The Effects of 8-week Dance and Tai Chi Randomized Controlled Trial on Balance,Wellbeing and Moods Among Healthy Adults Aged 18 to 60: A Study Protocol

Abstract

Purpose:

The aim of the proposed randomized controlled study is to compare the effects and efficacy of a dance, a Tai Chi and a waiting list control group intervention over an 8-week period on physical functions and mental benefits among non-clinical adults aged between 18 and 60.

Method:

A double-blind, randomized controlled trial will be adopted to evaluate the effects and efficacy of an 8-week dance intervention compared with Tai Chi and a control group on physical and mental benefits. Participants will be randomly assigned to 3 groups, dance, Tai Chi, and Control group, using stratified random sampling based on sex. Isometric Mid-thigh Pull (IMTP), Y-Balance test (YBT), Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS), and The Brunel Mood Scale (BRUMS) are utilized for collecting physical and mental data. All measurements will be conducted by research assistants blinded to participants’ group allocation and analysis will be carried out by statistician blinded to the group and test parameters.

Expected result:

Mental wellbeing parameters are predicted to be increasing during the learning phase and the physical parameters are predicted to have an improvement in the practising phase.

Keywords

dance Tai Chi balance wellbeing protocol

Introduction

Both dance and Tai Chi have been used as physical activity interventions to improve the health of various populations.^1
-3 As a performing art, dance requires high levels of technical skill and physical fitness similar to sport,⁴ and therefore practising such a physical activity could positively improve participants’ health by enhancing physical and physiological functions. Psychologically, dance can also be used as a non-pharmacological panacea with research reporting mental and social benefits such as improved quality of life, reduced stress, sense of satisfaction, and sharpened social skills.^5
-7 Tai Chi has been practised over centuries for health promoting purpose in China, and was studied as a health intervention exercise in the West since 1990s.⁸ Its characteristics, including slow circular movements, regulated breath, mindfulness, half-squat stance, and meditative way of practice, are closely related to its potential physical and mental benefits on lower extremity strength, range of motion, coordination, stress, depression, and anxiety.^9,10

Dance and Tai Chi seem to have the potential to improve balance and promote mental health/wellbeing which is largely relevant to the aging population in particular. In a recent systematic review previously conducted (under review) on the benefits of dance and Tai Chi interventions we identified 27 out of 38 dance or Tai Chi studies on people over 60, its results, along with meta-analysis, supported that both physical activities have significant benefits on balance and mental health. However, the review also noted a lack of methodological details such as intensity monitoring, exercise progression, and pedagogy making replication very difficult.

Literature Review

Previous studies done on dance and Tai Chi have provided an insight into its potential for health promotion. Both physical and mental outcomes have been studied, with physical outcomes mainly focusing on 3 parameters: balance, strength (lower extremities), and mobility, meanwhile the mental outcomes included wellbeing, mood, stress, and the quality of life.

Due to its emphasis on slow, controlled movements, semi-squat body positions, and constant bodyweight shifting,¹¹ Tai Chi contributed to balance and lower extremity strength improvements. Numerous studies^11
-14 have indicated that despite different durations of their interventions, participants showed a significant improvement in balance and leg strength afterward, which also outperformed other physical activities such as brisk walking, lower extremity training, and Otago exercise. Dance, on the other hand, emphasizes mostly on rhythmic movements and coordination which can be a helpful tool for enhancing mobility. A study using 6-week Thai dance¹⁵ and another one using 10-week Greek dance intervention¹⁶ both reported that participants demonstrated a better functional mobility in their post-tests.

Studies on both physical activities suggested that they can be beneficial for mental health promotion in different aspects. Although the mechanism could differ considering the opposite nature of dance and Tai Chi, studies showed statistically significant improvements in depression, anxiety, and stress reduction from both dance¹⁷ and Tai Chi^18
-20 interventions. There are also studies mentioned benefits of Tai Chi in mood change²¹ and overall quality of life from dance.^7,22

Despite the findings are positive, it also exposes a few gaps in the area. Firstly, a need for standardized outcome measures was highlighted to facilitate cross-study comparison. Secondly, the selected physical activities have not been studied within the same trial, and it is hard to identify which can be more effective for specific outcomes. Thirdly, most of the current studies were conducted on the old generation (60+ years old), which makes the effects of dance and Tai Chi on younger generations unknown. Hence, this study was designed trying to find the missing puzzles.

Research Purpose

This study is registered at Clinical Trials (NCT06294080). The aim of the proposed randomized controlled study is to compare the effects and efficacy between a dance, a Tai Chi and a waiting list control group intervention over an 8-week period on physical functions and mental benefits among non-clinical adults aged between 18 and 60. The study’s primary outcome is mental wellbeing and secondary parameters are physical functions and mood. A tertiary outcome will examine how the physical and mental parameters change during the learning and practice phases.

Materials and Methods

Participants

The study is a methodological design of a dance and Tai Chi interventional research. It has been approved by the Ethics Committee University of Wolverhampton (9/23/JL/UOW). However, Information sheet and registration form will be filled by participants before engaging in the study.

Participants will be recruited via posters, stalls and Student Union social media based on two university campuses, it also opens to the local community for non-student residents who meet the inclusion criteria. In previous systematic review we pointed out that the current studies are predominately female adults aged over 60 and little included younger population and male participants. Thus, the recruitment will aim at university students, local residents and university staff between 18 and 60 years old. No delimitation on sexes, ethnicities, and previous experience of dance or Tai Chi.

Ethical Considerations

Consent forms will be given to participants before they take part in this study, informing them the potential risk of harm and benefits, rights to withdraw, approaches of reporting academic dishonesty and contact information of researchers. Also, it promises participants that all data collected in this study will be anonymized and only used for research purposes. Recordings containing personal information during the intervention will only be stored on the computer of leading researcher’s protected by password and immediately deleted after transcription. Participants are allowed to ask any questions in regard to the study before they decide to sign the consent forms.

Inclusion and Exclusion Criteria

Inclusion criteria are (1) healthy male and female adults of any ethnicity aged from 18 to 60, (2) no chronic medical conditions, and (3) no physical injuries in the past 3 months that could potentially affect physical activities. Exclusion criteria will include participants who are currently engaging in regular dance or Tai Chi classes.

Sample Size Calculation

The total sample size was estimated through an a-priori power analysis, using the G power v3.1.9.7 software (Heinrich-Heine-Universität, Düsseldorf, Germany). Under the guidance of Pourhoseingholi et al²³ and Noordzij et al,²⁴ the following input parameters were applied using a repeated-measure ANOVA design: effect size f = 0.33, α = .05, power = 0.80, and correlation between repeated measures r = .50. The a-priori power calculation revealed that the initial sample size required is 63, 21 participants in each group. By considering a 10% dropout rate, 70 individuals will be recruited to voluntarily participate in this study.

Experimental Design

A double-blind, randomized controlled trial will be adopted to evaluate the effects and efficacy of an 8-week dance intervention compare with Tai Chi and control group on physical and mental benefits.

Participants will be asked to attend baseline testing 1 week prior to the first session, which will include lower extremity muscle strength, balance, and mental wellbeing. Participants will also be asked to fill in the mood evaluating questionnaire before and after each session to measure the acute effect of each intervention. The first 4 weeks of the interventions are the learning phase, participants will mainly focus on learning the movements of dance or Tai Chi. After the last session of the fourth week and before the first session of the fifth, participants will be asked to complete the previous test procedure as the mid-term test. The last 4 weeks are the practising phase, participants will mainly focus on practising the learned movements with reduced direction from the instructor. The post-intervention test will be completed within 1 week after the last session, alongside an interview on their perceptions of the intervention.

Randomization and Blinding

Participants will be randomly assigned to 3 groups, dance, Tai Chi, and Control group, using stratified random sampling based on sex. Participant mental wellbeing scores will be ranked from highest to lowest in each sex group before being systematically assigned to 1 of the 3 intervention groups, this will reduce potential differences in baseline data between groups. All measurements will be conducted by research assistants blinded to participants’ group allocation and analysis will be carried out by statistician blinded to the group and test parameters.

Interventions

Participants will complete informed consent and Physical Activity Readiness Questionnaire (PAR-Q) prior to data collection. At the first testing session basic anthropometric (stature, body mass, age) and personal information (ethnicity, activity level) will be recorded and each participant issued with a Unique Identifying Code (UIC).

The Dance Group, participants will be provided with 3 dance genre options to choose from, ballroom dance, street dance/Hip-pop and ballet, and the most-voted genre will be delivered with an intentionally controlled moderate intensity. Dance sessions are instructed twice a week for 8 weeks. Every session lasts 45 to 60 minutes, containing 5 to 10 minutes of warm-up and 35 to 55 minutes of learning or practicing. In the first 4 weeks, a short dance sequence will be taught and in the following 4 weeks, participants will mainly practicing the learnt sequence along with music (details see Appendix 2).

The Tai Chi Group will be given the essential 18-form of Chen’s style Tai Chi Chuan (陈式太极拳精要十八式) which is comparatively easier for beginners to learn the iconic forms with less movements and moderate intensity. Each session lasts 45 to 60 minutes, twice a week for 8 weeks. Every session contains 5 to 10 minutes of warm-up, 5 minutes of standing exercise (站桩) with calming music, and 30 to 45 minutes of learning or practicing. In the first 8 sessions, 15 forms will be taught in total, averaging 2 forms taught every session. In the following 8 sessions, participants will practise the complete 18-form repeatedly following the lead of an instructor with background music. Each repetition takes approximately 2 minutes 20 seconds. Apart from movements, the Taoism philosophy as the origin of Tai Chi will also be embedded during the intervention (details see Appendix 2).

Participants in Control Group will be told to maintain their usual lifestyle and only attend for physical assessments.

Based on previous dance/Tai Chi studies which reported significant positive results, the duration of interventions are vary from 1.5 hours for 4 weeks,¹² to 1 hour per week for 52 weeks.²⁵ Thus, it was determined to use a relatively conservative duration of 2 hours per week for 8 weeks^17,26
-29 to make sure the outcome change is observable.

The pedagogy is also considered as a vital factor in this study. Thus, instructors should record each session and briefly summarize the teaching content, descriptions, and emphases if mentioned.

Intensity Monitoring and Progression

While delivering both dance and Tai Chi interventions, the intensity will be monitored using sessions Rate of Perceived Exertion (sRPE)³⁰ with CR-10 modified by Foster et al,³¹ which is proved to be a valid, reliable tool.³² Given the targeted age group, instructors will maintain the intended RPE between 3 (moderate) and 5 (hard), with the arbitrary unit (A.U. = RPE × session duration in minutes) from 135 to 300. Participants are asked to provide a number from CR-10 retrospectively after every session and the instructor then adjusts the training load accordingly if necessary. No progression is designed in the learning phase, only studying the planned form(s) of the day. While in the practicing phase, instructors should gradually raise the standard of movements and slower the speed of practicing the full sequence to increase the difficulty and intensity.

Outcome Measures

Among the current dance and Tai Chi intervention studies, the health-related outcomes mainly focused on 2 themes, 1 is factors in relation to balance, such as static/dynamic balance,³³ fall prevention,³⁴ and mobility¹⁵; the other is mental health which includes numerous outcomes such as anxiety, depression, stress, quality of life and well-being.^7,9 Therefore, dynamic balance ability was chosen as the physical outcome. Leg strength was also included as it is believed to be also highly relevant with balance.³⁵ Well-being and mood were selected as psychological outcomes as they are believed to be significant contributors to mental health.³⁶

As demonstrated in literature review, the outcome measures used in previous studies are various and is difficult to identify which is the most appropriate method for the chosen outcomes at this stage considering the test bias reported before.³⁷ In this case, the methods using advance technology/device such as the sequential weight shifting test (SWS),³³ and those which might be less sensitive for younger populations such as OLS, are eliminated from options, and the methods that can easily access, use, and display the change of outcomes directly are considered. Despite the potential problems of self-report questionnaire methods are aware,^38
-40 it is still utilized due to its nature of being user-friendly and economical.

The Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS)⁴¹ will be utilized to evaluate participants mental wellbeing state change. The WEMWBS is a 14-item self-evaluating scale containing hedonic and eudaimonic statements such as “I’ve been feeling relaxed” or “I’ve been feeling close to other people.” The respondents rate each statement spontaneously with a 5-point Likert scale from 1 to 5 (none, rarely, sometimes, often, all the time), resulting in a minimum score of 14 and maximum score of 70. The higher WEMWBS score suggests the better mental wellbeing.

The Isometric Mid-Thigh Pull (IMTP) will be used to measure lower extremity maximum strength using Hawkins Dynamic force plate.⁴² It is considered as a safe, time-effective, and reliable measurement.^43,44 Participants will be asked to stand on force plates with hips and knees slightly bent. The bar height is adjusted so that it is at mid-thigh height of each participant and the height recorded. The participant grips the bar with a slight pretension. The participant is to remain completely still for 2 to 3 seconds before and between each repetition. The participant will then be instructed to contract as hard and as fast as possible pulling against the bar and hold the maximum pull for 2 to 3 seconds before resting. Each participant will carry out 3 repetitions and the maximum and mean power recorded (details see Appendix 1).

The Y Balance Test (YBT)⁴⁵ will be used to assess participants’ dynamic balance. Participants will be instructed to stand barefoot unilaterally on the center of a tape-made “Y.” While standing on 1 leg, participants will reach out with their non-stance leg as far as possible in the 3 directions of the “Y.” No weight can be transferred to the non-stance leg. Three attempts for each direction for each leg will be taken and calculated as a percentage of their leg length; the greatest distance for each direction will be recorded. Leg length will be measured from the greater trochanter to the lateral malleolus (details see Appendix 1).

The Brunel Mood Scale (BRUMS)⁴⁶ will be used pre and post each dance or Tai Chi session to monitor participants’ mood changes. The BRUMS contains 6 categories including anger, confusion, depression, fatigue, tension, and vigor, each is comprised of 4 adjectives such as panicky, exhausted, energetic, or active. Participants are asked to indicate their mood using a 5-point Likert scale (0 = not at all, 1 = a little, 2 = moderately, 3 = quite a bit, 4 = extremely).

Statistical Analysis

Dataset’s normal distribution will be assessed using the Shapiro-Wilk test. Analyses of variance (ANOVAs) with repeated measures will be used to analyze physical and mental parameters between the 2 interventions and control groups between the 3 time points. Significant interactions and main effects will be further examined using Bonferroni post hoc analysis. The significance level will be set at P < .05.

Expected Results

The purpose of the proposed study is to use a suitable design to evaluate the effectiveness of 8-week dance sessions on lower extremity strength, balance, wellbeing, and mood among non-clinical adults aged between 18 and 60, comparing with Tai Chi sessions and waiting list control group under the similar intensity. The primary outcome of this study is the change of mental wellbeing, and the secondary parameters are physical functions and mood. A tertiary outcome will explore how physical and mental parameters vary between learning and practising phases.

A recent systematic review on dance and Tai Chi interventional studies highlighted that both physical activity interventions have been shown to have statistical improvements on the primary and secondary outcomes in older populations. Tai Chi’s movements in the selected form require them to stand in a squat or semi-squat position and shift their center of gravity frequently thereby challenging leg strength and although previous dance interventions have less targeted movement patterns, changes in vertical displacement with the use of pliés also place stress on leg muscles. Additionally, both physical activities will be enhanced with appropriate music, which was also suggested to be beneficial for physical performance and psychological wellbeing.⁴⁶ Furthermore, meditation will be contained in Tai Chi sessions which has been proved to be beneficial for wellbeing and moods.^47,48

Despite the success among older populations, whether its effectiveness can generalize to a younger age group is unknown, a single study²¹ found no measurable change in strength and balance among college-aged participants while conducting a Pilates and Tai Chi intervention. Due to the aftermath of COVID-19 a report indicated the number of physical active young people (aged 16-34) is now nearly half a million less in England than compared to 2017.⁴⁹ Another report from British Medical Association⁵⁰ points out that the mental health problem in children and young people has been rising between 2017 and 2022, and the COVID-19 accelerated this trend. Comparing with pre-pandemic era, the current physical activity and mental health status in young generation may amplify the effects of physical activity interventions and elicit an observable change.

The changes of both physical and mental parameters are expected to be various during learning and practicing phases. Theoretically the learning phase should see an improvement in mental wellbeing. Hammond⁵¹ and Field⁵² both indicated the behavior of learning new skills can enhance self-esteem, self-efficacy, and confidence, which directly contributes to the improvement of mental wellbeing and create happiness. The increase in leg muscle strength may not occur until the practice phase as the intensity of movement can increase to illicit adaptation. The theory supports this assumption is the enhancement from muscle memory. Sharples and Turner⁵³ supports this assumption as the learning phase develops muscle memory whilst the practice phase utilizes this memory to illicit a quicker response and better efficacy for gaining muscle strength,^53,54 through the improvement of neuromuscular coordination from repeated practice.⁵⁵

Limitations

Since most of the current dance/Tai Chi interventions for health promotion are on participants over 60, this study intends to focus on the physical and psychological changes in general among participants whose age between 18 and 60 after an 8-week physical activity intervention. However, the design overlooks the individual differences given across the wide range of age covered. It is suggested that more details should be bought into consideration based on the actual participant recruitment situations, such as difference in aging, genders, and potentially, the impact of lifestyle factors.^56,57

The impact of genres is unidentified in this study. Whether different genres of dance, or different forms of Tai Chi could differ the health outcomes remains uncertain in previous studies, except ballet seems to be disadvantaged in mental well-being promotion.⁵⁸ The genres of physical activity chosen in this study protocol are those which the researchers have convenient access to and were only displayed as an example. It may change based on the reality when replicate.

Support and Application

This study provides an ideal design for a dance and Tai Chi intervention based on previous literature and practical experience. Initially, this research could support those working in public health by offering insights into aspects of dance and Tai Chi intervention that offer physical and mental benefits for non-clinical population, as well as evidencing the point at which such outcomes become perceptible to participants. It could also bring inspirations and references to similar fields using recreational or meditative physical activities for health promotion purposes. Applications are around does-response, intensity, modality, and frequency considerations to be applied in practice could be anticipated.

Footnotes

Appendix 1. Physical Measure Procedure

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Institutional Review Board Statement

Ethic approval has been granted by Ethics Committee of University of Wolverhampton (9/23/JL/UOW).

Informed Consent Statement

Informed consent will obtain from all subjects involved in the study.

ORCID iDs

Jie Lu

Jake K. Ngo

Tracey J. Devonport

Matthew A. Wyon

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