Adapted tango has demonstrated efficacy for improving mobility and balance. We describe the dissemination of adapted tango teaching methods to dance instructor trainees and the implementation of adapted tango by the trainees in the community for improving mobility and balance in older adults and individuals with Parkinson’s disease.
Adapted tango dancing improves mobility and balance in older adults and additional populations with balance impairments. It is composed of very simple step elements. Adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics likely underlie adapted tango’s demonstrated efficacy for improving mobility and balance. In this paper, we describe the methodology to disseminate the adapted tango teaching methods to dance instructor trainees and to implement the adapted tango by the trainees in the community for older adults and individuals with Parkinson’s Disease (PD). Efficacy in improving mobility (measured with the Timed Up and Go, Tandem stance, Berg Balance Scale, Gait Speed and 30 sec chair stand), safety and fidelity of the program is maximized through targeted instructor and volunteer training and a structured detailed syllabus outlining class practices and progression.
Older adults and individuals with Parkinson’s Disease (PD) suffer decreased quality of life (QOL), 1-3 poor mobility, and high risk of falls 4 secondary to their motor and cognitive impairments. Physical activities that challenge mobility have beneficial effects on balance and can increase self-efficacy in performing activities of daily living (ADLs). 5 Specifically, exercise programs that 1) incorporate dynamic balance practice and 2) involve motor adaptation according to task and environmental demands can rehabilitate balance impairment.6
Dance has recently garnered attention as a potentially effective exercise therapy to address balance impairments. Frequent participation in partnered dance is associated with superior balance, gait, and reaction time in older dancers compared to age-matched non-dancers.7 In institutional settings, adapted Argentine tango (adapted tango) has improved mobility, balance and QOL in those with PD,8-12 stroke,13 and older individuals with visual impairment.14 Adapted tango is designed to address motor impairments including those specific to individuals with PD, i.e., bradykinesia, shortened stride length, backward instability, turning issues, and freezing of gait.
Composed of simple step elements, adapted tango involves movement initiation and cessation, multi-directional perturbations, varied speeds and rhythms. Participants focus on foot placement, whole body coordination, and attention to partner, path of movement, and aesthetics. Within the context of adapted tango, partner dancing is a sophisticated, yet accessible system of tactile communication that conveys motor intentions and goals between a ‘leader’ (planner of movement) and ‘follower’ (externally cued mover).
To ensure engaging, effective exercise programs like adapted tango are accessible by community-dwelling older adults, individuals with PD, and others with motor impairments, adapted tango must be disseminated beyond the academic research setting and into the community. Few evidence-based exercise programs are being systematically disseminated through delivery systems.15 This has resulted in insufficient numbers of adequately trained fitness personnel to provide community-based exercise activities suited to the unique needs of individuals with motor impairments. 16 This paper outlines methodology for dissemination of adapted tango, including standardization of an evidence-based curriculum and comprehensive training of dance teachers without clinical qualifications.
The adapted tango program described here incorporates key, novel elements based upon curricula developed through an empirical approach in several studies. 9,11-13,17 Uniquely, the program described here implemented an uninvestigated dose of 20, 1.5h biweekly sessions, which meets recommendations that older adults exceed 150 min of weekly exercise, 18 and provides additional learning time for individuals with PD to overcome motor learning challenges. 19 The program also expanded the rhythmic training component to harness the known movement facilitation effects of auditory cueing for PD. 20-22
The teacher training workshop focuses on the mechanics of teaching adapted tango, and includes didactic and experiential instruction regarding teaching populations with sensory and motor impairments (e.g., older adults and individuals with PD). A manual composed for this workshop provides a description of the five sections of the Adapted Tango class, a complete syllabus that describes the plan for each lesson (including rhythms, steps of the day, and embellishments) as well as information about people with movement disorders and motor impairments, fall risk and prevention. Classroom management, partnering and rhythmic training are also described in detail.
Any attempt to disseminate academically developed methodology into a community-based setting should include measures to ensure that program quality, safety and participant satisfaction are not sacrificed. Herein the methodology for assessing feasibility, efficacy and generalizability of a disseminated program are described. These measure include 1) evaluation of teacher trainees for teaching the adapted tango syllabus, as per instructions provided in the manual and 15 hr workshop, 2) measurement of adverse events and falls in and out of the class, 3) investigation of participant attrition and satisfaction 4) comparison of the feasibility, adherence and efficacy measures between older adults and individuals with PD, and 5) changes in mobility compared to results from previous studies.8,9,12
A successful dissemination should allow teacher trainees to deliver classes with very low incidence of adverse events (i.e., less than or equal to 1 event during a 12 week course of instruction or 48 classes). Additionally mobility improvements, as demonstrated by decreased fall risk, improved functional mobility, and increased lower body strength should be similar to those from prior studies.8 Finally, a well delivered program should have low attrition, (>80% compliance), and be acceptable for individuals with PD as well as older and oldest-old individuals (85+ years) residing in senior independent living communities.
Engaging in habitual exercise remains overwhelmingly poor in the general older adult population: only 1 in 8 older adults engage in strength or balance-challenging activities. 31 Recently, exercise has gained approval as a complementary approach to accompany conventional medicine. To further ‘aging in place’ and maintain independence in a growing older population, the widespread implementation of evidence-based exercise programs is necessary. Additionally, given that pharmacological and surgical approaches incompletely address motor and cognitive challenges of the growing PD population, access to complementary therapies, like adapted tango, is necessary. Since 2006, this adapted tango program has been iterated, refined and tested several times, but only at academic centers, not in a community-based setting. 10,13 The methods described above provide a guide to dissemination of adapted tango to the community in such a way that the fidelity, efficacy, safety, and enjoyment of the program are preserved.
Translating health behavior research into sustainable applications is frequently overlooked 32 and underfunded. 33 This methodological guide may allow wider dissemination of adapted tango thus providing access to needed therapy for numerous community dwelling older adults and individuals with balance impairments. Key to dissemination of adapted tango are the selection of appropriate teacher trainees, proper safety training, ample volunteer/family member recruitment, and rigorous assessment of participants before and after completion of the program.
Without a qualified pool of teacher trainees, the adapted tango program will not function. Trainees must possess not only dance knowledge and skill but also a willingness to work outside the traditional realm of able-bodied dance. Teacher trainee enthusiasm, patience, and attention to detail (especially safety) cannot be overstated. One of the main barriers to a multitude of engaging exercise activities for older adults and those with balance impairments is the inability to guarantee safety. Indeed, safety cannot be guaranteed within the adapted tango curricula but if the measures described above regarding volunteer recruitment, participant file review, and partnering are followed, adverse events would be kept to a minimum.
Rigorous assessment of participants before and after the tango program with validated standard measures is necessary to demonstrate that community-based tango is as efficacious as that conducted in academic centers. One of the main limitations of the study as we have implemented it here is the small sample size. Although we were able to show dissemination did not compromise effect size, this should be replicated in future larger studies. The replicated demonstration of efficacy may lead to increased awareness of the benefits of complementary therapy and foster further accessibility to those in need.
The adapted tango dance manual (unpublished), adapted tango class syllabus, this text, and accompanying video are designed to allow individuals in diverse communities to implement this program. Yet, successful utilization of these print and video resources assumes some baseline knowledge of dance, older adults, movement disorders, and fall risk. The above protocol also assumes prior knowledge or familiarity with pre-and-post assessment tests. While all of these tests are cited in validated research papers available to the wider community, implementation of each research measure from a written description alone would be daunting. However, many of these tests are commonly utilized within the physical therapy community. Therefore, it may be advantageous to partner with a physical therapist when attempting to implement this program. Physical therapy involvement could help with implementing pre and post testing, fine-tuning fall prevention strategies and further dissemination/implementation of the program itself, with added expertise to ensure safety.
As stated earlier, implementation of a dancing exercise program for individuals with balance impairments is a big risk and represents a potentially unsafe situation if proper measures are not taken. Future dissemination of this program will necessitate strict safety standards to ensure community leaders and community facilities are willing to host such a program. Integral to safety is also the recruitment of volunteers and family members to partner during the class. While urban areas generally contain an abundance of pre-medical and other health profession students, rural areas lacking major academic centers may find volunteer recruitment more difficult. In this scenario we suggest reaching out to local schools/churches/clubs to enlist able-bodied youth in community service projects to partner for these dance classes.
Lack of mechanistic understanding may prevent more rapid evolution of dance/exercise as a complementary medicine. However, several mechanisms may explain the generally positive changes in physical function produced by adapted tango. The creativity involved in a dance form through exposure to novel steps, and choreographic patterns could tap into mechanisms of neural plasticity. A recent study of adapted tango noted improvement in PD disease severity 29 leading to speculation about potential neuroprotective or neurorestorative effects of adapted tango. The positive functional gains of older adults undergoing regular aerobic activity may be explained by plasticity-related changes in synaptogenesis, angiogenesis and neurogenesis. 34 Future research should delineate ideal frequency, duration and intensity of dance sessions to obtain and retain gains in function.
Individuals with PD were considerably more likely to comply with therapy and finish the program than were older adults, which is curious given that individuals with PD are less active than age-matched peers without PD. 35 Further, the PD group came from the community and needed to travel to the classes; whilst the older adults received the therapy at their senior living communities. As PD remains a condition with many intractable symptoms, those with PD may be more likely to comply with therapy suggestions, including novel, and appealing non-pharmacological treatments. Older adults lost to attrition may have felt less urgency to adopt a new exercise habit. Traditional exercise programs for older adults suffer more than 30% attrition, 36 which is comparable to the rate observed here for the older adult cohort.
The etiology of high satisfaction with the program is likely multifactorial. Music, which has been found to activate specific neural pathways associated with emotion, might reduce stress and enhance social relationships. 37In a randomized controlled trial of Tango over 2 weeks (meeting 1.5 hr and 4 times per week) with middle-aged adults with self-referred symptoms of anxiety, and depression, significant improvements in their symptoms were noted at post-test, and maintained at a 1 month follow-up and similar improvements were noted in the same population after 8 weeks of tango dance. 38 Because social dance often involves meeting regularly to work in pairs or groups for honing skill and/or to enjoy the activity, dance may encourage teamwork that can allow the cultivation of friendships and larger community involvement. Further, therapies involving the arts and self-expression, both emotional and physical, may be especially helpful for managing motor and cognitive symptoms resulting from aging-related morbidities. Therapies that 1) allow the patient to regain and exert control on their body and 2) involve extensive social interaction have been shown to be effective at improving quality of life. 39 Future research should evaluate the role of a regained locus of control and consider depression and cognitive impairment as they relate to interventional success.
Limitations with dissemination media (ie: text and video), safety concerns, and potential difficulty in recruiting teachers and volunteers may limit further dissemination of adapted tango. As this study was primarily methodological in focus, hypothesis testing to determine the significance of results was not performed, but will be necessary to perform in future work. The effect sizes in this work for the mobility measures were relatively small, which does call into question the true efficacy of this form of therapy. Evaluating measures of cognition, psychosocial function and quality of life, not performed here, are needed.
That the program was safely implemented by novice teachers in the community and for individuals with varied impairments and a large age range (36-95 years) suggests the generalizability of the program, and flexibility for addressing multiple needs. Rehabilitation to restore and/or improve function in people with PD and older adults must be efficient and effective. Creating sustained behavioral change through targeted and effective programs may be most effective at addressing functional independence issues for older adults with and without movement disorders. 40 Although effect sizes are often compromised during dissemination, 32 this study suggests that adapted tango could be disseminated in the community under the instruction of non-clinically trained individuals, with only minimally attenuated effect sizes. More research is needed to refine dissemination methods while maintaining program fidelity.
The authors have nothing to disclose.
We would like to thank the teachers, Ronda and Manuel Patino, and Gabriela Lopez of Tango Rio, Erik Renz, Sarah Kelley Kerr, Mark Needelman and Shelley Brooks. We also acknowledge volunteers Adrienne Wimberly, Allison Bascas, Marco Coelho, Dabin Choi, Carly DiLeo, Margaret Fang, Kevin Huang, Twinkle Mehta, Malije Obi, Mina Taheb, Diana Tiwari, Kedra Woodard, Dawa Tsering, Sabine Povian, Dhondup Tso King, Mylinh Vo, Rebecca Dillard and Marisa Warner. We acknowledge Medlock Gardens retirement community for providing space for the adapted tango workshop, Clairmont Oaks retirement community and Wesley Woods Towers for providing space for the interventions and we thank the administrative staff of each institution. We acknowledge Dr. William De L’Aune for statistical assistance. The study was supported by the Dan and Merrie Boone Foundation, the Emory Center for Injury Control, and the Emory Center for Health in Aging. This study was also supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1TR000454. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The Emory School of Medicine Discovery Program supported KE McKee, and Department of VA R&D Service Career Development Awards (E7108M and N0870W) supported ME Hackney. We would also like to thank Mr. Aaron Bozzorg.
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Space to hold dance classes |