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Apathy in Early Relapsing-Remitting Multiple Sclerosis: Prevalence and Predictors

 To access the article and evaluation online, go to 

 The target audience for this activity is physicians, advanced practice clinicians, nursing professionals, social workers, rehabilitation professionals, and other health care providers involved in the management of patients with multiple sclerosis (MS).

Describe the feasibility and potential effects of dance to improve functional, psychosocial, and participation outcomes in people with MS.

Explain the limitations of current evidence for dance on functional and psychosocial outcomes in persons with MS in order to better inform patient recommendations.

In support of improving patient care, this activity has been planned and implemented by the Consortium of Multiple Sclerosis Centers (CMSC) and Intellisphere, LLC. The CMSC is jointly accredited by the Accreditation Council for Continuing Medical Education, the Accreditation Council for Pharmacy Education, and the American Nurses Credentialing Center, to provide continuing education for the healthcare team.

This activity was planned by and for the health care team, and learners will receive 1.0 Interprofessional Continuing Education credit for learning and change.

 The CMSC designates this journal-based activity for a maximum of 1.0 

. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 The CMSC designates this enduring material for 1.0 contact hour of nursing continuing professional development (none in the area of pharmacology).

 This activity is awarded 1.0 CE credits.

 As a Jointly Accredited Organization, the CMSC is approved to offer social work continuing education by the Association of Social Work Boards Approved Continuing Education program. Organizations, not individual courses, are approved under this program. Regulatory boards are the final authority on courses accepted for continuing education credit. Social workers completing this course receive 1.0 general continuing education credits.

 It is the policy of the Consortium of Multiple Sclerosis Centers to mitigate all relevant financial disclosures from planners, faculty, and other persons that can affect the content of this CE activity. For this activity, all relevant disclosures have been mitigated.

, has served as physician planner for this activity. He has disclosed no relevant financial relationships. 

, has disclosed no relevant financial relationships. Authors 

Emily Davis, BA; Amy Webster, MSc; Bethany Whiteside, PhD; and Lorna Paul, PhD,

 have disclosed no relevant financial relationships.

, CMSC, and Intellisphere, LLC who are in a position to influence content have disclosed no relevant financial relationships. 

 CMSC continuing education director, has served as a planner and reviewer for this activity. She has disclosed no relevant financial relationships.

Release Date: July 1, 2023. Valid for credit through July 1, 2024.

(1) Review the continuing education information, including learning objectives and author disclosures.

(3) Complete the evaluation, which is available at 

Statements of Credit are awarded upon successful completion of the evaluation. There is no fee to participate in this activity.

 This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the FDA. The CMSC and Intellisphere, LLC do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the CMSC or Intellisphere, LLC.

 Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any medications, diagnostic procedures, or treatments discussed in this publication should not be used by clinicians or other health care professionals without first evaluating their patients’ conditions, considering possible contraindications or risks, reviewing any applicable manufacturer’s product information, and comparing any therapeutic approach with the recommendations of other authorities.

Evidence of the benefits of dance for people with Parkinson disease is well established, but only recently has dance been investigated for people with multiple sclerosis (MS). The purpose of this review was to identify and evaluate the feasibility and effectiveness of dance interventions to improve functional, psychosocial, and participation outcomes in people with MS.

Eight databases and gray literature sources were searched from inception to March 2022. Quantitative, mixed-methods, and qualitative studies evaluating dance interventions for adults with MS were included. Included studies were critically appraised using the Mixed Methods Appraisal Tool, and results were analyzed through a parallel-results convergent synthesis.

Thirteen studies were included, with a total of 174 participants. Various dance genres were investigated, and only 1 mild adverse event was reported. Four to 12 weeks of twice-weekly, 60-minute dance sessions were feasible in those with mild to moderate relapsing-remitting MS. Positive effects were identified mainly in motor outcomes, with qualitative themes indicating psychological and social benefits.

A variety of dance interventions are likely feasible and potentially beneficial for people with mild to moderate relapsing-remitting MS, but studies were generally of low-moderate quality. High-quality studies are needed to determine the effectiveness of dance interventions for people with MS, including those with progressive forms of MS and higher levels of disability.

 The authors declare no conflicts of interest.

 Ms Davis is funded by a scholarship from the Thouron Award. Ms Webster is funded by the Multiple Sclerosis (MS) Society, UK (grant 115).

 A part of this review was presented as a poster at the Annual Conference of the International Association for Dance Medicine and Science; October 28-31, 2022; Limerick, Ireland.

Multiple sclerosis (MS) is a chronic autoimmune inflammatory disease of the central nervous system characterized by neurodegeneration leading to a variety of symptoms and, often, disability.

 A growing number of disease-modifying therapies are available that can help reduce relapse rates and disability severity; however, disease-modifying therapies do not target the multifaceted symptoms of MS or the psychological, emotional, and social consequences of living with an unpredictable degenerative condition.

 Nonpharmacologic and lifestyle interventions are safe and effective for ameliorating common symptoms and improving quality of life for people with MS.

 Exercise training, physical activity, cognitive behavioral therapy, and mindfulness-based interventions have been shown to support physical and emotional wellness in people with MS, an identified priority among the MS community.

Extensive research evidences the benefits of exercise for a range of physical functioning outcomes,

 but there is a low rate of adequate physical activity among people with MS.

 Although a variety of personal and contextual barriers limit their exercise participation, personalized exercise suited to the needs, abilities, goals, and interests of people with MS could help to overcome these barriers.

 Mindfulness-based movement practices such as tai chi and yoga have been investigated as alternative, attractive exercise forms for people with MS that may provide physical and psychosocial benefits owing to their movement and meditative components.

 Dance is another potentially attractive form of physical activity that generally incorporates types of exercise recommended for people with MS (eg, aerobics, balance, coordination, stretching

) into an enjoyable and emotionally, socially, and artistically enriching experience.

Dance is the synchronization of movement to rhythm, most often characterized by genre, function, or context.

 Because dance can be delivered in a variety of forms across different settings and easily tailored to different abilities, it has been characterized as an accessible and adaptable activity.

 Dance interventions have been found to be equally and occasionally more effective than other exercise forms for improving a range of physical health outcomes, including musculoskeletal functions such as mobility and balance.

 Several psychosocial benefits have also been reported from dance interventions, including improvements in stress levels, depressive symptoms, and anxiety

 and positive psychological constructs such as well-being, coping strategies, and self-esteem.

Research shows that dance yields a variety of physical and psychosocial benefits in populations with other chronic neurologic conditions, such as dementia and Parkinson disease (PD).

 Dance has been especially widely investigated in the context of rehabilitation for PD,

 with several systematic reviews demonstrating the effectiveness of dance for improving motor impairments.

 Given the benefits of dance for PD and the extensive research on the benefits of exercise for MS, there has been a growing practical and research interest in the use of dance for people with MS.

 Literature reviews have been conducted on therapeutic arts for MS

 and music-based therapeutic approaches for MS

; however, to our knowledge, there has yet to be a systematic literature review concerning only dance interventions for people with MS. Therefore, the aim of this study was to systematically review the evidence on the feasibility and effectiveness of dance for improving functional, psychosocial, and participation outcomes in people with MS.

The method of this systematic review was developed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline.

 The review protocol was registered on the PROSPERO database.

Searches were performed from inception through March 2022 in MEDLINE, the Allied and Complementary Medicine Database, the Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science, Scopus, ProQuest Central Health & Medical Collection, and ProQuest Nursing & Allied Health Database. The search strategy was adapted for use in each database (

, available online at IJMSC.org). Key terms were built around 2 domains, dance and MS. Due to the anticipated dearth of studies in this area, the database search was complemented by a gray literature search of reference lists of included studies, Conference Proceedings Citation Index, ProQuest Dissertations & Theses Database, Science Citation Index, and Google Scholar (citation searching of included studies). Experts from organizations with publicized community-based dance for MS programs were also contacted to identify evidence that may not appear in academic databases.

Articles were included if they met the following eligibility criteria: (1) included adults with a diagnosis of MS (formal or self-report), and, if included alongside other clinical populations, data on adults with MS had to be extractable; (2) evaluated an intervention defined as dance or characterized by purposefully selected, rhythmic movement sequences

; and (3) assessed any outcome related to the body function, activity, or participation domains in the World Health Organization’s International Classification of Functioning, Disability, and Health

 or psychosocial aspects such as self-efficacy, well-being, or quality of life. There were no restrictions on the study design or publication period. Gray literature (ie, evaluation reports, unpublished studies, theses) was eligible for inclusion in line with the stance of a recent systematic review on dance for health across the life span

 to allow for all available evidence on the topic to be included.

 Studies were excluded if they were reviews or opinion articles, not full texts, or not available in English or Spanish.

All database and gray literature search results were entered into Covidence systematic review software (Version 2156; Veritas Health Innovation [available at 

 and duplicates were removed. Two independent reviewers (E.D. and A.W.) screened the titles and abstracts against the selection criteria and then screened full texts of the remaining articles for eligibility. Any disagreements were resolved through discussion among the reviewers or consultation with a third reviewer (L.P.).

Quality was assessed using the McGill University Mixed Methods Appraisal Tool (MMAT),

 which was selected to account for the heterogeneity of the study designs. Quality assessment was completed independently by 2 reviewers (E.D. and A.W.), and any disagreements were resolved through consensus in consultation with a third reviewer (L.P.). No studies were excluded based on the result of the quality assessment.

One reviewer (E.D.) extracted the relevant data from eligible studies using a standardized data extraction table. Data extracted included study details, study design, participant information, intervention characteristics, data collection methods/outcomes, and main findings. Qualitative data such as participant quotes and author interpretations were extracted as individual data.

A parallel-results convergent synthesis was conducted: quantitative and qualitative data were analyzed and presented separately, and the integration of the results occurred in the interpretation of the findings.

 The quantitative and qualitative data were analyzed using narrative synthesis following the Economic and Social Research Council Guidance on Conducting Narrative Synthesis.

 Qualitative data were further synthesized using a thematic analysis process adapted from Thomas and Harden,

 in which results were coded line-by-line according to content and meaning, and the resulting codes were organized into descriptive themes and, subsequently, analytical themes. Due to the inclusion of quasi-experimental studies and the heterogeneity of the included quantitative study designs and outcome measures, meta-analysis was not appropriate.

Through the search of the 8 selected databases, 734 studies were identified (

). After duplicates were removed, 491 studies were screened for relevance. After title and abstract screening, 462 studies were excluded. The remaining 29 studies were retrieved and screened for eligibility; 19 were excluded . An additional 5 records were identified by contacting experts (n = 4) and by citation searching via Google Scholar (n = 1). Four reports were retrieved, and 3 full texts met the eligibility criteria. In total, 13 studies were accepted for inclusion in the review. Seven studies were conducted in the United States, and the other 6 studies were conducted in Spain, Belgium, Scotland, Canada, and Brazil.

Ten of the included studies used quantitative methods: 1 was a proof-of-concept randomized controlled trial (RCT) with 3 trial arms (ie, movement-to-music, adapted yoga, waitlist control)

; 2 quasi-experimental studies compared dance with visual arts

; 3 were uncontrolled, before-and-after studies

; and 3 were descriptive studies (ie, 1 program evaluation

). Two studies used mixed methods (ie, master’s thesis

). One case study used only qualitative methods.

Across the 13 studies, 174 participants with MS were included, 81 in 1 study.

 All other studies had small sample sizes, with 4 studies each including only 1 person with MS.

 with 95% of participants having relapsing-remitting MS. Across validated and subjective measures of disability status, assessments ranged from no disability to bilateral support (score, 0-6) on the Patient-Determined Disease Steps scale

 with most participants having a mild to moderate disability. Disease duration was reported in 6 studies,

 Most studies had limited reporting of other sample characteristics (eg, ethnicity, educational level, socioeconomic status, previous dance experience).

Intervention types ranged from clinical dance therapy

 Only 2 studies implemented the same intervention type, targeted ballet training.

 Two studies investigated partnered dance styles, salsa

 Dance-based exercise was also instructed in 2 studies, Jazzercise

 Spanish dance combined with physiotherapy,

 choreography-based dancing showcased in a public performance,

 were investigated by 1 study each. Only 1 intervention was delivered remotely

; most interventions were delivered in a group in a community setting such as fitness facilities.

; the median intervention length was 10 weeks. The average session duration was 71.9 minutes, with 6 interventions delivering hour-long sessions.

 Eight interventions delivered sessions twice weekly.

 Only 1 study reported the intensity of the intervention as light to moderate exercise intensity using ratings of perceived exertion and ambulatory heart rate.

 Other studies detailed the relative intensities and purposes of the session’s components (eg, the target fitness, motor, or cognitive domain) and durations of components.

 Some studies also described the intervention’s progression, such as incorporating new dance steps

 or progressively increasing the difficulty of dance sequences over the course of the sessions.

When reported, dropouts from the dance intervention ranged from 0

 Reasons for discontinuing the dance intervention were personal or scheduling conflicts,

 Eight studies reported adherence, with 4 reporting attendance rates greater than 90%.

 The lowest attendance rates were for the dance-based exercise interventions, mixed genre at 53.7%

 Adherence was not reported in the 1 study delivered remotely.

 Across the 6 studies reporting adverse events,

 dance was well-tolerated, with only 1 study reporting 1 adverse event related to the dance intervention studied, a mild muscle strain treated with rest and ice.

 Studies noted adaptations made to the dance sessions or environment to support adherence and tolerability, including thermoregulation of the dance studio,

Effects of Dance Interventions on Outcome Measures

 Eight of the 13 studies included examined balance.

 Balance improved in 6 studies after the intervention,

 including the 3 before-and-after studies that showed statistically significant improvements in the Mini-Balance Evaluation Systems Test results, with large effect sizes compared with baseline,

 1 of which also reported a significant change in balance in a backward step-to-stand task.

 One case report of Spanish dance physiotherapy showed a 25-point improvement in the participant’s Berg Balance Scale score after the intervention,

 and another study showed a statistically significant change in the Dynamic Gait Index at 3-month follow-up compared with baseline.

 Three studies examined balance confidence

 which significantly improved in only 1 study after the intervention in the dance group but not the control art group.

 Four studies assessed changes in overall walking ability using the 12-item Multiple Sclerosis Walking Scale

 Two of three studies using the scale reported significant improvements.

 Three studies evaluated changes in specific gait parameters

; 2 before-and-after studies showed statistically significant improvements after the intervention in the smoothness of gait,

 and a case report showed improvements in spatiotemporal gait parameters (ie, speed, step length, cadence) after the intervention.

 Three studies assessed changes in walking endurance using the 6-Minute Walk Test.

 The case report of Spanish dance physiotherapy showed a 37.76-m increase in the participant’s 6-Minute Walk Test after the intervention,

 but only 1 study, an RCT, showed a statistically significant difference in walking endurance between the dance-based exercise group and the waitlist control group; this difference was not observed between the adapted yoga group and controls.

 Three studies evaluated functional mobility using the Timed Up and Go test.

 Two studies, 1 RCT and 1 before-and-after study, showed statistically significant improvements in functional mobility.

 Two studies measured changes in ataxia, both of which were before-and-after studies of targeted ballet.

 The studies demonstrated statistically significant reductions in ataxia after the intervention compared with baseline in clinical and direct assessments.

 Two studies assessed lower extremity function using the Five Times Sit-to-Stand Test

 (5XSTS) and upper-extremity function using the Nine-Hole Peg Test

; one study showed significant improvements after the intervention in the dance group in both the 5XSTS and the Nine-Hole Peg Test in the dominant hand; these improvements were not observed in the control art group.

 This was also the only study to investigate leg coordination, showing a significant increase in the dance group compared with baseline but not in the control art group.

 Two quasi-experimental studies measured changes in cognitive functioning.

 Both studies showed positive changes in performance of the Paced Auditory Serial Addition Test; however, only 1 study demonstrated a statistically significant improvement compared with the no-dance control group,

 with the other study demonstrating only a trend toward significance in both the dance group and the control art group.

 Significant improvements were also reported in this study in executive cognitive performance during dual tasking in both the dance and control art groups after the intervention, but a significant improvement in the Symbol Digit Modalities Test was reported only in the control art group.

Overall physical functioning and MS symptoms.

 Three studies evaluated changes in overall physical functioning.

 One study showed a statistically significant improvement in MS Functional Composite scores after the intervention compared with the control group,

 and a case report demonstrated improvements in 3 clinical assessments of neurologic disability, including a 1-point decrease in the Expanded Disability Status Scale score.

 The only study monitoring changes in MS symptoms, using the MS Symptoms Checklist, showed a statistically significant worsening of MS symptoms after the 4-week intervention, which was not replicated at the 3-month follow-up.

 Two studies assessed overall strength, 1 noting a self-reported overall improvement in strength after the intervention

 and the other citing an improvement in ankle strength only.

 One case report assessed spasticity using the Modified Ashworth Scale, which decreased in both sural triceps after the intervention.

 No significant change was reported in the only study assessing sensory function.

Psychosocial and Participation Outcomes  

 Four of the 13 included studies assessed fatigue

; only 1 study examined fatigue as the primary outcome.

 This study demonstrated statistically significant improvements in the Modified Fatigue Impact Scale after the intervention in both the dance and control art groups compared with baseline but no significant changes in performance motor fatigability or cognitive fatigability.

 One before-and-after study showed a significant improvement in the Fatigue Severity Scale score after the intervention in the morning dance group but not in the evening dance group.

 The other 2 studies demonstrated positive trends toward significance not observed in their waitlist

 One study reported a significant change in the Patient-Reported Outcomes Measurement Information System–Global Health score in the dance intervention group compared with controls,

 and the other showed a positive statistical trend after the intervention in the 29-item Multiple Sclerosis Impact Scale score in the dance group not observed in the control art group.

 and dimensions of mental health and well-being

 were each measured by 1 study. No significant changes were reported after the interventions in validated assessments, but 78% to 100% of participants in 1 study reported experiencing positive changes in confidence, energy, and mood.

 One study examined physical activity, reporting statistically significant improvements in total leisure activity ratings (time and metabolic equivalents) after the intervention compared with baseline.

Thematic Synthesis of Qualitative Findings on the Effects of Dance Interventions

Three studies included qualitative analyses, 2 mixed-methods studies

 Qualitative methods used included interviews,

 Four themes concerning perceived effects were identified across the included qualitative data: body awareness and physical confidence, psychological well-being, sense of belonging, and social relationships (

Theme 1: Body Awareness and Physical Confidence

Participants experienced an improved sense of body awareness and physical confidence during the dance sessions

 They explained that dancing helped them become more “in tune” with their bodies and better understand how to cope with movement limitations and motor fatigue.

 Some in-person dance program participants reported that dance helped them when navigating physical challenges in their daily lives.

In-person or remote dance sessions resulted in positive emotions and improved mental states among participants. Afterward, they said they were “feeling good”

 and “feeling better, more energetic.”

 The studies associated these positive emotional changes with the enjoyable and expressive nature of the sessions. Some participants said that the sense of well-being and achievement after the sessions outweighed or lessened their fatigue.

 Sustained improvements in self-esteem were also reported across the studies.

 For in-person participants, these self-esteem improvements were attributed to the encouraging dance class environment and sense of achievement felt after mastering dance skills.

Participants reported feeling an increased sense of belonging as a result of taking part in remote or in-person dance sessions.

 Feelings of belonging emerged from feeling safe and comfortable practicing movements at home

 or feeling accepted, understood, and included in the dance class environment.

 Dancing in a group in-person setting provided the additional benefit of connecting with like-minded individuals.

Dance also provided the opportunity for participants to create or enhance interpersonal relationships.

 Remote dancing provided a meaningful way for the case study participant to connect creatively with her family members,

 and the in-person dance classes facilitated the development of new social relationships with other participants.

Because presenting solely an overall score is discouraged by the MMAT, an overall score is provided alongside a summary of justification for each criterion in the MMAT.

 Two studies were moderate-high quality (80% of the quality criteria met),

 6 were moderate quality (60% of the quality criteria met),

Inês Brás Marques, MD

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