IJNHCR

Introduction

Falls, defined as an unintentional coming to rest on the ground or at a lower level, with or without loss of consciousness, represent the second leading cause of death from unintentional injury worldwide. It is a major public health concern due to their high incidence among older adults [1]. World Health Organization (WHO) projecting that by 2030 one in six individuals will be aged 60 or older, reflecting a demographic shift towards an aging population globally. According to the Census and Statistics Department local census study in 2023, there will be more than one-third of Hong Kong’s population as aged 65 or above after twenty years [2]; whereas fall prevention has emerged as a critical priority in geriatric care; physical frailty and poorer subjective well-being in older adults are widely discussed [3,4].

Alarmingly, there is estimated that 28–35% of older adults aged 65 years or above experience at least one fall annually in Hong Kong, with this proportion escalating to 32 to 42% among those aged 70 and above [1]. Among those hospitalized older fallers, approximately 9.9% sustain fractures and 31.3% suffer soft tissue injuries [5]. The consequences of falls in older adults are substantial, including increased risk of hospitalization, disability, morbidity, and mortality [6]. A higher risk of falling has been demonstrated in older individuals with comorbidity, such as diabetes and hypertension, whereas low levels of physical activity and a history of previous falls constitute additional predisposing factors [7,8]. Beyond these physical and medical determinants, falls can inflict long-lasting psychological sequence, including depression and an increased fear of falling, which has been identified as an important predictor of future falls independent of objective balance performance [9,10]. And it can subsequently limit daily and social activities, deteriorate physical fitness and function, and exacerbate the risk of future falls as a various cycle. Associated with other factors, physical inactivity is one of the common unhealthy lifestyles contributing to adverse health outcomes [11]. In a community-based study of older adults in Hong Kong, it had reported a substantial burden of falls and subsequent health service use, underscoring the need for effective fall prevention strategies [12]. To prevent the suboptimal condition, additional to the above statistics highlighted, there is a pressing need for effective interventions to mitigate the burden of falls on older adults.

Community-based exercise programmes that emphasise balance and strength training have been shown to be effective in reducing fall risk among older adults at average or high risk of falling [13,14]. Recent international guidelines recommend multicomponent exercise or strength training as first-line interventions [1], reflecting the multifactorial nature of falls, which are commonly categorised into intrinsic and extrinsic risk factors. Intrinsic factors include age-related changes, chronic disease, reduced muscle strength, gait and balance impairments, and cognitive decline, whereas extrinsic factors encompass medication use, environmental hazards, and risk behaviours [15,16]. Despite this recognition, most fall-prevention studies have concentrated on physical outcomes and have paid comparatively little attention to psychological determinants [17]. Systematic reviews and meta-analyses of randomised controlled trials in communitydwelling older adults have predominantly evaluated physical parameters, with limited focus on fear of falling, self-efficacy, or motivation [18,19]. This is problematic given that fear of falling has been identified as both a consequence and a predictor of falls in older Chinese adults [20], underscoring the need to address psychological as well as physical risk factors. Furthermore, the majority of studies have been conducted overseas and tend to examine either physical or psychological outcomes in isolation, with limited assessment of their combined effects. Consequently, although current fall-prevention programmes are increasingly described as multifactorial, they remain largely exercise-centred and may insufficiently incorporate the psychological dimensions that are critical to comprehensive fall risk reduction.

Concurrently, an emerging body of literature has examined dance as a therapeutic modality to mitigate fall risk in healthy older adults because of its multifactorial features. A recent systematic review reported that dance interventions can improve balance, gait, dynamic mobility, muscular strength, and overall physical performance—key physical risk factors for falls [21]. As a light-intensity exercise, dance is widely used in community settings and is recommended as a way to replace sedentary time with active behaviours in older adults [22,23]. Within the spectrum of exercise-based interventions, dance has been identified as a popular leisure-time activity among older people, with the potential for better adherence than more traditional exercise formats [24]. It is considered an engaging and sustainable alternative to conventional balance and strength training because it combines rhythmic movement with physical, emotional, cognitive, and social stimulation. Evidence indicates that dance can improve balance, gait, strength, flexibility, and coordination, while also conferring benefits in cognition, social interaction, quality of life, life satisfaction, and intrinsic motivation to be active, particularly among individuals with chronic conditions [25–29]. Some authors have argued that dance shares the holistic characteristics of Tai Chi, integrating physical, cognitive, and social components [30]. Mechanistically, these benefits may be explained by the multidimensional nature of dance, which integrates sensorimotor demands and cognitive processing relevant to fall prevention [28].

Although some scholars contend that current evidence does not yet support dance as a full substitute for targeted strength and balance training, it is acknowledged as a low-cost, easily accessible, multifactorial intervention that addresses physical, cognitive, and emotional health in older adults [31,32].

Beyond recreational activity, dance or dance and movement therapy have also been conceptualised as psychotherapeutic modalities. According to the American Dance Therapy Association, dance/movement therapy (DMT) aims to foster emotional, social, cognitive, and physical integration to enhance health and well-being [33]. Meta-analyses on DMT and dance have shown that DMT is associated with reductions in depression and anxiety, and improvements in quality of life, interpersonal functioning, and cognitive skills, whereas broader dance-based interventions tend to enhance (psycho-)motor abilities [34,35]. A more recent meta-analysis suggested that dance-based interventions may be superior to other forms of physical activity in improving motivation, aspects of memory, social cognition, and psychological distress. These findings are in line with earlier systematic reviews in the context of fall prevention, which provided preliminary evidence that dance can reduce fear of falling [36]. A small number of studies of integrated DMT fall-prevention programmes have also reported improvements in balance and reductions in fear of falling [37,38]. Collectively, these results highlight the promise of integrative dance and DMT approaches, but their effectiveness and underlying mechanisms warrant further investigation.

Despite the above benefits, there was a paucity of global and Chinese studies investigating the integrated approach of dance and dance movement to fall prevention from physical and psychological health dimensions. A preliminary Integrated Dance and Dance Movement Therapeutic program (IDDMT) had positively showed effectiveness on improving balance and mobility of communitydwelling older adults, as well as enhancing their psychological well-being and fall-related emotion in Hong Kong community [38]. A similar study with a larger sample size was repeated to generate a greater generalization to local community-dwelling older population.

Study Aim and Objective

The present study employed a pre and post quasi-experimental intervention without control group. It aimed to examine the effects of an integrated dance and dance/movement therapeutic intervention on physical and psychological factors related to fall prevention among Chinese community dwelling older adults. In order to examine the difference between the pre-post test scores of the paired groups on balance, mobility, fear of fall, as well as psychological well-being after the IDMT intervention with greater sampler size, in order to enhance the generalizability.

Methods

Subject Recruitment

Participates were recruited from collaboration project with various local community centres in different districts of Hong Kong, those were providing primary health service especially serving community-dwelling elderly. One-hours educational health talks on fall prevention presented by occupational therapist were held in centres, subjects were recruited in the talks according to the selection criteria.

Participants were fully informed of the potential risks and benefits associated with participation in the program. Written informed consent was obtained for the use of program evaluation data for research purposes. No personally identifiable information was disclosed in any reports or publications arising from the study. Participants were advised that they could withdraw from the evaluation component at any time without any consequences for their continued participation in the program itself. Health screening for the contraindications to the program involvement such as uncontrolled hypertension, cognitive impairment and audio-visual problems status were conducted A physical fitness checklist was signed by all participants. Participants who were older than 75 years, the additional declaration of the health conditions for the program were also signed.

Eligibility Criteria

Inclusion criteria were as follows: (a) aged 50 years or above; (b) able to read Chinese and understand Cantonese in order to follow verbal and written instructions for the dance activities; (c) able to provide informed consent for participation in the study; and (d) able to attend a minimum of eight sessions, including both the first and final sessions, to enable completion of the pre-test and post-test assessments.

Exclusion criteria comprised: (a) history of bone or joint injury; and (b) history of falls within the preceding three months. Prior to program commencement, all participants were required to complete a self-declaration of physical fitness checklist to confirm their suitability for dance-based exercise. Individuals who were unable or unwilling to complete this fitness declaration were excluded.

Intervention

A total of twelve IDMT fall prevention groups were implemented at different district community centres. Total 240 communitydwelling elderlies were recruited. Each IDMT session consisted of eight-session, a weekly 1.5 hours of rhythmic dance movements, physical exercises, and body-mind awareness training, were facilitated by a dance/movement therapist and an occupational therapist respectively. Apart from muscle strengthening and balance training, processing of sensory inputs and body-mind awareness training were crucial to the intervention. Rhythmic dance movements and dance choreography involved a greater social and emotion expression, positive group dynamic align with body-mind dance/movement therapy elements. Strength and balance exercises are embedded within varied dance patterns to develop lower-limb strength while maintaining enjoyment. A takehome video was provided for the seniors to practice at home. A community dance troupe was established in order to sustain the benefit and cohesion after completion of the program.

Outcome Measure

The subject variables included demographics, history of fall and health conditions. The baseline data were collected at the first session before the IDMT program, the outcome measures were collected at the last session of the program. The outcome measure consisted of the objective assessments on balance and mobility, as well as the self-reported fear of falls and psychological well-being.

The details of the selected outcome measures were as follow:

Unipedal Stance Test (UPST)

Physical balance was assessed using the unilateral (uni-pedal) stance test, a widely used clinical measure that is sensitive to balance impairment and fall risk in older adults. In this test, participants are instructed to stand on single leg (left or right) while the duration of maintained stance is timed. Shorter uni-pedal stance times have been associated with increased likelihood of falls and functional decline in community-dwelling older adults [39,40].

Timed-Up & Go Test (TUG)

Physical mobility was evaluated using the Timed Up and Go (TUG) test, a standardized measure with excellent intra-rater, inter-rater, and test–retest reliability in older populations [41-43]. The TUG is extensively adopted in health and rehabilitation services as a brief screening tool for functional mobility and fall risk, as it captures the integrated performance of sit-to-stand, walking, turning, and sitting down [44,45].

Fear of Fall (FFQ-R)

Fear of falling was measured using the Revised Fear of Falling Questionnaire (FFQ-R), a 15-item self-report scale rated on a 4-point Likert scale from 1 (strongly disagree) to 4 (strongly agree). Total scores range from 15 to 60, with higher scores indicating greater fear of falling [46]. The FFQ-R has demonstrated satisfactory internal consistency, with Cronbach’s α values ranging from 0.72 to 0.83, and good test–retest reliability (r = 0.82), supporting its use in older adult populations.

World Health Organization Well-Being Index (WHO-5)

Psychological well-being was assessed using the 5-item World Health Organization Well-Being Index (WHO-5), a brief selfreport instrument validated across age groups from youth to older adults. The WHO-5 has shown high sensitivity (0.93) and specificity (0.83) for detecting clinically relevant depression, making it a robust indicator of subjective well-being and emotional functioning [47,48].

Statistical Methods

All statistical analyses were conducted using IBM SPSS Statistics, version 28.0 (IBM Corp., Armonk, NY, USA). Descriptive statistics were employed to summarize participants’ sociodemographic characteristics and baseline health-related variables. To evaluate changes in physical performance, paired-samples t-tests were used to examine pre–post differences in balance (UPST) and mobility (TUG), under the assumption of approximately normally distributed difference scores. For psychological outcomes-fear of falling (FFQ-R) and psychological well-being (WHO-5)-the paired non-parametric Wilcoxon signed-rank test was applied to compare pre- and post-intervention median scores, given the ordinal nature of the scales and potential deviations from normality. All tests were two-tailed, and the level of statistical significance was set at p < 0.05. The results of these analyses are summarized in Table 1.

Results

Table 1: Summarizes the demographics and attendance of the sample.

Demographic Data (session attendance)

Two hundred thirty-three over two-hundreds forty participants completed the program with only 3.33% attrition rate. Over two

hundred (209) of the sample were females (89.7%) and twenty-four of them were males (10.3%). Their age ranged from 50-93, the mean age is 67.9. Eighty (34.3%) of them were young-old seniors aged between 50-64, and most of the seniors (65.7%) were aged over 65. Most of the participants maintained good attendance, with mean attendance achieved at 76.1% of full attendance. Nearly ninety percent (88.4%) of participants showed up more than half of the overall sessions, and above seventy-five percent (77.3%) of participants maintained over 70% attendance.

Effects on Mobility and Balance

Table 2 summarized the paired T-Test on both the balanced test (UPST) and mobility test (TUG) score. Balance scores of participants showed very strong significantly higher following the intervention (p < 0.001) in both legs; there was 81.3% and 66.9% of increase in left and right leg respectively. Similarly, TUG performance demonstrated statistically high significant improvement after completion of the IDDMT program (p < 0.001); majority of elderlies gain greater mobility to decrease 15.57% of time to perform the movement in average. Both results reflecting enhanced postural stability and mobility of participated older adults.

Table 2: Paired T Test.

Effects on Fear of fall and Well-being

Table 3 summarized the Wilcoxon tests measuring fear of fall and phycological well-being. Results revealed that the fear of falling scores of the participants were significantly reduced (p < 0.001). The state of positive well-being (WHO-5) was significantly promoted (p < 0.001) with very strong significance as well, there was average 6.8% increase of scores among the participants.

Table 3: Wilcoxon Test.

Comparison of the pilot and actual study

Table 4 summarized the significant values on all four paired tests results, compared those independent domains in pilot program and current study which improved on sampling methods and simple size. In the pilot program, there was statistically significant in all four paired tests, that means the pilot IDMT program showed effectiveness on improving bilateral balance, mobility, fear of fall and psychological well-being of community-dwelling older adults [38]. However, that pilot study may reveal a variation of effectiveness level of IDMT, whereas the improvement of psychological well-being was significantly higher than the other parameters, i.e. bilateral balance. On the contrary, the actual IDMT program showed strong effectiveness in all four selected parameters.

Table 4: Comparison of pilot and actual program on its significant values and change in means.