Effects of dancing heart program (DHP) as therapeutic recreation intervention on risk of falling among community dwelling elders.
There is a growing body of research that demonstrates benefits of dance for elders who are at risk of falling. One benefit of having a dance program as exercise regimen for preventing falls may be that the universal, primal nature of dance entrances participants to stay in the program. Since adherence to the program remains an issue for physical activity for older adults, dance can provide an outlet for older adults to enjoy leisure, and at the same time to enhance their physiological function, thus preventing falls. The current study used the Dancing Heart Program as a therapeutic recreation intervention to examine its effects on risk of falling among community dwelling elders living in Minneapolis, Minnesota. The study used longitudinal design that involved three time periods, and utilized both quantitative and qualitative measures. Although effects of the DHP in quantitative analysis of the study were not evidenced, qualitative analysis revealed some beneficial effects of the DHP on risk of falling. Three themes were identified confirming the effectiveness of the DHP on falls.
Falls are the leading cause of emergency room visits in the US and are also the number one cause of accidental death for persons over the age of 65 (Fuller, 2000). The study also indicated that compared with children, elderly persons who fall are ten times more likely to be hospitalized and eight times more likely to die as the result of a fall. According to Lee (2008), morbidity and mortality associated with falls are in fact among the biggest medical problems among older adults. There are many different types of physical and psychological conditions that may cause elders to experience a fall including impaired hearing, loss of cognitive function, reduced vision, ambulatory problems, foot problems, neurological changes slowing reaction time, and negative consequences of over-medication, and prolonged or excessive use of prescriptions (Fuller, 2000). The fear that a fall might occur is also a risk factor for elders that might actually cause them to fall. The fear starts a deleterious cycle beginning with avoiding leaving home to barely moving about in the house. According to Brouwer, Musselman, and Culham (2004), fear of falling diminishes participation in activities and reduces efforts to socialize thus decreasing quality of life. Negative self talk can aggravate self isolation, increase concern about potential danger in the external environment, then confirm the wisdom of doing as little as possible in order to reduce risks.
Social cognitive theory posits that human behaviour is affected by three factors; personal, environmental, and behavioural (Bandura, 1997). Self-efficacy is one personal factor that probably has received most attention in research related to physical activity. According to Bandura, "self-efficacy is a belief in one's own capacity to organize and execute the course of action required to produce a given attainment" (1997, p. 3). Fear of falling may result from decreased self-efficacy causing restricted levels of physical activity and further resulting in decreased physical function that may exacerbate the risk for falls.
Thus, addressing these deficits along with fear of falling should improve functional capacity and self-efficacy resulting in fewer incidences of falls and fall related injury.
Numerous studies have indicated that physical activity is an intervention that can increase self-efficacy and can be used to reach positive effects on falls among the older adults (Carter et al., 2002; Kannus, 1999; Lee, 2008; Province et al., 1995). Research has shown many positive effects of engaging in a physically active program. Nied and Franklin (2002) agree that activity levels decrease with age and physical exercise such as walking, aerobic exercise, strength training, balance, and flexibility programs can help older adults experience fewer complications such as cardiovascular diseases and accidents. They further state that there are also increases in life expectancy for those who do not begin regular exercise until late in life compared to those who were active only in younger years and then stopped exercising (2002). This suggests that it is never too late to benefit from being physically active. However, many physical activity programs are too strenuous for the elderly population to participate in. Many older adults would love to find a physical activity that promotes regular exercise and wellness but does not seem boring or exhausting, or risks injury and pain. Research reveals that 50% of elders who began exercise stop after six months of engagement (Desharis, Bouillon, & Godin, 1986; Dishman, 1994; Ettinger et al., 1997; Fitzgerald, Singlton, Neale, Prasad, & Hess, 1994). Factors that affect adherence to physical activity among elders include lack of motivation (Dishman, 1994), insufficient resources, coexisting disease states (Morey, Pieper, & Cornoni-Huntley, 1998), impaired health (Blair et al., 1998), and lack of knowledge about the benefits of the physical activity.
According to Greenspan, Wolf, Kelley, and O'Grady (2007), 86% of the elders participated and attended a Tai Chi program on a regular basis. They stated that once an elderly individual tries something new and interesting he or she is are more likely to participate and stick with the program whether it is yoga, ballroom dancing, polka, salsa, Tai Chi.
Dancing, in particular, can be a positive outlet that promotes overall well being and creativity (Lee, 2008). In recent systematic literature review, Lee found that one program possibility encouraging participation in physical activity and engagement by elders is a dance program. The study found that dance is an effective and safe exercise regimen to motivate elders to stay in a program that might also decrease their risk of falling. According to Shigematsu et al. (2002), dance can be an effective exercise intervention in decreasing risk of falls among the elderly population. The study found that the benefits of dance on falls relate to factors of kinesiology and to relatively low incidence rates of injury. McKinley et al. (2008) examined the effect of a community based Argentine Tango Dance Program on functional balance and confidence in older adults. They evaluated physical activities that could be implemented in a community setting, would attract seniors, and could be challenging enough to increase functional balance and improve confidence. Argentine tango was one such physical activity they identified that met these criteria to improve balance, mobility, and fitness. The study found that Argentine tango had a significant impact on functional improvement in balance, thus decreasing the risk of falling.
Therefore, the main purpose of the current study is to examine effects of dance as therapeutic recreation intervention on the risk of falls among community dwelling elders living in Minneapolis, Minnesota. Risk for falling includes physical deficits such as balance, muscular strength, endurance, and fear of falling that may restrict the level of physical activity among elderly persons.
Dancing Heart Program
The Dancing Heart Program (DHP) developed by Maria D. Genne in 2001 for elders involves improvisational dance and personal storytelling (reminiscing about the participants' past). Various therapeutic techniques were employed to facilitate sharing, to increase self-expression, and there were opportunities for generativity through intergenerational dance performances with children.
The program sessions, held in the morning at Walker Senior Care Center in Minneapolis, Minnesota in 2004, began with playing music that the instructors selected in advance and expected to trigger memories for the participants. The participants shared life experience then they expressed their feelings about these experiences in dance. The instructors emphasized that every dance movement has meaning and the participants shared the meaning of their movements with the other participants. The program met once a week for 90 minutes with the dance instructors from Kairos Dance Theatre.
A total of nine subjects were recruited by the primary researcher and dance instructors at Karios Dance Theatre for the present study from the adult care center of the Walker Senior Care Services located in Minneapolis, Minnesota in accordance with the Institutional Review Board's approval at the University of Minnesota. The study was part of a larger grant funded by the Jay and Rose Phillips Family Foundation. Criteria for sample selection were: (a) age 65 years or older, (b) without severe physical and cognitive impairment that would interfere with participation. Before the program began, a consent form was distributed and read to the participants. Because some participants had mild cognitive deficits symptomatic of Alzheimer's disease, subjects with limited ability to read the questionnaire completed questionnaires with assistance from a TRS reading the questions to tile subject.
Since there was no control group, statistical analysis on the demographic variable was not conducted to determine group difference.
The SAFFE (Survey of Activities and Fear of Falling in the Elderly) was approved for use by the developers, Lachman, et al., (1998). SAFFE was employed to assess fear of falling and avoidance of physical activity. Tile SAFFE is composed of three subscales that include fear of falling, activity restriction, and activity level. The fear-of-falling subscale measures the extent to which participants are worried about the chance of falling while engaging in daily activities. Activity-restriction subscale reflects the number of activities that are avoided (compared past 5 years) to prevent falls. Activity-level subscale concerns participant's level of engagement of activities (e.g., Do you currently visit a friend or relative). Lachman et al. (1998) demonstrated that the SAFFE has satisfactory psychometric properties on its validity and reliability.
Participants were also asked for their self-appraisal of the degree to which they met performance measures related to the objectives of the program. Interview questions were developed for qualitative analysis of data and one on one guided interview was conducted by primary researcher. Content validity of the interview guide was established by conducting extensive literature review and by expert panel review.
Both the SAFFE and interview data were collected at three points over eight months. Initial data were obtained in January to establish a baseline. Data were then collected at midpoint and at the conclusion of the sessions. SAFFE data were treated as repeated measures using the SPSS statistical package while content analysis was conducted on qualitative data.
Analysis and Findings
Recruiting participants for the current study was one of the major challenges. The sample size of the study was too small to reach a general conclusion for the target population. Initially, the study was designed to include treatment and control groups with random assignment to both groups. However, because of the small number of the participants, it was not a proper method to involve treatment and control group design. Thus, the research design was changed to include treatment group only with repeated measure. Using the repeated measure of multivariate analysis of variance (MANOVA) statistic, the power of the data analysis for the study is not greatly affected. MANOVA is used when there are more than two time periods of measure in study having repeated measure analysis. In general MANOVA is the preferred statistical method to the repeated measure ANOVA, especially when study involves more than two time periods of measures because it does not require the restrictive assumption of sphericity (Howell, 1997). Since the current study involved three time periods of measures, MANOVA was the appropriate statistical technique to determine treatment effects between pre, mid, and post test. Using MANOVA, the results of the statistical analysis are inferential in nature to a target population so as to generalize the findings to this population. The SPSS 11.5 statistical package was used for statistical analysis.
As shown in Table 1, the SAFFE instrument was employed to measure participants' level of fear of falling and activity level. The descriptive data shown in Table 1 shows not much difference in all three areas SAFFE in terms of mean differences. For inferential examination, Multivariate Analysis of Variance (MANOVA) was conducted.
MANOVA reveals that there was no significant difference across all areas of SAFFE as shown in Table 2. This may be due to the small samples and more importantly, possibly due to nature of dementia which most of the participants exhibited to some degree.
The sample size and deficits in participants' cognitive function were major constraints to general consensus on the effect of DHP for participants in the current study. Nonetheless, the study analysis did reveal some positive effects of the program by conducting qualitative analysis of interview data collected in multiple repetitions of the program. A primary researcher reviewed the interview data isolating meaning units of text. One member of the research team then reviewed all data to ensure all individual meaning units were identified. To categorize responses into themes, the data were then analyzed by employing thematic content analysis (Smith, 1992).
Thematic content analysis, a commonly used qualitative technique, involves the systematic examination of linguistic data allowing for the recognition of potential themes and common elements in textual material. Thematic content analysis provides for greater objectivity than other qualitative methods, while still allowing themes to emerge from the text (Smith, Feld, & Franz, 1992). The data were categorized into the following three themes: functional improvement (physical and cognitive), decreased fear of falling, and increased socialization.
Theme one: Dancing Heart Program (DHP) helped functional improvement (physical and cognitive).
The first theme to discuss is effectiveness of the DHP on functional improvement. Most of the participants indicated that the DHP helped increase following areas; flexibility, circulation, energy, balance, thinking, learning new things, remembering, coordination, strength, and endurance. Physical functional improvement was expected due to nature of the dancing activity that requires physical movement. However, one area that the study did not anticipate was in the area of increases in cognitive function. Participants indicated that the DHP helped improve memory skill because they needed to share their life story while engaging in dance. Sessions usually began with a theme such as occupation. Then, an instructor asked participants to describe their occupations in dance movement. This naturally led to a discussion of participants' past occupations. Remote memory may have been stimulated and helped to increase cognitive function. One elder said, "Now l can recall some of my friends' names who used go fishing with me."
Theme two: DHP helped to decrease fear of falling.
One major aim of the current study was to determine whether there was a decrease in fear of falling for the elders in the DHP. While evidence was not found in quantitative analysis, participants indicated that they felt their health was now good enough to do things they wanted to do and to try to discover new things. This was one of the most significant findings of the current study because fear of falling can lead to reduction in the level of physical activity that can increase the risk for falls. One elder mentioned that she was confident that she could go outside with her friends for a walk. Another participant stated that "Increased balance really helped me to begin walking outside again."
Theme three: DHP helped increase social interaction.
The most consistent finding across the data, stated by all participants was that they really enjoyed interacting with other participants. Many of them indicated that they would like to have an opportunity to interact with other age groups too. In fact, social interaction was a big part of the DHP because it was a catalyst to empower participants to experience leisure through sharing life stories and through expressing their emotion in dance while in the DHP. One elder stated, "I made lots friends here so I just love to be here." Another elder stated, "I went out for a walk with others after a session was done."
The current study examined effects of dancing on the risk of falling among community dwelling elders by implementing the Dancing Heart Program (DHP). The desire of the study was to obtain objective data about the impact of the DHP on risk of falling among the participants, and to be able to say with some confidence how well the stated objectives of the program was met and expected outcomes for the participants were reached. The study found evidence of effect of the DHP on falls. Although statistical analysis of the data did not yield statistically significant evidence due in part nature of Alzheimer's disease and small sample size, qualitative analysis showed beneficial effects of the DHP on factors leading to falls. Given the potential negative influence on effective interviews of cognitive deficits with some participants, most of the participants were capable of voicing their perceptions of the benefits in several areas of functioning derived from the DHP and from participating in the study as evidenced in qualitative analysis.
Physical activity is very important for elders to offset changes in physical functional capacity increasing the risk for falls. Physical activity can delay or significantly reduce the risk of the devastating event of fall resulting in hip fracture, loss of independence, and accelerating time of death. In addition, fear of falling that diminishes participation in activities among elders can be decreased due to improvement in physical functional capacity after engaging in physical activity. DHP can be very effective therapeutic recreation intervention technique to help decrease risk of falling while promoting adherence to the program.
Implications for Therapeutic Recreation Practice
Dance is a physical activity that can provide fun in a relatively safe environment, inexpensive, easily available, and enjoyed alone in one's own home with a radio turned on. If dance is offered as a therapeutic activity, with professional supervision, it can be effective for a variety of physical, social, emotional, and cognitive purposes. Credentialed recreation therapy staff can safely lead or assist dance instructors to develop, implement, and monitor dance interventions aimed at decreasing the risk of falling for elder populations.
Some elders may be afraid to chance dancing for fear of injury and are reluctant to explore the benefits of a program like the DHP. If elderly individuals would risk dancing but are afraid of possible injury, seated dance movement programs may meet their needs. A large percentage of dance programs designed for elders are practiced in sitting positions. This type of dance program is especially viable for mixed ability groups of elders because those who use a wheelchair can easily be included with little or no modifications. Individuals with sensory deficits can also be included by employing tactile cues with objects like balloons or scarves, and by partnering the elder with a peer, aide, or with a much younger participant who adds the intergenerational element.
Implications for Therapeutic Recreation Research
Future studies of the Dancing Heart Program should examine the impact of dance movement specifically to improve a target skill (e.g., endurance or balance). This study involved generalized physical capacity to participate in dance. The program sessions might be more structured in future iterations and incremental by difficulty or sequentially ordered with pre scheduled weekly themes. The researchers in this study recognize that an important aspect of the DHP is the ability of the instructors to respond quickly to the mood, presentation, or creative movements of the participants. Researchers will have to determine to what extent controlling the spontaneity of the moment transforms the DHP into a different program and impacts the validity of the research on the effect of the DHP. Future studies must improve the statistical power of the results by involving a much larger sample or a more sophisticated method such as a randomized controlled design conducted ill multiple sites to be able to generalize to the larger target population.
CEU OBJECTIVES AND POST-TEST QUESTIONS
Learning Outcomes: The reader will be able to:
1. Identify impact that falling or the fear of falling can have on an elderly person
2. Explain the value of physical activity with elderly persons
3. Identify the components of the Dancing Heart Program
Questions: Please select the most appropriate answer. 1. What is the leading cause of emergency room visits in the US? a. Falls b. The flu c. Colds d. Broken bones 2. What can the fear of falling cause? a. Reduced vision b. Slowing reaction time c. Loss of cognitive problems d. Decrease in quality of life 3. Research reveals that--% of elders who began exercise stop their engagement alter--months of engagement. a. 75.3 b. 50.6 c. 25.9 d. 35.4 4. According to one study, what dance had a significant impact on functional improvement in balance? a. Foxtrot b. Cha Cha c. Argentine Tango d. Rumba 5. What components does the Dancing Heart Program contain? a. Modern dance and journaling b. Improvisational dance and personal storytelling c. Ballroom dancing and personal storytelling d. Folk dancing and journaling 6. What assessment tool was used to collect data? a. The SAFFE b. The LCM c. The LDB d. The FALSAF 7. How frequently was data collected? a. 2x--beginning and end of study b. 3x--beginning, middle and end of study c. 4x--beginning, alter 3 weeks, after 6 weeks and at end d. 5x--beginning, after 2 weeks, alter 4 weeks, after 6 weeks and at the end 8. What was the unexpected outcome of the study? a. Participants improved their physical functioning b. Participants improved their leisure functioning c. Participants improved their social functioning d. Participants improved their cognitive functioning 9. Which of the following was NOT an "outcome" theme of the study? a. Dancing Heart Program helped functional improvement b. Dancing Heart Program helped to decrease fear of falling c. Dancing Heart Program helped increase socialization d. Dancing Heart Program helped cardiovascular functioning 10. According to this study what can reduce the risk of falling? a. Physical activity, b. Brain game c. Feeling good about your self d. Watching others walk through a maze
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Yongho Lee, Ph.D., CTRS; Carla E. S. Tabourne, Ph.D., CTRS and Jalon E. Harris, BS Dr. Yongho Lee is currently an assistant professor in the Department of Health and Rehabilitative Services at the University of Toledo, Toledo, OH. Dr. Carla E. S. Tabourne is currently an associate professor in School of Kinesiology at the University of Minnesota in Minneapolis, MN. Ms. Jalon E. Harris is currently a graduate student at the University of Toledo.
Table 1 DESCRIPTIVE STATISTICS OF SCORE ON EACH SCALE Pre-Test Middle test Post test SAFFE Mean SD Mean SD Mean SD N Activity Level 7.14 1.46 6.14 2.19 6.71 1.98 9 Fear of Falling .25 .39 .39 .59 .27 .48 9 Activity Restriction 4.78 4.24 5.30 4.19 4.78 3.53 9 Table 2 MULTIVARIATE ANALYSIS OF VARIANCE Wilkes' Lamda SAFFE F Hypothesis df Error df p N Activity Level 1.18 2 5 .397 9 Fear of Falling .500 2 5 .634 9 Activity Restriction 2.51 2 5 .176 9
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|Author:||Lee, Yongho; Tabourne, Carla E.S.; Harris, Jalon E.|
|Publication:||Annual in Therapeutic Recreation|
|Date:||Jan 1, 2010|
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