CRITICALLY APPRAISED PAPER (CAP) Kaltsatoui, A., Mameletzi, D., & Douka, S. (2011). Physical and psychological benefits of a 24- week traditional dance program in breast cancer survivors. Journal of Bodywork and Movement Therapies, 15(2), 162 167 http://dx.doi.org/10.1016/j.jbmt.2010.03.002 CLINICAL BOTTOM LINE: The purpose of this randomized controlled study was to assess the influence of participating in a mixed exercise program on breast cancer survivors. The interventions included were Greek traditional dancing and upper body training. Women were asked to participate to examine the effects of the activities on their physical functions, strength, and emotional well-being. Twentyseven randomly selected survivors from 3 centers participated in this study. The control group consisted of 13 sedentary women. The experimental group consisted of 14 women. The experimental group participated in the interventions three 1-hour sessions per week over a 24-week period. Heart rate, blood pressure, physical function hand grip strength, arm volume, and psychological condition were evaluated before and after the 24-week period. In reference to the study s effect, the only effects that were detected were those that were strong significant, and meaningful. It was found that hand grip strength (both right and left) increased immensely. There was a change in arm volume (left hand only). Psychological conditions improved as well. The results of this study showed that engaging in dance had a positive effect on breast cancer survivors. Dance is an enjoyable and meaningful occupation. Participants are motivated by being given the opportunity to express their culture and identity. Greek traditional dancing has shown positive psychological and cardiovascular effects. Given the level of rigor of the study and strength of the intervention s effect, occupational therapists should consider dance as an occupation to improve significant and meaningful qualities of life. According to the researchers, this is the first study involving the effects of traditional Greek traditional dancing on breast cancer survivors. In addition, the sample size is not appropriate to generalize to all breast cancer survivors. Therefore, caution should be taken in assuming this type of program will be beneficial for all breast cancer survivors. RESEARCH OBJECTIVE(S) List study objectives. Assess the influence of a mixed exercise program of Greek traditional dances and upper body training on quality of life and physical functioning of breast cancer survivors. 1
DESIGN TYPE AND LEVEL OF EVIDENCE: Level I: Randomized controlled trial SAMPLE SELECTION How were subjects recruited and selected to participate? Please describe. Breast cancer survivors from 3 centers from the city of Thessaloniki, Greece, were asked and agreed to volunteer to participate in this study. They were randomly selected to participate in this study. They were divided into two randomized groups: a control group and an experimental group. Inclusion Criteria Participants were partaking in only the dance exercising program, and none of the participants had prior physical practice or experience in traditional Greek dances. They had completed cancer therapies including surgery, radiotherapy, and chemotherapy and stopped all medical treatments 3 months prior to the start of the study. Exclusion Criteria Researchers excluded survivors who had poorly controlled hypertension and any health condition that would deter them from performing the exercise. SAMPLE CHARACTERISTICS N= (Number of participants taking part in the study) 27 #/ (%) Male 0% #/ (%) Female 100% Ethnicity Greek Disease/disability diagnosis Breast cancer survivor INTERVENTION(S) AND CONTROL GROUPS Add groups if necessary Group 1 Brief description of the intervention How many participants in the group? Where did the intervention take place? Participants in the experimental group partook in a mixed exercise program that included aerobic training with Greek traditional dances and upper body training. 14 (mean age = 56.6) The intervention took place in a community setting in Thessaloniki, Greece. The researchers did not clarify if the intervention was provided in a group or individual setting. 2
Who delivered? How often? For how long? Jointly by a specialist physical therapist and a physical education teacher who is a professional, experienced dance instructor and has an extensive experience in fitness, dancing, and rehabilitation 60-minute sessions, 3 days per week 24 weeks Group 2 Brief description of the intervention How many participants in the group? Where did the intervention take place? Who delivered? How often? For how long? Participants in the control group continued their usual daily schedule 13 (mean age = 57.1) NR NR NR 24 weeks Intervention Biases: Check yes, no, or NR and explain, if needed. Contamination: Co-intervention: Timing: NO The researchers failed to mention whether participants had any pharmacological intervention for depression during the study. If patients in both groups were taking antidepressants, it may alter the psychological outcome. The timespan is accurate for what the researchers are measuring. 3
Site: The researcher did not specify the site of the intervention. However, if the study was conducted in a breast cancer survivor center, then there may be a higher level of satisfaction that favors the treatment group. Use of different therapists to provide intervention: NO The researchers reported a specialized physical therapist and a physical education teacher provided the intervention. MEASURES AND OUTCOMES Complete for each measure relevant to occupational therapy: Measure 1: Beck Depression Inventory (BDI) Severity of depression YES YES Measure 2: Measure 3: Life Satisfactory Inventory (LSI) Satisfaction of lifestyle YES YES Resting blood pressure and heart rate were measured after the individual had been sitting calmly for 5 minutes. Heart rate was estimated by palpation for 4 15-s periods and blood pressure was determined by a sphygmomanometer 4
Measure 4: Measure 4: Measure 5: Reduction in baseline blood pressure YES YES 6-minute endurance walk test, walking as comfortably as possible Physical function YES YES Baseline handheld dynamometer; the participants were seated with the forearm in neutral position and elbow at 90 handgrip strength YES YES Measuring tape Arm volume YES YES 5
Measurement Biases Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Were the evaluators blind to treatment status? Check yes, no, or NR, and if no, explain. Recall or memory bias. Check yes, no, or NR, and if yes, explain. NO The outcomes weren t measured using a self-report tool, survey, or interview, so the participants weren t recalling past events. Others (list and explain): The control group didn t receive any comparable intervention. It is well documented that an inactive lifestyle promotes depression and physical deconditioning. The intervention was effective, but to make a true comparison, the control group should have been given a program at home or a similar exercise. RESULTS List key findings based on study objectives Include statistical significance where appropriate (p < 0.05) Include effect size if reported There were significant differences between the intervention and control groups on posttest scores (p < 0.05), favoring the experimental group on handgrip strength for both the right (Cohen s ES = 1.41) and the left (Cohen s ES = 1.20) sides, indicating large effect sizes. With regard to systolic blood pressure, both groups were essentially equivalent (Cohen s ES = 0.00) after controlling for the covariates. Borderline differences were observed with regard to diastolic blood pressure (Cohen s ES = 0.23). There were also significant differences between groups on arm volume (p = 0.028), but only for the left hand (Cohen s ES = 0.50) and not the right (Cohen s ES = 0.71), although the later effect was between medium and large. Last, with regard to psychological condition, there were significant differences on the LSI (p < 0.05, Cohen s ES = 2.69), and the BDI (p < 0.05, Cohen s ES = 2.36). 6
Was this study adequately powered (large enough to show a difference)? Check yes, no, or NR, and if no, explain. YES This study was adequately powered. Were appropriate analytic methods used? Check yes, no, or NR, and if no, explain. YES An analysis of covariance (ANCOVA) was used to ensure that both groups were equivalent across these variables: the independent variable (the posttest scores) and the dependent variables (the pretest scores, age, height, and weight). In essence, the adjusted means were compared with each other using an analysis of variance. A power analysis was conducted to ensure that effects were both statistically significant and meaningful. To this effect, the researchers estimated that to attain levels of power 0.80 for a large effect size at a one-tailed test, working on a 5% level of significance, the researchers needed 20 participants per group. The sample estimates that they were close to their hypothetical suggestions, ensuring that there were adequate levels of power for the detection of large effects only. A p value of <0.05 was considered as statistically significant. An analysis of covariance is fine to test for initial group homogeneity, but with such a small sample, not all the assumptions for parametric testing (normal distribution) are met. A Mann-Whitney U should have been used to compare the group mean change scores. Were statistics appropriately reported (in written or table format)? Check yes or no, and if no, explain. YES There was a table of the unadjusted and adjusted means between experimental and control groups on posttest after adjusting for the presence of the covariates. Was the percent/number of subjects/participants who dropped out of the study reported? NO Limitations: What are the overall study limitations? Rather, was the correct design selected given the research question? The researchers do not mention if all study members were adherent to the exercise schedule. The researchers also do not define the control group s normal daily life schedule. 7
CONCLUSIONS State the authors conclusions related to the research objectives. The study showed that a combined exercise program that combines aerobic exercise with Greek traditional dances and upper body training has a beneficial effect on physical function, life satisfaction, and depressive symptoms in breast cancer survivors. Therefore, Greek traditional dances could be an effective means of exercise training, contributing to the improvement of the physical function and psychological condition in this target population. Traditional dances, as an aerobic activity, may be considered an alternative and pleasant choice of aerobic physical activity for cancer survivors. This work is based on the evidence-based literature review completed by Rita Porreca, OTS, University of the Sciences. Faculty mentors: Colleen Maher, OTD, OTR/L, CHT, and Rochelle Mendonca, PhD, OTR/L. CAP Worksheet adapted from Critical Review Form--Quantitative Studies. Copyright 1998, by M. Law, D. Stewart, N. Pollack, L. Letts, J. Bosch, & M. Westmorland, McMaster University. Used with permission. For personal or educational use only. All other uses require permission from AOTA. Contact: www.copyright.com 8