Dancing: More than a therapy for patients with venous insufficiency

Abstract

Objective

This study aims to figure out the effects of dance therapy on patients with chronic venous insufficiency disease.

Methods

Forty subjects with chronic venous insufficiency were recruited to either the control group or the dance therapy group. As the severity of chronic venous insufficiency was defined with the Venous Clinical Severity Scores (VCSS), patients in control group received only medical treatment. Twenty patients with chronic venous insufficiency in dance therapy group received three times a week, for five weeks, totally 15 sessions of dance therapy in addition to medical treatment.

Results

There was no significant difference in pre- and post-treatment results of Rivermead Index, VCSS parameters constipation complaint, assistive breath muscle activity, lower limb circumference, strength and range of motion between groups (p > 0.05). The remarkable result of this study was obtaining that the post-treatment quality of life scale’s bodily pain score was significantly higher in the dance therapy group than the control group (p < 0.05).

Conclusions

It was concluded that dance therapy has positive effects on quality of life. There were no barriers to chronic venous insufficiency patients in this form of gentle exercise, showing that it is to meliorate the cardiovascular, physical and psychological benefits of an activity that is enhancing of the self-esteem in addition to the quality of life. Treatment of chronic venous insufficiency should consist of methods that support the patient mentally, physically and psychologically, in addition to the medical treatment. Dance therapy might be a potential exercise intervention for improvements in chronic venous insufficiency patients, so clinicians focusing on them could recommend this form of gentle exercise in addition to the medical treatment.

Keywords

Dance therapy venous insufficiency quality of life

Introduction

Venous disorders of the legs occur frequently and common manifestation of venous incompetence in the lower limb is varicose veins. Varicose veins appear as dilated, elongated or tortuous superficial veins. Approximately 33.3% men and women suffer from varicose veins and chronic venous insufficiency and this rate increases by age.^1,2 Venous insufficiency may lead to venous ulcers and also has a significant impact on quality of life and work productivity.³ Treatment options for chronic venous insufficiency disease include conservative or medical treatment like invasive treatment, surgical methods and non-surgical vascular methods.⁴

Fear and avoidance beliefs are frequently reported by women with chronic venous insufficiency disease (CVI) and are associated with low physical activity and more severe pain.⁵ Moreover, patients with CVI have more limited treatment options and here is no firm evidence that one method is the best.^5,6 An appropriately prescribed compression provides substantial relief for patients with severe CVI, regardless of cause. If physiologic function can be improved with exercise, this means that exercise could provide additional therapeutic benefit for these patients suffering from CVI disease.^6,7

Exercise is a conservative treatment option which gives a potential of health benefits and also improves healing outcomes for people with venous leg ulcers. The improved outcomes in venous leg ulcers by exercise based on, its capacity to promote venous return and reduce the risk of secondary conditions in this population.⁸ Dance has been used therapeutically for thousands of years for its positive effects on children, adults, elders, psychiatric problems, body awareness and also has an association with self-concept.^8–10

Chronic venous diseases in the lower extremities have a substantial effect on functioning and quality of life.¹¹ Dance therapy may support patients’ quality of life and wellbeing. Although many of the studies have found therapeutic benefits of dance therapy, these results are based on generally poor-quality evidence and there are few studies about effect of dance therapy in CVI patients.⁷ But well-performed and observational studies are needed to determine the real value of dance therapy. This study aims to figure out the effects of dance therapy on patients with CVI disease.¹²

Methods

Subjects

Subjects with CVI were recruited from the Department of Cardiovascular Surgery in Mustafa Kemal University. Inclusion criteria were that patients that age between 18 and 60 years, who had evidence of venous incompetence demonstrated by physical examination or Doppler Ultrasound examination with at least one significant reflux (of more than 1 s duration in a standing position) in the superficial, deep and/or perforator veins. Patients who had or planned to have surgical endovascular treatments were excluded. Demographic data, symptoms and comorbidities were recorded in addition to the severity of CVI defined with the Venous Clinical Severity Scores (VCSS).¹³

Forty patients were included and randomly assigned to either the control group or the dance therapy group. Patients in control group received only medical treatment. Patients in dance therapy group received dance therapy in addition to medical treatment.

The patients were asked to make all possible effort to attend all of the sessions, to minimize compliance bias concerning participation in the dance program. The purpose of the study was explained to all of the patients, each gave written informed consent. The study was carried out in accordance with the provisions of the Declaration of Helsinki and it was approved by the local ethics committee at the Mustafa Kemal University.

Assessment protocol

To figure out the effects of dance therapy on CVI; assessments were done before and after the 15th session of the dance therapy. For the control group the re-assessments were done five weeks later than the first assessment.

Edema, numbness, fatigue, postural hypotension, constipation, ingrown toenails and erythema were examined. VCSS was used not only to identify the severity of CVI (as an including criteria), but also to evaluate the improvements after the treatment. The VCSS contains 10 clinical symptoms (varicose veins, venous edema, skin pigmentation, inflammation, induration, number of active ulcers, duration of active ulceration, size of ulcer, and compressive therapy use), scored from 0 to 3, that may be used to assess changes due to therapy.⁷

Participants’ quality of life (QoL) and functional capacity were questioned with the Turkish version of SF-36.¹⁴ Rivermead Mobility Index (RMI) comprises questions about 14 activities including transfer activities (walking, going up-down stairs) and physical activity of the patients frequently done in their daily life.^15–18

Intervention protocol

Twenty patients in the dance therapy group had three times a week, for five weeks, totally 15 sessions of dance therapy. Three sessions of dance therapy, each for 45 min, done under the supervision of a physiotherapist. The remaining sessions were performed as a home-based exercise program with video. The follow-up phone calls were done to control the regularity of given dance program during the home-based exercise period.

Medical treatment

Medical treatment includes Diosmin (450 mg) + hesperidin (50 mg) that is a semisynthetic and oral phlebotropic drug used in the treatment of venous disease, and used as 1000 mg total dose daily.

Dance therapy

Dance therapy consisted combination of proprioceptive neuromuscular facilitation (PNF) exercise patterns combined with dance movements, diaphragmatic breathing exercises and breath retraining. The patterns were done with a folk and enjoyable music.

The program consists of 10 steps configured as:

Breathing exercises. Diaphragmatic breathing exercises were done with slow-paced regular breathing pattern for 2 min in supine position with knees in flexion.

PNF patterns with the music in standing position for 5 min.

Active ROM exercises of ankle (dorsiflexion and plantar flexion) in supine position for 5 min.

PNF patterns with the music in standing position for 5 min.

Breathing exercises.

The patients performed a Turkish folk dance including reciprocal gait movements as stepping laterally with contact of fingertips anterior and posteriorly for 10 min. After performing this stepping pattern in standing position, the same choreography was performed during walking.

Active ROM exercises of ankle (dorsiflexion and plantar flexion) in supine position for 5 min.

Breathing exercises.

The patients performed another folk dance called Delilo for 10 min. Delilo is a unisex dance includes four steps forward diagonally to the right, followed by four steps straight backwards. Patients stand side by side, holding each other's hands, the tempo of the dance ranges from moderate to the fast.

Breathing exercises.

Statistical analysis

Statistical analysis was performed by analyzing the pre- and post-treatment results with Wilcoxon Signed Rank Test to explore the treatment effects in each two groups; to compare two treatment protocol Mann–Whitney U Test was performed. Type I error level of 5% was used to infer statistical significance (p < 0.05).

Results

We screened 46 patients for this prospective trial funded by the TUBITAK 2209-A between September 2014 and July 2015. Participants who had an objective evidence of CVI, as determined with duplex ultrasound scanning (reflux or scarring), were included. In the control group, no patients were dropped out and all of them completed the program. In the therapy group, totally six subjects dropped out. One of them participated just one session, three of them three sessions and two of them completed six sessions of the dance therapy. Forty subjects between 16 and 58 years old (38.55 ± 12.12) were included in the study; 20 of them were in therapy (39 ± 11.58 years) (15 women, 5 men) and 20 were included to the control group (38.10 ± 12.93 years) (14 women, 6 men).

There was no significant difference in pre- and post-treatment results of constipation complaint, assistive breath muscle activity, lower limb circumference, lower limb muscle strength and range of movement between the groups (p > 0.05). Age, height, weight and symptoms were typical for a population of subjects with advanced venous insufficiency (Table 1 and 2). Cardiac failure and postural hypotension were seen in 15% of our subjects, while the other comorbid medical conditions were not frequent.

Table 1.

Demographics.

	Therapy group	Control group
	X ± SD	X ± SD
Age (year)	39.00 ± 11.58	38.10 ± 12.93
Height (cm)	167.85 ± 7.51	165.45 ± 9.77
Weight (kg)	76.60 ± 10.36	71.05 ± 14.53

Table 2.

Clinical co-morbidities.

	Therapy group	Control group
	n (N=20)	n (N=20)
Diabetes mellitus	2	6
Heart failure	4	2
Hypertension	2	0
Edema	5	3
Numbness	2	1
Fatigue	9	6
Postural hypotension	1	5
Constipation	2	5
Ingrown toenails	4	2
Erythema	3	1

Individuals’ pre- and post-results were shown in Table 3. No differences between groups were observed in the RMI and VCSS parameters, but SF-36 bodily pain score was significantly higher in the therapy group than the control group after the 15 sessions dance therapy (p < 0.05), (Table 3).

Table 3.

Venous clinical severity score, quality of life and mobility scores’ differences between the therapy and control groups.

		Pre-treatment				Post-treatment
		Therapy group	Control group			Therapy group	Control group
		X ± SD	X ± SD	z	p	X ± SD	X ± SD	z	p
SF-36	PF	54.50 ± 23.50	68.00 ± 32.98	−1.724	0.085	68.25 ± 22.55	66.75 ± 30.61	−0.204	0.839
	RP	50.00 ± 45.88	52.50 ± 45.08	−0.185	0.853	67.50 ± 42.99	53.75 ± 43.13	−1.078	0.281
	BP	52.10 ± 25.58	46.70 ± 22.78	−0.940	0.347	69.20 ± 14.54	48.50 ± 27.41	−2.478	0.013 ^*
	GH	58.60 ± 18.20	64.45 ± 24.93	−0.827	0.408	67.50 ± 17.70	59.35 ± 23.02	−1.072	0.284
	V	56.50 ± 21.77	60.58 ± 17.73	−0.599	0.549	67.00 ± 17.65	55.50 ± 21.45	−1.792	0.073
	SF	72.45 ± 33.81	64.97 ± 30.51	−1.114	0.265	78.72 ± 21.10	64.37 ± 28.46	−1.483	0.138
	RE	60.00 ± 46.64	51.67 ± 48.93	−0.491	0.624	75.00 ± 40.28	48.33 ± 50.11	−1.613	0.107
	MH	70.40 ± 16.58	76.00 ± 15.41	−0.872	0.383	75.40 ± 12.46	71.00 ± 16.81	−1.155	0.248
VCSS		6.95 ± 6.39	5.35 ± 4.64	−0.655	0.513	5.10 ± 3.43	5.21 ± 4.62	−0.142	0.887
RMI		14.45 ± 0.94	14.10 ± 1.29	−1.060	0.289	14.80 ± 0.52	14.45 ± 0.75	−1.745	0.081

PF: physical function; RP: role physical; BP: bodily pain; GH: general health; V: vitality; SF: social function; RE: role emotional; MH: mental health; VCSS: Venous Clinical Severity Score; RMI: Rivermead Mobility Index.

*p < 0.05, Mann–Whitney U Test.

We found that there was no significant difference between pre- and post-results in all parameters for patients with Diabetes Mellitus both in therapy and control group (p > 0.05).

There was a significant difference between pre- and post-treatment results of SF-36's all parameters and VCSS in therapy group. Meanwhile, the significant difference was recorded just in General Health and Mental Health parameters of SF-36 in the control group (p < 0.05), (Table 4).

Table 4.

Venous clinical severity score, quality of life and mobility scores’ differences between the pre- and post-treatment results in therapy and control groups.

		Therapy group		Control group
		Pre-post		Pre-post
		p	z	p	z
SF-36	Physical function	0.002 ^*	−3.069	0.663	−0.435
	Role physical	0.017 ^*	−2.392	0.705	−0.378
	Bodily pain	0.002 ^*	−3.103	0.600	−0.525
	General health	0.007 ^*	−2.703	0.045 ^*	−2.001
	Vitality	0.003 ^*	−2.966	0.140	−1.477
	Social function	0.206	−1.265	0.848	−0.192
	Role emotional	0.041 ^*	−2.041	0.414	−0.816
	Mental health	0.045 ^*	−2.009	0.016 ^*	−2.407
Venous Clinical Severity Score		0.003 ^*	−2.941	0.059	−1.890
Rivermead Mobility Index		0.059	−1.890	0.096	−1.667

*p < 0.05, Wilcoxon Signed Ranks Test.

Discussion

CVI is a common disorder which has limited treatment options and has a significant impact on pain and quality of life. It is characterized by persistent lower limb venous hypertension as a consequence of venous reflux or obstruction and failure of calf muscle pump function.⁵ Meanwhile, many patients remain chronically debilitated as a result of CVI symptoms. The treatment options cover medical, pharmacological and conservative methods. Among these, because of being non-invasive and causing less adverse effects than other methods, conservative approaches are used frequently to treat, to reduce the symptoms and, to prevent development of secondary complications and progression of the disease. It includes the structured exercise program, elevation of the limb together with the supportive methods, pharmacotherapy, as well as complex decongestive physiotherapy, intermittent pneumatic compression, compression stocking, patient training and kinesio taping.^19,20 Dance therapy is one of the conservative treatment options nowadays focused on and which gives potential of health benefits with different aspects. This study reasoned to figure out the effects of dance therapy on patients with CVI disease.

CVI has a complex and multifactorial progress which involves interactions between predisposing risk factors including age, female gender, family history, pregnancy, obesity, and prolonged standing and the genetic makeup of the individual.^11,21 Females were affected more than the males more and the age group varied between 41 and 60 years; and secondly most common age group, on the other hand, was between 21 and 40 years in the literature.²² Our individuals’ female prevalence was 72.5% with a mean age of 38.55 ± 12.12 years and these are consistent with the literature.

The complaints associated with CVI could be removed with the appropriate exercises. The choice of sports is essential for patients with venous insufficiency since sports, depending on the choice, may both result in an enhancement or aggravation in the patient’s condition. It should be considered that the choice of sports should involve balanced and rhythmic movements as well as avoiding hurt movements.²³ The movements of folk dance may be the same as any movements in space (i.e. leaping, running, galloping, sliding or walking), and they can be done at different tempos, in different rhythms, and with varying degrees of effort.²⁴ The exercises that were done in the dance therapy program were a part of PNF exercises which consist of rhythmic movements and folk dance with the dynamic balance movements. While the folk dance is traditional, it is also living cultural behavior, with a character that reflects people and their World.^7,24,25 So our patients had done it easily and showed willingness while performing the folk dance movements.

CVI diseases in the lower extremities have a substantial effect on functioning and quality of life. Kaplan et al. reported that there were significant associations between quality of life and venous disease severity as assessed with both visual and ultrasound methods. These differences were observed for both men and women for functional scales of the SF-36. The relationships were significant and were graded with degree of disease severity.¹⁰ Recreational folk dance provides a gentle form of exercise for people of all age groups, and may be used to provide a different leisure option. Recreational folk dance provides an activity that is socially engaging, physically challenging, creative, and culturally and mentally stimulating.²⁴ We recorded that dance therapy had a positive effect on quality of life of CVI patients in our study. We had seen that patients were happy and smiling while they were in the dance therapy program, because they were making exercises with the enjoyable music. Sounds can create a mood such as ‘quiet and peaceful’ or ‘happy and bright’. The music was a folk music that listened mostly in the weddings and festivals. And we think patients felt themselves like in an enjoyable treatment environment. Meanwhile, it integrates psychological, physiological and sociological aspects in the process of movement. These feelings might provide improvement in the quality of life aspects. Involvement in the dance activity brought along general exercise benefits, which contributed to a healthy lifestyle, meanwhile folk dance has a beneficial effect on interpersonal and intrapersonal aspects of self-esteem.²⁴

Although pain in individuals with CVI has been ignored for a long time, it is now considered to be a significant problem because of its prevalence and its repercussions on their quality of life.⁵ A hypothetical explanation for the lower pain threshold is that the venous stasis in CVI may augment the leukocyteendothelial inflammatory reaction, which is considered the main stimulator of nociceptors in the venous wall and in paravasal tissue. In addition, ischemia caused by venous microangiopathy and increased endoneurial pressure may result in nerve impairment, which may account for the underlying neuropathic pain.⁵ When we reviewed the post-treatment results there was no significant difference between groups in the RMI and VCSS parameters (p > 0.05), but SF-36 scale’s bodily pain score (p < 0.05) was significantly higher in the dance therapy group. Dance therapy affected positively CVI patient’s quality of life.

Significant difference was found in therapy group’s quality of life and VCSS scores, between the pre- and post-treatment results. There was significant difference in SF-36 scale’s general health and mental health parameters of control group between the pre- and post-treatment results. It was found that there were significant differences in many parameters in dance therapy group. But when we compared results between the groups we could not find significant difference as we expected. It was thought that the therapy’s duration and number of patient caused these results. And the patients who had or planned to have surgical endovascular treatments were excluded. The patients who included in this study were in early stage of the CVI, so they were not affected so much by the CVI. So we could not find significant difference for all parameters between groups. The following studies including different stages of patient could show improvements in different parameters with dance therapy.

CVI patients’ musculoskeletal impairment is mainly related to gastrocnemius muscle dysfunction and reduced range of ankle motion, especially dorsiflexion, which is thought to be required for normal functioning of the calf muscle pump.⁵ Physical therapy may prove to be effective, providing a superior response with the supervision of the exercise. The beneficial effects of muscle stretch and strengthening are coaxed quickly and they are sustainable with minimal additional therapeutic encounters.²² Several studies have demonstrated that the periodic contractions significantly decreases venous stasis, and that ankle motion restriction can have a negative impact on venous hemodynamics.^5,24–26 Both the tip-toe exercise while standing and flexing-stretching of the feet in the sitting positions stimulate the calf muscle effectively and enhance venous return.²⁷ The dance therapy program’ exercises in a folk dance like Delilo consist of tip-toe exercises. Folk dance patterns were chosen to support calf muscle activity. Post-treatment results showed that calf muscle pump function was activated and it was thought that those patterns in folk dance helped this.

Short-term (six weeks) exercise with pedal ergometer improved ankle joint motion and symptoms of pain and limb swelling considerably in an observational study.²⁸ Yang et al. who conducted a single-arm pilot study evaluating calf strengthening in relationship to calf pump function, in a six-week home-based program, they found significant differences in both ejection fraction and residual volume fraction; although strength and power demonstrated an inclination toward improvement, it did not achieve statistical significance.²⁷ In another study Padberget al. reported that calf muscle pump function and dynamic calf muscle strength were improved after a six-month program of structured exercise.^7,22 In our study, patients performed active ankle movement exercises in supine lying position and also we combined active ankle movement with dance therapy. We could not find significant difference between groups while there was clinically improvement difference between pre- and post-treatment results in dance therapy group.

Patients who have chronic venous disorders have a reduced quality of life compared with the general population and they need surgery for various reasons – regardless of those what they may be. Use of the SF-36 to assess patients with varicose veins has shown that if varicose veins trouble a patient then physical component could be affected significantly.^29,30 Specialists say that dance is an activity which decreases tension, owing to the dilatation of a great number of blood-vessels. The number of functional capillaries per square millimeter is about 200 during rest, while it rises up to 820 per square millimeter for a person who dances. It was declared that dance is, as well, an efficient means of prevention against CVI.³¹ But still proper reporting on adverse events is needed to base the benefits of dancing for the CVI patients on both efficacy and safety by considering duration of the intervention, frequency, and intensity.

Dance therapy may provide reduction in BMI and abdominal circumference, but unfortunately we did not evaluated them in post-treatment. We offer future studies to evaluate weight and all the body circumference in pre- and post-therapy.

Conclusion

World Health Organization defines health as “a state of complete physical, mental and social well-being.” Dance therapy provides scope for progress in imagination, freedom and knowledge in addition to the physical well-being and optimism. There were no barriers (e.g. age and background) to participation in this form of gentle exercise, showing that it is to meliorate the cardiovascular, physical and psychological benefits of an activity that is enhancing of the self-esteem in addition to the quality of life.

Treatment of CVI should consist of methods not only about medical status; it should consist of methods that support the patient mentally, physically and psychologically. We concluded that dance therapy might be a potential exercise intervention with a low cost intervention without reported side effects for CVI patients. Meanwhile, prescription for this form of gentle exercise in addition to medical treatment could be recommended by health professionals as doctors, physiotherapists and occupational therapists for improvements in CVI patients. Further high-quality clinical trials are necessary to confirm on both efficacy and safety of the dance therapy in individuals with CVI.

Footnotes

Acknowledgements

The authors would like to thank for support to Seyda Ciler Soylemez, Ayse Karakaya, Tugce Erkovan, Yonca Elci as well as the CVI patients who participated in this study. The study was conducted in Hatay, Turkey.

Authors’ contribution

Study design: Esra Dogru-Huzmeli, Iyad Fansa; Data collection: Esra Dogru-Huzmeli, Iyad Fansa, Cem Lale; Analysis: Esra Dogru-Huzmeli, Yagmur Cam; Manuscript writing: Esra Dogru-Huzmeli, Iyad Fansa, Gul Oznur-Karabicak, Nilufer Cetisli-Korkmaz, Cem Lale, Ozden Gokcek.

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) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors gratefully acknowledge the financial support received from the Scientific and Technological Research Council of Turkey (TUBITAK).

ORCID iD

Esra Dogru-Huzmeli

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