29]. Adapted classical dance protocol used in our study constantly engaged these systems, thereby improving outcomes of balance.

Dance being a form of an aerobic activity, results in improvements in parameters of body composition and cardiorespiratory fitness. Continuous and rhythmic nature of dance activity engages large muscle groups utilizing aerobic metabolism by extracting energy in the form of adenosine triphosphate (ATP) from amino acids, carbohydrates and fatty acids [21].

Limitations:

Participants selected in the present study healthy and motivated; hence, whether it results can be generalized to all individuals with Down syndrome, as a whole, needs to be investigated in future studies.

Conclusion:

In conclusion, present study recommends Bharatnatyam based dance therapy as a part of rehabilitation of children with DS for improving strength, balance and cardio respiratory fitness.

Clinical Implication:

As an art form, Indian classical dance training principles systematically enhance alignment, flexibility, core strength, postural control and selective motor control which can be utilized as an adjunct in rehabilitation of children with DS.

REFERENCES

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[15.] Hawli Y., M. Nasrallah, and G.E. Fuleihan. Endocrine and musculoskeletal abnormalities in patients with Down syndrome. Nature Rev Endocr 5(6):327, 2009.

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[28.] Trepman E., R.E. Gellman, R.U. Solomon, K. Ramesh Murthy, L.J. Micheli LJ, and C.J. De-Luca. Electromyographic analysis of standing posture and demi-pile in ballet and modern dancers. Med Sci Sports Exerc 26:771-782, 1994.

[29.] Wulf G. Attention and Motor Skill Learning. Champaign, IL: Human Kinetics, 2007.

Shrutika Parab, Meruna Bose, Sakina Shayer, Ramandeep Kaur Saini, Madhura Salvi, Pooja Ravi, Prajakta Sawant

Department of Neuro-Physiotherapy, MGM School of Physiotherapy, MGM Institute of Health Sciences, Navi Mumbai, Maharashtra, India

AUTHOR CORRESPONDENCE:

Meruna Bose

MGM School of Physiotherapy, Sector-1, Kamothe, Navi Mumbai-410209

Maharashtra, India

merunabose.mgmsop@gmail.com
Table 1: Adapted semi classical Dance therapy Protocol

  Exercise    Duration  Repetitions            Techniques

   Phase      10 mins       10        Heel raises, Spot marching,
  Warm up               repetitions   Jumping jacks, Trunk rotations.
Experimental  40 mins       15        * Ardhamandalam/ Araimandi
  Protocol              repetitions/    (attaining half squat position)
                         dance step   * Tattavadu (Squat and foot tap)
                                      * Prenkhana (Attaining Side lunge
                                        position with hands clasped
                                        while performing alternate toe
                                        raises and calf raises)
                                      * Ekapadam (One leg stance with
                                        hand postures)
                                      * Paarvasuchi (Standing to half
                                        kneeling while performing hand
                                        postures with trunk movements)
                                      * Modita/Poornamandalam
                                        /Muzumandalam (Full Squat with
                                        alternate knees touching the
                                        ground)
                                      * Chalana Chaari (Tandem walking
                                        forward and backward with
                                        lateral trunk movements in
                                        squat position)
                                      * Swastika (Tandem standing with
                                        hands on waist)
 Cool down    10 mins       10        Movements involving
                        repetitions   self-stretching for hamstring,
                                      quadriceps and gastro soleus with
                                      therapist supervision.

Table 2: Descriptive statistics of outcomes at baseline, post 6 weeks
and post 12 weeks

Variables                   Baseline       Post 6       Post 12
                            M (SD)         weeks         weeks
                                           M (SD)       M (SD)

Body Composition
Body Mass Index            17.9 (4.4)    17.6 (4.5)    17.5 (4.4)
Waist/Hip Ratio             0.9 (0.1)     0.9 (0.1)     0.9 (0.1)
Skin Fold Thickness         1.6 (0.4)     1.3 (0.4)     1.3 (0.4)
Triceps
Skin Fold Thickness         2.3 (0.5)     1.2 (0.5)     2 (0.5)
Gastrocnemius
Cardiorespiratory
Fitness
Maximal Inspiratory         7.1 (4.5)     9 (4.7)      11.3 (5.5)
Pressure
Maximal Expiratory         15.6 (10.8)   18.9 (11.9)   23 (13.1)
Pressure
Six Minute Walk Test      338.2 (99.2)  393 (81.6)    431 (92.2)
Isometric Lower Limb
Muscle Strength
Standing Broad Jump        41.6 (20.9)   46.1 (22.8)   56 (27.2)
Hip Flexors Right           8.5 (2.3)    11.4 (3.4)    13.9 (3.5)
Hip Flexors Left            8.2 (2.1)    10.6 (3.3)    13.6 (3.6)
Hip Extensors Right         6.7 (2.3)     9.1 (2.5)    12.5 (3.9)
Hip Extensors Left          6.5 (2.1)     9 (2.4)      11.8 (2.7)
Hip Abductors Right         7.3 (2.5)     8.8 (2.2)    11.3 (2.7)
Hip Abductors Left          7.2 (2.5)     9.3 (2.5)    11.7 (3.1)
Hip Adductors Right         6.5 (2.6)     8.8 (3.2)    11.5 (3.6)
Hip Adductors Left          6.3 (2)       8.2 (2)      11 (3.6)
Knee Flexors Right          6.7 (1.8)     8.9 (2.7)    11.2 (3.3)
Knee Flexors Left           6.5 (2.2)     8.9 (2.5)    11.2 (3.1)
Knee Extensors Right        8.4 (2.9)     9.6 (3.1)    12.1 (4)
Knee Extensors Left         7.8 (2.8)     9.7 (3)      12.1 (3.9)
Ankle Dorsiflexors Right    4.9 (2.1)     6.8 (2)       8.4 (2.4)
Ankle Dorsiflexors Left     4. 8(2.1)     6.6 (1.5)     7.9 (1.9)
Balance
Four Square Step Test      20 (10)       15.5 (7)      12.2 (6.7)
Paediatric Berg's          41.9 (5.1)    47.7 (4.7)    49.7 (4.3)
Balance Scale
Reaction Time
Reaction Time (Distance)   21.6 (6.6)    18.3 (5.5)    16.1 (4.9)
Reaction Time (Time)        0.3 (0.1)     0.3 (0.3)     0.2 (0.1)
Reaction Time (Grade)       3.4 (1)       3.2 (0.9)     3.4 (0.9)

Variables                     F      P value     df
                          statistic

Body Composition
Body Mass Index             12.6     0.0001 (*)  0.3
Waist/Hip Ratio              2.1     0.2         0.1
Skin Fold Thickness         38.6     0.0001 (*)  0.6
Triceps
Skin Fold Thickness         37.2     0.0001 (*)  0.6
Gastrocnemius
Cardiorespiratory
Fitness
Maximal Inspiratory         23.1     0.0001 (*)  0.4
Pressure
Maximal Expiratory          38.9     0.0001 (*)  0.6
Pressure
Six Minute Walk Test       107.2     0.0001 (*)  0.8
Isometric Lower Limb
Muscle Strength
Standing Broad Jump         24.5     0.0001 (*)  0.5
Hip Flexors Right           79.6     0.0001 (*)  0.7
Hip Flexors Left            63.2     0.0001 (*)  0.7
Hip Extensors Right         78.4     0.0001 (*)  0.7
Hip Extensors Left         134.6     0.0001 (*)  0.8
Hip Abductors Right         98.3     0.0001 (*)  0.8
Hip Abductors Left          74.8     0.0001 (*)  0.7
Hip Adductors Right         70.8     0.0001 (*)  0.7
Hip Adductors Left          72.7     0.0001 (*)  0.7
Knee Flexors Right          80       0.0001 (*)  0.7
Knee Flexors Left           86.5     0.0001 (*)  0.7
Knee Extensors Right        50.9     0.0001 (*)  0.6
Knee Extensors Left         55.1     0.0001 (*)  0.7
Ankle Dorsiflexors Right    60.9     0.0001 (*)  0.7
Ankle Dorsiflexors Left     66.3     0.0001 (*)  0.7
Balance
Four Square Step Test       24.2     0.0001 (*)  0.5
Paediatric Berg's           88       0.0001 (*)  0.8
Balance Scale
Reaction Time
Reaction Time (Distance)    44.4     0.0001 (*)  0.6
Reaction Time (Time)         1.1     0.3         0.0
Reaction Time (Grade)        2.4     1.0         0.1
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Author:Parab, Shrutika; Bose, Meruna; Shayer, Sakina; Saini, Ramandeep Kaur; Salvi, Madhura; Ravi, Pooja; S
Publication:Clinical Kinesiology: Journal of the American Kinesiotherapy Association
Article Type:Dance review
Geographic Code:9INDI
Date:Sep 22, 2019
Words:3839
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