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Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis Mansueto Gomes Neto, Mayara Alves Menezes and Vitor Oliveira Carvalho Clin Rehabil published online 21 May 2014 DOI: 10.1177/0269215514534089 The online version of this article can be found at: http://cre.sagepub.com/content/early/2014/05/21/0269215514534089
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CRE0010.1177/0269215514534089Clinical RehabilitationNeto et al.
CLINICAL REHABILITATION
Article
Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis
Clinical Rehabilitation 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215514534089 cre.sagepub.com
Mansueto Gomes Neto1, Mayara Alves Menezes2 and Vitor Oliveira Carvalho2
Abstract Objective: To see whether dance therapy was more effective than conventional exercise in exercise capacity and health-related quality of life (HRQOL) in patients with chronic heart failure. Design and methods: Systematic review and meta-analysis. We searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, SPORT Scielo, CINAHL (from the earliest date available to August 2013) for randomized controlled trials (RCTs), examining effects of dance therapy versus exercise and/or dance therapy versus control on exercise capacity (VO2peak), and quality-of-life (QOL) in chronic heart failure. Two reviewers selected studies independently. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated, and heterogeneity was assessed using the I(2) test. Results: Two studies met the study criteria (62 dance therapy patients, 60 exercise patients and 61 controls patients). The results suggested that dance therapy compared with control had a positive impact on peak VO2 and HRQOL. Dance therapy resulted in improvement in: peak VO2 peak weighted mean difference (4.86 95% CI: 2.81 to 6.91) and global HRQOL standardized mean differences (2.09 95% CI: 1.65 to 2.54). Non-significant difference in VO2 peak and HRQOL for participants in the exercise group compared with dance therapy. No serious adverse events were reported. Conclusions: Dance therapy may improve peak VO2 and HRQOL in patients with chronic heart failure (CHF) and could be considered for inclusion in cardiac rehabilitation programmes. Keywords Exercise tolerance, quality of life, cardiac failure, dance Received: 29 January 2014; accepted: 12 April 2014
1Departamento
de Biofunçāo, Curso de Fisioterapia da Universidade Federal da Bahia - UFBA, Programa de Pós Graduação em Medicina e Saúde - UFBA Salvador BA, Brazil 2Departamento de Fisioterapia da Universidade Federal de Sergipe —UFS, Aracaju - SE, Brazil
Corresponding author: Mansueto Gomes Neto, Departamento de Biofuncão, Curso de Fisioterapia - Universidade Federal da Bahia- UFBA, Instituto de Ciências da Saúde. Av. Reitor Miguel Calmon s/n Vale do Canela, Salvador, BA, CEP 40.110-100, Brazil. Email: [email protected]
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Clinical Rehabilitation
Introduction Chronic heart failure (CHF) is a syndrome with high prevalence and a debilitating condition characterized by poor exercise capacity and quality of life. In addition to the medical treatment, exercise training is a well established non-pharmacological tool to improve patient’s functional status and symptoms.1 Despite the incontestable positive effects of exercise training in patients with heart failure, the adherence to cardiac rehabilitation programs is still under the expectancy.2 On the other hand, new modalities of exercise training in heart failure patients have been rising up in the literature as an alternative to fit patients taste, optimize adherence and clinical outcomes, such as peak VO2 and health-related quality of life (HRQOL).3 The need to encourage heart failure patients and increase participation in exercise rehabilitation programs is an important challenge and that is why alternative modalities of exercise training are required. Dance therapy is one promising alternative modality that involves cognitive, emotional, physical, and social integration of a person. Dance therapy fits to patient’s culture and motivates them to exercise in a playful way. This alternative mode of exercise has been tested in patients with Parkinson’s disease4 and depression.5 Some studies about dance therapy in patients with CHF have been published with good results, however, no meta-analysis has never been performed. The aim of this systematic review was to analyze the published randomized controlled trials that investigated the effects of dance therapy in patients with heart failure.
Methods This systematic review included all randomized controlled trials (RCTs) that studied the effects of any kind of dance therapy in patients with heart failure. Studies were considered for inclusion regardless of their publication status, language or size. Trials enrolling patients with heart failure were included in this meta-analysis. To be eligible, the trial should have randomized patients with heart
failure to, at least, one group of dance therapy. The studies that enrolled patients with respiratory diseases were excluded from this systematic review. The main outcomes measures of interest were peak oxygen consumption (peak VO2, mL/Kg/min) and HRQOL (measured by any questionnaire). We searched for references on MEDLINE, LILACS, EMBASE, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), PEDro, and the Cochrane Library up to August 2013 without language restrictions. A standard protocol for this search was developed and whenever possible, controlled vocabulary (Mesh term for MEDLINE and Cochrane and EMTREE for EMBASE) were used. Keywords and their synonymous were used to sensitize the search. For the identification of RCTs in PUBMED/ MEDLINE the optimally sensitive strategy developed for the Cochrane Collaboration was used.6 (Appendix A, online supplementary material). To identify the RCTs in EMBASE, a search strategy using similar terms was adopted. In the search strategy, there were four groups of keywords: study design, participants, interventions, and outcome measures. All eligible articles for this systematic review had their references lists analyzed in order to detect other potentially eligible studies. For ongoing studies or when the confirmation of any data or additional information was needed, the authors were contacted by email. The search strategy was used to obtain titles and abstracts of studies that might be relevant for this review. Each abstract identified in the research was independently evaluated by two authors. If at least one of the authors considered one reference eligible, the full text was obtained for complete assessment. In a similar fashion, two authors independently evaluated full text articles for eligibility and filled inclusion and exclusion criteria in a standard form. A standardized data extraction form was used to inclusion and exclusion criteria. In case of any disagreement, the authors discussed the reasons for their decisions and a final decision was made by consensus. Two authors independently extracted data from the published reports using standard data extraction
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Neto et al. forms adapted from the Cochrane Collaboration’s6 model for data extraction, considering 1) aspects of the study population, such as the average age and sex; 2) aspects of the intervention performed (sample size, type of dance therapy performed, presence of supervision, frequency, and duration of each session); 3) follow-up; 4) loss to followup; 5) outcome measures; and 6) presented results. Disagreements were resolved by one of the authors. Any further information required from the original author was requested by email. The risk of bias of included studies was assessed independently by two authors using The Cochrane Collaboration’s ‘Risk of bias’ tool.6 The following criteria were assessed: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, intention-totreat analysis and completeness of follow-up. The quality of evidence generated by this systematic review was classified using the PEDro scale. There are several scales for assessing the quality of RCTs. The PEDro scale assesses the methodological quality of a study based on important criteria, such as concealed allocation, intention-to-treat analysis, and the adequacy of follow-up. These characteristics make the PEDro scale a useful tool for assessing the quality of physical therapy and rehabilitation trials.7 Methodological quality was independently assessed by two researchers. Studies were scored on the PEDro scale based on a Delphi list8 that consisted of 11 items. One item on the PEDro scale (eligibility criteria) is related to external validity and is generally not used to calculate the method score, leaving a score range of 0 to 10.9 Studies were excluded in the subsequent analysis if the cutoff of four points was not reached. Any disagreements were resolved by a third rater.
Statistical assessment Pooled-effect estimates were obtained by comparing the least square mean percentage change from baseline to study end for each group, and were expressed as the weighted mean difference between groups. Calculations were done using a
Figure 1. Search and selection of studies for systematic review according PRISMA.
random-effects model. Two comparisons were made: dance therapy versus control group (nonexercise) and dance therapy versus exercise group. An α value of 0.05 was considered significant. Statistical heterogeneity of the treatment effect among studies was assessed using Cochran’s Q-test and the inconsistency I2 test, in which values above 25 and 50% were considered indicative of moderate and high heterogeneity, respectively.10 All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration).11
Results The initial search led to the identification of 11 abstracts, from which 2 studies were considered as potentially relevant and were retrieved for detailed analysis. Only two papers12,13 met the eligibility criteria. Figure 1 shows the PRISMA flow diagram of studies in this review. The remaining two articles were fully analyzed and approved by both reviewers and had the
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Table 1. Characteristics of the outcomes e results of concurrent training in the trials included in the review. Study
Participants
Outcomes
1
Belardinelli et al., 200813
130 CHF NYHA II and III
2
Kaltsatou et al., 201312
51 CHF NYHA II and III
Aerobic capacity HRQOL Aerobic capacity HRQOL
Measures
Results
Aerobic capacity
HRQOL
Aerobic capacity
HRQOL
Cardiopulmonary exercise testing
MHFLQ
↑ VO2peak
↑ QOL
Graded exercise stress test
SF-36
↑ VO2peak
↑ QOL
CHF: Chronic Heart Failure, NYHA: New York Heart Association, MHFLQ: Minnesota Living With Heart Failure Questionnaire, MOS: Medical Outcomes Study, SF-36: Short Form-36 questionnaire.
Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Control Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI 19.5 26.1
5 2.6
44 18 62
15.8 4.5 20.3 2
42 44.7% 19 55.3%
3.70 [1.69, 5.71] 5.80 [4.30, 7.30]
61 100.0%
4.86 [2.81, 6.91]
Heterogeneity: Tau² = 1.39; Chi² = 2.69, df = 1 (P = 0.10); I² = 63% Test for overall effect: Z = 4.65 (P < 0.00001)
Mean Difference IV, Random, 95% CI
-20
-10 0 10 20 Favours [Control] Favours [Dance Therapy]
Figure 2. Dance therapy versus controls: VO2 Peak. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
extraction of data from each RCT. Each of the papers was assessed using the PEDro scale methodology by both reviewers, with the pre-defined cutoff (4). The results of the assessment of the PEDro scale are presented individually in the online supplementary material table. The initial sample size for the selected studies ranged from 5712 to 130.13 The final sample ranged from 5112 a 128,13 and mean age of participants ranged from 59 to 67 years. One study included only men and the other study included patients of both genders, but there was a predominance of male. All studies analyzed in this review included out patients with documented heart failure New York Heart Association (NYHA) class II–III. Peak VO2 was assessed in both studies by a cardiopulmonary exercise test. The study by Kaltsatouet al.12 used a treadmill and the study by Belardinelli et al.13 a cicloergometer. The study by Kaltsatouet al.12 used the SF36 and the study by Belardinelli et al.13 the Minnessota
Living with Heart Failure Questionnaire. Table 1 presents summary data from the two RCTs eligible for this systematic review. The parameters used in the application of dance therapy have been reported in the studies, and all described the progressive nature of the programs. The duration of dance therapy programs ranged from 813 to 3212 weeks. Regarding the time of the session, there was a variation from 4012 to 5013 minutes. The frequency of sessions was three times a week in all studies. The intensity of dance therapy was adjusted by Borg 6–20 category scale (between 13–14 - somewhat hard) in the study by Kaltsatou et al.12 and 70% of peak VO2 in the study by Belardinelli study.13 Significant improvements were found among individual trials of dance therapy when compared with non-exercising controls. Two studies assessed peakVO2 as an outcome.12,13 The meta-analyses showed (Figure 2) a significant improvement in peakVO2 of 4.86 mL·kg-1·min-1 (95% CI: 2.81,
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Neto et al.
Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013
Dance Therapy Exercise Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI 19.5 26.1
5 2.6
44 18
19.6 4.5 25.8 2
62
Total (95% CI)
37.3% 62.7%
-0.10 [-2.09, 1.89] 0.30 [-1.23, 1.83]
61 100.0%
0.15 [-1.06, 1.36]
44 17
Heterogeneity: Tau² = 0.00; Chi² = 0.10, df = 1 (P = 0.75); I² = 0% Test for overall effect: Z = 0.24 (P = 0.81)
Mean Difference IV, Random, 95% CI
-20
-10 0 10 20 Favours [Exercise] Favours [Dance Therapy]
Figure 3. Dance therapy versus exercise: VO2 Peak. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Control Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI -39 88.6
8 2.4
42 18 60
-57 9 81.9 3.7
44 70.4% 19 29.6%
2.09 [1.56, 2.62] 2.09 [1.27, 2.91]
63 100.0%
2.09 [1.65, 2.54]
Heterogeneity: Tau² = 0.00; Chi² = 0.00, df = 1 (P = 1.00); I² = 0% Test for overall effect: Z = 9.21 (P < 0.00001)
Std. Mean Difference IV, Random, 95% CI
-10
-5 0 5 10 Favours [Control] Favours [Dance Therapy]
Figure 4. Dance therapy versus controls: Quality of life. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
6.91, N =123) for participants in the dance therapy group compared with non-exercising control group. A non-significant improvement in peak VO2 of 0.15mL·kg-1·min-1 (95% CI: -1.06,1.36, N =123) was found for participants in the exercise group compared with dance therapy (Figure 3).
Quality of life Two studies measured HRQOL.12,13 Significant improvements were found among individual trials of dance therapy when compared with nonexercising controls. Due to the difference between the instruments used in the measurement of quality of life, it was performed a metaanalysis with standardized mean difference. The meta-analyses showed (Figure 4) significant improvement in HRQOL of 2.09 (95% CI: 1.65, 2.54, N =123) for participants in the dance therapy group compared with non-exercising control group. A non-significant improvement in HRQOL of 0.14 (95% CI: -0.21, 050, N =123) was found for
participants in the exercise group compared with dance therapy (Figure 5). The studies failed to give enough detail for us to assess the potential risk of bias. Details of the generation and concealment of the random allocation sequence was particularly poorly reported. Only one study presented objective evidence of the random allocation characteristics.13 The two studies presented objective evidence of balance in baseline characteristics.12,13 Only one study stated that they took measures to blind those involved in assessments.12
Discussion In the present systematic review, a meta-analysis of two studies demonstrated a significant difference in peak VO2 and HRQOL between patients with CHF submitted to dance therapy and sedentary controls. Moreover, dance therapy was as efficient as conventional exercise training in peak VO2 and HRQOL. Dance therapy is a potential tool in the rehabilitation of chronic diseases. However, no systematic
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Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Exercise Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI -39 88.6
8 2.4
44 18 62
-40 8 87.6 6.7
44 71.6% 17 28.4%
0.12 [-0.29, 0.54] 0.20 [-0.47, 0.86]
61 100.0%
0.14 [-0.21, 0.50]
Heterogeneity: Tau² = 0.00; Chi² = 0.03, df = 1 (P = 0.86); I² = 0% Test for overall effect: Z = 0.80 (P = 0.42)
Std. Mean Difference IV, Random, 95% CI
-10
-5 0 5 10 Favours [Exercise] Favours [Dance Therapy]
Figure 5. Dance therapy versus exercise: Quality of life. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
review has been performed concerning dance therapy and patients with CHF. This systematic review with meta-analysis is important because it analyzes the dance therapy as a potential coadjuvant modality in cardiovascular rehabilitation. Moreover, the eligibility of peak VO2 and HRQOL as outcomes in this systematic review is important because they are related to prognosis in patients with heart failure.1 In the present review, one of the included studies did not report concealment allocation or randomization in an appropriate way, which may have interfered in the results. Thus, it is possible that the effectiveness of dance therapy is even lower in studies with proper randomization and concealment allocation. Despite this, our meta-analysis showed that the dance therapy was as efficient as the conventional exercise program in peak VO2 and HRQOL. However, the dance therapy showed to be a good intervention when compared to sedentary patients. Considering peak VO2, it is known that improvements above 10% after a cardiovascular rehabilitation program are satisfactory and represents a good prognosis in patients with heart failure.14 Our meta-analysis showed a 26.4% of improvement in peak VO2 in the dance group. Considering the quality of life, the dance therapy showed a 12% of improvement. The mean of peak VO2 in two studies analyzed was 18.5 mL·kg-1·min-1 at baseline, being 22.8 mL·kg-1·min-1 at the end of the intervention. Paterson et al.15 demonstrated that a minimum VO2 peak of 15 mL·kg-1·min-1 in women and 18 mL·kg-1·min-1 in men aged 85 years was necessary for full and independent living (e.g., garden
activities, walking up stairs). Thus the improvement generated by dance program can contribute to that patients with insufficiency have better conditions to carry out their everyday activities. The assessment of the HRQOL is an essential component during a rehabilitation program. Dance is reported to improve self-awareness and self-confidence and to facilitate interpersonal sharing of feelings. In addition, the physiological adaptations and functional generated by dancing can reduce functional limitations and consequently improve the quality of life.16 Considering the quality of life, in Belardinelli et al.13 study, the mean of MLFHQ was 55 at baseline, being 39 at the end of the intervention, demonstrating an improvement of 16 points on the scale, whereas the minimal clinically important difference for the MLFHQ is 5 points,17 a dance therapy program can benefit patients with CHF. In Kaltsatou et al.12 study, it was also observed improvement in functional capacity tests (Sit-tostand test, Strength testing, and Berg Balance Scale) in the dance therapy group compared with the control sedentary group. Similar result was found in a the large study of over 100 older women that demonstrated improvements in 6-minute timed walking test, Timed Up and Go, lower limb endurance and the ‘general health’ and ‘bodily pain’ domains of SF-36 after a twice weekly, 12-week dance program.18 It is difficult to make a pragmatic recommendation about dance therapy in patients with heart failure. Our search strategy only found two studies and they tested two different kinds of dance. Different variables must be influencing the effects of the
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Neto et al. dance therapy, as the local culture and motivation. The study by Kaltsatou et al.,12 for example, used a Greek dance, which may not be applied in other cultures. Despite this, the dance therapy seems to be an interesting tool in cardiac rehabilitation and deserves more investigation with well controlled RCTs. The dance has an important characteristic in the motivation of the patient, which can increase the adherence in the rehabilitation process, as an alternative to conventional exercises.19 The advantages of dancing are probably related to improvements in self-awareness and self-confidence (facilitate interpersonal sharing of feelings which involves cognitive, emotional, physical, and social integration of a person).16 Moreover, no specific risks were reported in the dance trials and it can represent a positive aspect in clinical practice. Dance therapy should be considered as an alternative mode of exercise for patients with heart failure. Caution is warranted when interpreting the present results given the small amount of studies and the significant heterogeneity evident in the primary analyses. Further research is required to investigate how to sustain positive effects of dance therapy over time and to determine essential attributes of dance (mode, rhythm, intensity, frequency, duration, and timing) for optimal effects on HRQOL and its domains.
Clinical messages • Dance therapy is as effective as conventional exercises in cardiac rehabilitation for patients with heart failure. • Dance therapy should be considered as an alternative mode of exercise for patients with heart failure. Conflict of interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Dickstein K, Cohen-Solal A, Filippatos G, McMurray JJ, Ponikowski P, Poole-Wilson PA, et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 2008; 29: 2388–2442. 2. Thomas RJ, King M, Lui K, Oldridge N, Piña IL, Spertus J, et al. AACVPR/ACC/AHA 2007 Performance Measures on Cardiac Rehabilitation for Referral to and Delivery of Cardiac Rehabilitation/Secondary Prevention Services. J Am Coll Cardiol 2007; 50: 1400–1433. 3. Cider A, Schaufelberger M, Sunnerhagen KS and Andersson B. Hydrotherapy—a new approach to improve function in the older patient with chronic heart failure. Eur J Heart Fail 2003; 5: 527–535. 4. Kaski D, Allum JH, Bronstein AM and Dominguez RO. Applying anodal tDCS during tango dancing in a patient with Parkinson’s disease. Neurosci Lett 2014; pii: S0304– 3940(14)00242–0. 5. Murrock CJ and Graor CH. The effects of dance on depression, physical function, and disability in underserved adults. J Aging Phys Act 2013 Epub ahead of print Aug 12. 6. Higgins JPT and Green S. Cochrane handbook for Systematic Reviews of Interventions 4.2.6 [update September 2006]. The Cochrane Library. Issue 4. Chichester: John Wiley & Sons, 2006. 7. Olivo SA, Macedo LG, Gadotti IN, Fuentes J, Stanton T and Magee DJ. Scales to assess the quality of randomized controlled trials: a systematic review. PhysTher 2008; 88: 156–75. 8. Verhagen AP, de Vet HCW, de Bie RA, Kessels AGH, Boers M, Bouter LM, et al. The Delphi List: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi Consensus. J ClinEpidemiol 1998; 51: 1235– 1241. 9. Maher CG, Sherrington C, Herbert RD, Moseley AM and Elkins M. Reliability of the PEDro scale for rating of quality randomized controlled trials. PhysTher 2003; 83: 713–721. 10. Higgins JP, Thompson SG, Deeks JJ and Altman DG. Measuring inconsistency in meta-analyses. BMJ 2003; 327: 557–560. 11. Collaboration TC. Available at: www.cochrane.org. (accessed 3 Feb 2008). 12. Kaltsatou ACH, Kouidi EI, Anifanti MA, Douka SI and Deligiannis AP. Functional and psychosocial effects of either a traditional dancing or a formal exercising training program in patients with chronic heart failure: a comparative randomized controlled study. Clinical Rehabilitation 2013; 28: 128–138.
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13. Belardinelli P, Lacalaprice F, Ventrella C, Volpe L and Faccenda E. Waltz dancing in patients with chronic heart failure: New form of exercise training. Circ Heart Fail 2008; 1: 107–114. 14. Frankenstein L, Nelles M, Hallerbach M, Dukic D, Fluegel A, Schellberg D, et al. Prognostic impact of peakVO2changes in stable CHF on chronic beta-blocker treatment. Int J Cardiol 2007; 122: 125–130 15. Paterson DH, Cunningham DA, Koval JJ, et al. Aerobic fitness in a population of independently living men and women aged 55–86 years. Med Sci Sports Exerc 1999; 31: 1813–1820. 16. Pratt RR. Art, dance, and music therapy. Phys Med Rehabil Clin N Am 2004; 15: 827–841.
17. Arnold M, Rajda M, Ignaszewski A, Howlett J and Leblanc M-H. Changes in the Minnesota Living with Heart Failure Questionnaire Score and Clinical Outcomes in a Large Contemporary Population of Ambulatory Heart Failure Patients in the Canadian Heart Failure Network. Journal of Cardiac Failure 2012; 18 (8 Supplement): S79. 18. Hui E, Chui BT and Woo J. Effects of dance on physical and psychological well-being in older persons. Arch Gerontol Geriatr 2009; 49: e45–50. 19. Strassel JK, Cherkin DC, Steuten L, Sherman KJ and Vrijhoef HJM. A systematic review of the evidence for the effectiveness of dance therapy. Alternative Therapies 2011; 17: 50–59
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Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis Mansueto Gomes Neto, Mayara Alves Menezes and Vitor Oliveira Carvalho Clin Rehabil published online 21 May 2014 DOI: 10.1177/0269215514534089 The online version of this article can be found at: http://cre.sagepub.com/content/early/2014/05/21/0269215514534089
Published by: http://www.sagepublications.com
Additional services and information for Clinical Rehabilitation can be found at: Email Alerts: http://cre.sagepub.com/cgi/alerts Subscriptions: http://cre.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - May 21, 2014 What is This?
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534089
research-article2014
CRE0010.1177/0269215514534089Clinical RehabilitationNeto et al.
CLINICAL REHABILITATION
Article
Dance therapy in patients with chronic heart failure: a systematic review and a meta-analysis
Clinical Rehabilitation 1–8 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0269215514534089 cre.sagepub.com
Mansueto Gomes Neto1, Mayara Alves Menezes2 and Vitor Oliveira Carvalho2
Abstract Objective: To see whether dance therapy was more effective than conventional exercise in exercise capacity and health-related quality of life (HRQOL) in patients with chronic heart failure. Design and methods: Systematic review and meta-analysis. We searched MEDLINE, Cochrane Controlled Trials Register, EMBASE, SPORT Scielo, CINAHL (from the earliest date available to August 2013) for randomized controlled trials (RCTs), examining effects of dance therapy versus exercise and/or dance therapy versus control on exercise capacity (VO2peak), and quality-of-life (QOL) in chronic heart failure. Two reviewers selected studies independently. Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated, and heterogeneity was assessed using the I(2) test. Results: Two studies met the study criteria (62 dance therapy patients, 60 exercise patients and 61 controls patients). The results suggested that dance therapy compared with control had a positive impact on peak VO2 and HRQOL. Dance therapy resulted in improvement in: peak VO2 peak weighted mean difference (4.86 95% CI: 2.81 to 6.91) and global HRQOL standardized mean differences (2.09 95% CI: 1.65 to 2.54). Non-significant difference in VO2 peak and HRQOL for participants in the exercise group compared with dance therapy. No serious adverse events were reported. Conclusions: Dance therapy may improve peak VO2 and HRQOL in patients with chronic heart failure (CHF) and could be considered for inclusion in cardiac rehabilitation programmes. Keywords Exercise tolerance, quality of life, cardiac failure, dance Received: 29 January 2014; accepted: 12 April 2014
1Departamento
de Biofunçāo, Curso de Fisioterapia da Universidade Federal da Bahia - UFBA, Programa de Pós Graduação em Medicina e Saúde - UFBA Salvador BA, Brazil 2Departamento de Fisioterapia da Universidade Federal de Sergipe —UFS, Aracaju - SE, Brazil
Corresponding author: Mansueto Gomes Neto, Departamento de Biofuncão, Curso de Fisioterapia - Universidade Federal da Bahia- UFBA, Instituto de Ciências da Saúde. Av. Reitor Miguel Calmon s/n Vale do Canela, Salvador, BA, CEP 40.110-100, Brazil. Email: [email protected]
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Introduction Chronic heart failure (CHF) is a syndrome with high prevalence and a debilitating condition characterized by poor exercise capacity and quality of life. In addition to the medical treatment, exercise training is a well established non-pharmacological tool to improve patient’s functional status and symptoms.1 Despite the incontestable positive effects of exercise training in patients with heart failure, the adherence to cardiac rehabilitation programs is still under the expectancy.2 On the other hand, new modalities of exercise training in heart failure patients have been rising up in the literature as an alternative to fit patients taste, optimize adherence and clinical outcomes, such as peak VO2 and health-related quality of life (HRQOL).3 The need to encourage heart failure patients and increase participation in exercise rehabilitation programs is an important challenge and that is why alternative modalities of exercise training are required. Dance therapy is one promising alternative modality that involves cognitive, emotional, physical, and social integration of a person. Dance therapy fits to patient’s culture and motivates them to exercise in a playful way. This alternative mode of exercise has been tested in patients with Parkinson’s disease4 and depression.5 Some studies about dance therapy in patients with CHF have been published with good results, however, no meta-analysis has never been performed. The aim of this systematic review was to analyze the published randomized controlled trials that investigated the effects of dance therapy in patients with heart failure.
Methods This systematic review included all randomized controlled trials (RCTs) that studied the effects of any kind of dance therapy in patients with heart failure. Studies were considered for inclusion regardless of their publication status, language or size. Trials enrolling patients with heart failure were included in this meta-analysis. To be eligible, the trial should have randomized patients with heart
failure to, at least, one group of dance therapy. The studies that enrolled patients with respiratory diseases were excluded from this systematic review. The main outcomes measures of interest were peak oxygen consumption (peak VO2, mL/Kg/min) and HRQOL (measured by any questionnaire). We searched for references on MEDLINE, LILACS, EMBASE, SciELO, Cumulative Index to Nursing and Allied Health (CINAHL), PEDro, and the Cochrane Library up to August 2013 without language restrictions. A standard protocol for this search was developed and whenever possible, controlled vocabulary (Mesh term for MEDLINE and Cochrane and EMTREE for EMBASE) were used. Keywords and their synonymous were used to sensitize the search. For the identification of RCTs in PUBMED/ MEDLINE the optimally sensitive strategy developed for the Cochrane Collaboration was used.6 (Appendix A, online supplementary material). To identify the RCTs in EMBASE, a search strategy using similar terms was adopted. In the search strategy, there were four groups of keywords: study design, participants, interventions, and outcome measures. All eligible articles for this systematic review had their references lists analyzed in order to detect other potentially eligible studies. For ongoing studies or when the confirmation of any data or additional information was needed, the authors were contacted by email. The search strategy was used to obtain titles and abstracts of studies that might be relevant for this review. Each abstract identified in the research was independently evaluated by two authors. If at least one of the authors considered one reference eligible, the full text was obtained for complete assessment. In a similar fashion, two authors independently evaluated full text articles for eligibility and filled inclusion and exclusion criteria in a standard form. A standardized data extraction form was used to inclusion and exclusion criteria. In case of any disagreement, the authors discussed the reasons for their decisions and a final decision was made by consensus. Two authors independently extracted data from the published reports using standard data extraction
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Neto et al. forms adapted from the Cochrane Collaboration’s6 model for data extraction, considering 1) aspects of the study population, such as the average age and sex; 2) aspects of the intervention performed (sample size, type of dance therapy performed, presence of supervision, frequency, and duration of each session); 3) follow-up; 4) loss to followup; 5) outcome measures; and 6) presented results. Disagreements were resolved by one of the authors. Any further information required from the original author was requested by email. The risk of bias of included studies was assessed independently by two authors using The Cochrane Collaboration’s ‘Risk of bias’ tool.6 The following criteria were assessed: random sequence generation, allocation concealment, blinding of participants and personnel, blinding of outcome assessment, incomplete outcome data, selective reporting, intention-totreat analysis and completeness of follow-up. The quality of evidence generated by this systematic review was classified using the PEDro scale. There are several scales for assessing the quality of RCTs. The PEDro scale assesses the methodological quality of a study based on important criteria, such as concealed allocation, intention-to-treat analysis, and the adequacy of follow-up. These characteristics make the PEDro scale a useful tool for assessing the quality of physical therapy and rehabilitation trials.7 Methodological quality was independently assessed by two researchers. Studies were scored on the PEDro scale based on a Delphi list8 that consisted of 11 items. One item on the PEDro scale (eligibility criteria) is related to external validity and is generally not used to calculate the method score, leaving a score range of 0 to 10.9 Studies were excluded in the subsequent analysis if the cutoff of four points was not reached. Any disagreements were resolved by a third rater.
Statistical assessment Pooled-effect estimates were obtained by comparing the least square mean percentage change from baseline to study end for each group, and were expressed as the weighted mean difference between groups. Calculations were done using a
Figure 1. Search and selection of studies for systematic review according PRISMA.
random-effects model. Two comparisons were made: dance therapy versus control group (nonexercise) and dance therapy versus exercise group. An α value of 0.05 was considered significant. Statistical heterogeneity of the treatment effect among studies was assessed using Cochran’s Q-test and the inconsistency I2 test, in which values above 25 and 50% were considered indicative of moderate and high heterogeneity, respectively.10 All analyses were conducted using Review Manager Version 5.0 (Cochrane Collaboration).11
Results The initial search led to the identification of 11 abstracts, from which 2 studies were considered as potentially relevant and were retrieved for detailed analysis. Only two papers12,13 met the eligibility criteria. Figure 1 shows the PRISMA flow diagram of studies in this review. The remaining two articles were fully analyzed and approved by both reviewers and had the
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Table 1. Characteristics of the outcomes e results of concurrent training in the trials included in the review. Study
Participants
Outcomes
1
Belardinelli et al., 200813
130 CHF NYHA II and III
2
Kaltsatou et al., 201312
51 CHF NYHA II and III
Aerobic capacity HRQOL Aerobic capacity HRQOL
Measures
Results
Aerobic capacity
HRQOL
Aerobic capacity
HRQOL
Cardiopulmonary exercise testing
MHFLQ
↑ VO2peak
↑ QOL
Graded exercise stress test
SF-36
↑ VO2peak
↑ QOL
CHF: Chronic Heart Failure, NYHA: New York Heart Association, MHFLQ: Minnesota Living With Heart Failure Questionnaire, MOS: Medical Outcomes Study, SF-36: Short Form-36 questionnaire.
Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Control Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI 19.5 26.1
5 2.6
44 18 62
15.8 4.5 20.3 2
42 44.7% 19 55.3%
3.70 [1.69, 5.71] 5.80 [4.30, 7.30]
61 100.0%
4.86 [2.81, 6.91]
Heterogeneity: Tau² = 1.39; Chi² = 2.69, df = 1 (P = 0.10); I² = 63% Test for overall effect: Z = 4.65 (P < 0.00001)
Mean Difference IV, Random, 95% CI
-20
-10 0 10 20 Favours [Control] Favours [Dance Therapy]
Figure 2. Dance therapy versus controls: VO2 Peak. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
extraction of data from each RCT. Each of the papers was assessed using the PEDro scale methodology by both reviewers, with the pre-defined cutoff (4). The results of the assessment of the PEDro scale are presented individually in the online supplementary material table. The initial sample size for the selected studies ranged from 5712 to 130.13 The final sample ranged from 5112 a 128,13 and mean age of participants ranged from 59 to 67 years. One study included only men and the other study included patients of both genders, but there was a predominance of male. All studies analyzed in this review included out patients with documented heart failure New York Heart Association (NYHA) class II–III. Peak VO2 was assessed in both studies by a cardiopulmonary exercise test. The study by Kaltsatouet al.12 used a treadmill and the study by Belardinelli et al.13 a cicloergometer. The study by Kaltsatouet al.12 used the SF36 and the study by Belardinelli et al.13 the Minnessota
Living with Heart Failure Questionnaire. Table 1 presents summary data from the two RCTs eligible for this systematic review. The parameters used in the application of dance therapy have been reported in the studies, and all described the progressive nature of the programs. The duration of dance therapy programs ranged from 813 to 3212 weeks. Regarding the time of the session, there was a variation from 4012 to 5013 minutes. The frequency of sessions was three times a week in all studies. The intensity of dance therapy was adjusted by Borg 6–20 category scale (between 13–14 - somewhat hard) in the study by Kaltsatou et al.12 and 70% of peak VO2 in the study by Belardinelli study.13 Significant improvements were found among individual trials of dance therapy when compared with non-exercising controls. Two studies assessed peakVO2 as an outcome.12,13 The meta-analyses showed (Figure 2) a significant improvement in peakVO2 of 4.86 mL·kg-1·min-1 (95% CI: 2.81,
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Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013
Dance Therapy Exercise Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI 19.5 26.1
5 2.6
44 18
19.6 4.5 25.8 2
62
Total (95% CI)
37.3% 62.7%
-0.10 [-2.09, 1.89] 0.30 [-1.23, 1.83]
61 100.0%
0.15 [-1.06, 1.36]
44 17
Heterogeneity: Tau² = 0.00; Chi² = 0.10, df = 1 (P = 0.75); I² = 0% Test for overall effect: Z = 0.24 (P = 0.81)
Mean Difference IV, Random, 95% CI
-20
-10 0 10 20 Favours [Exercise] Favours [Dance Therapy]
Figure 3. Dance therapy versus exercise: VO2 Peak. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Control Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI -39 88.6
8 2.4
42 18 60
-57 9 81.9 3.7
44 70.4% 19 29.6%
2.09 [1.56, 2.62] 2.09 [1.27, 2.91]
63 100.0%
2.09 [1.65, 2.54]
Heterogeneity: Tau² = 0.00; Chi² = 0.00, df = 1 (P = 1.00); I² = 0% Test for overall effect: Z = 9.21 (P < 0.00001)
Std. Mean Difference IV, Random, 95% CI
-10
-5 0 5 10 Favours [Control] Favours [Dance Therapy]
Figure 4. Dance therapy versus controls: Quality of life. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
6.91, N =123) for participants in the dance therapy group compared with non-exercising control group. A non-significant improvement in peak VO2 of 0.15mL·kg-1·min-1 (95% CI: -1.06,1.36, N =123) was found for participants in the exercise group compared with dance therapy (Figure 3).
Quality of life Two studies measured HRQOL.12,13 Significant improvements were found among individual trials of dance therapy when compared with nonexercising controls. Due to the difference between the instruments used in the measurement of quality of life, it was performed a metaanalysis with standardized mean difference. The meta-analyses showed (Figure 4) significant improvement in HRQOL of 2.09 (95% CI: 1.65, 2.54, N =123) for participants in the dance therapy group compared with non-exercising control group. A non-significant improvement in HRQOL of 0.14 (95% CI: -0.21, 050, N =123) was found for
participants in the exercise group compared with dance therapy (Figure 5). The studies failed to give enough detail for us to assess the potential risk of bias. Details of the generation and concealment of the random allocation sequence was particularly poorly reported. Only one study presented objective evidence of the random allocation characteristics.13 The two studies presented objective evidence of balance in baseline characteristics.12,13 Only one study stated that they took measures to blind those involved in assessments.12
Discussion In the present systematic review, a meta-analysis of two studies demonstrated a significant difference in peak VO2 and HRQOL between patients with CHF submitted to dance therapy and sedentary controls. Moreover, dance therapy was as efficient as conventional exercise training in peak VO2 and HRQOL. Dance therapy is a potential tool in the rehabilitation of chronic diseases. However, no systematic
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Study or Subgroup Belardinelli et al, 2008 Kaltsatou et al, 2013 Total (95% CI)
Dance Therapy Exercise Std. Mean Difference Mean SD Total Mean SD Total Weight IV, Random, 95% CI -39 88.6
8 2.4
44 18 62
-40 8 87.6 6.7
44 71.6% 17 28.4%
0.12 [-0.29, 0.54] 0.20 [-0.47, 0.86]
61 100.0%
0.14 [-0.21, 0.50]
Heterogeneity: Tau² = 0.00; Chi² = 0.03, df = 1 (P = 0.86); I² = 0% Test for overall effect: Z = 0.80 (P = 0.42)
Std. Mean Difference IV, Random, 95% CI
-10
-5 0 5 10 Favours [Exercise] Favours [Dance Therapy]
Figure 5. Dance therapy versus exercise: Quality of life. Review Manager (RevMan). Version 5.2 The Cochrane Collaboration, 2013.
review has been performed concerning dance therapy and patients with CHF. This systematic review with meta-analysis is important because it analyzes the dance therapy as a potential coadjuvant modality in cardiovascular rehabilitation. Moreover, the eligibility of peak VO2 and HRQOL as outcomes in this systematic review is important because they are related to prognosis in patients with heart failure.1 In the present review, one of the included studies did not report concealment allocation or randomization in an appropriate way, which may have interfered in the results. Thus, it is possible that the effectiveness of dance therapy is even lower in studies with proper randomization and concealment allocation. Despite this, our meta-analysis showed that the dance therapy was as efficient as the conventional exercise program in peak VO2 and HRQOL. However, the dance therapy showed to be a good intervention when compared to sedentary patients. Considering peak VO2, it is known that improvements above 10% after a cardiovascular rehabilitation program are satisfactory and represents a good prognosis in patients with heart failure.14 Our meta-analysis showed a 26.4% of improvement in peak VO2 in the dance group. Considering the quality of life, the dance therapy showed a 12% of improvement. The mean of peak VO2 in two studies analyzed was 18.5 mL·kg-1·min-1 at baseline, being 22.8 mL·kg-1·min-1 at the end of the intervention. Paterson et al.15 demonstrated that a minimum VO2 peak of 15 mL·kg-1·min-1 in women and 18 mL·kg-1·min-1 in men aged 85 years was necessary for full and independent living (e.g., garden
activities, walking up stairs). Thus the improvement generated by dance program can contribute to that patients with insufficiency have better conditions to carry out their everyday activities. The assessment of the HRQOL is an essential component during a rehabilitation program. Dance is reported to improve self-awareness and self-confidence and to facilitate interpersonal sharing of feelings. In addition, the physiological adaptations and functional generated by dancing can reduce functional limitations and consequently improve the quality of life.16 Considering the quality of life, in Belardinelli et al.13 study, the mean of MLFHQ was 55 at baseline, being 39 at the end of the intervention, demonstrating an improvement of 16 points on the scale, whereas the minimal clinically important difference for the MLFHQ is 5 points,17 a dance therapy program can benefit patients with CHF. In Kaltsatou et al.12 study, it was also observed improvement in functional capacity tests (Sit-tostand test, Strength testing, and Berg Balance Scale) in the dance therapy group compared with the control sedentary group. Similar result was found in a the large study of over 100 older women that demonstrated improvements in 6-minute timed walking test, Timed Up and Go, lower limb endurance and the ‘general health’ and ‘bodily pain’ domains of SF-36 after a twice weekly, 12-week dance program.18 It is difficult to make a pragmatic recommendation about dance therapy in patients with heart failure. Our search strategy only found two studies and they tested two different kinds of dance. Different variables must be influencing the effects of the
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Neto et al. dance therapy, as the local culture and motivation. The study by Kaltsatou et al.,12 for example, used a Greek dance, which may not be applied in other cultures. Despite this, the dance therapy seems to be an interesting tool in cardiac rehabilitation and deserves more investigation with well controlled RCTs. The dance has an important characteristic in the motivation of the patient, which can increase the adherence in the rehabilitation process, as an alternative to conventional exercises.19 The advantages of dancing are probably related to improvements in self-awareness and self-confidence (facilitate interpersonal sharing of feelings which involves cognitive, emotional, physical, and social integration of a person).16 Moreover, no specific risks were reported in the dance trials and it can represent a positive aspect in clinical practice. Dance therapy should be considered as an alternative mode of exercise for patients with heart failure. Caution is warranted when interpreting the present results given the small amount of studies and the significant heterogeneity evident in the primary analyses. Further research is required to investigate how to sustain positive effects of dance therapy over time and to determine essential attributes of dance (mode, rhythm, intensity, frequency, duration, and timing) for optimal effects on HRQOL and its domains.
Clinical messages • Dance therapy is as effective as conventional exercises in cardiac rehabilitation for patients with heart failure. • Dance therapy should be considered as an alternative mode of exercise for patients with heart failure. Conflict of interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
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