effects of dance movement therapy and dance on health ... of dance movement...are the ones primarily...

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EffectsofDanceMovementTherapyandDanceonHealth-RelatedPsychologicalOutcomes:AMeta-Analysis

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Elsevier Editorial System(tm) for The Arts

in Psychotherapy

Manuscript Draft

Manuscript Number: AIP-D-13-00077R1

Title: Effects of Dance Movement Therapy and Dance on Health-Related

Psychological Outcomes: A Meta-Analysis

Article Type: Full Length Article

Keywords: dance movement therapy; therapeutic use of dance; meta-

analysis; review; randomized controlled trials; clinical controlled

trials; integrative medicine.

Corresponding Author: Dr. Sabine Christa Koch, PhD, Psychology, M.A.,

Creative Arts

Corresponding Author's Institution: SRH University Heidelberg

First Author: Sabine C Koch, Prof. Dr.

Order of Authors: Sabine C Koch, Prof. Dr.; Sabine Christa Koch, PhD,

Psychology, M.A., Creative Arts; Teresa Kunz, M.A.; Sissy Lykou, M.A.;

Robyn F Cruz, PhD

Ms. Ref. No.: AIP-D-13-00077

Title: Effects of Dance Movement Therapy and Dance on Health-Related Psychological Outcomes: A

Meta-Analysis, The Arts in Psychotherapy

Dear editorial office,

We would like to thank the reviewers for their comments and addressed each one in the outline of

our details on changes. We integrated them in blue text color into the manuscript.

With best regards,

Sabine Koch

*Covering Letter

Running head: EFFECTS OF DANCE MOVEMENT THERAPY AND DANCE. A META-

ANALYSIS.

Effects of Dance Movement Therapy and Dance on Health-Related Psychological Outcomes:

A Meta-Analysis

Sabine Koch1, Teresa Kunz

2, Sissy Lykou

2, & Robyn Cruz

3

1SRH University Heidelberg,

2University of Heidelberg,

3Lesley University, Cambridge, MA

Contact details:

Prof. Dr. Sabine C. Koch

SRH University Heidelberg

Maria Probst Str.. 3

69123 Heidelberg

Germany

Email: [email protected]

Acknowledgements

We would like to thank Astrid Kolter, who accompanied the first part of the collection and

systematization of the studies, Annabelle Humm for her help with data extraction and

retrieval of articles, and Joke Bradt and Malte Stopsack for methodological advice.

Correspondence concerning this article should be addressed to: Prof. Dr. Sabine C. Koch,

SRH University Heidelberg, Maria Probst Str. 3, 69123 Heidelberg; email:

[email protected]

*Title page with author details

Ms. Ref. No.: AIP-D-13-00077

Title: Effects of Dance Movement Therapy and Dance on Health-Related Psychological Outcomes: A

Meta-Analysis, The Arts in Psychotherapy

Dear editorial office,

We would like to thank the reviewers for their comments and addressed each one in this outline of

our details on changes.

Reviewer #1:

Reviewer 1 lists some problems with validity issues:

* Of the 23 studies analyzed, 16 were DMT and 7 various dance/movement forms;

this is true, but not a problem since our criterion was to include studies aiming at health-related

psychological outcomes, which both groups of studies did.

* More than half had no intervention

this is not true, all of them had an intervention

* 7 of the control groups were on waiting lists; 6 offered an alternative and 10 had no control

group;

this is not true, all of the included studies had a control group

* the sparsity of control groups (i.e., offering some alternative activity administered during a

parallel time frame as the experimental group) is problematic and, likewise, increases the probability

of a Hawthorne effect.

the problem is in fact that the majority if control groups did not all follow other activities while the

treatment group received treatment, increasing the probability of Hawthorne effects; one of the

major reasons for missing alternative interventions is that DMT-primary studies, operating in a field

without research funding, can often plain not afford to offer patients in control groups alternative

treatment (for time and money constraints); this fact is mirrored in the reality of the primary studies’

designs. The danger of a Hawthorne effect is discussed in some of the primary studies, but not in all.

We addressed this on page 25 of the discussion (see below).

* Twelve were clinical interventions, the rest were not

the rest were mostly community-based interventions; however, the variability of the populations

and the interventions actually strengthens the generalizability and the validity of the study. Breadth

was an aim.

* Operational definitions could not be discerned, as diverse assessments measured common

dependent variables (e.g., Quality of Life, Well Being and Affect, Body Image, Depression, etc.)

Operational definitions are provided in the primary studies, when instruments were non-

standardized, which we checked. Many instruments were standardized, providing operational

*Detailed Response to Reviewers

definitions in their manuals. Space constraints did not allow us to go further with this in the meta

analysis.

* Descriptive variables, such as length of a study, length and frequency of sessions varied: e. g.,

from a one time, 20 minute session to five sessions of 30 minutes in two weeks, to 180 minute

sessions for six months (curious as to whether these three hours were purely DMT or combined with

other activities).

The data on length of intervention varied widely; however, it can be seen as a strength of the

study that even with such wide variability effects were detected (besides: the 180min or three hours

were authentic movement, so yes, purely DMT).

* In one subclinical DMT study (of self selected participants) the experimental group, ages 16-65,

contained an N of 97. The sheer number and range of ages suggests that this was an aggregate of

several disparate groups. One wonders how such diversity impacted the process and analysis, or

importantly, how it might have skewed the validity of the meta analysis despite the compensatory

pooling of the variables of the statistical analyses.

The great diversity and heterogeneity of this analysis is purposeful and again can be seen as a positive: despite the large variance in age and population effects were detected. Cochrane protocols are the alternative and they are followed by other research groups; for our research group the big picture was more important. Validity issues summary: We limited our review to health-related psychological outcomes, since these are the ones primarily aimed at by DMT, and added dance research studies that aimed at improving the same or similar outcomes. We defined this aim and the selected studies really do address those health related psychological outcomes, thus validity being generally given. We only used studies that had control groups, so the reviewer missed that. Combining clinical and nonclinical samples can be argued to make the study stronger – showing effects in the general population is very useful. The different types of control groups (active alternative vs wait list) can be addressed as a limitation (which we did on page…). We checked for sufficient operational definitions in each study. Length and age variability were embraced for this study, heterogeneity was controlled for, limitations of such heterogeneity were discussed in detail.

* Importantly, although the authors acknowledge many of the individual studies may have been

quite flawed, inclusion criteria were not based on their robustness but rather, other factors (listed in

inclusion and exclusion section). From this reader's perusal of the information included here, many

would not have withstood the scrutiny of standard research protocols.

This is true and we reasoned for this on p. 5. “Cochrane Reviews employ the highest standards of

evidence-based health care research, and thus only studies of the highest quality can enter. The small number of

studies eligible to be included in the Cochrane Reviews shows that there is a clear need for improvement of

research designs. It also indicates that the present state of findings calls for another general meta-analysis

assembling the best evidence in the field in a broader manner.”

Reviewer 1 had difficulty reading and interpreting the Figures, i.e., the Forest Plots. Perhaps an

explanation of this statistical procedure should be explicated, including the various symbols, in the

methods section.

We added an explanation on page 16, where the first forest plot is introduced: “The forest plots

indicate the direction of the effects found in the primary studies and the magnitude of the

effects on the x-axis, the sample size is indicated by the size of the square symbol, and the

rhombus indicates the overall effect size.”

Statistical procedures are described in the SMD-paragraph on page 8 / 9.

One overarching concern re the studies selected in this meta analysis is, a wide range of dance and

movement forms with varying objectives -from clinical and sub-clinical interventions, to the

recreational- are employed to examine their effects on various aspects of mood and emotional

function. This leads one to question whether engagement in other types of activities -that is, any

experiences activating mood enhancing neurotransmitters that produce positive change- that may

last for hours, days, or perhaps, weeks- would have evidenced comparable outcomes? In light of the

fact that, in most instances here, the purpose was not necessarily therapy (but would be considered

therapeutic), does the type of activity (dance or other) really matter?

type of activity matters as seen for example in the Koch et al., 2007 study; the authors used a

dance condition, a sports condition (moving up to same arousal) and a simulation condition (just

listening to the music of the – well known- dance). The dance condition improved vitality and

decreased depressive affect significantly more than the sports condition and the music listening

condition. Overall, a number of studies had control groups with alternative activities (9 studies used

control groups of either counselling or activity type), and in these and DMT was consistently shown to

be more effective; but of course there are a trillion of other “other activities” that had not been

included; under the logic of falsification, we can only assume the effect with assuming error.

This issue is now newly addressed on page 26/27 of the discussion (see below).

Reviewer #2

As reviewer 2 suspected, this project started out as one focusing on DMT (as intimated early on), but

the lack of sufficient published research studies led to the inclusion of sub- and non- clinical research

( as mentioned above this fact strengthens the generalizability of the study).

A further concern is the dearth of control groups receiving alternatives administered during the same

period as the experimental participants. (I don't perceive the waiting list as a valid control group

yes, there are only… cases with a true treatment alternative; but given the lack of funding for

DMT-studies, one cannot expect that such an optimal design can often be afforded).

We addressed the “non-active” control group issue newly on p. 25: “One important limitation of the

primary studies was that in many of the control groups, no alternative activities were offered;

only nine studies included an alternative counseling or activity intervention. There is always

the danger of a Hawthorn effect in cases where the control group is not provided with the

same attention as the treatment group.”

Given these factors, I questioned what difference it made whether this analysis was based on

dance/movement forms or any other mood enhancing (therapeutic) experiences set up with

comparable research objectives. I think the authors need to address that issue further.

We addressed this issue in the discussion on p. 26/27

“Two additional questions are relevant for discussion. Firstly: Does the type of activity (dance

or other) really matter? From the data, we need to state that yes, type of activity seems to

matter as seen for example, in the Koch et al. (2007) study using a dance condition, a sports

condition (moving up to same level of arousal) and a simulation condition (just listening to

the music of the dance); the dance condition improved vitality and decreased depressive

affect significantly more than the sports condition and the music listening condition. Overall,

a number of studies in the present analysis had control groups with alternative activities (nine

studies used control groups of other activities; five DMT and four dance studies), and in these

studies DMT and dance were consistently shown to be more effective; but of course there are

an endless number of other “other activities” that were not included and make the effect

subject to potential falsification. Secondly: Is there any difference between DMT and any

other mood enhancing therapeutic experience with comparable objectives? This question can

be only tentatively addressed. Dance research in this meta-analysis was carefully chosen for

aiming at the same outcomes with therapeutic intentions. These studies did improve mood and

decrease depression in subclinical and nonclinical populations. DMT did the same and more

(decrease of anxiety, increase in quality of life) in mainly clinical and a few subclinical

populations. While at this point comparability is limited, and there is a need for more

research, we can state that the fact that effects were detected for both clinical and community

populations is promising for future work.”

Finally:

There is the possibility that there may be no difference in results whether this analysis was based on

dance/movement forms or any other mood enhancing (therapeutic) experiences set up with

comparable research objectives. However, on the basis of the studies that controlled for this factor

thoroughly, we would like to argue that there is a fair amount of evidence for a specific effect of

DMT… If you consider the studies on dance vs DMT and their effect on decrease of depression

presented here as evidence for the hypothesis that there is no difference here, then evidence stands

against evidence and more studies controlling for exactly that specific effect are needed. On the other

side, since the studies on the effects of dance on decrease of depression were all done with sub- or

non clinical populations, and the DMT studies almost all with clinical populations, you cannot truly

compare them or at least make such a strong claim. …

In general, we cannot control the quality of the research that is out there, but we can do as much as

possible to carefully get the most out of what is out there – which we did, using our best knowledge.

We would like to thank the reviewers for bringing up the important points making our review

more complete or pointing out more open questions!

Highlights

Meta-analysis of DMT interventions and the therapeutic use of dance

Provides a systematic summary of the last 20 years of research findings.

Includes the effects of 23 evidence-based primary studies (N= 1078).

Shows moderate effects for quality of life and clinical outcomes (depression, anxiety).

Yields small but consistent effects for well-being, mood, affect, and body image.

*Highlights (for review)

Running head: EFFECTS OF DANCE MOVEMENT THERAPY AND DANCE. A META-

ANALYSIS.


A Meta-Analysis

*Manuscript without author identifiersClick here to view linked References

http://ees.elsevier.com/aip/viewRCResults.aspx?pdf=1&docID=1013&rev=1&fileID=18846&msid=B727493C-D629-49C8-B0B7-0EE68569A257

META-ANALYSIS OF DANCE MOVEMENT THERAPY AND DANCE 2

Abstract

In this meta-analysis, we evaluated the effectiveness of dance movement therapy1 (DMT) and

the therapeutic use of dance for the treatment of health-related psychological problems.

Research in the field of DMT is growing, and 17 years have passed since the last and only

general meta-analysis on DMT (Ritter & Low, 1996) was conducted. This study examines the

current state of knowledge regarding the effectiveness of DMT and dance from 23 primary

trials (N=1078) on the variables of quality of life, body image, well-being, and clinical

outcomes, with sub-analysis of depression, anxiety, and interpersonal competence. Results

suggest that DMT and dance are effective for increasing quality of life and decreasing clinical

symptoms such as depression and anxiety. Positive effects were also found on the increase of

subjective well-being, positive mood, affect, and body image. Effects for interpersonal

competence were encouraging, but due to the heterogenity of the data remained inconclusive.

Methodological shortcomings of many primary studies limit these encouraging results and,

therefore, further investigations to strengthen and expand upon evidence-based research in

DMT are necessary. Implications of the findings for health care, research, and practice are

discussed.

Keywords: dance movement therapy, therapeutic use of dance, meta-analysis, review,

randomized controlled trials, clinical controlled trials, integrative medicine

1This term includes the practice of dance movement psychotherapy (UK) and dance/movement therapy (USA).



A Meta-Analysis

Dance is one of the most ancient forms of healing. Today, dance movement therapy

(DMT) is an established profession and, following the definition of the American Dance

Therapy Association (ADTA), it is used therapeutically to strengthen the emotional,

cognitive, physical and social integration of the individual (ADTA, 2013; cf. EADMT, 2013).

Yet, in order to establish dance and particularly DMT as an evidence-based treatment,

empirical proof of its effects is important. Research in DMT has considerably increased in the

last decades, particularly in the last part of the 20th and at the beginning of the 21st century

(Meekums, 2010). Since the foundation of the ADTA in 1966, an increasing interest in dance

movement therapy, its functions, goals, and effects has been observed. Most of the research

over the past 50 years has focused on qualitative descriptions and case studies (Hervey, 2009).

This focus on qualitative rather than quantitative research is mainly due to the nature of

creative arts therapy, which emphasizes creativity and subjective ways of knowing (Junge &

Linesch, 1993). The arts can be employed as methods of inquiry and ways of knowing

(Hervey, 2000; McDougall, Bevan, & Semper, 2011). Many arts therapists, therefore, take a

critical stance on empirical science and the quantitative paradigm which is engaged in

causality or prediction – it is, for instance, questionable whether a few outcomes measured in

a quantitative investigation could meet and capture therapeutic processes, individual change,

the therapeutic relationship, or aesthetics and creativity (Junge & Linesch, 1993). However,

evidence-based research is important in order to ensure that DMT and the therapeutic use of

dance are effective interventions for health-related psychological problems. The

demonstration of its effectiveness is essential for promoting DMT to healthcare and/or

education providers, and to the survival of the profession. Being involved in this challenging

area of disparity between arts and science, it seems necessary to strengthen the development


of both DMT as an evidence-based discipline, such as in the present analysis, and through

phenomenological-approaches (i.e., subjective, first-person, experience-based approaches)

and qualitative methods (e.g., Serlin, 1996).

Because DMT is increasingly used to treat a variety of behavioral, psychological, and

medical conditions, it is important that the research addresses the increasing standards of

evidence-based medical research. In the hierarchy of evidence, case studies are at the lowest

level followed by clinical controlled studies without randomization at an intermediate level.

Randomized controlled trials (RCTs), meta-analyses and systematic reviews are at the top

levels of evidence (Sackett, 2000). Across the creative arts therapies we found more than 15

meta-analyses in music therapy (e.g., Bradt, & Dileo, 2009; 2010; Bradt, Dileo, & Shim,

2013; Gold, Heldal, Dahle, & Wigram, 2005; Mössler, Chen, Heldal, & Gold, C., 2011;

Pesek, 2007), four in art therapy (e.g., Ruddy & Milnes, 2005; Campbell, 2010), and one in

drama therapy (Ruddy & Dent-Brown, 2007). We found three meta-analyses that summarize

studies in DMT (Bradt, Goodill, & Dileo, 2011, for psychooncology; Ritter & Low, 1996,

general overview; and Xia & Grant, 2009, for schizophrenia), one descriptive review for

DMT and depression (Mala, Karkou, & Meekums, 2012), and two systematic reviews for

effects of DMT and dance (Kiepe, Stöckigt, & Keil, 2012; Strassel, Cherkin, Steuten,

Sherman, & Vrijhoef, 2011; both reviews of 2012 were not actively included into our

analysis, since they were published after April 2012). Three meta-analyses in DMT were in

progress: next to our own, there were two Cochrane Reviews at protocol stage by UK-based

dance movement therapists Bonnie Meekums and Vicky Karkou (Karkou & Meekums, 2013;

Meekums, Karkou, & Nelson, 2012). Effects of dance were not yet included into a DMT

meta-analysis.

Out of all of the meta-analyses in DMT, Ritter and Low‟s meta-analysis (1996)

provides the only general overview of quantitative DMT studies, including 23 studies

published between 1973 and 1993. The authors showed that DMT is an effective intervention


for a wide range of symptoms, with particularly good results in the reduction of anxiety. The

study also provides support for the effectiveness of DMT with different client groups.

Moderate effect sizes for DMT interventions were found in subclinical participants (i.e.,

participants “at risk”, but yet without diagnosis), children, adult psychiatric patients, adults

with developmental or physical disabilities, as well as in elderly populations. However,

limitations in calculations and interpretation of the Ritter and Low study (e.g., combined

effect sizes (r) for between-groups and repeated measure designs), led Cruz and Sabers (1998)

to recalculate the data with the result that DMT was found to be even more effective than

reported by Ritter and Low (1996). In fact, DMT-effects were found to be comparable to

effects of other types of therapies including pharmacological and verbal psychotherapies.

Examining the meta-analyses from the Cochrane Reviews (Bradt, et al., 2011; Xia &

Grant, 2009) more closely, only very few primary studies fulfilled the criteria to enter the

final analyses: in the first case – out of 17 studies reviewed - only the studies by Dibbell-Hope

(2000) and Sandel et al. (2005) entered the analysis and in the second case – out of 6 studies

reviewed – only the primary study of Röhricht and Priebe (2006) yielded the quality to enter

the review. Cochrane Reviews employ the highest standards of evidence-based health care

research, and thus only studies of the highest quality can enter. The small number of studies

eligible to be included in the Cochrane Reviews shows that there is a clear need for

improvement of research designs. It also indicates that the present state of findings calls for

another general meta-analysis assembling the best evidence in the field in a broader manner.

Regarding the dependent variables, we limited our review to health-related

psychological outcomes, since these are the ones primarily aimed at by DMT, and added

dance research studies that aimed at improving the same or similar outcomes. In addition to

individual health outcomes we also included interpersonal outcomes (such as interpersonal

sensitivity and social relatedness). The clusters resulting from repeated reviewing of the

outcome measures and the comparability of the measurement instruments employed in the


primary studies (i.e., the single studies included) were: (a) quality of life; (b) body image; (c)

well-being, mood and affect; and (d) clinical outcomes. For the clinical outcomes we did one

main analysis and three sub-analyses of depression, anxiety and interpersonal competence.

Many of the studies we examined did not enter this meta-analysis because they did not fulfill

the inclusion criteria (see methods section for details). However, they frequently contributed

important aspects to evidence-based research. Such as a study on the effectiveness of creative

dance on children vs. senior citizens in terms of enhancing their social functioning,

administered in separate groups vs. intergenerational groups, favoring the intergenerational

group (Rossberg-Gempton, Dickinson, & Poole, 1999). Or a study researching the effects of

Waltz-lessons on skill learning for patients with mild Alzheimer dementia vs. patients with

depression, showing that the patients with Alzheimer benefited more than the patients with

depression (Rösler et al., 2002). These studies could not be included in our meta-analysis,

because there was no clear control group and a very low N in the second case. Other studies

had not been completed by the time our data analysis was conducted (e.g., Janković Marušić

& Boban, 2013, on eating disorders), or there were studies with an appropriate design but

available descriptive data were insufficient (Berrol, 1984, on school children; Berrol, Ooi, &

Katz, 1997, on older adults with neurological insult; Kaplan Westbrook & McKibben, 1989,

on patients with Parkinson's disease; or Skye, Christensen, & England, 1989, on stress and

anxiety reduction). The study by Skye et al. (1989), for example, – based on an educational

doctoral dissertation – investigated effects of a dance program on stress reduction in

American Indian adolescent girls, and demonstrated a significant decrease of STAI trait

anxiety and state anxiety after the dance intervention.

In sum, there is a need for a new general meta-analysis that provides evidence for the

effectiveness of DMT and dance in health-related psychological issues. We compiled and

systematized all evidence-based findings published since the last general meta-analysis in the

field, to provide an overview as valid and comprehensive as possible. Our aim was to examine


the effectiveness of DMT and dance as psychotherapeutic interventions for various

populations.

Methods

Search Methods

The systematic research of suitable primary studies was finalized in April 2012.

Initially the focus of the search was on studies investigating the effects of DMT. Later on, the

search was expanded to the effects of the therapeutic use of dance. The relevant electronic

databases used were PubMed/Medline, Psyndex, PsycINFO, ERIC, CENTRAL, and Google

Scholar. The following keywords were used in order to find eligible results: “dance

movement psychotherapy”, “dance movement therapy”, “dance therapy”, “therapeutic

movement”, “dance-effectiveness”, “dance” and “dance-therapy” with the additional search

terms “controlled trial” and “random”. The journal “Body, Movement and Dance in

Psychotherapy” was hand-searched from its first issue in March 2006 until March 2012.

Additionally, through the European Association of Dance Movement Therapy (EADMT), the

American Dance Therapy Association (ADTA), the German Association of Dance Therapy

(BTD) and through personal e-mail distribution lists, a letter was sent out to dance movement

therapists and researchers, requesting them to help identify relevant research studies.

Selection of Studies

Three independent researchers carried out the selection of relevant studies. They

included studies that fulfilled the following criteria:

a. Intervention study (investigating the effect of dance movement therapy, creative

movement or dance) conducted as a controlled trial using a between-group design and

at least two assessments (pre-test and post-test)

b. Focusing on health-related psychological outcomes (as opposed to health-related

physical outcomes such as shoulder range of motion)


c. Presentation of all necessary statistics to enable the calculation of effect sizes (plus

contact with the authors to include missing statistics)

d. Conducted after 1993 (with two exceptions that were not included in the meta-analysis

of Ritter and Low, 1996)

There were no restrictions on age, gender, ethnicity, clinical or non-clinical samples,

published or unpublished papers, length of treatment, or language.

Data Extraction

Two researchers independently extracted the data from the selected trials. When any

important information was missing, the authors of the corresponding study were contacted for

clarification. The data extractions were compared and, when there were any differences, the

aspects were once again checked and discussed.

The following aspects were extracted: title, author, year of publication, sample size,

diagnosis, clinical vs. non-clinical sample, age range, kind of intervention, kind of control

group activity, length and frequency of treatment, randomization (see Table 1). Variables and

statistics are presented in Table 2, alongside the corresponding data.

– Insert Table 1 about here –

Data Synthesis

This meta-analysis was performed using the Review Manager 5.1 software program

(2011). Because outcomes were derived from different scales, standardized mean differences

(SMD) with 95% confidence intervals (CI) were calculated. SMD were calculated using post-

treatment data. The formula implemented in Review Manager 5.1 for SMD is Hedges‟

adjusted g, which is similar to Cohen‟s d, but additionally includes an adjustment for small

sample size bias (Deeks & Higgins, 2010):


SMD<0.40 are interpreted as small, SMD of 0.40 to 0.70 as moderate, and SMD larger than

0.70 are considered to be large (Higgins & Green, 2008).

It was assumed that the studies were not all estimating the same intervention effect,

but estimated intervention effects that follow a distribution across studies. Therefore, the

random effects model was implemented. In order to avoid dependence among multiple effect

sizes within the same study in one cluster, a decision was made as to which outcome measure

would be the main one for each study and cluster, and this main outcome measure was used in

the respective analysis.

To ensure the comparability of the groups within the single trials, baseline differences

for pre-test scores were calculated for each study. If there were baseline differences larger

than d = 0.5, change scores were calculated in addition. These outcomes could not be

included in the analysis of post-test scores because it is not possible to combine post-test data

and change scores when using SMD (Higgins & Green, 2008). Therefore, when baseline

differences were detected, we conducted additional analyses on change scores. One trial

(Dibbell-Hope, 2000) only reported post-test data, therefore no investigation of baseline

differences was possible and, consequently, only post-test values from that trial were reported

and analyzed.

When two or more experimental groups were compared to one control group

(Hackney & Earhart, 2009), or more than one control group was compared to one

experimental group (Koch, Morlinghaus, & Fuchs, 2007; Meekums, Vaverniece, Majore-

Dusele, & Rasnacs, 2012), then the groups were combined, resulting in one experimental and

one control group, as recommended by Higgins and Green (2008). In one case (Dibbell-Hope,

2000), two independent samples, two experimental groups and two control groups from

geographically distinct regions (Northern Alameda County vs. Southern Alameda County),


were reported. In order to avoid biases from reporting two samples that received the same

intervention, the one with more participants (Southern Alameda County) was chosen.

Assessment of Heterogeneity

To quantify inconsistency, I-squared tests were conducted. I² describes the percentage

of the variability in effect estimates that is due to heterogeneity rather than chance. I² > 40%

indicates heterogeneity (Higgins & Green, 2008). For a tentative classification of I², Higgins

and Thompson (2002) proposed that small heterogeneity corresponds to I2=25%, moderate

heterogeneity to values around I²=50%, and high heterogeneity to values higher than 50%.

Sensitivity Analysis

Sensitivity analyses were conducted to examine the impact of randomization methods.

These types of analyses are used to determine and assess whether results are robust to the

decisions made in the selection process (Higgins & Green, 2008). In the present meta-

analysis, six studies were included which did not use randomization. Therefore, sensitivity

analyses were conducted in which the results of trials with randomization were compared to

those of trials that were partially randomized or not randomized. For this purpose, first all

studies were included, and in a second step, studies without randomization were excluded in

each cluster. To investigate whether the difference between these tests was significant, Z-tests

were computed.

Quality of Included Trials

There is a risk that studies may overestimate or underestimate the true effect of an

intervention. Hence, the recommendation is to assess the risk of bias in reviews in order to

produce meaningful results and conclusions (Higgins & Green, 2008). There are many tools,

scales and checklists that provide summary scores to assess the quality of studies, but there is

no consensus on the best approach (Viswanathan et al., 2012). There were three reasons we

decided not to use any of these tools in this review. First, it was shown that summary scores

provide unreliable assessments of the validity of studies, because scores differ from scale to


scale (e.g., Jüni, Witschi, Bloch, & Egger, 1999; Moher, Jadad, & Tugwell, 1996). Second,

there is little empirical evidence supporting the existing risk-of-bias scales (Conn & Rantz,

2003). And third, none of the reviewed assessment methods seemed to fit the purpose of the

primary studies. For example, the participants in medical research are blind to whether they

are receiving the active ingredient or a placebo and this is a commonly used item in those

scales, but this form of blinding is not possible in DMT and/or dance studies. For all of these

reasons, study quality was characterized descriptively (see below under “Quality of included

trials”).

Results

Included Studies

Twenty-three studies were included in this meta-analysis. Sixteen of the included

studies investigated the effect of DMT on psychological variables, and seven investigated the

effects of dance on different clinical outcomes. Dance interventions varied in terms of dance

forms (e.g. ballroom dance or folk dance).

Regarding the control group activity, in 15 studies the control group received no

intervention or formed a wait-list control group (for an overview see Table 1). The other

studies differed in their control group activity. In the study by Hilf (2009), the control group

took part in a leisure time program and received a body experience intervention, whereas

Hokkanen et al. (2008) provided a control group who spent their time on regular nursing

home activities. In the study by Koch et al.(2007), there were initially two control groups – a

home trainer group and a music listening group. Because it is only possible to compare the

intervention group to one control group, we combined both control groups as recommended in

the Cochrane Handbook (Higgins & Green, 2008). Also, Meekums, Vaverniece, et al. (2012)

initially included two control groups; an exercise group and a non-exercise group, which were

combined into one control group. The control group in the study by Noreau, Martineau, Roy

and Belzile (1995) received counseling and discussion sessions, and Röhricht and Priebe


(2006) provided supportive counseling as a control group activity. In total, 15 studies reported

no intervention control groups, 6 studies offered some kind of activity for the control group,

and 2 studies did not specify the control group intervention (Hartshorn et al., 2001; Osgood,

Meyers, & Orchowsky, 1990).

With respect to the target groups, clinical, subclinical and non-clinical populations

were included. Out of the 23 studies, 15 focused on clinical populations, whereas 8 trials

worked with subclinical and non-clinical populations. The diagnoses of the clinical trials can

be summarized as follows: three studies investigated breast cancer (Dibbell-Hope, 2000;

Goldov, 2011; Sandel, et al., 2005) and three researched the effects of dance or DMT on

patients with depression (Haboush, Floyd, Caron, LaSota, & Alvarez, 2006; Jeong et al.,

2005; Koch, et al., 2007); two studies focused on patients with somatization problems (Bojner

Horwitz, Kowalski, Theorell, & Anderberg, 2006, on fibromyalgia; Hilf, 2009, on

somatoform disorder). In addition, the effects of DMT on patients with autism (Hartshorn, et

al., 2001; Koch et al., 2013), schizophrenia (Röhricht & Priebe, 2006), dementia (Hokkanen,

et al., 2008), Parkinson‟s disease (Hackney & Earhart, 2009), rheumatoid arthritis (Noreau, et

al., 1995) and cystic fibrosis (Goodill, 2005) were investigated. Three out of the eight

remaining studies were subclinical trials that worked with populations “at risk”: Karkou,

Fullarton and Scarth (2009) worked with young people who were at risk of developing mental

health problems, Bräuninger (2006) focused on adults suffering from stress, and Erwin-

Grabner, Goodill, Hill and Von Neida (1999) worked with students with test anxiety. The five

remaining non-clinical studies concentrated on students (Akandere & Demir, 2011), the

elderly (Eyigor, Karapolat, Durmaz, Ibisoglu, & Cakir, 2009; Hartshorn, Delage, Field, &

Olds, 2002; Osgood, et al., 1990) and women who participated in a commercial weight loss

program (Meekums, Vaverniece, et al., 2012).

For a description of the outcomes, a main outcome for each study was identified and

then all outcomes were summarized into four clusters – identified by the authors and then


discussed with and validated by two external clinicians – as follows. Clinical aspects were in

the focus of most studies: in three studies, data from depression scales were investigated

(Akandere & Demir, 2011; Haboush, et al., 2006; Koch, et al., 2007), one study examined

emotional eating (Meekums, Vaverniece, et al., 2012), and another (Erwin-Grabner, et al.,

1999) test anxiety. In the study by Röhricht and Priebe (2006), symptoms of schizophrenia

were targeted, whereas Hilf (2009) collected data on somatoform disorder, and Hokkanen et

al. (2008) analyzed scales for dementia. The studies by Koch et al. (2013), and Hartshorn et

al. (2001) focused on symptoms of autism. Karkou et al. (2009), Noreau et al. (1995), and

Jeong et al. (2005) mainly targeted data on mental health. Besides clinical aspects, quality of

life was examined as the main outcome measure in five studies (Bräuninger, 2006; Eyigor, et

al., 2009; Hackney & Earhart, 2009; Osgood, et al., 1990; Sandel, et al., 2005). Impact on

mood was selected from the studies by Goodill (2005) and Hartshorn et al. (2002). Dibbel-

Hope (2000) targeted psychological adaptation to breast cancer, Goldov (2011) examined

body image outcomes in patients with breast cancer, and from Bojner Horwitz (2006) we

selected the self-figure drawings to be included into the body image cluster.

Further details of the included studies are summarized in Table 1.

Quality of included trials.

All 23 studies described clearly the aim, objective or hypothesis of their investigation

and all of them addressed the characteristics of their participants as well as the inclusion and

exclusion criteria. The main anticipated outcomes and the main findings were described in all

of the included studies. The intervention was clearly described and clarified in all cases.

Baseline differences were reported and analyzed in 15 studies. Consequently, eight studies did

not explicitly report whether the groups were comparable prior to intervention (Bojner

Horwitz, et al., 2006; Goldov, 2011; Goodill, 2005; Hartshorn, et al., 2002; Hartshorn, et al.,

2001; Karkou, et al., 2009; Koch, et al., 2007; Osgood, et al., 1990). Due to the nature of

DMT interventions and the therapeutic use of dance, as stated earlier, participants were not


blind to the treatment condition in all of the included studies. Four studies (Bojner Horwitz, et

al., 2006; Erwin-Grabner, et al., 1999; Jeong, et al., 2005; Karkou, et al., 2009) explicitly

reported that randomization was conducted by a person blind to the experimental procedures.

Also, in four studies the assessors of the participants were blind to the experimental

conditions (Goodill, 2005; Haboush, et al., 2006; Röhricht & Priebe, 2006; Sandel, et al.,

2005).

With regard to randomization, 6 out of the 23 studies did not conduct (complete)

randomized trials and, therefore, did not offer randomization methods (Goldov, 2011;

Hartshorn, et al., 2001; Koch, et al., 2013; Meekums, Vaverniece, et al., 2012; Noreau, et al.,

1995; Osgood, et al., 1990). In small samples careful matching is often a better choice than

randomization. Meekums, Vavernice, et al. (2012) used partial randomization due to

limitations of sample size. Hartshorn, et al. (2001), Koch, et al. (2013), and Osgood, et al.

(1990) used matched samples due to logistic and situational demands, in Hartshorn et al.‟s

case parents and teachers were also blind to the conditions of the study. Noreau, et al. (1995)

did not further specify why randomization was not possible, and Goldov (2011) used self-

selection of patients with breast cancer into intervention and control group, because it was not

possible to “oblige women to give up their choice and control over their bodies at a vulnerable

and demanding time” (p. 94).

Overall, all of the included studies offered a quite satisfactory degree of

methodological quality. However, there were differences in the quality of the included

studies, especially with regard to randomization, blinding strategy, and the analysis of

baseline differences. Risk of bias and the impact of methodological quality on the results of

this meta-analysis will be further explored in the Discussion section.

Excluded Studies

Studies were excluded from the analysis when they did not meet the above mentioned

criteria for inclusion. Also, various studies were excluded because they did not contain the


necessary statistics (e.g., Berrol, et al., 1997; Kaplan Westbrook & McKibben, 1989; Kipp,

Herda, & Schwarz, 2000; Rösler, et al., 2002; Rossberg-Gempton, et al., 1999; Skye, et al.,

1989) or because the outcome variables were not targeted in this meta-analysis. This applied,

for example, to studies that examined cognitive variables (e.g., Jansen, Kellner, & Rieder,

2012), or studies that measured only functional physical effects (e.g., Couper, 1981; Flores,

1995; Hackney, Kantorovich, & Earhart, 2007; Hopkins, Murrah, Hoeger, & Rhodes, 1990;

Lausberg, 1998; Shigematsu et al., 2002). Two RCTs of the last category need further

inspection – because we found them too late for inclusion: McKinley, Jacobson, Leroux,

Bednarcyzk, Rossignol, and Fung (2008) on the effects of tango on elderly patients with fear

of falling, and Belardinelli, Lacalaprice, Ventrella, Volpe, and Faccenda (2008) on the effects

of Walz dancing on stable chronic heart failure. Finally, studies had to be excluded when the

intervention was neither dance nor DMT (e.g., Kissane et al., 2007; Van de Winckel, Feys, De

Weerdt, & Dom, 2004).

Effects of Interventions

In order to analyze the effects of interventions on the various variables, the outcomes

were classified into five main clusters: quality of life, well-being, mood and affect, body

image, and clinical outcomes. Moreover, sub-analyses of clinical outcomes related to

depression, anxiety, and interpersonal competence were conducted.

Table 2 summarizes the clusters and the corresponding studies and outcomes, Table 3

provides a summary of the results within each category including estimated effect sizes and

significance tests.




Quality of life. Ten trials (see Table 2) examined the effects of dance or DMT on

quality of life with 550 participants altogether (NEG= 301, NCG= 249). Out of these trials, the

data of one trial (Hackney & Earhart, 2009) could not be included in the analysis of post-test

scores, because baseline differences were detected between the control group and the dance

intervention groups, which were aggregated into one group. A meta-analysis of the remaining

nine trials (see Figure 1; N = 489; NEG= 257, NCG= 232) resulted in a pooled estimate of SMD

= 0.37 (see Table 3) that supported an effect of dance and DMT on quality of life, and the

results were consistent across studies (I² = 0%). The forest plots indicate the direction of the

effects found in the primary studies and the magnitude of the effects on the x-axis, the sample

size is indicated by the size of the square symbol, and the rhombus indicates the overall effect

size.

– Insert Figure 1 about here –

An additional analysis on change scores was performed because one study (Hackney

& Earhart, 2009) could not be included in the analysis of post-test scores due to baseline

differences. Therefore, all studies were analyzed based on change scores (N = 550; NEG= 301,

NCG= 249), resulting in a pooled estimate of SMD = 0.23 (see Table 3) with homogenous

results (I²= 0%).

Well-being, mood and affect. A total of seven studies (see Table 2) reported the

effects of dance or DMT on well-being, mood and affect. The pooled estimate of those seven

trials (see Figure 2; N = 350; NEG= 175, NCG= 175) indicated that DMT and dance

interventions improve well-being, mood and affect (SMD = 0.30; see Table 3). The results

were consistent across trials (I²= 5%).



Body Image. Six studies (see Table 2) reported the effects of DMT or dance on body

image (see Figure 3; N= 209; NEG=91, NCG= 118). Their pooled estimate yielded support for

an effect of dance or DMT on body image (SMD = 0.27; see Table 3) and the results were

consistent across trials (I²= 11%).


Clinical Outcomes. Ten trials (see Table 2) compared the effects of DMT or dance to

control group interventions on the reduction of negative clinical outcomes. Three trials

(Hartshorn, et al., 2001; Hilf, 2009; Jeong, et al., 2005) could not be included because

baseline differences in the outcome measure were detected between the control group and the

experimental group. Pooled estimate of the included trials (see Figure 4; N = 342; NEG= 173,

NCG= 169) indicated support for an effect of dance or DMT on depression (SMD = 0.44; see

Table 3), and the results were consistent across the trials (I²=0%).


An analysis of all trials based on change scores including the three trials with baseline

differences (excluding Dibbell-Hope, 2000 because change scores were not computable) (N =

474; NEG= 240, NCG= 233) revealed an effect of DMT or dance on clinical outcomes (SMD =

0.44; see Table 3). The results were consistent across trials (I²=0%).

Depression. Because 10 studies reported data regarding the effects of DMT or dance

on depression (Akandere & Demir, 2011; Bojner Horwitz, et al., 2006; Bräuninger, 2006;

Dibbell-Hope, 2000; Goodill, 2005; Haboush, et al., 2006; Hilf, 2009; Jeong, et al., 2005;

Koch, et al., 2007; Noreau, et al., 1995), a separate analysis on this variable was conducted.


A sub-analysis of global outcomes on depression was conducted with four studies that

had already entered the clinical outcome cluster (re-analysis of Bräuninger, 2006; Dibbell-

Hope, 2000; Goodill, 2005; Jeong, et al., 2005). Bojner Horwitz et al. (2006), Hilf (2009),

Akandere et al. (2011), Koch et al. (2007), Haboush et al. (2006), and Noreau et al. (1995) all

contributed new data to the analysis that had not entered the clinical outcome cluster before.

Two trials (Bojner Horwitz, et al., 2006; Jeong, et al., 2005) could not be included in

this analysis on post-test scores in the end, because baseline differences were detected

between the control group and the experimental group. The pooled estimate of the remaining

eight trials (see Figure 5; N = 424; NEG= 227, NCG= 197) showed support for an effect of

dance or DMT on depression (SMD = 0.36; see Table 3), and results were consistent across

the eight trials (I² = 0%).


In order to include and analyze the two studies with baseline differences, an additional

analysis of change scores was conducted. One trial could still not be included due to missing

pre-test scores (Dibbell-Hope, 2000). The pooled estimated effect of the nine included trials

(see Figure 6; N= 485; NEG= 261, NCG= 224) revealed an effect of DMT on depression (SMD

= 0.34, I²= 0%; see Table 3).

Anxiety. A sub-analysis was conducted for anxiety. Two trials reported additional data

on anxiety (Erwin-Grabner, et al., 1999; Noreau, et al., 1995). Anxiety subscales of global

outcome measures, which have already been analyzed in the clinical outcomes cluster, were

derived from the trials by Dibbell-Hope (2000) and Bräuninger (2006). Also, Jeong et al.

(2005) reported a subscale for anxiety, but, due to baseline differences, this outcome could not

be included in the analysis of post-test scores.

https://3c.gmx.net/mail/client/mailbody/tmai1318c755ebda8ac7/true;jsessionid=D35A66C46248B180C320177DE41EDFE2-n1.bs48a?selection=tfol11bf028bf8586f3a#_ENREF_7












The pooled estimate of the four included trials (see Figure 6; N= 203; NEG=120,

NCG=83) indicated that DMT and dance interventions decrease anxiety (SMD = 0.44; see

Table 3), and the results were consistent across the trials (I² = 0%).


An analysis of change scores, including the trial by Jeong et al. (2005), and excluding

the data by Dibbell-Hope (2000) because of missing pre-test scores, revealed a robust pooled

estimate that supported an effect of DMT and dance on anxiety (N= 228; NEG= 134, NCG= 94,

SMD= 0.46; see Table 3).

Interpersonal Competence. To analyze the effects of DMT on interpersonal

competence (which was not an outcome variable included in any of the dance investigations),

a sub-analysis on this dimension was conducted. In four studies, interpersonal competence

was measured as a sub-dimension of the already analyzed global clinical outcomes

(Bräuninger, 2006; Dibbell-Hope, 2000; Hokkanen, et al., 2008; Jeong, et al., 2005), and two

trials provided additional data on this dimension, which had not been analyzed before

(Hartshorn, et al., 2001; Koch, et al., 2013).

Five studies investigated the effects of DMT on interpersonal competence by

measuring interpersonal sensitivity (Bräuninger, 2006; Dibbell-Hope, 2000; Jeong, et al.,

2005; Koch, et al., 2013), or social relatedness (Hartshorn, et al., 2001), in 300 participants

(see Figure 7; NEG= 164, NCG= 136). The pooled estimate supported an effect of dance and

DMT on interpersonal competence (SMD= 0.45; see Table 3), but the results were

inconsistent across studies (I²= 52%).



One additional study examined the effects of DMT on social competence (Hokkanen,

et al., 2008) but could not be included because there were baseline differences between the

experimental group and the control group. Consequently, an additional analysis of change

scores was performed. Dibbell-Hope‟s study (2000) was excluded because of missing pre-test

scores. The analysis of the remaining five studies (N= 314; NEG=177, NCG= 137) based on

change scores resulted in a homogeneous outcome with a pooled estimate that found evidence

of an effect of DMT on interpersonal competence (SMD = 0.29, I²=17%; see Table 3).

Sensitivity Analysis. Sensitivity analyses, excluding those trials without or with only

partial randomization methods, did not significantly change the results in any cluster.

Additionally, differences between analyses of change scores and post-test scores were

explored in each cluster in which additional analysis on change scores had been conducted,

resulting in non-significant differences.

Discussion

This meta-analysis systematically reviewed the results of studies investigating the

effects of DMT interventions and the therapeutic use of dance since 1996. Twenty-three

primary studies of the last 20 years were included (N = 1078). Results suggest that DMT was

supported as effective intervention for the following populations or disorders: anxiety, autism

(children and adults), breast cancer, cystic fibrosis, depression (including geriatric and

adolescent forms), dementia, eating disorders (emotional eating and obesity), elderly,

fybromyalgia, youth at risk, rheumatoid arthritis, schizophrenia, somatoform disorder, and

stress. Dance was effective for depression, elderly patients, and Parkinson‟s disease. For a

differentiated quantification, data were classified into psychological outcome clusters. DMT

improved well-being, mood, affect, quality of life, body image and interpersonal competence,

and reduced clinical symptoms such as anxiety and depression. Dance was particularly

effective on quality of life and depression reduction. Pooled effect sizes varied from small to


moderate (SMD = 0.27 to 0.45), depending on the single clusters, which will now be

discussed in more detail.

With regard to quality of life, a moderate pooled effect size was observed. This result

strengthens the assumption that DMT and dance are beneficial interventions for increasing

quality of life (e.g., Earhart, 2009). Moreover, this finding is in agreement with previous

findings from other studies that showed a significant improvement in quality of life, for

example, in patients with cancer or Parkinson‟s disease (Earhart, 2009; Lacour, 2006;

Mannheim & Weis, 2005) but were not randomized controlled trials. Since quality of life is

regarded as an important objective criterion for evaluating medical interventions (Bräuninger,

2012), this finding has implications for the professional acceptance and standing of DMT and

dance interventions in the health sciences.

The analysis of the impact of DMT and dance on well-being, mood and affect revealed

a small pooled effect size, suggesting that DMT and dance may play a useful role as a

contributor to well-being, positive mood, and affect. Still, the findings of our study should be

interpreted with caution as this cluster was conceived as a more global cluster that included

quite different variables such as subjective well-being, affect, mood, and stress. Previous

findings for the effects of dance and DMT on well-being, mood and affect were mostly

supportive of DMT and dance. Goodill (2006) and van der Merwe (2010), for example,

reported beneficial effects of dance and movement on affect and well-being by reviewing the

literature.

For body image, a small effect was observed indicating limited impact of DMT and

dance on this variable. Three out of the six included primary studies did not initially find

significant differences in body image between the experimental and the control group

(Dibbell-Hope, 2000; Goodill, 2005; Sandel, et al., 2005) and one trial did not include tests of

significance (Goldov, 2011). Because body image is thought to be shaped by bodily

experiences amongst other things, and movement-based activities are thought to positively


influence body image (Leventhal & Schwartz, 1989), we would have expected a larger effect.

The findings of Lewis and Scannell (1995) regarding the impact of dance on body image

suggest that body image changes may happen only after longer time periodes, since they

found significantly more satisfying results for improvement of body image in participants

who had been dancing for at least five years. Following this reasoning, the included primary

studies would have needed a longer intervention time to yield larger effects. However, the

limited impact of DMT and dance on body image found in this meta-analysis could also stem

from the fact that studies varied widely in their operationalization of body image. For

instance, Sandel et al. (2005) and Goldov (2011) employed the Body Image Scale (Hopwood,

Fletcher, Lee, & Al Ghazal, 2001), whereas Goodill (2005) used human figure drawings to

assess body image. Therefore, the use of consistent, valid, and standardized measures of body

image are necessary in subsequent studies.

A moderate effect size was found for clinical outcomes. This result is consistent with

the finding of the meta-analysis of Ritter and Low (1996; recalculated by Cruz & Sabers,

1998) who also reported that DMT was moderately effective in psychiatric patients. Together

with numerous uncontrolled or partly controlled clinical trials, this finding supports the

effectiveness of DMT and dance with psychiatric patients and fostered the extension of the

implementation of DMT and dance to reduce clinical symptoms.

Three sub-analyses were conducted, including sub-categories of variables that have

partly been analyzed before. The first sub-analysis of clinical outcomes for depression

resulted in a moderate pooled effect size of DMT and dance interventions in reducing

depression. In the meta-analysis by Ritter and Low (1996; recalculated by Cruz and Sabers,

1998), one pilot study was included that investigated the effects of DMT on depression

(Brooks & Stark, 1989), which showed a moderate effect size. Clinical studies of other good

evidence levels contribute further encouraging findings to the effects of DMT and adjacent

body psychotherapies on the reduction of depression (e.g., Heimbeck, 2008; Kipp, Herda, &


Schwarz, 2000; Röhricht, Papadopoulos, & Priebe, 2013). Moreover, since many clinical

measures include depression, there are many trials that provide scores on depression as a sub-

measurement. The present findings support the effectiveness of DMT and dance on

depression including ten primary studies with convergent evidence. More studies,

investigating the effects of DMT on depression are underway. Most notably, Meekums,

Karkou and Nelson (2012) are currently conducting a Cochrane Review on the effects of

DMT on depression.

A second sub-analysis was carried out to examine the effects of DMT and dance on

anxiety, also suggesting a moderate pooled effect. The meta-analysis of Ritter and Low (1996)

had also analyzed changes in anxiety. According to the recalculation of Cruz and Sabers

(1998), there were large effects in anxiety reduction. Although the finding of the present

meta-analysis is somewhat smaller, the positive impact of DMT and dance on anxiety,

including test anxiety in academic settings (Erwin-Grabner et al., 1999), can be confirmed by

the more recent trials.

In order to investigate interpersonal aspects, the third sub-analysis focused on

interpersonal competence. To the best of our knowledge, this meta-analysis is among the first

to provide empirical support for the frequently stated assumption that DMT and dance affect

social and interpersonal variables. The result supported the assumption that DMT influences

interpersonal variables, because a moderate pooled effect size was found. Yet, the percentage

of total variation across studies was moderate (I² = 52%), possibly due to the many different

operationalizations of interpersonal competence. Such heterogeneity can usually be explored

by subgroup analyses. However, due to the small number of included studies subgroup

analyses were not meaningful here. The heterogeneity of the studies thus indicates the need

for more research.

The additional analysis of change scores we conducted confirmed the robustness of

the results, because magnitude and direction of observed effects for both analyses were quite


similar (see Table 1). Furthermore, with the exemption of interpersonal competence, the

percentage of the variability in effect estimates that was due to heterogeneity rather than

sampling error was small, suggesting homogeneous results. This implies that, despite

differences in study characteristics, magnitude and direction of observed effects were

comparable and quite similar, suggesting robustness of the effects.

The impact of missing or only partial randomization was addressed by sensitivity

analyses. Results did not differ significantly when the six studies without adequate

randomization methods were exlcluded. This finding underlines that, in the present analyses,

the results of randomized and non-randomized trials were comparable. However, non-

significant results could also be due to the small samples. On the one hand, it is frequently

argued that trials without randomization overestimate effect sizes (Higgins & Green, 2008).

On the other hand, Deeks et al. (2003) analyzed eight reviews and concluded that the effects

estimated by randomized and non-randomized trials did not differ consistently. Additionally,

in the field of creative arts therapies, randomized controlled trials may miss valuable

information, for example experiences of participants regarding the acceptability of such

interventions. Therefore, as a solitary source, randomized controlled trials are not sufficient

for assessing the effects of DMT and dance (Clay, 2010; Goldov, 2011).

Compared to the meta-analysis by Ritter and Low (1996), the present study provided a

more detailed analysis of outcomes and more analyses on health-related psychological

outcomes. Ritter and Low (1996) analyzed their data only regarding psychological change in

general (by evaluating anxiety, fatigue, self-esteem, trust, depression, sexual differentiation,

friendliness and anger in one analysis), and separately for anxiety, anger and self-concept.

Hence, more narrowly defined categories were analyzed in the present study providing more

accurate and more generalizable information. This rests on the fact that evidence-based

studies in DMT have increased since 1996 and more studies with more diverse measures and


specific trials (e.g., concerning population, diagnoses, and outcomes) have been published

since then, which enabled the analysis of more distinct outcome categories.

Limitations of the Present Study

The present meta-analysis provides encouraging results for DMT and dance

interventions. Although, several limitations should be considered when intepreting the results.

A common criticism in meta-analysis is “mixing apples and oranges” (i.e., the

inclusion of studies with very heterogeneous groups or outcomes) which could lead to

meaningless results (Higgins & Green, 2008). However, because our approach was a very

broad review to start with, we intended to focus on the higher order category of health-related

psychological outcomes. To address the critical aspects of the breadth of our analysis, it

should be mentioned that meaningful summaries can only be provided by meta-analyses that

include sufficiently homogeneous primary trials (e.g., with regard to participants or outcomes)

(Deeks, Higgins, & Altman, 2008). Because meta-analyses with more narrowly defined

approaches improve validity (O‟Connor, Green, & Higgins, 2008), the present analysis used

distinct clusters and investigated heterogeneity within each cluster to ensure the comparability

of results. Due to the limited number of primary studies in the single clusters, subgroup

analyses regarding the influence of DMT or dance interventions on specific age groups,

samples, or with a specific duration of intervention, were not conducted.

Another critical aspect lies in the limitations of the included primary studies. One

important limitation of the primary studies was that in many of the control groups, no

alternative activities were offered; only nine studies included an alternative counseling or

activity intervention. There is always the danger of a Hawthorn effect in cases where the

control group is not provided with the same attention as the treatment group. Due to the

varying quality of the included studies, results may be inconsistently biased. To counter the

common criticism of the „garbage in, garbage out‟ principle in meta-analyses, certain

inclusion criteria were chosen in the present meta-analysis, and the studies were carefully


selected with much attention to detail. However, the investigation of study quality revealed a

number of differences in the included studies, possibly confounding results, and thus limiting

the generalizability and validity of this research. Moreover, only a small number of studies

was included in this meta-analysis and consequently, the number of studies in the individual

clusters was limited. This affects the accuracy of the estimated effect size: Hedges and Vevea

(1998) pointed out that tests resulting from random effect models should be regarded as only

approximate, if the number of studies is less than five. In the present meta-analysis the

numbers of included studies were – with the exception of the anxiety analysis – five or more.

Results on anxiety should be interpreted with caution because only four studies were

included.

Furthermore, publication bias, also called the “file drawer problem”, is always a

critical issue that needs to be discussed. Statistically significant findings are more likely to be

published, and, therefore, effects in meta-analyses may be overestimated (Kugizaki, 2009;

Rosenthal, 1979). To minimize publication bias in the present study, comprehensive searches

were conducted, also including studies that had not been published and contacting authors

when data were missing. Still, it cannot be ruled out that studies on DMT or dance

interventions are missing. The file drawer problem was also examined visually in the form of

funnel plots, i.e., scatter plots of the estimated intervention effects against the standard errors

as a measure of study size. An asymetrical appearance of the funnel plot can indicate

publication bias (Higgins & Green, 2008). The funnel plots in this study did not show

evidence of publication bias. However, due to the limited number of included studies in the

single clusters, visual inspection of the funnel plots alone should be interpreted with caution.

Another critical aspect is that confidence intervals in the single clusters were relatively

wide, indicating that further information was needed to draw more definite conclusions as to

where the best estimate of the average effect was located. However, confidence intervals of


the average intervention effects will always be wider when the random effects method is

applied (Higgins & Green, 2008).

Finally, the present analysis only provides information on the effectiveness of DMT

and dance immediately following the intervention. No information about long-term effects

and follow-up developments could be included.

Two additional questions are relevant for discussion. Firstly: Does the type of activity

(dance or other) really matter? From the data, we need to state that yes, type of activity seems

to matter as seen for example, in the Koch et al. (2007) study using a dance condition, a sports

condition (moving up to same level of arousal) and a simulation condition (just listening to

the music of the dance); the dance condition improved vitality and decreased depressive

affect significantly more than the sports condition and the music listening condition. Overall,

a number of studies in the present analysis had control groups with alternative activities (nine

studies used control groups of other activities; five DMT and four dance studies), and in these

studies DMT and dance were consistently shown to be more effective; but of course there are

an endless number of other “other activities” that were not included and make the effect

subject to potential falsification. Secondly: Is there any difference between DMT and any

other mood enhancing therapeutic experience with comparable objectives? This question can

be only tentatively addressed. Dance research in this meta-analysis was carefully chosen for

aiming at the same outcomes with therapeutic intentions. These studies did improve mood and

decrease depression in subclinical and nonclinical populations. DMT did the same and more

(decrease of anxiety, increase in quality of life) in mainly clinical and a few subclinical

populations. While at this point comparability is limited, and there is a need for more

research, we can state that the fact that effects were detected for both clinical and community

populations is promising for future work.

Recommendations for Further Research


As the reviewed studies differed greatly in their quality, more well-designed studies

are generally needed. To meet criteria of evidence-based research, study designs in DMT and

dance research need to be adapted and improved. Next to further qualitative investigations,

more randomized controlled trials with well-suited control groups are desirable. Regarding

experimenter effects, blinding of the randomization procedure and blindness of the assessor

should be a standard in future research. Dance movement therapists or dance instructors

guiding the sessions should ideally also be blind to the hypotheses. However, qualitative

research including non-traditional and creative approaches are undoubtedly of utmost

importance for research in DMT and dance. Thus, in order to obtain a holistic and integrated

view of effects in the fields of DMT and dance, methodological diversity is required.

Therefore, qualitative and quantitative approaches should be combined into mixed methods

designs, resulting in an appropriate approach within the creative arts therapies, but also in

meaningful and comparable quantitative results.

Since the majority of trials were conducted with small samples, comprehensive studies

with larger sample sizes should be carried out. In the field of DMT and dance, however, there

is a lack of funded research, which makes it difficult to gather large sample sizes, conduct

long-term studies, or multicenter studies (i.e., studies conducted in more than one institution

with the same population). In such studies, a better generalizabuility of results could be

achieved.

A third important point would be the use of more standardized measurements. In

many studies, self-constructed items were used, and often non-standardized measurements

were employed. Homogeneous measurements and measurement methods should be applied in

order to establish consistency and to guarantee comparability of results. Taking into account

that nonverbal interventions were measured with verbal intervention tools here, more specific

measures geared to the body or behavioral level and nonverbal communication should in


future studies yield effects of greater magnitude than the ones reported here. There are several

such instruments in development in DMT at this point in time.

Moreover, statistical meticulousness is indicated. The inclusion of all descriptive

statistics (all means, standard deviations, and exact N for all pre- and post measures) into the

results section needs to become a standard of the primary studies in the field. Several studies

we reviewed missed this information.

DMT studies – and in fact any psychotherapy research – need to provide detailed

descriptions of the interventions used. Given that in the 23 studies included here only seven

described their interventions in a replicable way and only two used treatment manuals this is

an important factor for increasing the replicability of DMT studies. This criterion should be

more emphasized as an evidence-based standard in general.

An increased focus in the future should also lay on the investigation of specific factors

of effectiveness: What specific method and what specific part of the intervention is actually

effective for addressing specific aspects of a problem? Movement analysis tools in the field of

DMT offer differentiated hypotheses about the connection of movement and meaning, we

only need to start testing them more soundly and systematically in the context of evidence-

based or experimental research (e.g., Koch, et al., 2007). On the basis of the evidence-based

knowledge gained thus far, we could also gear our interventions even more specifically to

directly addressing the desired outcome (e.g., Röhricht & Priebe, 2006). In the future, a

Cochrane review on effects of DMT on anxiety reduction could be next, after one or two more

good quality primary studies with such a focus. A systematic review on the effects of DMT

and dance on interpersonal variables would further be important. Variables capturing positive

resources such as joy, hedonism, well-being, quality of life, life satisfaction and affect

expression – which are difficult to address with medication – should remain in the research

focus of the arts therapies in general.


Finally, the present study has implications for researchers, practitioners and the health

care system. Researchers can benefit from this work through obtaing a comprehensive

overview of the current state of research in the field of dance and DMT. Moreover, the

present work provides important ideas for future research, and offers researchers the

possibility to discuss and classify their results in light of the latest findings. For practitioners

and clinicians, this work contributes to the developing knowledge and evidence base of their

profession. On the one hand, it has implications for their self-perception as they learn about

their work‟s verifiable effects. On the other hand, this analysis delivers many arguments that

can lead to more acceptance and approval, and hence raise the awareness and appreciation of

DMT and the therapeutic use of dance by health care professionals. On a more global level,

implications can also be drawn for health care providers. Meta-analyses improve the

accessibility of research to decision makers. The present study intends to meet the current

evidence-based research standards of our health care systems. Based on the findings, it is

suggested that health care policy makers and providers should encourage the further

implementation of DMT and dance interventions, particularly with regard to the treatment of

clinical symptoms such as anxiety or depression, and the improvement of patients‟ quality of

life. A conceivable implication resulting from this analysis could be to encourage the

combination of DMT as a nonverbal psychotherapeutic component with other therapeutic

approaches, because of its effects on health-related psychological outcomes. However,

additional research evidence for this assumption is needed.

Conclusions

In sum, the present study provides a comprehensive summary of the current state of

research on effects of DMT and the therapeutic use of dance on health-related psychological

outcomes. It suggests that DMT and dance are effective interventions in many clinical

contexts. Empirical support was found for an increase in quality of life, well-being, mood,

affect, body image, and clinical outcomes, and particularly for a decrease of depression and


anxiety. Due to unexplained heterogeneity across results, effects for interpersonal competence

remained inconclusive, requiring further attention. In general, the resulting effect sizes from

SMD = 0.27 to 0.45 indicate that DMT is a meaningful evidence-based intervention for

health-related psychological outcomes, with according implications for decision making of

health care providers. The study supports DMT and dance as an effective and useful treatment

method in clinical and prevention contexts. Future research needs to investigate the effects of

DMT and dance by differentiating effects of specific interventions and analyzing further

characteristics and moderators, so that the present results can be put to test and expanded

upon.

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Table1

Summary of Studies, Sample Sizes, Age Ranges, Target Groups, Diagnoses, Interventions of Experimental Groups, Control Group Activities,

Length and Frequency of Treatment, and Assignments to Groups.

Title Author Year

of

Public

ation

Total

Sample

Size at

Pre-Test

Age Range

(or M, SD)

Target

Group

Diagnosis EG

Intervention

CG Activity Length and

Frequency

of Treatment

Assignment to

Groups

The effect of

dance over

depression

Akandere&

Demir

2011 120

(NEG=60;

NCG=60)

20-24 Non-

clinical

(students)

- Dance

(various

activities i.e.

rumba,

classic)

No

intervention

12 weeks;

3 times a

week;

100 minutes

Randomization

Dance/moveme

nt therapy in

patients with

fibromyalgia:

Changes in self-

figure drawings

and their

relation to

verbal self-

rating scales

BojnerHor

witz, et al.

2006 36

(NEG=20;

NCG=16)

M=57

(SD=7.2)

Clinical Fibromyalgia

(widespread

pain, and

pain in 11 of

18 tender

points)

DMT

(dance/move

ment therapy

intervention)

Waiting-list

control group

6 months;

weekly;

180 minutes

Randomization

Tanztherapie:

Verbesserung

der Lebens-

qualität und

Stress-

Bräuninger 2006 162

(NEG=97;

NCG=65)

16-65,

M = 44

(SD=9)

Subclinical Stress (self-

selected)

DMT Waiting-list

control group

10 weeks;

weekly

Randomization

in 9 of 12

groups (multi-

center study)


Bewältigung

The use of

dance/movemen

t therapy in

psychological

adaptation to

breast cancer

Dibbell-

Hope

2000 33 (N of

each

group

unclear;

only one

of the two

EGs,

n=17, was

focused in

this

analysis)

35-

80,M=54.7

Clinical Breast cancer

(stage I or II

tumor,

diagnosis

within at

least 1 year,

but no more

than 5 years

ago)

DMT

(authentic

movement)

Waiting-list

control group

6 weeks;

weekly;

180 minutes

Randomization

Effectiveness of

dance/movemen

t therapy on

reducing test

anxiety

Erwin-

Grabner, et

al.

1999 21

(NEG=11;

NCG=10)

19-

44,M=29

Subclinical Test anxiety

(self-

selected)

DMT (body-

oriented

techniques

and

expressive/in

teractive

movement

activity)

No

intervention

2 weeks;

5 sessions;

35 minutes

Randomization

A randomized

controlled trial

of Turkish

folklore dance

on the physical

performance,

balance,

depression and

quality of life in

older women

Eyigor, et

al.

2009 37(NEG=1

9;

NCG=18)

M=73.5

(SD=7.6)

Non-

clinical

(healthy

elderly

women)

- Dance

(group-based

Turkish

folklore

dances)

No

intervention

8 weeks;

3 times a

week;

60 minutes

Randomization

The effects of

individualized

Goldov 2011 14

(NEG=6;

47-71 Clinical Breast cancer DMT

(medical

No 2 weeks;

5 sessions;

No


brief medical

dance/

movement

therapy on body

image in

women with

breast cancer

NCG=8) of any type dance/move

ment

therapy)

intervention 30 minutes randomization

Dance/

movement

therapy for

adults with

cystic fibrosis:

Pilot data on

mood and

adherence

Goodill 2005 42

(NEG=24;

NCG=18)

17-67 Clinical Cystic

fibrosis

DMT No

intervention

7-10 days;

3 sessions;

45-60

minutes

Randomization

Ballroom dance

lessons for

geriatric

depression: An

exploratory

study

Haboush, et

al.

2006 24

(NEG=12;

NCG=12)

M=69.4

(SD=5.4)

Clinical Depression

(a score of

10 or higher

on the

Hamilton

Rating Scale)

Dance

(foxtrot,

waltz,

rumba,

swing, cha-

cha, and

tango)

Waiting-list

control group

8 weeks;

weekly;

45 minutes

Randomization

Health-related

quality of life

and alternative

forms of

exercise in

Parkinson

disease

Hackney &

Earhart

2009 61

(NEG=44;

NCG=17)

M=66.6

(SD=2.5)

Clinical Idiopathic

Parkinson‟s

disease

Dance (one

combined

experimental

group of

initially three

groups:

waltz/foxtrot,

tango and tai

chi)

No

intervention

13 weeks;

20 sessions;

60 minutes

Randomization


Creative

movement

therapy benefits

children with

autism

Hartshorn,

et al.

2001 76

(NEG=38;

NCG=38)

3-7,

M=5

Clinical Autism DMT No

description

2 months;

twice a

week;

30 minutes

No

randomization

Senior citizens

benefit from

movement

therapy

Hartshorn,

et al.

2002 32

(NEG=16;

NCG=16)

M=86

(SD=3.3)

Non-

clinical

(senior

citizens)

- DMT Waiting-list

control group

2 weeks;

twice a

week;

50 minutes

Randomization

Wirksamkeit

von Tanzthera-

pie bei somato-

former Störung

Hilf 2009 30

(NEG=15;

NCG=15)

M=46.7

(SD=11.8)

Clinical Somatoform

disorder

DMT Leisure time

program and

body

experience

intervention

6 weeks;

weekly;

100 minutes

Randomization

Dance and

movement

therapeutic

methods in

management of

dementia: A

randomized,

controlled study

Hokkanen,

et al.

2008 29

(NEG=19;

NCG=10)

M=81.5(SD

=6,8)

Clinical Dementia of

any type

DMT Regular

nursing home

activities

9 weeks;

weekly;

30-45

minutes

Randomization

Dance

movement

therapy

improves

emotional

responses and

modulates

neuro-hormones

in adolescents

with mild

Jeong, et al. 2005 40

(NEG=20;

NCG=20)

M=16 Clinical Mild

depression

DMT Waiting-list

control group

12 weeks;

3 times a

week;

45 minutes

Randomization


depression

Continuing in

the labyrinth?

The use of an

arts therapies

programme in

secondary

education as a

means of

mental health

promotion.

Karkou, et

al.

2009 12

(NEG=6;

NCG=6)

11-13 Subclinical Risk of

developing

mental health

problems

DMT Waiting-list

control group

10 weeks;

weekly;

45 minutes

Randomization

The joy dance:

Specific effects

of a single

dance

intervention on

psychiatric

patients with

depression

Koch, et al. 2007 31

(NEG=11;

NCG=20)

21-66,

M=42,7

(SD=14.9)

Clinical Depression

(main or

additional

diagnosis)

Dance (circle

dance)

One

combined

control group

of initially

two groups:

home trainer

group, music

group

1 time;

20 minutes

Randomization

Therapeutic

mirroring:

Dance

movement

therapy

improves

individual and

interpersonal

outcomes in

young adults

with autism

spectrum

disorder

Koch, et al. 2013 31

(NEG=16;

NCG=15)

16-47,

M=22.0

(SD=7.7)

Clinical Autism DMT No

intervention

7 weeks;

weekly;

60 minutes

Randomization


Dance

movement

therapy for

obese women

with emotional

eating: A

controlled pilot

study

Meekums,

Vaverniece,

et al.

2012 79

(NEG=24;

NCG=55)

M=39.1 Non-

clinical

(women

who

participated

in a

commercial

weight

loss)

- DMT One

combined

control group

of initially

two groups:

exercising

group, non-

exercising

group

5 weeks;

twice a

week;

90 minutes

Partial

randomization

Effects of a

modified dance-

based exercise

on cardio-

respiratory

fitness,

psychological

state and health

status of

persons with

rheumatoid

arthritis

Noreau, et

al.

1995 29

(NEG=19;

NCG=10)

M=49.3

(SD=12.4)

Clinical Rheumatoid

arthritis

(with a

functional

class I or II)

Dance

(dance-

basedexercis

e program)

Counseling

and

discussion

session

12 weeks;

twice a

week;

50 minutes

No

randomization

The impact of

creative dance

and movement

training on the

life satisfaction

of older adults:

An exploratory

study

Osgood, et

al.

1990 72

(NEG=37;

NCG=35)

M=72.9 Non-

clinical

(people

from

nursing

homes, but

many

cognitively

or

physically

impaired)

- Dance

(dance and

movement)

No

description

8 months;

weekly;

60 minutes

No

randomization


Effect of body-

oriented

psychological

therapy on

negative

symptoms in

schizophrenia:

A randomized

controlled trial

Röhricht&

Priebe

2006 45

(NEG=24;

NCG=21)

M=38.3

(SD=9.3)

Clinical Schizo-

phrenia

DMT (body-

oriented

psycho-

logical

therapy)

Supportive

counseling

10 weeks;

twice a

week;

60-90

minutes

Randomization

Dance and

movement

program

improves

quality-of-life

measures in

breast cancer

survivors

Sandel, et

al.

2005 38

(NEG=19;

NCG=19)

38-82,

M=59.6

(SD=11.5)

Clinical Breastcancer DMT (Lebed

Method)

Waiting-list

control group

12 weeks;

twice a week

in the first 6

weeks, once

a week in

the last 6

weeks;

60 minutes

Randomization


Table 2

Clusters Including Trials, Outcome Variables, Scales and Data

Cluster Study Scale Outcome

variable

Pole

change MeanEG SDEG MeanCG SDCG NEG NCG

Quality of

life Bräuninger

(2006)

World Health

Organization Quality of

Life Questionnaire 100

(WHOQOL-100)

Global value -

Post-test

scores 62.4 16.48 57.02 16.46 83 54

Change

scores 3.92 23.58 -0.97 23.05

Eyigor, et

al. (2009)

36-Item Short Form

Health Survey (SF-36) Mean score

b -

Post-test

scores 78.51 22.16 64.4 22.83 19 18

Change

scores 10.58 34.39 -6.56 31.41

Hackney &

Earhart et

al. (2009)a

39-Item

Parkinson‟sDisease

Questionnaire (PDQ-39)

Summary index Yes

Post-test

scores -22.02 2.31 -17.63 3.06 44 17

Change

scores 2.03 3.4 1.5 4.47

Hartshorn,

et al. (2002)

Visual Analogue

Scales(VITAS)

Mean score of

Overall Body

Pain, Leg Pain

and Back Pain b

Yes

Post-test

scores -2.26 2.73 -3.13 2.9 16 16

Change

scores 1.16 4.55 0.41 4.56

Hokkanen,

et al. (2008)

Nurses‟

Observation Scale for

Geriatric Patients

(NOSGER)

Mean score of

Instrumental

Activities of

Daily Living

and Self-Care

Subscaleb

Yes

Post-test

scores -16.74 3.67 -18.45 2.31 19 10

Change

scores 0.24 5.1 -0.95 3.32

Meekums,

et al. (2012)

Clinical Outcomes in

Routine Evaluation-

Subscale

General -

Post-test

scores 2.94 0.33 2.72 0.4 24 55



variable

Pole


Outcome Measure

(CORE-OM)

Functioning Change

scores 0.25 0.71 0.05 0.61

Noreau, et

al. (1995)

Arthritis Impact

Measurement Scale

(AIMS)

Subscale Self-

Perception of

Pain

Yes

Post-test

scores -3.47 1.85 -3.7 2.06 19 10

Change

scores 0.9 2.84 0.3 2.98

Osgood, et

al. (1990)

Philadelphia Geriatric

Center Morale Scale

(PGC)

Total score -

Post-test

scores 14.5 3.7 12.5 4.7 37 35

Change

scores 0.2 5.23 -1.8 5.92

Röhricht &

Priebe

(2006)

Manchester Short

Assessment of Quality

of Life (MANSA)

Total score -

Post-test

scores 4.1 0.7 4.1 0.8 21 18

Change

scores 0 1.14 0 1.06

Sandel, et

al. (2005)

36-Item Short Form

Health Survey (SF-36)

Mean score of

Physical and

Mental

Summary b

-

Post-test

scores 49.8 8.65 47.6 11.1 19 16

Change

scores 3 12.51 1.25 14.83

Well-being,

mood and

affect

Bräuninger

(2006)

Stress Management

Questionnaire 120 (SVF)

Mean score of

Positive

Strategies b

-

Post-test

scores 38.54 10.18 37.99 9.76 77 49

Change

scores 0.76 14.66 -0.4 13.68

Dibbell-

Hope

(2000)

Profile of Mood States

(POMS)

Total Mood

Disturbance Yes

Post-test

scores 13.67 15.36 12.22 15.79 6 9

Change

scores - - - - - -



variable

Pole


Goodill

(2005)


(POMS)

Total Mood

Disturbance Yes

Post-test

scores -8.14 26.43 -20.82 24.58 22 17

Change

scores 21.56 37.74 14.44 40.87

Koch, et al.

(2013)

Heidelberger State

Inventory (HIS)

Subscale

Psychological

Well-being

-

Post-test

scores 4.45 0.76 3.77 0.84 16 15

Change

scores 0.38 0.92 0.02 1.19

Koch, et al.

(2007)

Heidelberger

Befindlichkeitsskala(HBS)

Mean score of

Vitality and

Affect b

-

Post-test

scores 5.82 1.63 5.97 1.7 11 20

Change

scores 0.94 2.17 0.56 2.53

Meekums,

et al. (2012)


Routine Evaluation-

Outcome Measure

(CORE-OM)

Subscale

Subjective

Well-being

Yes

Post-test

scores 2.95 0.56 2.59 0.68 24 55

Change

scores 0.65 1.09 0.11 1

Noreau, et

al. (1995)


(POMS) Total score Yes

Post-test

scores -2.60 23.1 -11.90 28 19 10

Change

scores 19.8 36.07 12.3 46.4

Body Image Dibbell-

Hope

(2000)

Berscheid-Walster-

Bohrnstedt Body Image

Scale (BWB)

Mean score b Yes

Post-test

scores -4.22 0.73 -4.34 0.84 4 8

Change

scores - - - - - -

Goldov

(2011) Body Image Scale (BIS) Total score Yes

Post-test

scores -1.15 0.88 -1.69 0.97 6 8

Change 0.28 1.45 -0.07 1.3



variable

Pole


scores

Goodill

(2005) Human Figure Drawings Total score Yes

Post-test

scores 34.86 5.80 33.72 6.77 22 16

Change

scores 0.63 8.47 0.08 8.43

Koch, et al.

(2013)

Questionnaire of

Movement Therapy(FBT)

Subscale Body-

Awareness -

Post-test

scores 4.35 0.61 3.67 0.77 16 15

Change

scores 0.27 0.9 -0.17 1.1

Meekums,

et al. (2012)

The Situational Inventory

of Body Image Dysphoria

(SIBID)

Total score Yes

Post-test

scores -31.41 14.33 -33.54 13.1 24 55

Change

scores 10.54 20.23 3.4 17.95

Sandel, et

al. (2005) Body Image Scale (BIS) Total score Yes

Post-test

scores -15.20 6.1 -16.90 5.2 19 16

Change

scores 4.2 9.06 2.8 8.34

Clinical

Outcomes Bräuninger

(2006)

Brief Symptom Inventory

(BSI)

Global Severity

Index Yes

Post-test

scores -0.67 0.48 -0.79 0.53 87 54

Change

scores 0.23 0.7 0.04 0.74

Dibbell-

Hope

(2000)

Symptom Checklist 90,

Revised (SCL-90R)

Global Severity

Index Yes

Post-test

scores -0.23 0.2 -0,29 0.18 6 9

Change

scores - - - - - -

Haboush, et Symptom Checklist 90, Global Severity Yes Post-test -82.40 42.27 -89.42 42.47 10 12



variable

Pole


al. (2006) Revised (SCL-90R) Index scores

Change

scores 20.6 57.17 11.91 55.26

Hartshorn

(2001) a

Wandering (observational

measurement) Total score Yes

Post-test

scores -10 3.1 -15 2.9 38 38

Change

scores 4 3.92 1 4.03

Hilf (2009)a Brief Symptom Inventory

(BSI)

Global Severity

Index Yes

Post-test

scores -0.62 0.53 -0.71 0.38 15 15

Change

scores 0,76 0,87 0,37 0,54

Jeong, et al.

(2005)a


Revised (SCL-90R)

Global Severity

Index Yes

Post-test

scores -47.4 11.7 -46.7 6.2 20 20

Change

scores 3.9 16.69 -2.2 8,77

Karkou, et

al. (2009) Youth Self-Report (YSR) Total score -

Post-test

scores 67.7 6.8 58 18.9 6 5

Change

scores 0.2 8.1 -7.8 21.43

Koch, et al.

(2013)

Emotional Empathy Scale

(EES), short form Total score -

Post-test

scores 3.23 0.52 2.86 0.60 16 15

Change

scores 0.11 0.67 -0.1 0.86

Meekums,

et al. (2012)


Routine Evaluation-

Outcome Measure

(CORE-OM)

Subscale

Psychological

Symptoms

Yes

Post-test

scores -0.79 0.55 -1.24 0.69 24 55

Change

scores 0.63 1 0.06 0.92



variable

Pole


Röhricht &

Priebe

(2006)

Positive and Negative

Symptom Scale (PANSS)

Subscale

Negative

symptoms

Yes

Post-test

scores -18.90 4.3 -23.30 7.4 24 19

Change

scores 4.5 5.94 1.3 8.85

Depression Akandere&

Demir

(2011)

Beck Depression

Inventory (BDI) Total score Yes

Post-test

scores -13.9 5.57 -17.48 7.74 60 60

Change

scores 1.82 8.95 -0.95 9.75

Bojner

Horwitz, et

al. (2006)a

Montgomery Åsberg

Depression Rating Scale

(MADRS)

Total score Yes

Post-test

scores -16.26 7.94 -14.27 8.15 20 16

Change

scores 2.11 10.38 -1,07 11,04

Bräuninger

(2006)


(BSI)

Subscale

Depression Yes

Post-test

scores -0.65 0.75 -0.79 0.73 84 54

Change

scores 0.23 1.08 -0.14 1.05

Dibbell-

Hope

(2000)


Revised (SCL-90R)

Subscale

Depression Yes

Post-test

scores -0.28 0.25 -0.44 0.23 6 9

Change

scores - - - - - -

Goodill

(2005)


(POMS)

Subscale

Depression

Yes Post-test

scores -4.36 5.76 -6.76 6.28 22 17

Change

scores 4.39 10.21 3.26 9.91

Haboush, et

al. (2006)

Geriatric Depression Scale

(GDS) Total score Yes

Post-test

scores -13.00 6.75 -15.58 6.07 10 12

Change 4.08 8.18 2.5 7.56



variable

Pole


scores

Hilf (2009) Beck Depression

Inventory-II (BDI-II) Total score Yes

Post-test

scores -11.36 9.68 -14.91 9.33 15 15

Change

scores 14.71 14.84 10.23 11.7

Jeong, et al.

(2005)a


Revised (SCL-90R)

Subscale

Depression Yes

Post-test

scores -46.4 10.2 -46.10 5.7 20 20

Change

scores 5.40 15.60 -2.5 8.42

Koch, et al.

(2007)

Heidelberger

Befindlichkeitsskala (HBS

/ HSI)

Subscale

Depression Yes

Post-test

scores -3.59 1.2 -4.3 1.81 11 20

Change

scores 1.23 1.84 -0.15 2.38

Noreau, et

al. (1995)

Arthritis Impact

Measurement Scale

(AIMS)

Subscale

Depression Yes

Post-test

scores -1.18 1.29 -1.52 1.1 19 10

Change

scores 0.87 2.02 0.2 1.58

Anxiety

Bräuninger

(2006)


(BSI)

Subscale

Anxiety Yes

Post-test

scores -0.67 0.57 -1.02 1.32 84 54

Change

scores 0.29 0.82 -0.18 1.46

Dibbel-

Hope

(1990)


Revised (SCL-90R)

Subscale

Anxiety Yes

Post-test

scores -0.12 0.16 -0.18 0.2 6 9

Change

scores - - - - - -

Erwin- TestAttitudeInventory Total score Yes Post-test -36.60 7.8 -45.00 10.3 11 10



variable

Pole


Grabner et

al. (1999)

(TAI) scores

Change

scores 13.5 14.06 4.4 16.51

Jeong et al.

(2005)a


Revised (SCL-90R)

Subscale

Anxiety Yes

Post-test

scores -45.3 10.3 -47.8 6.5 20 20

Change

scores 5.9 15.59 -2.8 9.26

Noreau et

al. (1995)

Arthritis Impact

Measurement Scale

(AIMS)

Subscale

Anxiety Yes

Post-test

scores -3.07 1.74 -3.93 1.33 19 10

Change

scores 1.15 2.3 0.53 2.53

Interpersonal

Competence Bräuninger

(2006)


(BSI)

Subscale

Interpersonal

Sensitivity Yes

Post-test

scores -1.02 0.77 -1.17 0.9 84 54

Change

scores 0.35 1.14 0.11 1.29

Dibbell-

Hope

(2000)


Revised (SCL-90R)

Subscale

Interpersonal

Sensitivity

Yes

Post-test

scores -0.22 0.23 -0.14 0.12 6 9

Change

scores - - - - - -

Hartshorn

(2001)

Social-Relatedness

Toward Teacher

(observational

measurement)

Total score -

Post-test

scores 25.00 7.9 21.00 8.3 38 38

Change

scores -3 12.2 -4 13.94

Hokkanen

et al.

(2008)a

Nurses‟

Observation Scale for

Geriatric Patients

Subscale Social

Competence Yes

Post-test

scores -14.79 4.1 -17.6 2.59 19 10

Change 0.5 4.89 -0.3 3.73



variable

Pole


(NOSGER) scores

Jeong

(2005)


Revised (SCL-90R)

Subscale

Interpersonal

sensitivity Yes

Post-test

scores -44.30 8.2 -51.10 6.7 20 20

Change

scores 7.5 13.01 -3.2 9.76

999999999999999

Koch et al.

(2012)

Questionnaire of

Movement Therapy(FBT)

Mean score of

Awareness of

Self-Other-

Distinction and

Social

Competence b

-

Post-test

scores 4.42 0.81 3.72 0.61 16 15

Change

scores 0.28 1.12 -0,16 0.92

aDue to baseline differences, only change scores were analyzed in a separate analysis

bCalculated from reported variables


Table 3

Results of Analyses of Post-Test Scores and Change Scores of the Single Outcome Categories

Cluster

Post-test scores Change scores

Nstudies NEG NCG SMD (95 % CI) Z NEG NCG SMD (95 % CI) Z

Quality of life 9 257 232 0.37 (0.18 -

0.55)

3.9*** 301 249 0.23 (0.06 -

0.41)

2.64**

Well-being, mood and affect 7 175 175 0.30 (0.07 -

0.53)

2.52* 169 155 0.23 (0.00 -

0.45)

1.97*

Body image 6 91 118 0.27 (-0.04 -

0.57)

1.69† 87 109 0.27 (-0.02 -

0.56)

1.80†

Clinical outcomes 7 173 169 0.44 (0.22 -

0.66)

3.89*** 240 233 0.44 (0.25 -

0.63)

4.6***

Depression 8 227 197 0.36 (0.17 -

0.56)

3.66*** 261 224 0.34 (0.16 -

0.52)

3.64***

Anxiety 4 120 83 0.44 (0.15 -

0.72)

3.00* 134 94 0.46 (0.19 -

0.73)

3.33***

Interpersonal competence 5 164 136 0.45 (0.07 -

0.83)

2.33* 177 137 0.29 (0.03 -

0.55)

2.18*

Note. Nstudies = Number of studies included in the analysis; NEG = Number of participants in intervention/treatment groups; NCG = Number of

participants in control groups; 95% CI = 95% confidence interval; Z = test of overall effect; †p<.1, *p<.05, **p<.01, ***p<.001

Figure 1. Forest plot from nine trials assuming random effects, representing the SMDs (95%

CI) for effects of DMT and dance interventions (experimental groups vs. control groups) on

quality of life. SMD > 0 indicates an increase, SMD < 0 a decrease in quality of life.

EFFECTS OF DANCE MOVEMENT THERAPY AND DANCE. A META-ANALYSIS 60

Figure 2. Forest plot from seven trials assuming random effects, representing the SMDs (95%


well-being, mood and affect. SMD > 0 indicates an increase, SMD < 0 a decrease in well-

being, mood and affect.


Figure 3. Forest plot from six trials assuming random effects, representing the SMDs (95%


body image. SMD > 0 indicates an increase, SMD < 0 a decrease in body image.


Figure 4. Forest plot from seven trials assuming random effects, representing the SMDs (95%


clinical outcomes. SMD > 0 indicates a decrease, SMD < 0 an increase in clinical outcomes.


Figure 5. Forest plot from eight trials assuming random effects, representing the SMDs (95%


depression. SMD > 0 indicates a decrease, SMD < 0 an increase in depression.


Figure 6. Forest plot from four trials assuming random effects, representing the SMDs (95%


anxiety. SMD > 0 indicates a decrease, SMD < 0 an increase in anxiety.


Figure 7. Forest plot from five trials assuming random effects, representing the SMDs (95%


interpersonal competence. SMD > 0 indicates an increase, SMD < 0 a decrease in

interpersonal competence.

effects of dance movement therapy and dance on health ... of dance movement...are the ones primarily...

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