For some, balancing on one leg is easy. However, take away a person’s sight and this task becomes more challenging [1]. Strip away a person’s sense of hearing as well, and the task that used to be “easy” is now quite difficult. How do dancers make the act of balancing seem so effortless?

The brain uses three sources of information to keep the body upright and grounded while balancing: visual sense from the eyes, vestibular sense from the ears, and proprioception from the nervous system [2]. The eyes provide the body a sense of where the head and body are in space with respect to the surrounding environment, while the ears house fluid-filled semicircular canals that tell the brain whether the head is level to the ground [1][2]. Proprioception provides sensory signals from various mechanoreceptors, receptors that respond to extracellular stimulus, in order to help the brain recognize and determine where the body is in space while relying on the intimate relationship between the body’s central nervous system and musculoskeletal tissues, such as muscles, tendons, and ligaments [2][3]. Similar to the standard five senses, proprioception, our sixth sense, kicks into gear without conscious thought from the individual. On an anatomical level, the sensory nerve endings wrap themselves around soft tissues and change the intensity of neural signals fired when the soft tissue is contorted or stretched from its normal positioning and length in the body [3]. These signals are considered one of the main contributing factors to Joint Position Sense (JPS), which is the body’s ability to recognize where joints are in relation to one another [3]. Through the JPS, proprioception provides feedback to the brain when joints and muscles move to compensate for trying to stay balanced. This can be seen when a ballerina uses her arms as a counterbalance when balancing on one foot.

In relation to balance control, recent studies have noted how ankle proprioception may be one of the most important components of balance control because of its direct-contact relationship with the ground [2]. Dance training has been shown to improve a dancer’s proprioceptive abilities and is one of the fundamental reasons why dancers are able to flawlessly execute complex balance movements on a very small base of support with lights shining in their eyes and while under constant pressure from a judgmental audience. Such findings are also supported by anecdotal evidence that I have heard while working at 2 Claps 1 Snap, a local health and wellness small business tailored for corporate individuals. From group training to yoga and dance, the most frequent posture instructors emphasize during every class is to vertically stack their joints while holding movements. Muscle movements seen on a daily basis, such as a simple step forward, are guided by proprioceptive information that is sent to the brain for processing and execution [2][3]. While recent research has suggested that dance could be used as a therapy to improve balance through the relationship between proprioception and balance, there's a fine line that must be tied to ensure that several implications and concerns of the therapy are addressed before it can be implemented in a standardized fashion. This article aims to discuss proprioception’s relationship with the kinesiology of balance, how recent research has suggested that dance could be used to improve balance, and future implications and concerns that could prevent dance from being used as a standard therapeutic intervention.

Proprioception Improvement Through Dance

Though balancing on one leg with eyes closed and ears plugged feels daunting now, the task can feel easier after strengthening an individual’s proprioceptive abilities. Knowing where the body and joints are in space requires much training to perfect, as proprioception is a skill that can be lost if not continuously practiced.

To study how proprioception could be indirectly improved through exercise, Dr. Shim had a group of twenty college students train their proprioception skills for four weeks by balancing on a slackline device tethered to two trees every week for 20-30 minutes [4]. Each of the individual’s following parameters were measured: Center of Pressure (CoP), the average location of pressure in the foot, the Limit of Stability (LoS), and the maximum amount of movement an individual can move forwards (F), backwards (B), left (L), or right (R) before having to take a step [5]. Compared to the control group, the slack training group did not have statistically significant improvements on average in CoP, normal stability with eyes open (NSEO), or normal stability with eyes closed (NSEC) [4]. Significant average differences were only noted in LoS L, with notable trends for significance for LoS R, suggesting that there was improvement in ankle stability and proprioceptive abilities through passive training techniques.

Identifying three professional sports in which athletes must passively train their ankle joints, Dr. Li in 2009 examined the ankle proprioception in young regular practitioners of ice hockey, running, and ballet dancing. The 45 individuals were split among the three experimental groups and one sedentary control group. Using a custom-made sensor, the research team measured proprioception in four directions: toes pointing downwards, upwards, inwards, and outwards [6]. Results showed that ballet dancers and hockey players had a statistically significant increase in proprioception of the ankle as compared to the control group, while runners did not [6]. In other words, some forms of exercise like dance that involve a greater degree of balance may have a greater impact on ankle proprioception when compared to other exercises like running. This further suggests that dancing could be used as a form of therapy to increase an individual’s proprioceptive abilities.

To investigate whether dance increases proprioception in older individuals who do not regularly participate in dance, Dr. Marmeleira and colleagues recruited 37 men and women between 55 and 80 years old, who also had not engaged in any exercise for one year, to participate in their 2009 study [3]. The experimental group participated in a creative dance program for 12 weeks, with a total of 36 individual sessions, each lasting 90 minutes. Investigators measured knee proprioception, knee JPS, and arm positioning in space [3]. Results after 12 weeks showed a statistically significant increase in all three measurements after the dance therapy intervention, suggesting that dance can cause an immediate increase of proprioceptive abilities in individuals who live more sedentary lifestyles. Of particular note, the researchers also did a follow-up with the experimental group and discovered that arm positioning performance levels remained elevated. This suggests that the immediate benefits of dance training may have a long-term increase in an individual’s proprioception.

Although there is a lack of cohesiveness in the methodology of the aforementioned studies, research suggests that dance could be used as a training method to improve proprioceptive abilities of an individual, regardless of their lifestyle. Current studies do not all follow the same dance regimen and may vary on dance type, number of dance classes taken a week, and amount of time danced per session. Improvements may also be maintained for an extended period of time. This provides an alternative platform to heighten the sixth sense and improve balance through an unconventional yet effective technique: dance movement therapy.

Balance Improvement Using Dance in Medicine

Once it had been established that dance therapy/intervention was associated with improvements in proprioception, researchers began to explore the possibility of using that relationship as a therapeutic/clinical intervention for individuals with chronic illness as well as the elderly. Dr. Hee Joung Joung and her colleagues in 2019 splitted 82 older adults into two groups: an experimental group participating in creative dance (CD) and a control group participating in stretching training (ST). For eight weeks, each participated in two 90-minute sessions in their respective assigned group. CD individuals danced and incorporated exercises to explore movement elements, like the body, the environment, the timing of movements, and the force of movements. ST individuals participated in regimens that had several upper and lower body stretching poses [7]. The results showed a significant increase in gait speed during the 10-Meter Walking Test for individuals in the CD group, suggesting that CD may improve dynamic balance and mobility more than stretching for elderly individuals [7]. A benefit of similar CD training for elderly individuals could be they are less prone to falling, which can improve quality of life of elderly individuals and decrease the chance of experiencing head trauma.

Other potential uses for balanced-based dance therapy could be to help alleviate irregular gait symptoms of Parkinson’s Disease. Parkinson’s Disease (PD) is a neurodegenerative disease that primarily results from death of dopaminergic neurons in the substantia nigra, which is located in the basal ganglia – an area of the brain typically associated with movement and learning [8]. PD patients typically suffer from many symptoms: tremor, poor balance, and memory loss. This leads to a decreased quality of life as it becomes harder to complete simple day-to-day tasks, like picking up a fork or walking to the bathroom. Thus, much research has focused on holistic treatment of symptoms such as engaging in dance-based exercises [9].

Dr. Jessica Allen and her colleagues in 2017 were able to show an increase in neuromuscular consistency in gait and balance of PD persons after partnered, dance-based rehabilitation [10]. The number of motor modules recruited to perform a motor task is frequently used as a measure of neuromuscular complexity, with higher complexity associated with better motor performance. Through dance, individuals may have an increased neuromuscular complexity observed with refined motor development and long-term motor training [11]. Conversely, reduced neuromuscular complexity has been identified in various populations that exhibit impaired motor performance such as individuals after a stroke or with PD [12]. Dr. Allen measured neuromuscular control of gait and balanced of 22 PD persons after participating in fifteen 90-minute exercise-based Adapted Tango (AT) dance classes over the course of three weeks [10]. Results showed an increase in motor recruitment during the Walking and Reactive Balance post-program tests. Because proprioception aids the body in walking, proprioception kinesiology could also play a major role in the increase of motor recruitment in the PD individuals. With a better sense of where the body is in space, the brain could activate more motor units to complete an action quicker and faster. This aligns well with Dr. Allen’s results that show the increase in motor recruitment consequently led to faster walking speeds during a 7.5 meter walk and more positive score on the Berg Balance Scale, indicating an increase in proprioception.

If elderly individuals are able to walk at a quicker pace with more confidence, then they may also have more control of their body and a better sense of proprioception. Greater control of the body leads to a healthier and safer aging process. Having dance be used as an alternative therapy in medicine to increase an individual’s proprioception and balance is a large milestone for elderly to participate in a social dance style that also reaps positive health benefits.

Future Implications and Caveats

As research for new therapeutics develop, proprioception research has the capabilities to slowly expand and become a more interdisciplinary work, specifically with dance through Dance Movement Therapy (DMT), an alternative treatment that uses dance movements to alleviate symptoms of an illness. To highlight, a recent study done in 2015 suggested that elderly use proprioception, rather than visual or vestibular cues, to control postural movements and balance [13]. With the average age of PD onset being around 62 years old and with ankle proprioception being one of the main contributors to balance, future therapists could tailor regimen movements to what the patients specifically need, such as ankle-specific stability movement sequences for PD persons [2][14]. Not only could the targeted regimen increase effectiveness of treatment, but it could also result in a longer-lasting effect on proprioception, when compared to non-targeted DMT. Preliminary data in recent years has also shown a relationship between subpar cervical neck proprioception in individuals with chronic neck pain (CNP) [15]. A potential therapy to look into for CNP persons could be neck-specific DMT regimens, providing a novel alternative approach for a condition where current treatment typically consists solely of pharmaceutical approaches [15].

An area of research to continue exploring could be how foot awareness affects ankle proprioception. Recent research by Dr. Waddington in 2018 showed how textured insoles improved the discrimination scores of dancers with low ankle inversion movement discrimination, suggesting that textured insoles may trigger the cutaneous receptors in the plantar surface of the foot, increasing the awareness of ankle positioning and potentially decreasing the chance of a future ankle injury [4]. Ankle taping or bracing for an injured ankle is commonly used to prevent further injury, possibly by improving proprioception at the ankle [16][17]. Given Dr. Waddington’s recent research with dancers, a plausible conclusion could be that taping healthy, non-dancer ankles could improve proprioception. However, results by Li Long in a study recently published in 2017 indicate otherwise. His results suggest that ankle taping may amplify sensory input in a way that enhances proprioception of poor performers but produces an input overload that impairs proprioception in those who originally performed well when no-taping [17]. A possible hypothesis for these observations could be that taping inhibits the local muscle’s full potential to stretch and move in unique ways that aid in proprioception, almost as if the tape is acting like an unneeded handicap for a foot that never needed the assistance in the first place. However further research must be conducted to explore why taping a healthy ankle inhibits proprioception.

In order to get a better understanding of how proprioception contributes to proper balance, researchers should try to get a better understanding of how fascia contributes to the body’s capability to know where a body part resides in space. Fascia is a type of tissue that occurs throughout the body [18]. Injuries of deep fascia, a specific kind of fascia, have been found to cause dysfunction in proprioception, balance, and muscle coordination – all of which are essential to maintaining balance on one leg [18]. Previous ankle research showed morphological evidence of the proprioceptive role of the fascial system, as results round a thickening of the fascia around the ankle region where most mechanical support was necessary to optimally operate [19][20]. Therefore, getting a better understanding for fascia’s importance in proprioception and movement optimization may aid future patients during rehabilitation with dance medicine.

Though some may believe that proprioception does not live up to its title, this sixth sense has proved to be an essential mechanism of the body in order to complete daily tasks, such as walking the dog, grabbing groceries, or maintaining balance. Recent studies have shown that dance is one effective way to improve proprioception and could be used as a creative preventative therapy for the elderly or persons with PD. Further research regarding proprioception performance during DMT, ankle taping, and in relation to fascia should be conducted in order to better understand how proprioception works and how future therapeutics can capitalize on this knowledge to create disease-tailored regimens. By honing in on the best dance therapeutic practice that is built upon proprioception knowledge and understanding, healthcare providers will have a more effective alternative treatment option for chronic illnesses with physical impairments.

References

1. Robertson S, Collins J, Elliott D, Starkes J. The Influence of Skill and Intermittent Vision on Dynamic Balance. J Mot Behav. 1994;26(4):333-339. doi:10.1080/00222895.1994.9941689
2. Paillard T, Noé F. Techniques and Methods for Testing the Postural Function in Healthy and Pathological Subjects. BioMed Res Int. 2015;2015:1-15. doi:10.1155/2015/891390
3. Marmeleira JF, Pereira C, Cruz-Ferreira A, Fretes V, Pisco R, Fernandes OM. Creative dance can enhance proprioception in older adults. J Sports Med Phys Fitness. 2009;49(4):480-485.
4. Shim A, Steffen K, Hauer P, Cross P. The effects of balance training on stability and proprioception scores of the ankle in college students. J Sci Med Sport. 2017;20:e34. doi:10.1016/j.jsams.2017.01.098
5. Kuo F-C, Chang S-T, Liao Y-Y, Lee C-H. Center of Pressure Trace and Sensory Components of the Limits of Stability Test in Older Adults With Vertebral Compression Fractures. J Geriatr Phys Ther. 2020;43(1):24-31. doi:10.1519/JPT.0000000000000201
6. Waddington G, Steinberg N, Adams R, Karin J, Tirosh O. Enhancing ankle proprioception in dancers. J Sci Med Sport. 2017;20:e36. doi:10.1016/j.jsams.2017.01.104
7. Li JX, Xu DQ, Hoshizaki B. Proprioception of Foot and Ankle Complex in Young Regular Practitioners of Ice Hockey, Ballet Dancing and Running. Res Sports Med. 2009;17(4):205-216. doi:10.1080/15438620903324353
8. Joung HJ, Lee Y. Effect of Creative Dance on Fitness, Functional Balance, and Mobility Control in the Elderly. Gerontology. 2019;65(5):537-546. doi:10.1159/000499402
9. Dauer W, Przedborski S. Parkinson’s Disease: Mechanisms and Models. Neuron. 2003;39(6):889-909. doi:10.1016/S0896-6273(03)00568-3
10. Wang Y, Wang Z, Zhuang J, Han J, Waddington G, Adams R. Ankle proprioception and postural sway in people with Parkinson’s disease. J Sci Med Sport. 2018;21:S67. doi:10.1016/j.jsams.2018.09.151
11. Allen JL, McKay JL, Sawers A, Hackney ME, Ting LH. Increased neuromuscular consistency in gait and balance after partnered, dance-based rehabilitation in Parkinson’s disease. J Neurophysiol. 2017;118(1):363-373. doi:10.1152/jn.00813.2016
12. Sawers A, Allen JL, Ting LH. Long-term training modifies the modular structure and organization of walking balance control. J Neurophysiol. 2015;114(6):3359-3373. doi:10.1152/jn.00758.2015
13. Wiesmeier IK, Dalin D, Maurer C. Elderly Use Proprioception Rather than Visual and Vestibular Cues for Postural Motor Control. Front Aging Neurosci. 2015;7. doi:10.3389/fnagi.2015.00097
14. Hamada K, Hirayama M, Watanabe H, et al. Onset age and severity of motor impairment are associated with reduction of myocardial 123I-MIBG uptake in Parkinson’s disease. J Neurol Neurosurg Psychiatry. 2003;74(4):423-426. doi:10.1136/jnnp.74.4.423
15. Stanton TR, Leake HB, Chalmers KJ, Moseley GL. Evidence of impaired proprioception in chronic, idiopathic neck pain: systematic review and meta-analysis. Phys Ther. 2016;96(6):876-888. doi:10.2522/ptj.20150241
16. Janssen KW, Kamper SJ. Ankle taping and bracing for proprioception. Br J Sports Med. 2013;47(8):527-528. doi:10.1136/bjsports-2012-091836
17. Long Z, Wang R, Han J, Waddington G, Adams R, Anson J. Optimizing ankle performance when taped: Effects of kinesiology and athletic taping on proprioception in full weight-bearing stance. J Sci Med Sport. 2017;20(3):236-240. doi:10.1016/j.jsams.2016.08.024
18. Stecco A, Stern R, Fantoni I, De Caro R, Stecco C. Fascial Disorders: Implications for Treatment. PM&R. 2016;8(2):161-168. doi:10.1016/j.pmrj.2015.06.006
19. Numkarunarunrote N, Malik A, Aguiar RO, Trudell DJ, Resnick D. Retinacula of the Foot and Ankle: MRI with Anatomic Correlation in Cadavers. Am J Roentgenol. 2007;188(4):W348-W354. doi:10.2214/AJR.05.106621.
20. Stecco C, Macchi V, Porzionato A, et al. The Ankle Retinacula: Morphological Evidence of the Proprioceptive Role of the Fascial System. Cells Tissues Organs. 2010;192:200-210. doi:10.1159/000290225