Dance/movement therapy for improving psychological and physical outcomes in cancer patients
Current cancer care increasingly incorporates psychosocial interventions. Cancer patients use dance/movement therapy to learn to accept and reconnect with their bodies, build new self‐confidence, enhance self‐expression, address feelings of isolation, depression, anger and fear and to strengthen personal resources.
To update the previously published review that examined the effects of dance/movement therapy and standard care versus standard care alone or standard care and other interventions on psychological and physical outcomes in patients with cancer.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 6), MEDLINE (OvidSP, 1950 to June week 4, 2014), EMBASE (OvidSP, 1980 to 2014 week 26), CINAHL (EBSCOhost, 1982 to July 15 2014), PsycINFO (EBSCOhost, 1806 to July 15 2014), LILACS (Virual Health Library, 1982 to July 15 2014), Science Citation Index (ISI, 1974 to July 15 2014), CancerLit (1983 to 2003), International Bibliography of Theatre and Dance (1989 to July 15 2014), the National Research Register (2000 to September 2007), Proquest Digital Dissertations, ClinicalTrials.gov, and Current Controlled Trials (all to July 15 2014). We handsearched dance/movement therapy and related topics journals, reviewed reference lists and contacted experts. There was no language restriction.
We included all randomized and quasi‐randomized controlled trials of dance/movement therapy interventions for improving psychological and physical outcomes in patients with cancer. We considered studies only if dance/movement therapy was provided by a formally trained dance/movement therapist or by trainees in a formal dance/movement therapy program.
Data collection and analysis
Two review authors independently extracted the data and assessed the methodological quality, seeking additional information from the trial researchers when necessary. Results were presented using standardized mean differences.
We identified one new trial for inclusion in this update. In total, the evidence for this review rests on three studies with a total of 207 participants.
We found no evidence for an effect of dance/movement therapy on depression (standardized mean difference (SMD) = 0.02, 95% confidence interval (CI) ‐0.28 to 0.32, P = 0.89, I2 = 0%) (two studies, N = 170), stress (SMD = ‐0.18, 95% CI ‐0.48 to 0.12, P = 0.24, I2 = 0%) (two studies, N = 170), anxiety (SMD = 0.21, 95% CI ‐0.09 to 0.51 P = 0.18, I2 = 0%) (two studies, N = 170), fatigue (SMD = ‐0.36, 95% ‐1.26 to 0.55, P = 0.44, I² = 80%) (two studies, N = 170) and body image (SMD = ‐0.13, 95% CI ‐0.61 to 0.34, P = 0.58, I2 = 0%) (two studies, N = 68) in women with breast cancer. The data of one study with moderate risk of bias suggested that dance/movement therapy had a large beneficial effect on 37 participants' quality of life (QoL) (SMD = 0.89, 95% CI 0.21 to 1.57). One study with a high risk of bias reported greater improvements in vigor and greater reduction in somatization in the dance/movement therapy group compared to a standard care control group (N = 31). The individual studies did not find support for an effect of dance/movement therapy on mood, mental health, and pain. It is unclear whether this was due to ineffectiveness of the treatment, inappropriate outcome measures or limited power of the trials. Finally, the results of one study did not find evidence for an effect of dance/movement therapy on shoulder range of motion (ROM) or arm circumference in 37 women who underwent a lumpectomy or breast surgery. However, this was likely due to large within‐group variability for shoulder ROM and a limited number of participants with lymphedema.
Two studies presented moderate risk of bias and one study high risk of bias. Therefore, overall, the quality of the evidence is very low.
We did not find support for an effect of dance/movement therapy on depression, stress, anxiety, fatigue and body image. The findings of individual studies suggest that dance/movement therapy may have a beneficial effect on QoL, somatization, and vigor. However, the limited number of studies prevents us from drawing conclusions concerning the effects of dance/movement therapy on psychological and physical outcomes in cancer patients.
Joke Bradt, Minjung Shim, Sherry W Goodill
Plain language summary
Dance/movement therapy for cancer patients
The issue-Cancer may result in extensive emotional, physical and social suffering. Current cancer care increasingly incorporates psychosocial interventions to improve quality of life. Creative arts therapies such as dance/movement, music, art and drama therapy have been used to aid care and recovery. Following medical therapies, which can be invasive, people with cancer use dance/movement therapy to learn to accept and reconnect with their bodies, build new self‐confidence, enhance self‐expression, address feelings of isolation, depression, anger, fear and distrust and strengthen personal resources. It has also been used to improve range of arm motion and to reduce arm circumference after mastectomy or lumpectomy. For this review, studies were considered only if dance/movement therapy was provided by a formally trained dance/movement therapist or by trainees in a formal program.
The aim of the review-This review is an update of a previous Cochrane review from 2011, which included two studies which did not find support for an effect of dance/movement therapy on body image, the only common outcome between the two studies. The aim was to examine the impact of dance/movement therapy on psychological and physical outcomes in people with cancer.
For this review update, we searched for additional trials on the effect of dance/movement therapy on psychological and physical outcomes in people with cancer. We searched for published and ongoing studies up toJuly 2014. We considered all studies in which dance/movement therapy was compared with any form of standard treatment.
What are the main findings?-We identified one new study for this update. The three studies included a a total of 207 participants, which were women with breast cancer. The studies were small in size. We found no evidence of an effect for depression, stress, anxiety, fatigue, and body image. The findings of individual studies suggest that dance/movement therapy may have a beneficial effect on the quality of life, somatization (i.e. distress arising from perceptions of bodily dysfunction) and vigor of women with breast cancer. No adverse effects of dance/movement therapy interventions were reported.
Quality of the evidence-The evidence is based on only three small studies and the quality of the evidence is not strong.
What are the conclusions?-No conclusions could be drawn regarding the effect of dance/movement therapy on psychological and physical outcomes in cancer patients because of an insufficient number of studies. More research is needed. We did not identify any conflicts of interests in the included studies.
Joke Bradt, Minjung Shim, Sherry W Goodill
Implications for practice
Dance/movement therapy has been used with patients with cancer for provision of social support, reduction of stress, anxiety, depression and fatigue, improvement in role, social, emotional and physical functioning and enhancement of QoL variables such as spirituality and self‐esteem. The results of this review are based on two small‐scale trials and one moderately sized trial in women with breast cancer. The pooled effect of these studies did not find evidence for effect on depression, stress, anxiety, fatigue or body image. In contrast, the results of individual trials suggest that dance/movement therapy may be beneficial for QoL, somatization, and vigor in women with breast cancer. Data of individual studies included in this review did not find support for effect of dance/movement therapy on other outcomes included in this review such as mood, mental health, pain, ROM or arm circumference. The low drop‐out rate indicates that dance/movement therapy is well tolerated by these patients. However, in the absence of sufficient evidence, recommendations for clinical practice cannot be made at this time.
Implications for research
The results of individual studies suggest that dance/movement therapy may have a beneficial effect on QoL, somatization and vigor in women with breast cancer. However, more RCTs are needed to strengthen this evidence. The limited number of RCTs in dance/movement therapy with cancer patients may be due to lack of research training and few funding sources for dance/movement therapy research. There are few opportunities for doctoral research training specifically in dance/movement therapy and thus currently not enough researchers prepared to obtain funding for, and carry out, high‐quality large‐scale outcome studies.
As this review did not find support for an effect of dance/movement therapy for several outcomes included in this review, researchers should consider whether the poor results from the reviewed studies are possibly due to the lack of sensitivity or inappropriateness of the outcome measures that were employed. Several dance/movement therapy researchers have emphasized the importance of using outcome measures that can capture the effect of a unique intervention such as dance/movement therapy (Bojner Horwitz 2006; Koch 2014; Meekums 2010). Koch and colleagues discuss the challenge of measuring the impact of nonverbal interventions with verbal intervention tools (Koch 2014).
Brevity of the treatment period is recognized as one of the possible causes of lack of treatment effect in dance/movement therapy research. The treatment duration in the three studies included in this review ranged from three weeks to 12 weeks. Future research should investigate optimal treatment dose and duration for dance/movement therapy interventions with people with cancer. This must take into consideration that dance/movement therapy, like other treatment options in the complementary and integrative therapy realm, has been identified as requiring “systematic therapeutic learning” (Cassileth 1994, p. 293) meaning that a period of initial learning to become conversant in the therapy medium (in this case expressive movement) is typically necessary before benefits are manifest and measurable.
Dance/movement therapy is not a manualized therapy and the necessarily improvisational clinical methods render it challenging for researchers to systematize the intervention. Dance/movement therapy researchers should develop ways to ensure treatment fidelity in RCTs while retaining the spontaneous, client‐centered properties of the therapy. Berrol, Ooi and Katz (Berrol 1997) have demonstrated that this can be done in a large multi‐site dance/movement therapy project with older adults.
Although we strongly recommend that more RCTs are needed, it is important that qualitative research and results of non‐controlled research be considered, as these enhance our understanding of the qualitative aspects of a patients' experience and identify factors that may contribute to, or limit, the effectiveness of dance/movement therapy interventions. In addition, mixed methodology is appropriate for investigating emerging therapies such as dance/movement therapy. The use of rigorous mixed‐method designs will both generate useful outcome data and provide insight as to the possible mechanisms of dance/movement therapy with cancer patients. Qualitative findings can yield more targeted hypotheses for future RCTs as well.
Sandel and colleagues recommend that future trials include an active control group (e.g. exercise group without music and dance) to further differentiate the particular benefits of dance/movement therapy. One such study of a short‐term dance/movement therapy intervention successfully controlled for the effects of exercise alone and music alone, demonstrating the benefits of interactive dance for the reduction of depression in psychiatric patients (Koch 2007).
Researchers need to consider examining the effects of dance/movement therapy with population groups other than women with breast cancer. Future studies should explore the utility of this modality for men with cancer as well as for women with other types of cancer. Furthermore, the influence of factors such as gender, age and culture should be carefully examined.
Future trials will also need to examine the relationship between frequency and duration of dance/movement therapy interventions and treatment effects. Researchers should also evaluate the impact of treatment timing relative to diagnosis and treatment stage.
It is important that future studies include power analysis so that adequate sample sizes are used.
Finally, formal evaluation of the cost and benefit of dance/movement therapy is needed.