Dance-based versus conventional exercise in pulmonary rehabilitation: A retrospective service evaluation

Introduction

Chronic obstructive pulmonary disease (COPD) is characterised by persistent respiratory symptoms and airflow limitation owing to airway and/or alveolar abnormalities, usually resulting from significant exposure to noxious particles or gases (GOLD 2019). Dynamic hyperinflation leading to inefficient breathing and further breathlessness can make physical activity challenging for patients with COPD. Increased breathlessness can induce anxiety, exacerbation of symptoms and panic, all of which can lead to activity avoidance, further muscle de-conditioning and reduced health-related quality of life (HRQoL) (McCarthy et al. 2015).

Recommended management of people with stable COPD includes smoking cessation, vaccinations (pneumococcal and flu), pulmonary rehabilitation (PR) and inhaled therapies (NICE 2018). The American Thoracic Society and European Respiratory Society define PR as:

 ‘A comprehensive intervention based on a thorough patient assessment followed by patient tailored therapies that include, but are not limited to, exercise training, education, and behaviour change, designed to improve the physical and psychological condition ... and to promote the long-term adherence to health-enhancing behaviours’ (Spruit et al. 2013, pp. e14).

It has been clearly demonstrated within the literature that PR reduces dyspnoea, increases exercise capacity and improves HRQoL in people with COPD (McCarthy et al. 2015). However, despite being one of the most effective and high value interventions for people with COPD, attendance and completion of PR remains poor (Royal College of Physicians 2018). Factors affecting attendance and non-completion are multi-faceted and complex. Four analytical themes of: attitude, social influences, illness, and intervention representation, were identified by Sohanpal et al. (2015) in their qualitative synthesis reviewing patient participation behaviours in studies of COPD support programmes. There is growing interest in the use of alternative exercise modalities in the COPD population, which may serve to address the issue of negative perceptions associated with exercise and PR.

A dance-based PR programme was introduced in January 2019 as an alternative to conventional PR in an attempt to address long-standing issues of adherence and completion rates within the borough of Tower Hamlets. Domene et al. (2016) suggested that Latin-based dance (such as Salsa and Zumba) may assist in overcoming the negative perception of traditional modalities of exercise, promoting engagement in an increasingly sedentary adult population. Dance has been established as an effective alternative modality of exercise training in other chronic disease populations, such as chronic heart failure (CHF) (Gomes Neto et al. 2014). The efficacy of dance-based exercise in the COPD population is yet to be established.

The aim of the service evaluation was to explore whether the newly established Latin dance-based programme resulted in improvements in exercise tolerance and health related quality of life, as compared with a conventional programme running concurrently. Further, to determine any differences in completion rates between the dance-based and conventional programmes.

Methods

Study design

This was a retrospective service evaluation comparing two types of intervention provided by Barts PR service.

Inclusion and exclusion criteria

All patients referred to Barts Health PR services between February and May 2019, with a diagnosis of COPD who were enrolled onto a PR programme at one site were included in the service evaluation. Patients were excluded if they had a primary respiratory diagnosis other than COPD, and/or if their primary exercise limitation was not breathlessness. As per usual care, patients were given the choice of attending one of four venues within Tower Hamlets. This included the options of attending either a dance-based or conventional exercise-based programme, both held at the same site. Patients were excluded if they chose to attend a programme at an alternative venue to eliminate the possibility of bias associated with venue choice.

Participants were identified from data collected during initial assessment, upon written confirmation of a primary respiratory diagnosis and exercise limitation factor, and PR venue choice (all of which was available from the patients’ medical notes).

Pulmonary rehabilitation programme

According to usual local practice, initial assessment for PR comprises a review of medical history, exercise tolerance, strength testing, COPD-specific HRQoL, perceived respiratory disability, and mood disorder. The PR programmes delivered by Barts Health comprise an eight-week rolling programme of twice weekly, two-hourly supervised sessions. The first hour consists of exercise performed to music involving warm-up, conditioning and cool- down, and the second hour of self-management education. Aerobic exercise intensity is prescribed using the modified Borg scale, which is a self-reported measure of dyspnoea (Kendrick et al. 2000).

Progression over eight weeks is achieved by increasing total continuous aerobic exercise time and titration of intensity to modified Borg 3–4 (BTS 2013). Exercises include: walking, step-ups, sit-to-stand, and cycling. Strengthening exercises using weights or bodyweight are utilised as a means of active recovery. Prescription and progression of resistance is based on evoking fatigue after 10 to 15 reps (Garvey et al. 2016).

The dance-based programme differs from the conventional exercise-based programme described above only in the form of aerobic exercise being Latin-style dance. The dance routine was originally choreographed by the physiotherapist leading the programme, who was not specifically trained in dance. It consists of basic steps (e.g. three-step weight transfer), simple movements of salsa in forward, backward, and transversal directions, and rhythmic strutting (Granacher et al. 2012). All other elements of the programme are identical, including prescription and progression of aerobic exercise intensity using modified Borg 3–4 and use of strengthening exercise as active recovery.  Music was standardised across both programmes, using a selection of popular music from 1960s to 1990s. Whilst music is integral to the choreography of the dance programme, in the conventional programme it serves only as background music. Costings were not looked at as part of this evaluation. However, there was no cost difference associated with the provision of the two programmes; both programmes were delivered at the same venue, using the same equipment, with the same level of staffing.

Outcome measures for the programmes include the incremental shuttle walk test (ISWT) or six-minute walk test (6MWT), COPD Assessment Test (CAT) as a measure of HRQoL and PR completion rates. During the timeframe of the service evaluation, although 6MWT was initially utilised as a measure of exercise tolerance, this was changed to ISWT in recognition of the fact that the 6MWT was not being performed on a 30-metre track (Singh et al. 2014). No additional tests were added for the purposes of the service evaluation.

Data analysis and graphics were performed using SPSS software (version 25) and Microsoft Excel (version 1906).

Results

Patient characteristics

During the study period of February to July 2019, four patients successfully completed the dance-based PR programme and five patients completed conventional PR. Baseline characteristics of participants in the dance and conventional groups are summarised and compared in Table 1. No statistically significant differences were identified for characteristics tested. However, a clinically significant difference in baseline COPD severity was reported between groups. In accordance with GOLD (2019) classification, the median FEV1% predicted values of the dance and conventional groups are reflective of moderate and severe COPD, respectively. Notably, this was not reflected in reported CAT with a lower reported median in the conventional group. The dance group only included women, a high proportion of whom were current smokers. Differences in exercise tolerance could not be tested as different measures were used between groups.

Response to pulmonary rehabilitation

Within-group response to PR for all measures is shown in Table 2. No statistically significant differences were identified either within- or between- groups for the measures tested. However, change in exercise tolerance exceeded the minimal clinically important difference (MCID) of the 6MWT (30m) in the conventional group and met the MCID of the ISWT (47.5m) in the dance group (Singh et al. 2014). Improvements in the CAT met the MCID (-2 units) in the dance group (Gupta et al. 2014). The wide-ranging interquartile ranges reported are indicative of the great variance between individuals in both groups. This is also reflected in the individual response to PR of primary outcome measures displayed in Figure 1.

The proportion of individual participants who achieved the MCID in exercise tolerance (ISWT or 6MWT), CAT and Hospital Anxiety and Depression Scale (HADS) in both the dance and conventional groups is summarised in Figure 2.

Completion rate

The number of patients recruited to the dance and conventional programmes was 5 and 11, respectively. The proportion of participants who completed PR, did not complete or never started is presented in Table 3. Completion rate was 34.5% higher in the dance group and all participants who chose dance-based PR, started the programme.

Discussion and conclusion

To the author’s knowledge, this is the first paper to explore the use of dance-based exercise as part of a PR programme in the COPD population. It is well established that PR results in clinically significant improvements in exercise tolerance and HRQoL (McCarthy et al. 2015). Clinically significant improvements were achieved in exercise tolerance in both groups, and in HRQoL in the dance group. However, there were no statistically significant improvements reported within the groups for any of the primary or secondary outcome measures in this study, which may have been due to inadequate power resultant from the small number of programme participants.

The use of the ISWT rather than the 6MWT (on a 10m track) in the dance group may have influenced the low proportion of participants in the dance group achieving the MCID. It is unclear as to why none of the dance participants met the MCID for change in depression (as measured by HADS). The individual responses to PR in primary outcomes presented in Figure 1 show a mixture of negative and positive results in change following PR. Interpretation is challenging due to issues of confounding and power. The current COPD literature base in dance-based interventions is similarly limited. Further adequately powered research into the use of dance as a rehabilitative strategy in the COPD population is required. Completion rates were 34.5% higher in the dance group compared with the conventional group. The small sample size limits the reliability of this result, which is reflected in the inability to assess for statistical significance, although this finding is in keeping with the chronic heart failure literature base (Vordos et al. 2017). Of note, all participants enrolled onto the dance programme started their programme, compared with 4/11 who never started the conventional programme. In a thematic synthesis, it was identified that positive perception of COPD interventions and perception of symptoms influenced attendance (Sohanpal et al. 2015).

In agreement with principles of health behaviour change, it has been suggested that providing patients with a choice of exercise styles may assist in improving uptake to PR and adherence to regular physical activity (McNamara et al. 2018). Further research is required to explore optimal models of care and their influence on attendance.

The retrospective service evaluation model was an appropriate design to provide a reflection of clinical effectiveness in the local population of Tower Hamlets. Unlike Randomised Control Trials (RCTs), observational studies do not have the benefit of randomisation in reducing selection bias. However, it can be argued that RCTs are too far removed from real-life clinical practice, thereby reducing their external validity. Patient choice of PR programme is routine protocol and removing choice could lead to possible ethical issues should the patient decline to participate based on their allocation.

A convenience sample is vulnerable to bias, under-representation and sampling error, limiting the ability to generalise findings. However no statistically significant differences in baseline characteristics recognised to be confounding factors were identified. These included: age, COPD severity (FEV1 % predicted), self-reported health status (mMRC and CAT), smoking status and BMI (Selzler et al. 2012). The clinically significant difference in COPD severity between groups may have negatively biased the results of the dance group. Baseline exercise tolerance (ISWT or 6MWT) could not be statistically compared due to the differing measures used. This both limited the ability to compare exercise tolerance between groups and may have influenced the reported results owing to differing qualities of the two outcome measures. The dance group was comprised of females only which may reflect cultural influences as well as personal preference of exercise style.

A strength of this service evaluation was the matched elements of the two PR programmes other than the form of aerobic exercise used. It is often the case in clinical practice that the choice of programme is based on geographical location due to challenges associated with travel in this population. The matched venue removed this as a potential confounding variable.

The Latin style of dance was chosen with the aim of overcoming the traditional perception of exercise and optimising enjoyment (Domene et al. 2016). The population in Tower Hamlets has a significant Bangladeshi community. Future studies in the local COPD population could consider the use of traditional Bangladeshi dance with the aim of optimising engagement.

Clinical implications and recommendations for practice

A larger service evaluation is warranted using consistent, appropriately selected measures of exercise tolerance. It is recommended that evidence-based protocol for performing these measures is documented in the standard operating procedure of the Barts PR service to ensure validity of reported results.

The introduction of an alternative measure of exercise tolerance, which is appropriate for patients who are limited by co-morbidities as well as breathlessness, has been discussed with the Trust. As a result of these discussions, the Barts PR service is planning to implement the 1-minute sit to stand into routine practice. This will be in conjunction with the ISWT to gain a broader understanding of exercise tolerance across the full range of physical limitation.

Discussions are also underway regarding the use of traditional Bangladeshi dance in the dance-based programme to promote engagement of the local population. Further consideration regarding the music used in both dance and conventional PR programmes is indicated.

Conclusion

The results of this service evaluation of the Barts PR service provided inconclusive findings. Completion rate was found to be higher in the dance-based PR programme compared with the conventional programme. However, caution should be exercised in interpreting this finding due to the recognised limitations of this retrospective, single centre study. A larger, adequately powered observational study is required to address the intended primary aim of this evaluation.

Acknowledgement

I am indebted to my academic supervisors, Dr Leyla Osman and Dr Harriet Shannon, for their expert feedback and guidance, as well as their unwavering support throughout this project.

I would like to thank my colleagues in the Barts adult respiratory care team for their support, with particular thanks to clinical lead Jane Simpson. I am also very thankful to the patients who attended our pulmonary rehabilitation programme.

Funding

The author’s MSc dissertation with UCL was funded by Barts Charity.

Ethical and R&D approval

This study was not considered research as confirmed by the NHS Health Research Authority decision tool. Ethical approval was therefore not required, as confirmed by both the research services of Barts Health and University College London. The study was registered with, and approved by, the Barts Clinical Effectiveness department (registration number 9884), as per local policy.

Pulmonary rehabilitation was delivered within the definition of usual practice. The Barts PR service regularly collects data for the purpose of audit and evaluation. Article nine of the General Data Protection Regulation (2018) states that it is permissible to use personal data concerning health for direct care and related administrative purposes including local clinical audit (UK Parliament 2018).

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