The efficacy of dance interventions for the activity and participation of individuals with cerebral palsy – a systematic review and meta-analysis

Figures & data

Figure 1. PRISMA flow diagram.

A flow diagram showing literature search results and included and excluded records at each stage of the screening process.

Figure 2. Methodological quality assessment of case-control, pilots, and randomised controlled trials on a dance intervention for people with CP using the Modified CASP scale.

Traffic light plot summarising methodological quality for each included case-control, pre-post, post-test, and randomised controlled trials studies using the Modified CASP scale.

Figure 3. Methodological quality assessment of case studies on a dance intervention for people with CP using the JBI critical appraisal checklist for case reports.

Traffic light plot summarising methodological quality for each case study using the JBI Critical Appraisal Checklist for Case Reports.

Table 1. Summary of studies characteristics and proposed ICF codes.

References	Study design	Participants	Dance group size	Dance style	Description of the dance protocol	Dance performance	Intervention frequency	Intervention total sessions	Total dose of intervention (min)	Outcomes	Evaluation methods	Results	ICF (proposed code)
Cherriere, et al. [42]	Pre-post	CP; GMFCS I - III; mean age 14 y 1 mo; n = 10	10	Contemporary, jazz, break dance, and tap	10-mins warm-up Dance practice 5-mins cool-down	Dance performance presented to the families and members of the rehabilitation centre	60 mins sessions/ two times per week	20	1200	Balance	Pediatric Balance Scale (PBS)	Improved balance (PBS static and dynamic sub-score and PBS total score, p < 0.05).	d4103–d4106, d4153, d4154, d4200, d4452
										Static balance	Force platform: Max amplitude and speed of the centre of force displacements.	No significant change was observed on the centre of force amplitude and speed, for static balance test.	b755, b760
										Limits of stability	Pediatric Reach Test (PRT)	Improved maximal reach position and displacement of the centre of force, p < 0.05.	d4106, d4452
										Gait	10-meter walking test (10MWT)	No significant change was found on the walking test.	b770
										Rhythmic reproduction	21 Rhythmic structures reproduction	Significant improvement in rhythm reproduction, p < 0.05.	b176
										Attention	Test of Everyday Attention for Children: Score! and Score DT	No significant change on the two attention scores.	b1400-b403
Joung, et al. [12]	Pre-post	CP; GMFCS I - II; mean age 18 y 5 mo; n = 10	10	Creative Dance (CD)	Divided in three stages: Play stage Move stage Dance stage	Dance performance at the Bundang Hospital	120 mins sessions/ two times per week	24	2880	Gait	10-camera Vicon Motion Analysis System	Changes in spatiotemporal gait parameters (opposite foot off, first double limb support time, single limb support time, step length, cadence, and walking speed, p < 0.05).	b770, b710
										Lower limb Range of Motion (ROM)	Pelvis, Knee, and Ankle ROM in sagittal plane using 16-marker arrangement.	Increase in right hip and ankle ROM, p < 0.05.	b7100
										Gross Motor Function	GMFM-88: D (standing) and E (walking, running, and jumping).	Positive changes on dimension D and E, p < 0.05.	d410–d429, d4302, d4351, d451, d455
										Body Image	Body Cathexis Scale (BCS)	Improved BCS score, p = 0.005.	b1801
Joung, et al. [20]	Pre-post	CP; GMFCS I - II; 30-54 y; n = 10	10	Creative Dance (CD)	Divided in three stages: Sensory awareness (static) Dynamic sequential movement (dynamic) Create a dance piece (static motions + dynamic sequential movement patterns)	Performance on an open stage at the Bundang Hospital	90 mins sessions/ two times per week	24	2160	Balance	Berg Balance Scale (BBS)	Improved BBS score on pre- post-, and at 3 months follow-up (p < 0.005)	b755, b760, d4103, d4104, d4105, d4106, d4452
											Activities-specific Balance Confidence Scale (K-ABC)	Significant improvements on K-ABC after intervention (p < 0.008) and at the 3 months follow-up (p < 0.008).	d4105, d4106, d4452, d4502, d4551, d460
										Static balance	Gaitview AFA-50 (CoP EO and EC)	Improved CoP-EO p < 0.047 (pre- post-) and p < 0.022 (follow-up). No significant difference on CoP-EC.	b755, b760
										Gait	Time up and go (TUG)	Improved gait (TUG pre- post- p < 0.037), and at the 3 months follow-up (p < 0.015).	b770, d4103, d4104
											Dynamic Gait Index (DGI)	Improved DGI (pre- post- p < 0.005), and at the three-month follow-up (p < 0.007).	b770, d4551, d450, d455
										ADL’s	Modified Barthel index (K-MBI)	There was no significant difference in K-MBI score.	b144, b147, b760, d159, d369, d450, d455, d510–d550
Korobko, et al. [65]	Pre-post (Pedagogical observation)	CP; GMFCS III-IV; Spastic tetraparesis; 12-14 y; n = 5	5	Creative Dance (CD)	Included Physical and Social vectors in three stages: Initial – learning movements of dance and acquaintance with the music Basic – profound study of dance elements, their combination with music Final – consolidation and improvement of dance performance.	Participation of the dance group in the cultural events of the school and the town.	30-40 mins sessions/ two times per week.	Not reported	Not reported	ICF Structures and functions	GMFCS; MACS; Modified Ashworth scale	No changes in pre- post- assessments.	b147, b735, b755, b760, d440, d450
										ICF Activity and participation	Observation	Increased engagement in community activities. Two participants reported improved fine hand use.	d440, d550, d560, d710, d920
										ICF Environmental factors	Observation	Improved independent mobility within the classroom and buildings.	d460, d465, e120
										Emotional sphere	Survey	Increased interest in self-care, self-confidence, sense of community, and diligence	d177, d350, d520, d710, d750
										Hand Function	The Box and Block Test	Improved hand and arm function.	d440, d445
										Mobility	10 meters walking test (10MWT)	Improved mobility using the wheelchair and walkers.	d465
Lakes, et al. [41]	Pre-post	CP; spastic; Diplegic and hemiplegic; 9-14 y; n = 8	8	Therapeutic ballet intervention	Typical ballet classes including warm-up, stretching, barre exercises, and centre floor exercises with reverence to finish each class.	Class demonstration for parents and members of the community	60 mins sessions/ three times per week	18	1080	Body composition	Dual X-ray Absorptiometry (DXA)	No significant change on percent body fat or bone density.	s7700
										Muscle strength	Jamar handgrip dynamometer	No significant change, four participants showed a trend to improve hand grip.	b7300
										Habitual physical activity	Activity monitors (min/day)	No significant change in habitual physical activity after the intervention.	d2303
										Gait	GAITRite system	A significant change in pre, post and follow-up, p < 0.05.	b770, b710
										Motor control functions	Selective control assessment of lower extremity (SCALE)	No significant changes in selective control, however, changes were noticed in individual participants.	b760, b470
										Executive functioning	Hearts and flowers tasks	Significant changes in accuracy, and response time, p < 0.05.	b1400, b1401, b1443, d160, d220
Lasseter, et al. [63]	Case Study	CP; age 12 y; n = 1	1	Not reported	Relaxation and warm-up Review of previously skilled learned Performance rehearsal	Performed two varied routines to parents, therapist, and clinic employees	60 mins sessions/ two times per week	18	1080	Motor Proficiency	Saretzky test of motor proficiency	Increase of 12 credited months in motor proficiency.	d440, d445, d450, d4552
										Self-Concept	Self-concept inventory	No difference between pre and post-test.	b1800, b1801
										Self-Esteem	Coopersmith self-esteem inventory	Coopersmith suggests a positive change in feelings about self, school, and social situations.	b1800, b1801
Lopez-Ortiz, et al. [26]	Pilot Exploratory study	CP; GMFCS I – IV; n = 16; Parents; n = 16; Therapists; n = 13	16	Classical ballet training	Classical ballet exercises - conditioning exercises with progressive level of difficulty	Eight children performed in a formal recital.	Once a week	5 - 8	Not reported	Participants’ perceptions of the therapeutic benefit of the dance program	Surveys based on the LIFE-H (questions created to investigate specific aspects of the dance class).	The children expressed a desire for more classes, enjoyment, interest in participation in a school group, interest in watching a dance show, and new interest in attending an art show, p < 0.05.	d135, d155, d835, d9100, d9202
Lopez-Ortiz, et al. [43]	Case Control	CP; GMFCS II - IV; 7-15 y; n = 11	5	Targeted dance class (TDC)	Principles of classical ballet for postural control, trunk stabilization, balance, and movement control of individual joints.	Dance class presentation at the school theatre.	60 mins sessions/ three times per week	12	720	Balance	Pediatric Balance Scale (PBS)	Improved balance pre- post-, and at one-month follow-up p < 0.05. The same was not observed with the control group.	d4103–d4106, d4153, d4154, d4200, d4452
										Upper body function	Quality of Upper Extremity Skill Test (QUEST)	QUEST did not show statistical differences in either group.	d440, d445
Owens and Silkwood-Sherer [35]	Case Study	CP; GMFCS II spastic; quadriplegic age 15 y; n = 1	1	Informal Dance Intervention (IDI)	10 min warm-up 45 min IDI 5 min cool-down	Not reported	60 mins sessions/ two times per week	32	1920	Weight classification	BMI & Waist Circumference	BMI did not change. Waist circumference decreased 0.5 inches.	b530
										Gait	6MWT	Distance walked and walking speed improved.	d4501
											Functional Gait Assessment (FGA)	An 8-point increase on FGA.	b770, d4551, d450, d455
											Time Up and Down Stairs (TUDS)	TUDS improved by 4.14 s.	b770, d4103, d4104, d4551
										Balance	Activities-specific Balance Confidence (ABC)	Self-confidence ratings improved.	d4105, d4106, d4452, d4502, d4551, d460
											Community Balance and Mobility Scale (CB&M)	There was a 2-point decrease in CB&M score.	d4101, d4106, d4500, d4551- d4553
Morán Pascual, et al. [64]	Case Study	CP; age 12 y; n = 1	1	Ballet session	Not reported	Not reported	Weekly	Not reported	Not reported	Full port de bras forward (ROM)	Photogrammetry	Positive impact in ROM reported.	b710
Stribling and Christy [15]	Case Study	CP; GMFCS II spastic; triplegic age 11 y; n = 1	1	Creative Dance (CD)	Creative dance methods and the BrainDance movement sequences. Each dance class started in supine with a series of movements on the floor, followed by standing exercises.	Choreographed performance for CD’s friends and family.	60 mins sessions/ two times per week	16	960	Postural Control	Sensory organization test (SOT)	Better centre of gravity alignment.	b755, b760
											Limits of stability test (LOS)	Better centre of pressure control.
										Balance	Motor control test (MCT)	Average reaction time improved, more symmetric use of lower limbs.	b755, b760, d4106
											Adaptation test (ADT)	Able to complete the test after intervention.
Teixeira-Machado, et al. [33]	Randomized Controlled Trial	CP; GMFCS II - V; age 15-29 y; n = 26	13	Based on Feldenkrais, Horton, Graham, and Laban/Bartenieff concepts	Four sets with eight repetitions: (1) ROM (2) coordination (3) body image and environment (4) skill and agility	Not reported	60 mins sessions/ two times per week	24	1440	ADL’s	Functional independence measure (FIM)	Improved independence function, p = 0.004. Greater improvements when compared with control group, p < 0.05.	b144, b147, b760, d159, d369, d450, d455, d510–d550
										ICF body function, activity and participation domains	WHODAS	Improved WHODAS p = 0.001. Greater improvements when compared with the control group, p = 0.0002.	d159, d415, d450, d455, d649, d779–d799, d910
Teixeira-Machado and DeSantana [44]	Randomized Controlled Trial	CP; GMFCS III - V; age 15-29 y; n = 27	13	Técnica Aplicada Lavinia Teixeira [TALT]	Four sets with eight repetitions: (1) ROM (2) coordination (3) body image and environment (4) skill and agility	Dance school show in the theatre	60 mins sessions/ two times per week	24	1440	Lower body Range of Motion (ROM)	Sanny® pendular fleximeter	Improved ROM in all axes p < 0.05. Intergroup comparison, DG showed improvement in all axes of motion, except for hip left flexion (with the knee extended) and hip right extension.	b7100
Terada, et al. [45]	Pre-post	CP; GMFCS V; mean age 50 y 7 mo; n = 6	6	Wheelchair dance (Waltz and Jive)	Not reported	Not reported	6-15 mins sessions/ two times per week or more	Not reported	Not reported	Oxygen pulse (O2P)	VO2 divided by HR	O2P during waltz significantly increased compared with rest at 6 months of intervention (p = 0.026) and 12 months (p < 0.001) O2P during jive significantly increased compared with rest at 3, 6 and 12 months of intervention (p = 0.001; p = 0.026; p = 0.003).	b4301, b4551
Terada, et al. [46]	Pre-post	CP; GMFCS V; mean age 50 y 7 mo; n = 6	6	Wheelchair dance (Waltz and Jive)	Not reported	Not reported	6-15 mins sessions/ two times per week or more	Not reported	Not reported	Albumin (Alb) & Haemoglobin (Hb)	Medical check-up records	No statically significance changes within the normal range	b430
										Body weight	Weight scale for lying patients	No statically significance changes	b530
										Body mass	Body Mass Index (BMI)	No statically significance changes	b530
										Estimated energy consumption	Oxygen uptake (VO2) data	No statically significance changes	b540
										Estimated calorie consumption	Oxygen uptake (VO2) data	No statically significance changes	b540
Withers, et al. [6]	Case Control	CP; GMFCS I - II; Diplegic and hemiplegic; mean age 12 y 9 mo; n = 18	9	Adapted hip-hop dance	Group warm-up, overall stretching, choreographic composition, and improvisation, and relaxing.	Dance performance named: Onde está o amor? At Londrina Theatre	60 mins session/one time per week	Mean sessions 20.8	1200	Quality of Life (QOL)	Pediatric outcomes data collection instrument	Improved transfer, mobility, global function and symptoms, sporting, and physical function, when compared with the control group, p < 0,05	b760, b147, d420, d450, d455, d9201
										Biopsychosocial profile	Child behavior checklist	Reduced symptoms of anxious/depressed (p = 0.03), aggressive behaviour (p = 0.01), externalizing problems (p = 0.00), and total problems (p = 0.01)	b152, d720

Table 2. Studies mapped to the family of participation-related constructs (fPRC).

References	Attendance	Involvement	Activity competence	Sense of self	Preferences
Cherriere, et al. [42]	85% of attendance reported.	N/M	Balance, Limits of Stability, Gait, Rhythm Reproduction, and Attention.	N/M	N/M
		(Used retention rate of 100% to suggest motivation and enjoyment)
Joung, et al. [12]	98% of attendance reported.	N/M	Gait, Range of Motion (ROM).	Improved Body Image	N/M
		(Reported high level of satisfaction with the program)			(Reported motivation to be more active, join school choir, dance, and theatre clubs)
Joung, et al. [20]	98.2% attendance reported.	Post-performance interview: enjoyment performing.	Balance, Gait, ADL’s.	Post-performance interview: enjoyed presenting achievements to the public and receiving applause from the audience.	Post-performance interview: Participants highlighted motivation to be more active in daily life.
Korobko, et al. [65]	Attendance to performances at school, charity events and festivals.	N/M	Hand Function, Gross Motor Function, and Mobility.	Increased self-care, self-confidence, sense of community, and diligence.	Participants developed an interest in going to the hairdresser and engaged in art.
Lakes, et al. [41]	Adherence to intervention, and attendance in at least 16 out of the 18 intervention sessions.	N/M	Physical Activity, Muscle Strength, Gait, Motor Control, and Executive Functions.	N/M	N/M
Lasseter, et al. [63]	N/M	N/M	Motor Proficiency.	Participant developed and established her feelings of self-worth and self-esteem.	Participant began to experience and engage in the same activities as her age mates.
		(Participant exhibited pleasure in her achievements and enjoyed the experience)
Lopez-Ortiz, et al. [26]	N/M	High level of enjoyment, participants excited to engage in a dance performance.	Parents perception of child’s improvement in motor control.	N/M	Expressed a desire for more classes and a new interest in school groups and art shows.
Lopez-Ortiz, et al. [43]	N/M	N/M	Balance and Upper Body Function	N/M	N/M
Owens and Silkwood-Sherer [35]	Increased in compliance in therapy.	N/M	Gait and Balance	N/M	N/M
		(Reported participant was highly motivated by dancing)		(Reported increased confidence and self-awareness)
Morán Pascual, et al. [64]	N/M	N/M	Full port de bras forward (ROM)	N/M	N/M
Stribling and Christy [15]	N/M	N/M	Postural Control and Balance	N/M	Following the dance program, the participant was excited to begin a community dance class.
				(Reported participant felt more confident)
Teixeira-Machado, et al. [33]	N/M	N/M	Mobility, ADL’s, Cognitive Function, Psychosocial adjustments, IADL’s.	N/M	N/M
		(Reported involvement externalized by participants during public presentations)
Teixeira-Machado and DeSantana [44]	N/M	N/M	Lower-limb ROM	N/M	N/M
		(Indicates adherence due to sense of belonging)
Terada, et al. [45]	Attendance between 2.0 ± 1.5 and 3.1 ± 1.4 days a week.	N/M	Aerobic Fitness	N/M	N/M
Terada, et al. [46]	N/M	N/M	Nutritional aspects	N/M	N/M
Withers, et al. [6]	Classes attended 20.8 (± 7.4)	Focus assessed and correlated with other study variables. Participants interacted effectively in the activity.	Mobility, Global Function, Sports and Physical Function. Aptitude was assessed and correlated with other study variables.	The experienced feeling of belonging. Self-confidence was assessed and correlated with other study variables.	N/M

N/T refers to constructs not measured. Comments in brackets were extracted from the discussions, however, studies did not mention the tool used to measure the constructs. The Child Behavior Checklist outcomes were not included in this table, because it does not align with any of the fPRC constructs [66].

Table 3. Moderator analysis effect of dance type, dose, intensity, sample size and study design on outcomes effects size.

Moderator	W	df	p	k	n	Estimate	95% CI	Weight (%)
Design	190.951	1, 155	0.000	10	157
RCT				2	43	4.08	3.61, 4.54	20.1
Not RCT				8	114	0.42	0.18, 0.66	79.9
Sample size	2.976	1, 155	0.086	10	157
5–9 participants				5	58	0.39	–0.89, 1.67	49.6
10–13 participants				5	99	1.96	0.70, 3.23	50.4
Ability to ambulate	5.221	1, 108	0.024	7	110
No				2	31	0.02	–0.33, 0.36	27.0
Yes				5	79	0.48	0.27, 0.68	73.0
Dose	2.138	1, 124	0.146	8	126
720–1200 mins				4	57	0.70	–0.87, 2.26	49.7
1440–2880 mins				4	69	2.32	0.77, 3.88	50.3
Intensity (minutes/week)	1.742	3, 122	0.162	8	126
60				1	15	0.63	–2.29, 3.55	12.6
120				3	73	3.04	1.35, 4.72	38.0
180				3	19	0.68	–1.05, 2.40	36.7
240				1	19	0.25	–2.66, 3.16	12.7
Dance type	4.305	1, 155	0.040	10	157
Movement–based				4	69	2.27	0.93, 3.61	40.2
Step–based				6	88	0.45	–0.65, 1.55	59.8

Figure 4. Forest plots for the meta-analyses on all outcomes, with each outcome measure, entered as a moderator and as additional subgroups, including cognitive/mental function, motor function, social and emotional, and other outcome categories.

Meta-analyses forest plots showing the estimated effect size for each outcome type (cognitive, motor, social-emotional, engagement, and metabolism).

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