Abstract

Aim:

To propose a dance therapy and free dance protocol for women undergoing adjuvant treatment of breast cancer and to compare its effectiveness with the control group and the healthy group.

Method:

Protocol for a 12-week randomized clinical trial with a frequency of 2 times at progressive intensity, in which the participants will be allocated into 4 groups: (a) dance therapy intervention; (b) free dance intervention; (c) control group and (d) healthy group. Information related to personal and clinical characteristics as well as psychological aspects will be collected. The primary outcome will be analyzed through depressive symptoms while secondary outcomes include the variables: body image, anxiety, mood, perceived stress, and optimism. Assessments will be carried out in the pre-intervention period (baseline) and after 12 weeks of intervention in all groups.

Discussion:

As a hypothesis, there are improvements in psychological aspects after dance therapy interventions and free dance, reaching the level of healthy women, given the benefits of that protocol.

Keywords
psychological aspects; motor activity; dance; breast neoplasm; therapy

Introduction

In addition to physical exercise and art, expressive body movement has been considered in its therapeutic potential11. Boing L, Do Bem Fretta T, De Carvalho Souza Vieira M, Pereira GS, Moratelli J, Sperandio FF, et al. Pilates and dance to patients with breast cancer undergoing treatment: Study protocol for a randomized clinical trial - MoveMama study. Trials. 2020;21(1):1-17. doi
doi... . Dance, for excellence, is a form of expression with sensitivity, sense, and meaning, transcending the power of verbal communication22. Garaudy R. Dançar a Vida. São Paulo, Editora Nova Fronteira; 1980.. It accentuates a growing space in so-called complementary or alternative health therapies33. Tesser CD, Sousa IMC de, Nascimento MC do. Práticas Integrativas e Complementares na Atenção Primária à Saúde brasileira. Saúde em Debate. 2018;42(spe1):174-188. doi
doi... . As one of the bodily practices that seek the totality of the “being”, that is, that can add to the physical body, emotion, and spirit, dance provides support, strength, and meaning to verbal and non-verbal pronouncements, positions, and expressions of the body and the physical and symbolic space it occupies in time and space22. Garaudy R. Dançar a Vida. São Paulo, Editora Nova Fronteira; 1980..

Thinking about the sick body, not only in the biological sphere, allows a more appropriate treatment and recovery since the human being is understood as a biopsychosocial being and, therefore, liable to present demands in the three fields at any time of life. Welcoming the sick body and soul generates the opportunity to reframe movement and “being” in a complete, integrated, and complex way44. Gonçalves C de O, Tavares M da CGF, Cabello C, Shimo AKK. Instruments to evaluate body image in women with breast cancer. Psicol Teor e Prática. 2012;14(2):43-55. doi
doi... . One of the physical exercises which can be related to the care and improvement of patients with breast cancer due to its characteristics of being a pleasant and pleasurable practice is dance55. Sandel SL, Judge JO, Landry N, Faria L, Ouellette R, Majczak M. Dance and Movement Program Improves Quality-of-Life Measures in Breast Cancer Survivors. Cancer Nurs. 2005;28(4):301-309. doi
doi... . In this way, some studies have demonstrated the benefits brought to this population66. Kaltsatou A, Mameletzi D, Douka S. Physical and psychological benefits of a 24-week traditional dance program in breast cancer survivors. J Bodyw Mov Ther. 2011;15(2):162-167. doi
doi... .

The treatment of breast cancer and all its side effects, such as nausea, vomiting, insomnia, pain, loss of appetite, and fatigue77. Hopwood P, Haviland J, Mills J, Sumo G, Bliss JM. The impact of age and clinical factors on quality of life in early breast cancer: An analysis of 2208 women recruited to the UK START Trial (Standardisation of Breast Radiotherapy Trial). The Breast. 2007;16(3):241-251. doi
doi... are associated with the consequences on patients’ quality of life88. Lôbo SA, Fernandes AFC, Almeida PC de, Carvalho CM de L, Sawada NO. Qualidade de vida em mulheres com neoplasias de mama em quimioterapia. Acta Paul Enferm. 2014;27(6):554-559. doi
doi... . Some psychological aspects also change, such as body image99. Furlan VLA, Sabino Neto M, Abla LEF, Oliveira CJR, Lima AC de, Ruiz BF de O, et al. Qualidade de vida e autoestima de pacientes mastectomizadas submetidas ou não a reconstrução de mama. Rev Bras Cir Plástica. 2013;28(2):264-269. doi
doi... , self-esteem1010. Ha EH, Cho YK. The Mediating Effects of Self-Esteem and Optimism on the Relationship between Quality of Life and Depressive Symptoms of Breast Cancer Patients. Psychiatry Investig. 2014;11(4):437. doi
doi... , depressive symptoms1111. Cormanique TF, Almeida LEDF de, Rech CA, Rech D, Herrera AC da S do A, Panis C. Chronic psychological stress and its impact on the development of aggressive breast cancer. Einstein (São Paulo). 2015;13(3):352-356. doi
doi... , stress1212. Cuevas BT, Hughes DC, Parma DL, Treviño-Whitaker RA, Ghosh S, Li R, et al. Motivation, exercise, and stress in breast cancer survivors. Support Care Cancer. 2014;22(4):911-917. doi
doi... , and optimism1313. Juárez García DM, Landero Hernández R, González Ramírez MT, Jaime Bernal L. Variación diurna del cortisol y su relación con estrés, optimismo y estrategias de afrontamiento en mujeres con cáncer de mama. Acta Colomb Psicol. 2016;19(1):113-122. doi
doi... .

As a non-pharmacological and less costly possibility, it is believed that regular dance practice can be a plausible alternative to minimize the side effects of breast cancer treatment and improve the psychological aspects of patients. As these are two innovative protocols, both dance therapy and free dance, investigating the practice of dance during the period of clinical treatment may reflect on new perspectives as well as foster projects aimed exclusively at this period of treatment. In the literature, it is possible to identify studies with the same purpose by suggesting the elaboration of dance protocols specially developed for the population in question11. Boing L, Do Bem Fretta T, De Carvalho Souza Vieira M, Pereira GS, Moratelli J, Sperandio FF, et al. Pilates and dance to patients with breast cancer undergoing treatment: Study protocol for a randomized clinical trial - MoveMama study. Trials. 2020;21(1):1-17. doi
doi... . In this way, the results of this study can support new public policies for incentives and interventions aimed at these patients, considering the high incidence rates of breast cancer in the world, in the country, and in the southern region1414. Instituto Nacional de Câncer (INCA). Coordenação de Prevenção e Vigilância. Estimativa 2020: Incidência de Câncer no Brasil. Availabe from: https://www.inca.gov.br/publicacoes/livros/estimativa-2020-incidencia-de-cancer-no-brasil [Accessed 23th May 2022]
https://www.inca.gov.br/publicacoes/livr... .

Thus, both dance therapy and free dance protocol promote improvements in psychological aspects in women undergoing adjuvant treatment for breast cancer, which are beneficial activity options for this population.

Methods

Study design

A four-arm randomized controlled clinical trial will be carried out over 12 weeks to determine the effectiveness of two dance interventions (dance therapy and free dance) on the psychological aspects of women undergoing adjuvant breast cancer treatment having as primary outcome depressive symptoms and secondary outcome to self-esteem, body image, mood, stress, optimism, and anxiety.

The study will consist of four groups: Dance Therapy Group (GDT), Free Dance Group (GDL), Control Group (CG), and Healthy Control Group (GCS). Ethical approval was granted through the Human Research Ethics Committee (CEPSH) of UDESC (protocol 3.985.052) and registered in the Brazilian Registry of Clinical Trials (ReBEC) (number 0RBR-772ktp). All procedures followed the Helsinki declaration.

This protocol study was guided by the standard protocol items: recommendations for interventional trials. Figure 1 shows the CONSORT (Consolidated Standards of Reporting Trials) flowchart, enrollment schedules, interventions, and study evaluations. Figure 2 shows the checklist using the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) used in the study.

Participants

Women diagnosed with breast cancer will be allocated during a period of adjuvant clinical treatment for breast cancer, recruited in two ways: 1) dissemination in the media (radio, television, internet, and print media) and 2) in employing institutions or service providers in terms of education, justice, religion, health, and insurance in the city of Florianópolis and São José. In addition, healthy individuals will be recruited in the same way mentioned above, who correspond to the same age and sex of individuals with breast cancer in the city of Florianópolis and São José (Santa Catarina, Brazil).

Inclusion and exclusion criteria

Inclusion criteria are defined: (1) Age group: older than 18 years; (2) Clinical stage: 0 to III of breast cancer; (3) Being on adjuvant breast cancer treatment; (4) Being resident in the cities of Florianópolis or São José; (5) Presenting a release from the oncologist responsible for the practice of physical exercise.

Exclusion criteria were determined: (1) Presenting some orthopedic limitation that prevents the practice of systematic physical activity, defined by a questionnaire; (2) Performing combined practice of any physical exercises in order to avoid confusion bias in the face of the intervention; (3) Having practiced dance therapy or free dance in the past three months; (4) Not attending at least 75% of the prescribed classes.

Sample size calculation

The G * Power 3.1.9.2 software was used to perform the sample size calculation, The method of distinguishing was used between the means, with n = (α + β) 2σ / d2. The values of α = 0.05 and β = 0.80 were respected, according to the table of the Gaussian curve. The values 2.69 and 0.51 respectively were used. The variable considered for the calculation was depressive symptoms. And the difference between the means was obtained through the study by Boing et al.1515. Boing L, Baptista F, Pereira GS, Sperandio FF, Moratelli J, Cardoso AA, et al. Benefits of belly dance on quality of life, fatigue, and depressive symptoms in women with breast cancer - A pilot study of a non-randomised clinical trial. J Bodyw Mov Ther. 2018;22(2):460-466. doi
doi... which used dance for women with breast cancer. Therefore, a total number of 96 participants is expected to be distributed among the four study groups.

Randomization and blinding

The randomization of the sample will be carried out by two auxiliary researchers from the Laboratory of Research on Leisure and Physical Activity - LAPLAF/CNPq. They will receive a sealed envelope containing a nominal list of the women recruited and will be blinded to the allocation of the groups (free dance, dance therapy, and group control). Thus, among these participants, the randomization will be carried out in secret in a computer program, Randomization.org, which will predict the allocation of participants into three intervention groups: a) group A: intervention with the practice of Dance therapy; b) group B: intervention with the practice of Free Dance and c) control group: that will be invited to maintain their routine activities. Group D will not participate in the randomization process, formed by healthy individuals, that is, without breast cancer.

The blinding of the study will not be possible since it is an intervention with physical exercise. In this way, both the participants and the researchers will know the activity being taught. Thus, in order to avoid any bias, data analysis will be requested by a researcher external to the intervention and data collection.

Intervention

The dance modalities chosen for these interventions were dance therapy and free dance, as both are stimulated by music and provide well-being to the participants. Dance therapy will promote the integration of the emotional, social, cognitive, and physical through the bodily and emotional experiences that it carries with it. While free dance will bring movements proposed by the teacher, covering various dance modalities, such as funk, axé, forró, pop, and samba, among others.

Dance therapy intervention protocol for women undergoing adjuvant breast cancer treatment (Table 1)

The dance sessions will be held at CEFID/UDESC (Center for Physical Education, Physiotherapy and Sports at the State University of Santa Catarina) in the city of Florianópolis/SC. They will last 60 min, twice a week on non-consecutive days (Tuesday and Thursday), without rest, for 12 weeks, with light to vigorous intensity, verified through the rhythm of the songs (beats per minute - bpm) and the complexity of the movements, respecting the individuality of each participant. The speed of the chosen songs is measured according to the following classification: up to 80 bpm (slow time), up to 120 bpm (moderate time), and up to 150 bpm (vigorous time). The verification of the rhythm of the songs will be performed according to the beats per min (bpm), and counting will be performed using the bpm Detector Pro application.

A) Warm-up and Integration (15 min - Songs up to 80 bpm; and up to 120 bpm - Slow and moderate rhythm): 1- Starting Wheel. The group of students will start the class hand in hand, dancing freely to the music that will be repeated in all the classes. The connection between the individual body and the group body is sought from the gradual release of movements and the exchange of looks and facial expressions, guided by the intention of communication and welcoming. A droplet of essential oil (lavender or mint) will be used on each student's wrist. The friction of the wrists will enhance the aroma and, consequently, stimulate the sense of smell as a way of harmonization of the environment; 2- Music of integration between themselves and the group. The group is invited to undo the circle formation and each member can go to another one, in their turn, seeking the connection through physical contact. At this moment, it is proposed that the referred contact expresses the feeling of welcome, equality, respect, sonority, and belonging through gestures and touches on the other person's body; 3- Music for mobilization of upper limbs, lower limbs, and spinal muscles. In this song, there will be the execution of broad to specific joint movements, including flexion, extension, abduction, adduction, and internal and external shoulder rotations, starting from the upper body, going through trunk movements, until reaching the lower limbs; 4- Music for rhythmic movements around the room in different directions (timing, setbacks, and breaks); 5- Music for integrative body practice (IBP) based on experiential exercises, inspired by Biodanza.

B) Activities developed/Central contents (30 min - Music of up to 80 bpm; up to 120 bpm and up to 150 bpm - Slow, moderate, and vigorous rhythms): First block of dance content - Dance style (which can be samba, Rock, Salsa, Merengue, Waltz, Tango, Forró, Bolero, Kizomba, Zouk, Sertanejo, or Axé): 6 - Approach Music; 7 - Movement Learning Music; 8 - Practice Music; Second block of specific dance content - Dance Style: 9 - Approach Music; 10 - Movement Learning Music; 11 - Practice Music; 12 - Music for review/(Re) Creation of learned movements: the group is invited to record the movements learned in each dance style learned in class. However, each participant will have space of freedom to execute the form, sequence, cadence, and expression they desire and feel more comfortable performing. Two minutes of songs number 7 and 10 from the selection organized for a class that day will be repeated; 13 - Music for improvement/creation: at this moment, spaces for freedom of expression are proposed. Improving improvisation will always have a theme generated by the teacher and will be based on the feelings and sensations expressed by the participants at the end of each previous class (reflection round). Improvisation can also be stimulated by a poem, a phrase, a photograph, an object, or even by a theme that is proposed by some part of the group.

C) Final Experiences/Cooling Down and Reflection (15 min - Music of up to 80 bpm and up to 120 bpm - Slow and moderate rhythms): 14 - Music for vocal expression and dramatization in a circle: the students will be encouraged to sing the song chosen for this moment while they interpret it with movements. Such movements, at first, will be proposed by the researcher, and, afterward, students will be asked to make their corporal interpretation of the lyrics. Facial expressions will be well emphasized; 15 - Music for final stretching; 16 - Music for relaxation and final reflection: in a circle, students will be invited to close their eyes and notice in themselves the reflexes/effects of the class. In an attitude of connection, the teacher will walk around the circle, passing each student and touching their shoulders with a comfortable intensity. The intention of doing so is to convey feelings such as belonging, care, and acceptance. After passing through and touching all the students, the teacher invites them to touch their shoulders, with their eyes still closed, in sliding movements that, in turn, convey feelings of acceptance, affirmation, and recognition of themselves.

Free dance intervention protocol for women undergoing adjuvant breast cancer treatment (Tables 2 and 3)

The free dance sessions will be held at the CEFID/UDESC gym in the city of Florianópolis/SC. They will last 60 min and will occur twice a week (Tuesdays and Thursdays), in the afternoon, for 12 weeks, with increasing intensity from light to vigorous verified through the rhythm of the songs (bpm), respecting the individuality of each participant. The speed of the chosen songs will follow the following classification: up to 80 bpm (slow time), up to 120 bpm (moderate time), and up to 150 bpm (vigorous time). The verification of the rhythm of the songs will be performed according to the measurement in bpm. The counting will be carried out using the bpm Detector Pro application. It is important to highlight that the protocols will be applied by two different researchers since the period of classes takes place simultaneously.

A) Initial warm-up and stretching: the beginning of the class will feature a slower pace, in which the songs worked in the first instance will be determined with up to 80 bpm. A choreographed stretching (exercises performed to the rhythm of the music), exercises to mobilize the upper limbs, lower limbs, and spine muscles will be performed as well as rhythmic displacements in different directions and integration in a circle, lasting 15 min, as a way to increase the body temperature of the practitioners and the bond between them.

B) Main part: Develop free dance movements, stimulating motor coordination, rhythm, and body awareness, improving aspects of flexibility and range of motion of the upper limbs. The activity can be explored individually, in pairs, or groups, according to the rhythm of the music (axé, funk, pop, disco music, forró, hip hop, samba, pagode, vogue, and stylet), always respecting body awareness of each participant, and stimulating the expression of feelings. For this part of the class, songs considered to have a moderate pace (up to 120 bpm) will be used as well as those considered to have a fast/vigorous pace (up to 150 bpm). This class session will have an average duration of 30 min.

C) Relaxation: The end of the class, slower movements will be performed, through the practice of static stretching and relaxation techniques with breathing, using songs in which bpm varies from 80 to 120 (slow to the moderate rhythm). Stretching exercises for the mobility of the upper and lower limbs using the Swiss ball will be performed at the end of the classes to decrease heart rate and increase relaxation. With cardiac frequency normalization, this part will last for 15 min.

Control group and healthy control group

Patients randomly allocated to the control group will be invited to continue their routine activities along with the adjuvant treatment. In order to encourage them to maintain their routine activities, since it would be unethical to ask them not to practice physical activity during the intervention period, three calls will be made by the same researcher during the intervention period in the 4th week, the 8th week, and the 12th week from the beginning of the intervention. These calls are intended to keep track of patients in this group and identify if there have been changes concerning the practice of physical activity.

They will be part of the control group of healthy women with the same characteristics as the intervention and control group, but without breast cancer (absence of disease), matched by age. They will be invited to maintain their routine activities (without the practice of dances and physical exercises, only physical activity). In order to encourage them to maintain their routine activities, since it would be unethical to ask them not to practice physical activity during the intervention period, three calls will be made by the same researcher during the 12 weeks of intervention, in detail, in the 4th week, in the 8th week, and the 12th week from the beginning of the intervention. These calls are intended to keep track of the participants in this group and to identify if there have been changes concerning the practice of physical activity. At the end of the 12 weeks of intervention, this group will be invited to take part in the Ritmo e Movimento extension Project.

Security and intensity

Dance Therapy and Free Dance interventions will be carried out after all the evaluation procedures to start the 12 weeks of intervention. These evaluations consist of instruments to evaluate the psychological aspects where all information about the research will be provided to the participants.

Classes will be taught by two physical education professionals, both of them with experience in dance classes, dance therapy, and free dance classes.

The songs used in these protocols were characterized as slow (max. 80 bpm), medium (up to 120 bpm), and vigorous (max. 150 bpm), with detection made through the Detector Pro application. And a subjective scale of perceived exertion will be used to verify the intensity of the interventions.

Any adverse events that occur during the intervention will be immediately reported to the main researcher. The proposed movements will be executed respecting the limit of each participant in order to avoid embarrassment due to possible physical or even psychological difficulties. Likewise, any adverse events that may occur (pressure drops, dizziness, chest pain, blurred vision, irregular pulse, fainting, shortness of breath, falls, or others) will be handled through professional assistance provided by the responsible researcher and team.

Outcome measures

All measurements will be performed in two moments, namely, the baseline period (T0) (pre-intervention) and after the 12 weeks of study intervention (T1) (post-intervention). The measures will be carried out by trained evaluators, who will not be blinded to the allocation of groups. Data collection will take around 45 min at a time previously set by the researchers. A summary of all the results measures that will be collected at each moment is shown in Figure 2. This figure is based on the recommended content script for the composition of test protocols that will be used in tests with intervention, SPIRIT.

Primary outcome measure

Data will be collected one month before the intervention and one month after the intervention.

• Depressive symptoms: The instrument to assess depressive symptoms will be the Beck Depression Inventory (BDI).

Secondary outcome measures

Data will be collected one month before the intervention and one month after the intervention.

• Anxiety: The assessment instrument will be the Beck Anxiety Inventory (BAI).

• Humor: The assessment instrument will be the Brunel Mood Scale (BRUMS).

• Body image: The assessment instrument will be the Body Image After Breast Cancer (BIBCQ).

• Self-esteem: The assessment instrument will be the Self-Esteem Scale (EAR).

• Optimism about life: The assessment instrument will be the Life Orientation Test (TOV-R).

• Stress: The assessment instrument will be the Perceived Stress Scale (PSS).

Statistical analysis

An electronic spreadsheet will be created in the Microsoft Excel program. The data will be tabulated and transported to the SPSS statistical package, version 20.0. First, descriptive statistics (mean, standard deviation, and percentage) will be performed. Comparative analyzes will be carried out between the results of the Dance Therapy, Free Dance, and control groups after the intervention period, as well as pre- and post-intra-group comparisons so that you can observe changes after the interventions. Anovatwo-way tests with repeated measures and Sydak comparison can be used. (5% significance level).

References

Publication Dates

History