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Can you really dance away the pain?

Is dance and movement therapy effective as a complementary treatment for cancer?

Composed by Julie Harris

Fall 2008

 

What is dance and movement therapy?

According to the American Dance Therapy Association, dance and movement therapy is “the psychotherapeutic use of movement to further the emotional, cognitive, physical, and social integration of the individual.”  (http://www.adta.org/about/who.cfm) This definition is based on the assumption that the mind and body are connected.  If a person has an illness, this also affects his/her emotions and mental health.  Similarly if a person has a mental illness or emotional strain, this can affect his/her physical health.  Dance and movement therapy is based on this premise.  According to proponents of this therapy, dance and movement can be used to improve an individual’s emotional health, physical health, mental health, and social well-being.

 

Who is dance and movement therapy for and where is it offered?

Dance and movement therapy is suggested for individuals with physical, emotional, social or cognitive problems.  It is intended for people of all ages and may be practiced in groups or individually.

Dance and movement therapy may be offered in clinics, day cares, developmental centers, nursing homes, psychiatric hospitals, community mental health centers, corrections facilities, schools, and rehabilitation facilities. 

Dance and movement therapy is practiced in the United States, Canada, Europe, South America, Asia, the Middle East, Africa, and Australia.

(http://www.adta.org/faqs/index.cfm)

                              

 

What qualifications should I look for in a dance/movement therapist?

Dance and movement therapists need to have a master’s degree in dance/movement therapy and either have the title of “Dance Therapist Registered” (DTR) or “Academy of Dance/Therapists Registered” (ADTR).

A Dance Therapist Registered has to have completed 700 hours in a supervised clinical internship, while an Academy of Dance/Therapists Registered has to have completed 3,640 hours of supervised clinical work with additional supervision from a current ADTR.

(http://www.nccata.org/dance_therapy.htm)

 

What do dance/movement therapists do?

Dance and movement therapists focus on improving self-esteem, body image, non-verbal communication through movement, and coping strategies for stress management.

The components of the actual program may vary because dance and movement therapy involves observation of the participants, assessment of their needs, and a program tailored to the goals of the group or the individual.  Programs may be quite different from one group to another because dance and movement therapy is suggested for diverse populations of people with differing needs and goals.

(http://www.adta.org/faqs/index.cfm)

A common method of dance and movement therapy used with individuals with cancer, particularly women with breast cancer, is the Lebed Method.  More information about the Lebed Method can be found at:  http://www.lebedmethod.com/WhoWeAre.asp.

 

What are the main health claims made about dance and movement therapy as a complementary treatment for cancer?

Dance and movement therapy can be used by people with cancer to:

·  Physically

o   Provide exercise

o   Improve mobility and muscle coordination (specifically range of motion in the arm)

o   Reduce muscle tension

·  Emotionally/Cognitively/Spiritually

o   Improve self-awareness

o   Improve self-confidence and self-esteem

o   Express emotions and feelings

o   Develop a sense of renewal, unity, and completeness

·  Socially

o   Improve interpersonal interactions

o   Communicate feelings

 

(http://www.cancer.org/docroot/MIT/content/MIT_2_3X_Dance_Therapy.asp)

 

Who recommends dance and movement therapy?

Organizations for Therapeutic Arts:

The American Dance Therapy Association is a proponent of dance and movement therapy and is the organization which establishes and maintains the professional standards for dance/movement therapists.  This organization was founded in 1966 and continues to grow and shape the field of dance/movement therapy.  Further information about the ADTA may be found at:  http://www.adta.org/index.cfm.

The National Coalition of Creative Arts Therapies Associations also recommends dance and movement therapy.  This organization was founded in 1979 and advocates for the use of art therapy, dance/movement therapy, drama therapy, music therapy, poetry therapy, and psychodrama for the social, emotional, cognitive, and physical health.  Further information about the NCCATA may be found at http://www.nccata.org/index.htm.  The NCCATA provides examples of individuals who may benefit from dance therapy including:  people with eating disorders, people with emotional disorders, victims of violence, children who have been sexually and/or physically abused, children with autism, individuals with substance abuse problems, individuals who are homeless, individuals who are elderly, families in conflict, and individuals with chronic medical conditions such as:  cardiovascular disease, hypertension, chronic pain, arthritis, Alzheimer’s disease, and cancer.

News Media:

According to a Healthcast report on News 7 out of Boston, MA, dance therapy is a new therapy for cancer at Emerson Hospital in Concord.  The “I Hope You’ll Dance” program was started as a support group for women fighting breast cancer to empower them, encourage them to take control back in their lives, provide emotional healing, decrease scar tissue and swelling in the arm, increase range of motion in the arm, and provide a welcome distraction.  Since its conception, the program has become popular and has now been opened to people battling all types of cancer including men and women. 

(http://www3.whdh.com/features/articles/healthcast/BO77041/)

                                

Medical Institutions:

There are several medical institutions with dance therapy programs or that suggest dance therapy as a complementary treatment for individuals battling cancer including but not limited to: 

 

Foundations:

The Andrea Rizzo Foundation was created in honor of Andrea Rizzo who survived childhood leukemia but was killed by a drunk driver at age 24.  Andrea had been a gifted dancer and was studying to become a dance therapist at New York University.  After her passing, her mother worked to create this non-profit organization that provides dance/movement therapy at four hospitals, schools, and Ronald McDonald houses in several states.  Information about this foundation may be found at: http://www2.tbo.com/content/2008/jan/26/you-can-do-it/ and http://dreasdream.org/home/.  A listing of the dance therapists and programs funded by the Andrea Rizzo Foundation may be found at:  http://dreasdream.org/our-programs/.   

American Cancer Society:

According to the American Cancer Society, dance and movement therapy is recommended as a complementary treatment for individuals suffering with cancer to reduce stress and improve self-esteem.  The ACS indicates that supporters of dance/movement therapy claim it is beneficial for:  providing exercise, improving mobility, muscle coordination, reducing muscle tension, improving self awareness, self-confidence, interpersonal interaction, communicating feelings, and potentially strengthening the immune system.  Dance and movement therapists use nonverbal language expressed through a person’s body to assess his/her needs.  Dance therapists then design an intervention to meet that person’s individual needs.  The ACS recommends that individuals consult with their doctors before beginning therapy that involves manipulation or movement of joints and muscles. 

(http://www.cancer.org/docroot/MIT/content/MIT_2_3X_Dance_Therapy.asp)

 

Do these sources have any motives that might influence their recommendation?

It is possible that the organizations for the therapeutic arts such as the American Dance Therapy Association and the National Coalition for Creative Art Therapies Associations have motivation in recommending dance/movement therapy because they are involved in the promotion of it and the training of the people who provide it.  Without people participating in dance/movement therapy, there would not be a need for dance therapists or research about dance therapy.  This, however, is probably not their only motivation in recommending dance/movement therapy.  These organizations truly believe that it is beneficial.

The news media might have a motivation for promoting dance therapy that may be driven by political, cultural, or economic reason, but in this particular article dance therapy is simply promoted as a benefit to one’s health.  It would be impossible to determine their motives without knowing the exact political and cultural conditions in the Boston when the recommendation was made.  The motivations of the people at the “I Hope You’ll Dance” program at Emerson Hospital are most likely two-fold.  Similar to the therapeutic organizations, they may be trying to promote and recruit more participants to sustain the program, but it is difficult to know if this is driven by a desire for profit or a sincere belief that it is truly beneficial to women with breast cancer.

The foundation is motivated by the untimely death of the daughter and promotes what the daughter believed in and wanted to pursue before her passing.      

The medical institutions and the American Cancer Society have no motivation to recommend dance/movement therapy to patients other than improving their health and perhaps to decrease the total health care costs due to the beneficial effects of dance therapy physically and emotionally.  If a person remains active with a program like dance/movement therapy, it may decrease the likelihood of future need for treatment psychologically and/or physically which would increase health and decrease cost.

              

 

Do these sources provide scientific evidence for their recommendations?

Organizations for Therapeutic Arts:

The American Dance Therapy Association does its own research which is contained in the American Journal of Dance Therapy, however, to access this journal a person has to purchase access or have access through an academic institution.  The ADTA does not provide specific references or resources on their website to support their statements.

On their website, the National Coalition for Creative Arts Therapies Associations sites only the American Dance Therapy Association as being a source of further information.

Although it can be tempting to take recommendations from organizations like these at face value, because they did not provide specific examples of research that supports their claims, it is necessary to continue looking for evidence.

News Media:

The article about the dance therapy program at Emerson Hospital in Concord provides anecdotal evidence and testimonials, which are simply opinions of people who have participated in dance therapy.  While it is helpful to know that people enjoy dance/movement therapy when deciding whether or not to participate yourself, these statements do not provide scientific evidence of its benefit.

Medical Institutions:

The Reading Hospital and Medical Center, Comer Children’s Hospital, and Morgan Stanly Children’s Hospital all provide a link to online resources but do not specifically indicate where they found their information about the benefits of dance and movement therapy. 

Morgan Stanley Children’s Hospital, Comer Children’s Hospital, and Children’s Hospital of Pittsburg recommend before beginning an alternative or complementary therapy to research it, looking for controlled scientific studies, but do not actually provide any.

The website advertising a dance and movement therapy at Lutheran Hospital provides a link to the Mountain Dance Theatre which has testimonials and new articles about the benefits of dance and movement therapy.

Emerson Hospital, Virginia Commonwealth University Massey Cancer Center, St. Joseph’s Children’s Hospital, and Hahnemann University Hospital provide no evidence.

Even though these medical institutions suggest using dance therapy, and some have dance therapy programs, none provide resources to support their recommendations.

Foundations:  

The website dedicated to the Andrea Rizzo Foundation references the American Dance Therapy Association, provides news articles about their organization, and testimonials blogs.  While these all support dance therapy, they do not provide scientific evidence that dance therapy is beneficial.

American Cancer Society:

The American Cancer Society is the only source of information found in this search providing any real references for their claims.  They refer to articles in scientific journals that support the use of dance/movement therapy for individuals fighting cancer and other chronic illnesses.  Unfortunately, even within scientific journals, all articles are not created equally.  Some are more reputable than others based on the number of people in the study, the method the experimenters used, and the measurements and analyses completed to make their conclusions.   A listing of their references may be found at:  http://www.cancer.org/docroot/MIT/content/MIT_2_3X_Dance_Therapy.asp.

(Some of the articles referred to by the ACS will be reviewed below).       

        

Is there scientific evidence that dance and movement therapy is an effective complementary treatment for cancer?

To evaluate claims made about the benefits of dance and movement therapy for individuals fighting cancer, it is important to look to the available scientific literature.  After searching databases of scientific journals, there are a limited number of articles that address this topic.  Many articles about dance and movement therapy are only explanatory articles that describe what dance therapy is, its history, and who might benefit from it.  There are fewer articles that actually evaluate its clinical effect.  Still fewer of these specifically address the use of dance and movement therapy for people with cancer.  The available articles that specifically address dance therapy as a complementary treatment for cancer have a primary focus of children and adolescents and women with breast cancer.  These articles will be presented below.   

Review of the benefits of dance therapy

            Aktas & Ogce (2005) reviewed some of the available scientific literature about dance therapy as a complementary treatment for cancer.  Their search indicates that dance therapy is beneficial socially, physically, cognitively, and emotionally for people with cancer because dance therapy is based on the assumption that the mind and body are connected.  According to Aktas & Ogce (2005), dance therapists believe that if an individual is experiencing mental or emotional problems, these often appear in the form of muscle tension and limitations in movement patterns.  Additionally, if individuals are experiencing pain or illness, this can affect their mood and feelings. 

            Physically, dance therapy can help reduce muscle tension and fatigue and release endorphins in the brain that promote a sense of well-being (Aktas & Ogce, 2005).  Dance is also believed to have a strengthening effect on the immune system and possibly have healing effects.  Dance incorporates the whole body and is thought to enhance the functioning of the circulatory, respiratory, skeletal, and muscular systems.  According to Aktas & Ogce (2005), dance therapists also use the mind-body connection to help people develop greater self-awareness, positive emotional well-being, positive self-image, reduce stress, anxiety, and depression, and invoke a kind of emotional “catharsis.”  In addition to physical and emotional benefits, Aktas & Ogce (2005) describe social benefits of dance therapy including bringing people out of isolation into group settings and providing an environment where emotional and social bonds can be formed.  Aktas & Ogce (2005) describe dance therapy as being beneficial to cognitive function as well including improvements to motivation and memory.

            Unfortunately, this review has several limitations.  One limitation of this review is that the sources are primarily explanatory articles, not clinical research.  Aktas & Ogce (2005) only present information on two studies using experimental and control groups.  One study conducted by Berrol et al. included 134 older adults with neurotrauma, 70 who were in the experimental group receiving dance/movement therapy and 64 (controls) who were asked to participate in their usual activity routine.  Those in the dance/movement therapy group received two 45 minute sessions per week for five months.  The results of this study presented by Aktas & Ogce (2005) were that the people in the dance/movement therapy group enjoyed the sessions and perceived them as beneficial for their mood, social interaction, physical function, and level of energy.  Aktas & Ogce (2005) do not describe how the study was conducted or what was measured.  It is unknown whether individuals were randomized to groups or if they self-selected groups.  It is also unknown if any benefits were actually measured or if Berrol et al. simply asked participants about their experience.  Additionally the participants were all older adults with neurotrauma, not cancer.  The generalizability of this study is questionable.              

            The second study described by Aktas & Ogce (2005) was conducted by Erwin-Grabner et al.  Participants in this study had a mean age of 29 and were from a sample of university students. Of the 21 participants, 11 were randomly assigned to an experimental group and 10 were assigned to a control group.  Those in the experimental group participated in four 35 minute movement sessions over two weeks.  Both the experimental group and control group completed the Test Attitude Inventory before and after the intervention.  The goal of this study was to measure whether dance/movement therapy reduced self-reported test anxiety.  While the experimental group suggested that it may be an effective intervention for this goal, this study does not generalize well to individuals with cancer.  The participants were randomly assigned to groups, but this study is hardly representative enough of the general population to use the results for other populations. The sample size of 21 is far too small, and the participants were from a single university community also making it difficult to use these results to inform decisions for a considerably more diverse population, people with cancer.  Additionally, the duration of the intervention was only two weeks.  This may be sufficient for test anxiety, but it is unlikely that a duration of two weeks would create significant and meaningful change for individuals with a chronic disease like cancer.

            Although Aktas & Ogce (2005) present support for the health claims about dance and movement therapy for the complementary treatment of cancer, it can only be considered promising based on their review.  Aktas & Ogce (2005) do not present any limitations of the studies they reference.  Although it is clear that more research needs to be done to firmly support the use of this therapy for people with cancer, perceived benefits have been reported by individuals participating in dance/movement therapy, and no negative effects have been reported.       

    

           

Anthropological perspective

            A 1995 article by Hanna is often cited in research about dance and movement therapy.  (This article is cited by Aktas & Ogce (2005) as a reference and by the American Cancer Society).  In this article, Hanna describes the potential healing power and health benefits of dance from an anthropological perspective, using information about different cultural and historical beliefs about the power of dance as her evidence.   In this article, Hanna (1995) states “although there are few properly controlled studies that demonstrate specific relations between dance and healing, there are clinical case studies and theoretically inspired speculations” (324).  What Hanna primarily presents in this article are those theoretically inspired speculations, which provide support but not scientific evidence.

Hanna (1995) defines dance as purposeful, intentional, rhythmic, culturally patterned sequences of body movement that would not be considered ordinary non-verbal activity.  Dance incorporates all the senses as well as simultaneous usage of the right and left brain in the self-expression according to Hanna (1995).  Dance involves the body, the mind, and the emotions which are all mediated by culture.  According to this article, dance may increase pleasure, relieve stress, increase skill mastery, help people respond to social pressure, encourage people to participate in a group experience, express emotions, gain a sense of control, self-esteem, and self-confidence, and perhaps even “inoculate” individuals by conditioning them to be able to moderate, eliminate, and avoid tension, fatigue, and the effects of stress (Hanna, 1995).  Dance may also help individuals identify with a group culturally.            

Hanna (1995) provides examples of some cultures in Africa, the Caribbean, the Middle East, Brazil, and Korea as using dance for healing.  Illness is described in these cultures as a result of spiritual possession or difficulty with social relationships.  While these are significant to studies of anthropology and human cultural evolution, they are not scientific evidence.  Hanna (1995) also describes dance as increasing circulation of blood carrying oxygen to the muscles and the brain and altering the levels of particular brain chemicals.  While these examples have much more potential as scientific evidence of the benefit of dance therapy, Hanna does not provide a specific reference for this statement. 

Hanna (1995) does provide specific information about two scientific studies, but unfortunately like Aktas & Ogce (2005), these are not strong enough to conclude that dance therapy is beneficial for cancer.  One study by Berrol (1991) used dance therapy for head injury patients to help them with their feelings of helplessness and fear through ambulation, movement tasks, and tasks to improve posture, gait, coordination, reaction time, and ability.  These patients report enhanced body image and awareness as well.  Although this study is described as using dance therapy “successfully,” it does not provide any information about the size of the group, the demographics of the group, whether they had a matched control group, and whether there were any measures completed. 

The second study described by Hanna (1995) was completed by Perlman et al. (1990) with 43 participants with rheumatoid arthritis who were involved in a 16 week dance-based aerobic program.  This program was twice a week for 2 hours.  The dance-based aerobic program was folk dance format and involved slow and fast walking, variations in patterns and planes of movement, and imagery.  Participants were included if they had approval from their primary physician, no surgeries in the last 6 months, and the ability to walk with or without assistance.  Based on physician assessment, articular pain and swelling decreased significantly.  Fifty foot walk time, pain, and depression all decreased as well.  This study is much more promising because Hanna (1995) actually describes the intervention in more detail as well as inclusion criteria and physician assessment.  The limitations of this study are that it was conducted with only 43 participants without a clear comparison group.  Additionally although rheumatoid arthritis is also a chronic disease, generalizability to people with cancer is still a stretch.    

 

    

 

Dance and movement therapy for children and adolescents with cancer

            According to Mendelsohn (1999), dance and movement therapy can be used with children who are hospitalized to help them cope with the challenges of illness and hospitalization.  This is particularly salient for children with chronic illnesses such as childhood cancer that may require frequent or long hospitalizations as part of their ongoing treatment plans.  Dance and movement therapists work with these children to promote contact, communication, expression of physical needs, and expression of emotional needs.  Mendelsohn (1999) asserts that a “child’s posture, movement or avoidance of movement, quality of movement, initiative or lack of it, and breathing patterns, are all external manifestations of the child’s state of mind” (67).  Dance therapy watch the child’s movement, mimic it, and create a therapeutic relationship in which the child begins to feel comfortable and can expression his/her needs in a safe environment.  Sometimes children do not express needs to their families and are more comfortable with a third party, such as a dance therapist. 

            Mendelsohn (1999) provides case examples of children with whom dance/movement therapy has been used successfully.  One such example involves a seven year old girl who was diagnosed with leukemia; however, his young girl had been given a good prognosis.  When playing with the dance/movement therapist, she pretended she was dancing in an imaginary forest and kept tripping and falling.  On another occasion, she pretended she was a monster and kept making herself disappear.  Mendelsohn (1999) proposes that this young girl was symbolically communicating her anxiety about death.  The girl died several months later; dance therapists would argue that the girl understood she was dying and expressed it non-verbally through movement and play.

            In addition to the symbolic level, Mendelsohn (1999) advocates that dance/movement therapy can have effects at the body/functional level and the interpersonal level.  To illustrate the use of dance/movement therapy at the body/functional level, the author provides the case example of “Joel.”  Joel is a 5 year old boy suffering from a malignant tumor.  He demonstrated anxiety about treatments and fear that the disease would spread through quick, forceful movements with his fingers and feet as well as a tendency to bite.  While in dance/movement therapy, Joel’s movements and energies were scattered in every direction.  He expressed to the dance therapist that he needed counterpressure, so the dance therapist introduced games using Joel’s large torso muscles as stabilizers.  To illustrate the use of dance/movement therapy at the interpersonal level, Mendelsohn (1999) describes the case example of “Dana.”  Dana is an 8 year old suffering from a malignant tumor.  She has required frequent hospitalizations.  Through her interactions with the dance therapist, it was determined that Dana was uncomfortable separating with her grandfather.  Consequently, the dance therapist included the grandfather in the session.  As the session progressed, Dana initiated a game where she put scarves over the dance therapist’s head and asked her grandfather to step further and further away from the dance therapist.  The dance therapist determined that Dana was expressing fear and aloneness.

            In this article, Mendelsohn (1999) provides concrete examples of ways in which dance/movement therapy can be used to meet its goals (or health claims) physically, socially, and emotionally.  These case examples represent successes for those individual children, but it cannot necessarily be assumed that dance/movement therapy will provide the same benefits for all children suffering with cancer based on three cases.  Cancer differs greatly in its presentation, prognosis, and treatment depending on the type of cancer it is and when it is detected.  Children also differ greatly in their support systems, their perception of the experience, their preparedness, their emotional state prior to diagnosis, their developmental level, and several other ways that compose the makeup of each individual child.  Although many dance therapists contend that this type of therapy is individualized to the needs of the child, which is a beneficial practice, there still need to be some guidelines or measures used to standardize and make the dance therapists’ assessments reliable and valid across patients.  Making assessments reliable and valid would ensure that if another dance therapist observed the same child, he/she would make the same conclusions and that these conclusions would be correct – the anxieties and fears, for example, observed are actually present and troubling the child.  Mendelsohn does not discuss whether these children were evaluated in any other way than observation by the dance therapist.  While dance therapists receive training in child development and assessment, observation without clear clinical guidelines is subjective, not scientific.  This article is promising but not enough to make strong conclusions. 

 

 

Cohen & Walco (1999) have also studied the effects of dance and movement therapy for children and adolescents with cancer.  (This study is cited on the American Cancer Society website as one of their resources).  In their study, Cohen & Walco (1999) stress the connection between the mind and the body, and that change in one can lead to changes in the other.  This is consistent with the Internet claims that dance and movement therapy is effective due to this mind/body dualism.  Additionally, Cohen & Walco (1999) discuss “fairly universal” means of assessing movement in order to create effective dance therapy programs for patients.  According to this article, “Laban movement analysis involves a comprehensive notation system of body movements that may be integrated to define aspects of intra- and interpersonal functioning.  This system incorporates Bartenieff fundamentals, which stress identified anatomic functional aspects of movement, such as center of weight, connectedness, and muscle tension and relaxation, to address body awareness and feeling” (35).  While description does not fully explain how it is accomplished, it does provide evidence of “fairly universal” guidelines for assessment. 

Cohen & Walco (1999) present a developmental perspective to dance/movement, providing case examples in several age ranges through development from infancy to adolescence.  These authors also discuss the importance of stress models and the social ecological model when considering therapies for children suffering with cancer.  Stress models involve identifying daily hassles and chronic stressors, defining the outcomes that may be related to or result from those stressors, and identifying things that might exacerbate outcomes.  The social ecology model was first proposed by Bronfenbrenner.  It contends that people live in systems.  People are a part of families that live in neighborhoods within cities, who have friends, schools, workplaces, etc.  All of these things contribute to a person and how he/she thinks, feels, and acts.  According to Cohen & Walco (1999), the social ecological model as it relates to children with cancer includes the developmental factors (ontogenesis), the microsystem (home and close family), the mesosystem (school, medical facilities, and religious institutions), the exosystem (social supports), and the macrosystem (beliefs, cultural norms, political influences).

Cohen & Walco (1999) provide the following case example for children with cancer in infancy.  There was a four week old boy with infant acute leukemia who had spent 6 weeks in the pediatric intensive care unit due to the intensity and severity of his illness.  His sensorimotor development had been interrupted by this stay in the PICU.  Dance/movement therapy was used to engage the infant in interactions with the environment.  The dance therapist used her voice to calm and sooth the infant while stroking and gently stretching the infant’s body.  The therapist aimed to provide consistency, familiarity, and contact.  The dance therapist also engaged the infant with a scarf which he held lightly in his hands.  The infant also participated in wave-like motions using the scarf with his mother.  According to Cohen & Walco (1999), this was important to create a connection between the infant and his mother and provide interaction to decrease the experience of isolation caused by his treatments. 

While this example sounds beneficial and pleasant for the child and mother, there was no real evidence presented by Cohen & Walco in this article that the infant was actually feeling isolated and unengaged.  It would be difficult to measure the feeling of isolation in an infant because it is an abstract feeling and cannot be communicated verbally, but this example would be more compelling if a description of the actual assessment were included in addition to the intervention design and goals.

Cohen & Walco (1999) also present a case example of a dance therapy group for three 4 year old boys with acute lymphoblastic leukemia.  This program was 8 weeks long and encouraged the children to naturally experiment with the different ways to move their bodies and identify and express emotions and feeling through the whole body.  The boys participated in an obstacle course which was designed to elicit movement.  Although this group was not uniform in their impulsivity, self-control, awareness, and expression prior to the program, according to Cohen & Walco (1999) it was beneficial for all the boys in balance, adjusting to different spatial levels, and using patterns of movement for creative problem solving.  Similar to the infancy case example, the authors do not provide specific information about how they determined that the program was beneficial. 

As an example of school age children with cancer and the use of dance therapy, Cohen & Walco (1999) describe a seven year old boy undergoing a stem cell transplant with hydrocephalus and neurocognitive effects.  Because of these additional medical conditions, the boy had difficulty expressing speech and had slowed motor movements.  To help this boy communicate feelings and ideas, the dance therapist mirrored his movements, emotional tone, and breathing to empathize and form a rapport with the child.  Cohen & Walco (1999) describe that the dance therapist also suggested that the boy gently touch parts of his body to gain a connection with himself and greater self awareness.  Using props, the dance therapist encouraged the boy to focus his thoughts and feelings so that he eventually was able to express fantasy, interaction, and spontaneity.  A limitation of this example is that there is no description of the duration of the therapy or the frequency.

The final example provided by Cohen & Walco (1999) is an adolescent therapeutic support group for adolescents (ages 15-19) with cancer who had been newly diagnosed or off treatment for several years.  The group met weekly for a year to create a consistent peer support network.  The group focused on body image because physical disfiguration, weakness, weight changes, and restrictions to activity are often secondary outcomes of cancer which are especially important to adolescents and their self-concepts.  According to Cohen & Walco (1999), the adolescents participated in activities involving body movement, coordination, athletic skills, energy level, teamwork, self-esteem, problem solving, and interpersonal relationships.  This example suggests that it is still ongoing and has yet to be evaluated for effectiveness. 

Both Cohen & Walco (1999) and Mendelsohn (1999) present valuable case examples of using dance and movement therapy successfully as a complementary treatment for cancer with children and adolescents.  These are valuable in the same way that anecdotes are valuable.  They provide real examples and descriptions of experiences where someone observed that dance/movement therapy worked for someone.  Unfortunately anecdotes and case examples are not the same as clinical evidence of universal beneficence.  In order to conclude that dance/movement therapy is an effective complementary treatment for cancer in children and adolescents, it is necessary to have evidence from a controlled, randomized study.  In case examples, there is no one with whom to make comparisons.  Additionally, unless there is information documenting the use of several different techniques for the same child, it is difficult to determine whether another therapy might have been better.   Cohen & Walco (1999) state in their article, “we know of no published empirical studies evaluating treatment outcomes of dance/movement therapy to promote psychological adjustment in children with cancer or similar populations” (41).  Because empirical evidence is not yet available, these case examples illustrate that dance/movement therapy may be beneficial for children and adolescents with cancer physically, socially, and emotionally, but more research is needed to know how effective it is.  

 

Dance and movement therapy for women with breast cancer

            In searching for scientific evidence about whether dance and movement therapy is beneficial and effective as a complementary treatment for cancer, women with breast cancer were the only population among all the individuals with cancer for whom this had actually been studied using real clinical trials (at least clinical trials that have been published and that are available).  These articles focus on the health claims that dance/movement therapy is beneficial physically, emotionally, and socially, specifically improved range of motion, increased quality of life, and increased spirituality.

                 

Breast cancer-related lymphedema and dance and movement therapy for women with breast cancer:

            According to Bicego, Brown, Ruddick, Storey, Wong & Harris (2006), breast cancer can have many secondary outcomes that affect the well-being of women including decreased quality of life, sleep disturbances, weight gain, fatigue, poor body image, increased risk for osteoporosis, cardiovascular disease, premature menopause, and lymphedema which is chronic inflammation, pain, tightness, heaviness, and fluid accumulation usually in the arm after an axillary dissection or radiation treatment.  Lymphedema has three stages one of which is reversible and more mild; the other two stages are more serious.  Some of the treatments for lymphedema include elevation, massage, compression, and physical therapy.  In this article, Bicego et al. (2006) sought to determine whether exercise is beneficial for women with lymphedema or the risk of lymphedema as a secondary outcome of breast cancer treatment.  This article was written in response to concerns brought on by conflicting information about whether exercise was helpful or actually harmful to these women.     

            The argument against exercise is that “violent exercise and strenuous exertion” and repetitive movements need to be avoided to prevent lymphedema although there was no scientific evidence to support this claim at the time (Bicego et al., 2006).  The argument for exercise contends that it encourages skeletal muscle contractions that are the primary pumping mechanism for the lymphatic and venous drainage systems.  By exercising, contractions in the lymph vessels should be stimulated and help the management of lymphedema.  According to Bicego et al. (2006), compression is used with exercise to improve lymphatic and venous return as well as minimize the fluid leaking into the tissue space.

            Bicego et al. (2006) review and report findings from eight studies directly related to breast cancer-related lymphedema and exercise.  The authors evaluate the quality of these studies based on the level of scientific rigor of their design and suggest limitations to the studies.  The most rigorous redesign is a large randomized controlled trial, and the least rigorous is a case series without controls.  Two of the studies presented by Bicego et al. (2006) in this article about the effects of exercise on breast cancer-related lymphedema directly used dance/movement therapy as their aerobic component.  The remaining studies involved other forms of aerobic exercise as well as resistance training and stretching.

            According to Bicego et al. (2006), in a pilot study, 40 women who had been through surgery for breast cancer were included in a structured exercise group.  Although this pilot study ranks as a level 5, being the least rigorous (a case series without control), this study used a pre-test post-test design.  A pre-test post-test design involves assessing the women before and after they participate in the therapy to look for changes which does give information, at least for these women, about improvement.  Bicego et al. (2006) indicate that women were included who had been diagnosed with stage 1 to stage 3 breast cancer with no lymphedema reported, and 83% were within 12 months of diagnosis.  Most of the women were currently undergoing adjuvant therapies.  The program was 16 weeks long with 1 hour sessions 3 times per week.  These consisted of:  10-15 minute warm ups with slow, rhythmic range of motion and stretching; 20 minutes of aerobic exercise such as walking, cycling, step, and dance movements; and 20 minutes of resistance training with resistance bands, dumbbells, and resistance machines.  Bicego et al. (2006) report that the following outcome measures were taken:   blood pressure, heart rate, weight, body fat, aerobic capacity, flexibility, strength, and quality of life. 

            Eighty-eight percent of the participants completed the whole exercise program.  None of the participants reported any adverse effects, including lymphedema.  Bicego et al. (2006) indicate that significant improvements were identified in resting systolic blood pressure, flexibility, strength on bench press and leg press, and aerobic capacity.  These results indicate a physical improvement when dance/movement was used complementarily; however, dance/movement therapy were not the sole component of this program, so the improvements cannot be fully attributed to the dancing alone.  Additionally, according to Bicego et al. (2006), the women improved on the global measure of well-being, 4 of the 5 mood/distress measures, and all three measures of global functioning.  Similar to the physical benefits described by this study, the results support an improvement socially and emotionally, but it cannot be solely attributed to the dance/movement component.  Although making conclusions from just this study is not recommended because there was no comparison group, it does support the use of an exercise program involving dance/movement therapy for women at risk for lymphedema following treatment for breast cancer.

 

 

            The other study directly related to women with breast cancer and dance/movement therapy reviewed by Bicego et al. (2006) is a study by Sandel, Judge, Landry, Faria, Ouellette, & Majczak published in 2005.  (This study is also cited by the American Cancer Society on their website).  This pilot study was rated by Bicego et al. (2006) as a level 2 study which is a small randomized controlled trial.  This is a huge step in the right direction from case examples to actual randomized controlled trials to provide scientific support for the use of dance/movement therapy as a complementary treatment for cancer although a large randomized controlled trial is preferred. 

            Sandel et al. (2005) recruited women in Connecticut at cancer centers for participation in the study.  The Cancer Care Partnership of MidState Medical Center and the University of Connecticut Cancer Center were active sites for recruitment.  Surgeons, oncologists, and radiation oncologists supported the program and described it to their patients.  The training site was located adjacent to the cancer cares for ease of access.  The program was also promoted through newsletters, brochures, and in local print media.  According to Sandel et al. (2005), women were originally included in the study if they had undergone a lumpectomy or more intensive breast surgery at least 1 month to 18 months earlier with physician approval.  This was extended to include women who had surgery within 5 years.  Women were not included if they were diagnosed with metastatic breast cancer or were unable to stand independently for 3 minutes.

            Thirty-seven women ages 38 to 82 years old participated and were randomly assigned to the intervention group or the wait list group.  This design ensures that all of the women are able to participate, but the wait list group waits until the first group is done with the program before beginning.  According to Sandel et al. (2005), 19 women were assigned to the intervention group, and 16 were assigned to the wait list group.  After the women in the intervention group completed the program at 13 weeks, the wait list group completed the program for another 13 weeks, so Sandel et al. (2005) were able to see if changes were maintained over time.  To understand the effects of the dance/movement therapy, Sandel et al. (2005) completed measures at the beginning of the study (baseline), after 13 weeks, and after 26 weeks including:  the Functional Assessment of Cancer Therapy-Breast questionnaire which is a self-report questionnaire about quality of life related to breast cancer, the Body Image Scale, which measured an intended secondary outcome of improved body image, and shoulder range of motion and arm circumference measured by an experienced physical therapist (who did not know which group participants were in to prevent bias).  Shoulder ROM was measured by abduction, forward flexion, rotation, and extension.  Arm circumference was measured at the knuckles (metacarpo-phalangeal joints), wrist, and at standardized points on the forearm and arm. 

            According to Sandel et al. (2005), the program was based on the Lebed Method (for more information see:  http://www.lebedmethod.com/WhoWeAre.asp).  Sessions were led by a registered dance/movement therapist and certified Lebed method instructor.  The program met for 12 weeks with 2 sessions a week for the first 6 weeks and 1 session a week for the second 6 weeks.  Participants were instructed to ‘take your time, move at your own pace, stop if something is painful, don’t worry about coordination, and most importantly, have fun’ (Sandel et al., 2005, 303).  The program consisted of:  10-15 minute warm-up of deep breathing and head, neck, shoulder, torso, and arm stretching aimed to promote lymphatic drainage and alternated with lower body movements during the first few weeks; core exercises such as movements of the shoulder, elbow, and wrist, side to side hip swings, walking with “attitudes,” and balance exercises with chairs were performed to music with “playful” and “sensuous” imagery; 25-30 minutes of dance movements taught in routines of 4 simple movements progressing to more spontaneous, flowing dance from various traditions including Celtic, American, Jazz, Afro-Cuban, Reggae, Middle-Eastern, and Cajun as well as use of a large tubular stretch band of blue jersey to promote reduced anxiety and comfort moving in their bodies; 2-3 five to seven minute water breaks during which unstructured conversation took place; and 10 minutes of wrap-up including seated stretching, meditative movements, and quiet music.  According to Sandel et al. (2005), following the session, the instructor would ask the women about what they were feeling and if there were any questions; this lasted 10-30 minutes.         

            Sandel et al. (2005) indicate that the women demonstrated significant improvements in health-related quality of life as measured by the FACT-B scores, and that the women who participated in the program the first 13 weeks maintained this improvement over the following 13 weeks.  The women’s scores on the Body Image Scale improved during their 13 week programs, and the women in the first group continue to improve over the following 26 weeks.  According to Sandel et al. (2005), shoulder range of motion improved progressively.  At the end of 13 weeks, the intervention group had increased ROM by 15° while the wait list group who had not yet participated had increased their ROM by only 8°.  At the end of 26 weeks, the intervention group had increased 26° while the wait list group had only increased 20°.  Those in the intervention group demonstrated greater change over 26 weeks than the wait list group, even though both had participated in the same dance program.  Sandel et al. (2005) report no change in arm circumference at 13 weeks or 26 weeks for either group.

            This study has many strengths that have been lacking in previous studies.  It is one of the few randomized controlled trials for dance/movement therapy as a complementary treatment for breast cancer.  This is preferable to a case example, even though the size of the group was small which is a limitation.  The authors also specifically describe the exact components of the program and the duration of the program.  They also describe who they found participants and who was included or excluded from the study.  Additionally, Sandel et al. (2005) utilize standardized measures to assess the actual improvements made by the women participating.  Although there is some possibility of bias in terms of the quality of life measures because they are self-report, the physical measures of shoulder ROM and arm circumference are objective.  A limitation of the study is that because it is a based on a small group of women it is not sufficient to make assumptions about benefits for all women; however it is a step in the right direction.  Sandel et al. (2005) demonstrated that physical and emotional benefits can be achieved through dance/movement therapy with women with breast cancer.

 

                                                       

 

            A clinical report was composed by Molinaro, Kleinfeld, & Lebed (the inventor of the Lebed Method) in 1986 about the effects of dance therapy in the surgical management of breast cancer.  In this report, Molinaro et al. (1986) describe a breast cancer rehabilitation program at the Albert Einstein Medical Center-North Division that combines ballet and jazz movements to emphasize posture, balance, body symmetry, coordination, and controlled shoulder and trunk movements to promote physical and psychological benefit such as femininity, sexuality, and body image.  This program was developed in 1982 for patients who had a mastectomy or lumpectomy as part of their treatment for breast cancer and concentrates on the pectoralis major and minor, shoulder, neck, and trunk muscles.  According to Molinaro et al. (1986), ballet is used “to emphasize isolated, symmetrical upper extremity movements and to promote stretching of the entire body.  Isometric exercise can be incorporated using the ballet barre” (967).  The ballet phase is 25 to 30 minutes with breaks when needed.  Modern jazz is used to encourage full body movements and coordination for range of motion and focus on speed of movement as well as rhythm and harmony.  Molinaro et al. (1986) report that standard functional exercises such as wall-climbing, ironing, pulling, pushing, and unweighted pendulum motions are incorporated in the dances.  This phase also is 25 to 30 minutes. 

            According to Molinaro et al. (1986), the program meets biweekly for an hour.  Before entering the program, participants are evaluated by a physiatrist and by a physical therapist for range of motion, muscle strength, active function, sensation, upper extremity girth, pain, posture, balance, and skin changes.  The patients’ outpatient charts are also reviewed.  The participants are measured weekly for signs of lymphedema.  Molinaro et al. (1986) report that 37 women ages 30 to 81 years old have participated in the program.  Additionally, women currently undergoing chemotherapy and radiation therapy also attend but often are more sporadic in their attendance due to treatment side effects.  All but three of the participants achieved full active range of motion (although they do not define what “full active range of motion” is specifically).  Additionally Molinaro et al. (1986) report that the participants demonstrated a feeling of camaraderie, friendship, shared-experience, and support which provide some support for the claim that dance/movement therapy is beneficial to people with cancer socially and emotionally.

            This clinical report provides more case support for the use of dance/movement therapy, but it still has several limitations.  Molinaro et al. (1986) provide specific information about the kinds of measurements used although they do not report the actual results.  They also describe the composition of the dance/movement therapy program clearly and provide rationale for the components’ inclusion.  The clinical report does not provide any cases for comparison, however, which makes it difficult to know how beneficial this dance/movement therapy program really is. 

 

Quality of life, spirituality, and dance/movement therapy for women with breast cancer:

            A randomized controlled trial of a mind-body-spirit group was conducted by Targ & Levine (2002) to determine whether a complementary and alternative medicine approach would be beneficial for women with breast cancer.  One hundred one women ages 26 to 78 from the San Francisco Bay area participated in this study who were initially diagnosed with primary breast cancer in the last 18 months or who had been diagnosed with metastatic breast cancer in the last 18 months.  They were recruited by area hospitals, flyers, and public service announcements.  According to Targ & Levine (2002), 93 participants were randomized to participate in a 12 week complementary and alternative medicine (CAM) program, and 88 participants were randomly assigned to a 12 week standard program. 

The CAM program consisted of a 12 week “intensive lifestyle change and group support program with an emphasis on psychospiritual issues, and inner process” (Targ & Levine, 2002, 240).  This program met two times a week for 2 ½ hours.  On one day, the participants attended a 1 hour informational health discussion group led by a nurse.  Topics included:  nutrition, exercise, menopause, lymphedema, pain management, sexuality and other similar topics that were requested by members.  Following this session the women attended a dance/movement program consisting of six yoga classes and six dance therapy sessions involving body awareness, group ritual, self-touch, art-work, and emotional exploration.  According to Targ & Levine (2002), on the other day, the participants attended an hour of experiential work emphasizing guided imagery and silent meditation as well as drawing and writing exercises.  The remaining 90 minutes were dedicated to group discussion with topics such as:  relationship with cancer, views of healing, sexuality and body image, death and dying, compassion, anger, forgiveness, and healing.  Targ & Levine (2002) describe the standard program as a 12 week unstructured psycho-educational support group that met once a week for 1 ½ hours.  This group focused on:  coping with real life issues, communicating with friends, family, and medical staff, body image, sexuality, grief, anger, anxiety management and problem solving.  The standard group was led by a psychologist with 5 years of experience with women with breast cancer.

Targ & Levine (2002) utilized the Functional Assessment of Chronic Illness Therapy, Version 4 to assess aspects of quality of life such as:  physical well-being, social/family well-being, emotional well-being, functional well-being and spirituality.  The authors used the Profile of Mood States to measure tension-anxiety, depression-dejection, anger-hostility, fatigue-inertia, confusion-bewilderment, and vigor.  Additionally, Targ & Levine (2002) used the Spiritual Scale of the FACIT to measure meaning and purpose, harmony and peace, and closeness to God or a Higher Power as well as the Principles of Living Survey to measure spiritual practices, spiritual growth, and embracing life’s fullness.  The groups were also asked to rate their satisfaction with the therapy.

Targ & Levine (2002) report that 75% of the women in the study practiced some meditation or imagery previously, 10% had ever practiced yoga, 50% had prayed in the last week, 34% reported having a religious practice, and 69% reported having an exercise routine.  Based on their study, the participants in the CAM group showed a significantly higher increase in spiritual integration, spiritual practice, and spiritual growth.  According to Targ & Levine (2002), both groups showed significant increases in quality of life, increased functional and emotional well-being, and spiritual well-being.  The CAM group showed a decrease in distress and avoidance, but both groups showed decreases in depression, anxiety, and anxious preoccupation.  The standard group also showed a decrease in confusion and improvement in helplessness/hopelessness.  Additionally, significant decreases in psychiatric medication use over time were seen in both groups.  Targ & Levine (2002) report that the CAM group rated their experience higher than the standard group in terms of satisfaction although group reviewed high ratings. 

This study provides support for the emotional and spiritual benefits of dance and movement therapy for women with breast cancer.  It has several strengths as well as some limitations.  Targ & Levine (2002) provide specific descriptions of the standardized measures used.  They also utilize a randomized controlled design with a larger participant group than any of the other studies.  However, it is not possible to fully attribute the emotional and spiritual improvement of these women to the dance and movement therapy alone because it was only a component of a larger program.  To make more informed conclusions, it would be necessary to have a study in which dance/movement therapy was the only method being tested and through was a group of matched controls participating in a standard therapy for comparison.

 

Summary, Conclusions, and Recommendations:

            Dance and movement therapy is suggested for individuals with cancer as complementary treatment by organizations for the therapeutic arts such as the American Dance Therapy Association and the National Coalition for Creative Arts Therapies Associations, the news media, medical institutions, foundations like the Andrea Rizzo Foundation, and the American Cancer Society.  It involves using body movements and dance to improve physical, emotional, cognitive, and social well-being.  Although the individual components of a dance therapy program may vary because they are usually based on the needs of the individuals being served, there are some standard methods that are used to assess individuals’ needs (such as Laban movement analysis) and create interventions (such as the Lebed Method).  Dance and movement therapy is based on the rationale that the mind and body are connected and that changes in one cause changes in the other.  It is recommended for people with cancer based on this understanding.

            The main health claims about the benefits of dance and movement therapy for individuals with cancer are that it improves physical, emotional/cognitive/spiritual, and social aspects of their lives.  The most compelling evidence for the use of dance and movement therapy comes from literature about its use with women with breast cancer although progress is being made in the study of its use with children and adolescents with cancer.  Physically, dance/movement therapy is purposed to improve range of motion, provide exercise, reduce muscle tension, and improve coordination.  The current available literature from randomized controlled trials provides support for improvements in range of motion in women with breast cancer participating in dance and movement therapy.  There is some support for improved coordination in women with breast cancer and children and adolescents with childhood cancers although this is not as well documented.  Emotionally, cognitively, and spiritually, dance/movement therapy is advocated to improve self-awareness, improve self-confidence and self-esteem, express emotions and feelings, and develop a sense of renewal, unity, and completeness.  Based on a randomized controlled trial, there is support for the spiritual effects of dance/movement therapy with women with breast cancer; however dance/movement therapy was not the only component of this program, so the beneficial effects cannot be solely attributed to the dance component.  Women with breast cancer have shown improvement on measures of quality of life and body image supporting the emotional benefits of dance and movement therapy.  There is anecdotal, case evidence that supports improvements in self-awareness, self-confidence, self-esteem, and the expression emotions and feelings for women with breast cancer and children and adolescents with cancer; however, this still needs to be demonstrated scientifically in a randomized controlled trial.  Socially, dance and movement therapy is thought to improve interpersonal interactions and communicate feelings.  There have been several case examples, especially with children with cancer, illustrating the interpersonal benefits of dance/movement therapy, but social benefits have not been studied empirical like physical and emotional benefits have.

            Although there is support for the use of dance and movement therapy as a complementary treatment for cancer in women with breast cancer and children and adolescents with cancer, there is still a tremendous need for stronger scientific research and randomized controlled trials with larger sample sizes in order to make strong conclusions about its benefit.  None of the available studies provide any information about the demographics of the participants, so it is impossible to determine whether the participants were representative of the intended population.  It is somewhat concerning that so many organizations and medical institutions recommend dance and movement therapy to people with cancer despite the lack of strong scientific evidence for its benefit.  Experience and case examples are helpful, but they are not sufficient.  However, none of the studies evaluated in this search reported any negative consequences or effects of dance and movement therapy for individuals with cancer.  Based on the available evidence, it can be concluded that dance and movement therapy is not harmful and may be beneficial physically, emotionally, socially, spiritually, and cognitively for people with cancer as a complementary treatment; however substantial research still needs to be done.  If pursuing a dance and movement therapy program, look for one led by a Dance Therapist Registered or an Academy of Dance/Therapists Registered because they are trained, educated, and held to professional standards for dance and movement therapy.  

 

 

References:

Akta, G. & Ogce, F. (2005).  Dance as a therapy for cancer prevention.  Asian Pacific Journal of Cancer Prevention, 6, 408-411.

Bicego, D., Brown, K., Ruddick, M., Storey, D., Wong, C., & Harris, S. R.  (2006). Exercise for women with or at risk for breast cancer-related lymphedema.  Physical Therapy, 86(10), 1398-1405.

Cohen, S. O. & Walco, G. A.  (1999). Dance/movement therapy for children and adolescents with cancer.  Cancer Practice, 7(1), 34-42.

Hanna, J. L. (1995).  The power of dance:  Health and healing.  The Journal of Alternative and Complementary Medicine, 1(4), 323-331.

Mendelsohn, J.  (1999). Dance/movement therapy with hospitalized children.  American Journal of Dance Therapy, 21(2), 65-80.

Molinaro, J., Kleinfeld, M., & Lebed, S. (1986). Physical therapy and dance in the surgical management of breast cancer:  A clinical report.  Physical Therapy, 66(6), 967-969.

Sandel, S. L., PhD, ADTR, CLM, Judge, J. O., MD, Landry, N., BS, Faria, L., MA, Ouellette, R., PT, & Majczak, M., BA.  (2005). Dance and movement program improves quality-of-life measures in breast cancer survivors.  Cancer Nursing, 28(4), 301-309. 

Targ, E. F., MD & Levine, E. G., PhD, MPH (2002).  The efficacy of a mind-body-spirit group for women with breast cancer:  A randomized controlled trial.  General Hospital Psychiatry, 24, 238-248.

 

 

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