Chronic pulmonary diseases (CPD) are among the leading causes of mortality worldwide [1
] and it has been estimated that almost 550 million people live with a chronic respiratory disease globally [2
]. CPD are usually characterised by high dyspnoea levels, low tolerance for physical activity and exercise and reduced mobility [3
], which are leading causes of disability [4
]. Moreover, research has highlighted that patients living with CPD are more likely to (i) develop symptoms related to anxiety and depression [5
]; (ii) have poorer quality of life compared to healthy people [6
]; (iii) have balance-related problems, such as falls [7
]; and (iv) spend less time engaging in daily physical activity than healthy people [9
]. Idiopathic pulmonary fibrosis (IPF) is a rare, chronic, progressive, fibrosing interstitial pneumonia of unknown aetiology and is an incurable disease [10
]. The annual incidence in Europe ranges between 0.22 and 7.4 per 100,000 population [11
]. The prevalence of IPF in Ireland varies from 3 to 20 cases per 100,000 in the general population [12
]. Management of patients with pulmonary diseases, including IPF, include interventions such as daily physical activity [10
Sufficient levels of physical activity are associated with a reduced risk of hospitalisation and mortality [14
]. In this sense, exercise has been widely acknowledged to be an important tool to improve functional capacity, reduce breathlessness, fatigue and dyspnoea levels [17
], and contribute to help people living with CPD being more engaged in daily physical activity [21
]. However, despite these benefits and the global guidelines that recommend engaging in at least 30 min a day of moderate physical activity [22
], people with CPD still fail to engage in regular physical activity [23
]. Pulmonary rehabilitation (PR) as exercise is often delivered to patients at physiotherapy clinics or community settings, which may not be feasible for patients to attend and has higher dropout rates [24
]. Research has shown that low motivational levels, the lack of suitable exercise availability and the fear of breathlessness during activities are the most common barriers to exercise among people living with CPD [25
In this context of physical activity, dance has been highlighted to be a worthwhile and novel form of movement [26
], which is beneficial in terms of improved physical performance, mood levels and social interactions among older adults [27
]. Furthermore, dance has been also reported to have beneficial effects on people living with neurological and cardiovascular disorders [28
]. In relation to people living with CPD, although very limited, previous research has shown that dance activities may improve functional exercise capacity, balance, dyspnoea levels, disease control and emotional function [26
] and reduce depression levels [32
]. Qualitative research has also shown that people living with CPD enjoyed dance sessions and voiced them to be advantageous for their mental and physical health and their social cohesion [33
However, despite dance being acknowledged to be one of the most enjoyable, safe, feasible and low-cost interventions in respiratory care [34
], there is still limited evidence of the feasibility of dance-based interventions and their potential benefits on people with CPD. One study conducted in this research area reported that the dance intervention was safe and feasible [26
]. However, considering the current global pandemic and potential consequences that the exposure to COVID-19 may have on such a vulnerable population, research evidence is absent regarding the feasibility of online dance interventions for people living with CPD. There are no specific research studies available to assess the impact of dancing on the health and wellbeing of pulmonary fibrosis (PF) patients. The Irish Lung Fibrosis Association (ILFA) has delivered online exercise and yoga sessions for patients with PF in Ireland and found that patients prefer using online systems due to the pandemic. Hence, we proposed our research to examine the health impacts of online dancing among pulmonary fibrosis patients in Ireland. The aim of this feasibility study is to evaluate the structured online dancing programme’s physical and mental health benefits among patients with PF in Ireland. The objectives of this study are: 1. To assess the physical and mental health impacts of online dance intervention—(i) quality of life; (ii) dyspnoea levels, fatigue, emotional function and disease control; (iii) anxiety and depression levels; and (iv) health self-perception and 2. To assess the feasibility of dance intervention, we report on (1) the community engagement processes: idea conception and information about a structured online dance programme for individuals living with pulmonary fibrosis in Republic of Ireland; (2) methods and findings: delivery of dance programme and information reported from pre-post intervention measured via self-reported questionnaires; (3) feasibility aspects: acceptability, response and adherence. This information will be crucial for future planning of a sustainable community-based dance programme as a large-scale definitive research trial.
2.1. Community Engagement/Patient and Public Involvement (PPI) Processes
The ILFA is the national patient organisation that supports patients and families living with PF and provides education and support to respiratory healthcare professionals. ILFA is associated with various community development projects for patients with pulmonary fibrosis and their carers. A survey of patients engaged in online exercise classes revealed that patients would like to have a dance intervention. VN (Lead researcher) approached and discussed the online dance intervention with the ILFA. The ILFA played a key role as co-authors in preparing for funding application, helping to establish the communication between researcher and the patients. They also helped by planning and delivery of the programme, providing feedback on the questionnaires and evaluation reports and actively participating in research dissemination activity. The ILFA organised a social online interaction event entitled ‘Let’s talk dance’. This took place on 5 April 2022 with the aim to establish communication between researcher, choreographer (TB) and the patients. At this event, the dance intervention programme was explained, and queries of the patients and their carers were addressed. TB shared videos of previous dance programmes held in the UK as a part of the research and real experiences of those who participated. Our event resulted in on the spot registration by 13 patients. Two patient advisory members of the ILFA (FON and MC), who also participated in the study, were enthusiastically involved in the writing and reviewing of the manuscript.
2.2. Research Design
Our study adopted a transdisciplinary approach to measure the health and wellbeing impact and feasibility aspects via pre-post intervention testing [36
]. An equal status, simultaneous mixed methods study design was applied. This paper reports the quantitative analysis of the study.
Ethical approval for this study was granted by the institutional Human Research Ethics Committee—Sciences, UCD with reference No. LS-21-94-Niranjan.
2.3. Participants and Setting
A group of 16 patients with PF, residing in Ireland and of age group >25 years was recruited after the ‘Let’s talk dance’ event. At the initial self-assessment screening, patients confirmed the diagnosis of PF and that they were in a stable clinical state at the time of the study. We used Zoom for delivering online dance sessions. Patients participated from their home and informed their family regarding participation in the activity. Patients were advised to attend the dance sessions in the presence of a family member or carer. Participants were given full programme information with safety instructions and upon reading, signed an informed consent before taking part in the study.
2.4. Dance Programme
Every Tuesday, live dance classes, of seventy-five minutes duration, were offered for eight consecutive weeks. They were delivered by TB online; GT observed the participants for any adverse condition for all dance sessions and VN attended two sessions to offer motivation. TB danced with the group, demonstrating the dances in advance where necessary, but otherwise inviting participants to follow along.
The seated dance programme primarily focused on arm movements to music. Each routine was specifically choreographed to the music track used. In developing each of the seated dance routines the choreography included either, intro, verse and chorus choreography or was structured using the 32 beat phrases or beats in the music. Actions to words in the songs were also used, making the routines fun and easy to learn.
The music selection was from various genres, from the 1950s up to present day tracks. The music selection included familiar and recognisable songs, with artists like, Gene Kelly, Elvis, Abba, Neil Diamond, Diana Ross, Ed Sheeran and Justin Timberlake. The tracks selected had either a slow or a more upbeat tempo. Slower tempo tracks were used for the warmup, cool down and stretches.
Each class started with a 5-min warm up, as to mobilise the muscles and joints in the arms and upper body and prepare for the class. Each time the choreographer demonstrated the dance moves for a couple of minutes, followed by a song. Each song ran for 5 to 6 min, during which all the participants danced along with the choreographer. Through the main section of the dance class, a faster tempo track was alternated with a slower tempo track. A talk through and demonstration before each track allowed the participants a little pause and rest between songs.
The class finished off with a 5-min cool down. These slower movements lowered the pulse and stretched out the major muscles that were used in the dancing session. The participants selected some of their favourite Irish songs which were used when doing the warmups and cool downs. Having upbeat and uplifting music helped elevate the mood as well as engage and motivate the participants through each section of the class.
2.5. Data Collection
All the participants were asked to complete self-assessment questionnaires. It comprised of demographic characteristics of participants, their experience and satisfaction with and recommendation for the dance programme and two measures of self-rated quality of life. The Chronic Respiratory Questionnaire Self-Administered Standardised Format (CRQ-SAS) has been developed for use as a measure of quality of life for patients with chronic pulmonary disease [37
]. It records patients’ experiences and feelings in the last two weeks under four domains: dyspnoea, fatigue, emotional function and mastery. The European Quality of Life 5 Dimensions 3 Level Version (EQ-5D-3L) questionnaire was used for quality-of-life analysis, which is a descriptive system, comprising of the following five dimensions: mobility, self-care, usual activities, pain/discomfort and anxiety/depression [38
]. Each dimension has three levels: no problems, some problems and extreme problems. The participant was asked to indicate his/her health state by ticking the box next to the most appropriate statement in each of the five dimensions. The EQ Visual analogue scale (VAS) is the second part of the questionnaire, asking to mark health status on the day of the interview on a 20 cm vertical scale with endpoints of 0 and 100. VAS records the patient’s self-rated health on a vertical visual analogue scale where the endpoints are labelled ‘Best imaginable health state’ and ‘Worst imaginable health state’. The VAS can be used as a quantitative measure of health outcome that reflects the patient’s judgement.
2.6. Data Analysis
Data were encrypted, anonymised and stored in password protected file with access to PI (VN) only. We did comparative analysis with pre and post intervention data using SPSS version 27 (IBM Corp., Armonk, NY, USA). A paired-sample t
-test was employed to assess the mean differences between the pre-and post-intervention scores. The effect size of the mean difference was assessed using Cohen’s d
(the difference between the pre- and post-intervention scores divided by the pooled standard deviation). The following scale of magnitude was used to assess the effect sizes: <0.19 = trivial; 0.20 to 0.49 = small; 0.50 to 0.79 = moderate; and ≥0.80 = large [39
]. However, following Hopkins’ guidelines [40
], the uncertainty in the estimate or effect in this study were interpreted in terms of their magnitude and respective upper and lower confidence limits.
However, we also cross validated the magnitude of the mean differences following the CRQ-SAS guidelines, which suggest that when a respondent’s score improves an average of 0.5 per question per dimension, respondents generally report that they have been feeling better, and that the magnitude of change, while small, is important to their day-to-day lives. Changes between 0.75 and 1.25 represent important changes of moderate magnitude, and changes greater than 1.5 represent important changes of large magnitude [41
3.1. Participants’ Characteristics
Twenty members of the Irish Lung Fibrosis Association (ILFA) were contacted to participate in this study, of which 16 agreed to attend the dance sessions. At the baseline, the majority of the participants (80%) were older than 60 years, whereas 62.5% were females (n
= 10). In terms of pulmonary conditions, 64.3% of the participants (n
= 9) had IPF, whereas the remaining participants had other pulmonary conditions (e.g., systemic sclerosis, hypersensitivity pneumonitis and interstitial pulmonary disease due to antecedent fibrosis). Finally, all the participants had previously attended an online physical activity programme. The demographic characteristics of the study participants are fully reported in Table 1
3.2. Feasibility of the Intervention
Of the twenty members of the ILFA approached, only 16 were interested in the programme (80%), of which 10 completed the programme (completion rate = 62.5%). Of the 16 participants that expressed their interest to attend the programme, three withdrew from the intervention after completing the baseline questionnaires and attending the first session with no reasons given, and a further three participants did not complete the intervention due to a number of different reasons (pre-existing shoulder and back pain, not interested in dance activities and holiday already planned).
The average number of participants during the dance sessions was 9 ± 4, with a minimum of 5 participants and a maximum of 16 participants. The average attendance rate for the participants ranged from 25% (2 sessions) to 100% (8 sessions), with an average value of 51.5% (namely, on average, the participants attended 4 sessions).
There were no adverse effects reported by the participants during the sessions. However, some participants reported shortness of breath while performing the dance activity, which was resolved by taking a short rest during the session. Moreover, despite the dance steps being developed for sitting dance activities, a few (n = 2) participants felt comfortable enough to dance while standing.
The responses to the ten statements related to the feasibility, acceptability, satisfaction and recommendation of the online dance intervention were accompanied by a Likert scale ranging from 1 = strongly agree to 5 = strongly disagree and are reported in Table 2
Overall, participants indicated an absence of technical issues, reporting that they could clearly see and hear the dance teacher. All the participants agreed that the programme not only met the expectations (m = 1.82 ± 1.17), but it provided an experience as good as the face-to-face programmes that they had previously attended (m = 2.18 ± 1.08). Finally, participants indicated that they would attend such an online dance programme in the future (m = 2.00 ± 1.00), suggesting acceptability and strongly recommend it to other people living with pulmonary conditions (m = 1.55 ± 0.69).
3.3. Estimation of CRQ-SAS
The magnitude of the difference in the CRQ-SAS domains are reported in Table 3
. Noteworthy is the extent to which the fatigue levels slightly improved after the intervention. Despite the unclear differences that our results revealed (mean difference = 0.13; d
= 0.17; CIs = −0.462 to 0.787), participants reported that they felt less tired during the two weeks prior to post-intervention questionnaire. Furthermore, despite unclear, small-sized negative differences being found in terms of the disease control (mean difference = −0.10; d
= −0.23; CIs = −0.856 to 0.401), with participants reported that they felt less fearful when having difficulties to breathe (pre-intervention mean = 6.20; post-intervention mean = 6.30) and more confident about dealing with the illness (pre-intervention mean = 2.80; post-intervention mean = 2.70).
In terms of gender differences, our findings revealed that females had better emotional function than males, both pre- and post-intervention (Table 4
). In fact, our analyses revealed possible trivial-to-large-sized differences between males and females regarding the emotional function after participating in the dance sessions (mean difference = −0.62; d
= −1.25; CIs = −2.622 to 0.181), with females reporting that they felt less frustrated, upset, discouraged and restless and more relaxed and satisfied with their life than males. These differences were also found before the intervention, with the analyses revealing small-sized, although unclear, differences between males and females (mean difference = −0.22; d
= −0.46; CIs = −1.733 to 0.837).
3.4. Estimation of EQ-5DL
The magnitude of the differences in the quality-of-life questionnaire are reported in Table 5
. Despite the small sample size and the unclear effects, our investigation revealed small-sized differences in the anxiety levels among the participants, which slightly decreased after the intervention (mean difference = −0.11; d
= −0.33; CIs = −0.996 to 0.349). Small-sized, although unclear, differences were also found in the mobility capability (mean difference = 0.11; d
= 0.33; CIs = −0.349 to 0.996), which increased after participating in the dance sessions. Finally, unclear small-sized differences were found in the health self-perception (mean difference = 0.40; d
= 0.23; CIs = −0.401 to 0.856), which increased after participants attended the 8-week dance intervention.
In terms of gender differences, Table 6
summarises the mean differences between gender. Noteworthy is the extent to which females had lower anxiety levels both before and after the dance sessions. Our analyses revealed unclear large-sized differences before the dance sessions (mean difference = 0.55; d
= 1.17; CIs = −0.310 to 2.581) and moderate-to-large-sized differences after participation in the intervention (mean difference = 0.75; d
= 2.45; CIs = 0.681 to 4.140).