Examining Dance as an Intervention in Parkinson’s Disease: A Systematic Review

Dance interventions for individuals post-stroke - a scoping review

BACKGROUND

There is a growing body of literature assessing the potential benefits of dance for individuals post-stroke.

OBJECTIVES

We conducted a scoping review mapping the state of the literature on feasibility, intervention procedures, and efficacy of dance to improve health-related outcomes for individuals post-stroke.

ELIGIBILITY CRITERIA

Included studies were original research that described the use of a dance intervention for individuals post-stroke, included any health-related outcome, and were written in English.

SOURCES OF EVIDENCE

Databases selected were Pubmed, Scopus, Google Scholar, Proquest, MedRxiv, and CINHAL.

CHARTING METHODS

Two reviewers extracted relevant data and results were organized into themes and categories determined by all authors through discussion.

RESULTS

We searched electronic databases were in February 2021. We included 18 publications from 14 studies. Ten were quantitative, five were qualitative, one was mixed-methods, and two were community project descriptions. Twelve publications evaluated in-person dance classes and six evaluated dance exergaming. Based on the limited studies included, evidence suggests dance is a feasible and potentially effective intervention for individuals post-stroke. Studies demonstrate dance may facilitate changes in balance and fall risk, encourage confidence, promote comfort with the changed body, increase rehabilitation motivation, and facilitate community reintegration. Evidence is limited by number of studies, design (lack of control groups and blinded assessments), intervention descriptions, and outcomes reporting.

CONCLUSIONS

There is growing interest in dance for stroke interventions. Further research should focus on rigorous study design, optimal intervention timing, consistency of reporting outcomes, key elements of dance classes, and the impact of cultural dance styles.

Physical exercise and its effects on people with Parkinson's disease: Umbrella review

INTRODUCTION

Parkinson's disease is neurodegenerative, complex and progressive, manifesting in a slow and irreversible way. Physical exercise has been proposed as therapeutic alternative to people with Parkinson´s disease.

OBJECTIVE

To synthesize knowledge about the effects of physical exercise on people with Parkinson´s Disease as presented by published systematic reviews.

METHODS

Nine electronic databases and two grey literature databases were searched for systematic reviews reporting the effects of physical exercises on people with Parkinson´s Disease. Searches involved a two-phase process, by, at least, two independent reviewers. Methodological quality of the included systematic reviews was assessed using AMSTAR-2.

RESULTS

From 2,122 systematic reviews, 139 were included. Motor outcomes were assessed in 91% of the studies, with balance being the most studied. Non-motor outcomes were assessed in 68% of the studies, with emphasis on quality of life. Physical exercises were classified into five categories: aerobic exercises, strength, combined, sensorimotor activities and other activity protocols. Findings of the systematic reviews suggest that all exercise categories can be prescribed to improve balance and mobility, while combined exercises, strength, and specific activities improve both motor and non-motor outcomes, and aerobic exercise and sensorimotor activities improve motor outcomes.

CONCLUSION

Current evidence from systematic reviews suggests that physical exercises impacts both motor and non-motor outcomes in people with Parkinson´s Disease. Limits in evidence provided by the systematic reviews were related to methodological issues and to the description of the interventions and must be considered to improve decision-making and clinical application.

The Neuroscience of Dance: A Conceptual Framework and Systematic Review

Ancient and culturally universal, dance pervades many areas of life and has multiple benefits. In this article, we provide a conceptual framework and systematic review, as a guide for researching the neuroscience of dance. We identified relevant articles following PRISMA guidelines, and summarised and evaluated all original results. We identified avenues for future research in: the interactive and collective aspects of dance; groove; dance performance; dance observation; and dance therapy. Furthermore, the interactive and collective aspects of dance constitute a vital part of the field but have received almost no attention from a neuroscientific perspective so far. Dance and music engage overlapping brain networks, including common regions involved in perception, action, and emotion. In music and dance, rhythm, melody, and harmony are processed in an active, sustained pleasure cycle giving rise to action, emotion, and learning, led by activity in specific hedonic brain networks. The neuroscience of dance is an exciting field, which may yield information concerning links between psychological processes and behaviour, human flourishing, and the concept of eudaimonia.

Towards an evolutionary approach to learning from assumptions: Lessons from the evaluation of Dancing with Parkinson's

This paper highlights how learnings from exploring assumptions can be strengthened by taking an evolutionary approach to theory building and analysis. We discuss theory-driven evaluation applied to a community-based intervention implemented by Dancing With Parkinson's in Toronto, Canada, targeting Parkinson's disease (PD), a neurodegenerative condition affecting movement. A major gap in the literature is understanding the mechanisms by which dance might make a difference in the daily lives of people living with PD. This study was an early exploratory evaluation to better understand mechanisms and short-term outcomes. Conventional thinking generally favors "permanent" over "transitory" changes, and "long-term" over "short-term" effects. Yet, for people living with degenerative conditions (and also people experiencing chronic pain and other chronic symptoms), transitory and short-term changes may be highly valued and welcomed relief. In order to study and link multiple longitudinal events to explore key linkages in the theory of change, we piloted the use of diaries, with brief entries filled out daily by participants. The aim was to better understand the short-term experiences of participants using their daily routines as a means of learning about potential mechanisms, what matters to participants, and to see if small effects could be observed on days when participants danced versus days when they did not dance and also longitudinally over several months. Our initial theoretical stance began with a view of dance as exercise and the well-established benefits of exercise; yet, we explored through the diary data collected, as well as client interviews and literature review, potential other mechanisms of dancing (such as group interaction, touch, stimulation by the music, and esthetics including "feeling lovely"). This paper does not develop a full, comprehensive theory of dance but moves towards a more comprehensive view that locates dance within the routine activities of participants' daily lives. We argue that given the challenges of evaluating complex interventions comprising multiple, interacting components, there is a need for an evolutionary learning process to understand heterogeneities in mechanisms -- what works for whom -- when faced with knowledge incompleteness in the theory of change.

Effect of dancing on freezing of gait in patients with Parkinson's disease: A systematic review and meta-analysis

BACKGROUND

Freezing of gait (FOG) is one of the major debilitating motor symptoms that affect Parkinson's disease (PD) patients' gait,OBJECTIVE:To investigate the effect of dancing on FOG, motor symptoms, and balance in patients with Parkinsonism.

METHODS

Eight databases were searched for full-text English randomized control trials (RCTs). The freezing of gait (FOG) was the primary outcome while the balance and Unified Parkinson Disease Rating Scale (UPDRS-3) were the secondary outcomes. Methodological quality was evaluated by the Physiotherapy Evidence Database (PEDro) scale. Level of evidence was assessed by Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. A random-effect model of meta-analysis was used to calculate the standardized mean difference (SMD) at a 95% confidence interval (CI), and the effect size.

RESULTS

A total of nine studies (263 patients) were included. Qualitative data related to participants, dancing type, measured outcomes, and follow-up were extracted. PEDro scale showed one fair-quality and eight high-quality studies. GRADE showed a low to very low level of evidence with moderate effect size on both UPDRS (SMD -70 [-1.04, -0.36]) and Balance (SMD 0.35 [0.08, 0.63]).

CONCLUSION

Dance is an effective modality on improving UPDRS and balance with small effect on FOG. Further high-quality studies with high-quality of evidence are recommended to increase the confidence to the effect estimate and support the finding results.

Dance movement therapy for neurodegenerative diseases: A systematic review

Background

The proportion of the world's elderly population continues to rise, and the treatment and improvement of neurodegenerative diseases have become issue of public health importance as people live longer and many countries have aging populations. This systematic review aims to discuss the effects of dance movement therapy (DMT) on motor function, cognitive deficit, mood, and quality of life in people with neurodegenerative diseases, such as Parkinson's disease (PD), mild cognitive impairment (MCI), Alzheimer's disease (AD).

Methods

Two reviewers independently conducted systematic search on the Cochrane library, PubMed database, Web of Science Core Collection database, and Physiotherapy Evidence database until February 1, 2022. Only systematic analyses and randomized controlled trials were included and further analyzed.

Results

Thirty-three studies on PD, 16 studies on MCI, 4 studies on AD were obtained. This systematic review found that DMT substantially improved the global cognitive function, memory, and executive function on the population with MCI. Compared with the non-dance group, DMT remarkably improved general disease condition, balance, and gait for individuals with PD. The evidence of the efficacy of DMT on AD is insufficient, and further research is needed.

Conclusion

DMT can effectively improve the motor function and cognitive deficits in neurodegenerative diseases. Positive effects of DMT on the mood and quality of life in ND patients are controversial and require further evidence. Future research on the effects of DMT on AD requires scientific design, large sample size, long-term comprehensive intervention, and clear reporting standards.

Systematic review registration

www.osf.io/wktez, identifier: 10.17605/OSF.IO/UYBKT.

Benefits of Tango Therapy in Alleviating the Motor and Non-Motor Symptoms of Parkinson's Disease Patients-A Narrative Review

The present study examines the efficacy of tango therapy on motor and non-motor symptomatology in Parkinson's disease, as detailed in articles published over the previous four decades (1980-2022). All data was collected using PubMed, Google Scholar, Web of Science, and Science Direct. The present descriptive study outlines the advantages of tango in the rehabilitation of Parkinson's disease's motor and non-motor symptoms. Numerous studies have been conducted to determine the usefulness of tango for people with PD. Information from various research is critical for determining if tango is a useful supplementary therapy for the variety of symptoms related to Parkinson's disease. The purpose of this review was to describe the present state of research on this subject. Thus, the objective of this review is to promote awareness of tango therapy's therapeutic benefits for Parkinson's disease.

Feasibility of the basic movements of Azeri dance in the balance and posture of a person with Parkinson's disease: ABA single-subject design

Background/aims

Basic movements of Azeri dance as an intervention may have an impact on the physical and mental status of people with Parkinson's disease. The aim of this study was to assess the feasibility and efficacy of basic movements of Azeri dance on the balance and static posture of a person with Parkinson's disease. The effects of basic movements of Azeri dance on quality of life, quality of sleep and the performance in activities of daily living were reported before and after the intervention.

Methods

In this single-subject experimental ABA design, a 64-year-old man with a 4-year history of Parkinson's disease was selected. The outcome measures consisted of the Functional Reach Test, Timed Up and Go Test, qualitative static posture analysis, Short Form Health Survey, Modified Barthel Index and Pittsburgh Sleep Quality Index.

Results

An increasing trend in balance from the initial baseline stage through to the end of the intervention stage was found. Static posture analysis showed that the patient's posture improved qualitatively. His quality of life score changed after the intervention; however, his sleep quality and activites of daily living scores did not change.

Conclusions

Basic movements of Azeri dance are useful in the rehabilitation of patients with Parkinson's disease who have balance issues and postural instability, but further research is warranted.

Parkinson's Disease Motor Symptom Progression Slowed with Multisensory Dance Learning over 3-Years: A Preliminary Longitudinal Investigation

Parkinson's disease (PD) is a neurodegenerative disease that has a fast progression of motor dysfunction within the first 5 years of diagnosis, showing an annual motor rate of decline of the Movement Disorder Society Unified Parkinson's Disease Rating Scale (MDS-UPDRS) between 5.2 and 8.9 points. We aimed to determine both motor and non-motor PD symptom progression while participating in dance classes once per week over a period of three years. Longitudinal data was assessed for a total of 32 people with PD using MDS-UPDRS scores. Daily motor rate of decline was zero (slope = 0.000146) in PD-Dancers, indicating no motor impairment, whereas the PD-Reference group showed the expected motor decline across three years (p < 0.01). Similarly, non-motor aspects of daily living, motor experiences of daily living, and motor complications showed no significant decline. A significant group (PD-Dancers and PD-Reference) by days interaction showed that PD who train once per week have less motor impairment (M = 18.75) than PD-References who do not train (M = 24.61) over time (p < 0.05). Training is effective at slowing both motor and non-motor PD symptoms over three years as shown in decreased scores of the MDS-UPDRS.

'Digital Dancing' - "Can you see, what I feel" - An exploration of the physical 'experience' of dance for Parkinson's through 3-dimensional motion analysis

BACKGROUND

Parkinson's is a common, progressive, neurodegenerative movement disorder of the central nervous system. Research has consistently shown that dancing can have a positive impact on the lives of people living with Parkinson's (PwP). PwP who dance report that current measurement of the effects fails to appreciate the multifactorial presentation of the condition as well as the biopsychosocial potential of dance holistically.

AIM

To explore the feasibility of combining measurements of whole-body movement using 3-dimensional motion analysis with the lived experience of dance for PwP, to see if it is possible to 'see (measure)' what PwP say they 'feel (experience)' when dancing, in a 'mind/body approach' METHOD: : Thirteen PwP and ten Carers took part in three community delivered 'Parkinson's Dance Science' classes followed by focus group reflection. Three PwP wore a 3-dimensional, motion capture suit that recorded whole-body movement throughout the class and were interviewed about their experiences. Data were analysed using a 'Convergent Parallel' mixed methods design, mapping participant's experiences and reflections over six biomechanical movement variables.

RESULTS

Quantitative results indicate that it is possible to use 3-dimensional motion capture to measure biomechanical change during and following dance in PwP but the amount and direction of change was different for each participant. Qualitative results showed PwP felt the methods were feasible and reported a positive immediate and long-term effect of dance in a complete 'mind/body experience'. The sample size did not permit further analysis, but areas of development suggest it may not be the change in physical ability that is important, but more the perception of change following dance that is unique to each individual. Thus single measures of the effects of dance for PwP are likely to be insufficient when trying to understand the effect holistically.

CONCLUSION

A 'Convergent Parallel' mixed methods research design, mapping the experience of dance for PwP ('what I feel') and their peers against biomechanical change ('what you see') following dance is feasible. Further research is required to develop the method with a larger sample to truly begin to understand the potential and effects of dance for PwP.

Dance Fitness Classes Improve the Health-Related Quality of Life in Sedentary Women

Introduction: This study aims to analyze the effect of two dance-focused and choreographic fitness classes on Health-Related Quality of Life (HRQoL) in sedentary worker women. Methods: 65 sedentary middle-aged worker women (38 ± 7.3 years old) completed a 16-week intervention randomly assigned to: (1) dance fitness group based on Zumba Fitness classes (DF group, n = 25)], (2) dance fitness + functional strength training group (DFFT group, n = 20), and (3) control group (n = 20). HRQoL was assessed by the 36-Item Short-Form Health-Survey (SF-36), which evaluates 8 dimensions of health [General Health (GH), Physical Functioning (PF), Social Functioning (SF), Physical Role (PR), Emotional Role (ER), Bodily Pain (BP), Vitality (V), and Mental Health (MH)] scored from 0 (worst) to 100 (best health status). Results: The control group statistically differed from both exercise groups in PF and PR, and from the DF group in SF and MH showing a lower score. No statistical differences were observed between exercise groups post-intervention, except in V. DF group showed increases in GH, PF, SF, V, PR, and MH post-intervention. Conclusions: A 16-week dance fitness intervention based on Zumba Fitness classes generates notable improvements in a wide range of HRQoL dimensions in sedentary middle-aged worker women, especially in V, PR and MH dimensions.

Effects of Dance on Gait, Cognition, and Dual-Tasking in Parkinson's Disease: A Systematic Review and Meta-Analysis

Dance-based interventions have been proposed for the management of Parkinson's disease (PD) symptoms. This review critically appraises and synthesises the research on the effects of dance interventions on gait, cognition and dual-tasking in PD, through a meta-analysis of peer-reviewed literature from seven databases. Eligible studies included people with PD, used a parallel-group or cohort design with a dance-based intervention, reported outcome measures of gait, cognition or dual-tasking, and were published in English up until September 2017. Of the initial 1079 articles, 677 articles were reviewed for eligibility, and 25 articles were retained. Only 12 articles had sufficient common assessment items for meta-analysis. Two independent reviewers extracted the data and assessed the risk of bias of each study using the Cochrane risk-of-bias tool. Based on pre-post change scores, gait speed, Timed Up and Go (TUG) test performance, freezing of gait questionnaire, and six-minute walk test times significantly improved after a dance intervention compared to controls. Global cognition assessed with Montreal Cognitive Assessment, and cognitive dual-tasking measured using dual-task TUG, also exhibited greater improvement in dance groups. There was limited evidence to determine the most effective intensity, frequency, duration of dance interventions or the most beneficial music. Findings must be interpreted cautiously because of the lack of randomised control trials, and the moderate to high risk of bias of studies. However, the results of papers with level-I and level-II.1 evidence suggest that dance may have the potential to ameliorate PD symptoms, particularly gait, global cognition and cognitive dual-tasking.

Dance and Parkinson's: A review and exploration of the role of cognitive representations of action

Parkinson's disease (PD) is a neurodegenerative condition that causes both sensorimotor and non-motor impairments, and there is a clear need for non-medical approaches to improve quality of life. Dance is an increasingly popular activity among people with PD, which demonstrates potential therapeutic benefits. However, findings to date have been inconsistent, and little is known about the mechanisms underlying benefits of dance in PD. In this review, we provide an overview of research into dance for people with PD. The majority of quantitative evidence is in the sensorimotor domain, but cognitive, psychological and social effects have also been reported. We consider the role of cognitive representations of action within dance through observation, imitation and imagery, which may contribute to both sensorimotor and non-motor outcomes for people with PD. Moreover, we discuss how these processes may be enhanced through dance to provide further benefits in everyday life. Finally, we propose avenues for future research to increase understanding of action representation in dance for PD, which has the potential to inform practice and maximize benefits.

Ballroom dance for persons with multiple sclerosis: a pilot feasibility study

Purpose: The purpose of this study was to evaluate the exercise intensity and feasibility of recreational ballroom dance for persons with multiple sclerosis (MS).Methods: Seven persons with MS participated in 2 one-hour dance sessions per week for 6 weeks. Dance types included rumba, foxtrot, waltz, and push-pull. Six other persons with MS comprised a control group that did not dance. Heart rate and ratings of perceived exertion (RPE) were monitored during the sessions. Outcomes included: quality of life, fatigue, depression, self-efficacy, timed up and go, Berg Balance Scale, Dynamic Gait Index and the Multiple Sclerosis Functional Composite comprising 9-hole peg test, 25-ft walk test, and Paced Auditory Serial Addition Test (PASAT), a cognitive test.Results: Heart rates and RPE indicated that ballroom dance for persons with MS can provide a light to moderate exercise intensity. After the dance program, quality of life and PASAT improved as did the MS Functional Composite Score. No changes were noted in the control group.Conclusions: Recreational ballroom dance is feasible and can provide an exercise stimulus sufficient to help meet exercise recommendations for persons with multiple sclerosis as well as improve quality of life and cognition in persons with MS.Implications for rehabilitationExercise or physical activity is important for the health and wellness of persons with multiple sclerosis.Persons with multiple sclerosis often seek information about non-traditional low-impact physical activity.In a small controlled sample, partnered recreational ballroom or social dance for persons with multiple sclerosis has been shown to be feasible and of recommended exercise intensity.Further, partnered recreational ballroom dance for persons with multiple sclerosis can improve measures of quality of life and cognitive function.

Dance for the rehabilitation of balance and gait in adults with neurological conditions other than Parkinson's disease: A systematic review

PURPOSE

To conduct a systematic review that examined the effect of dance interventions on balance, gait and functional mobility outcomes in adults with neurological conditions other than Parkinson's disease.

METHODS

A systematic search of relevant databases was conducted. Data extraction and methodological appraisal were performed by two independent authors.

RESULTS

Nine studies were included (4 pre-post studies with no control group, 3 case reports, and 2 controlled studies) and results of the methodological quality assessment ranged from poor to good. Study groups included stroke, multiple sclerosis, spinal cord injury, and Huntington's disease. Dance interventions varied in frequency, type and duration, and only 1 study reported intensity. Study dropout rates ranged from 20-44%, and 88-100% of dance classes were attended. Only 3 studies mentioned adverse events, of which there were none. A summary of results revealed significant changes in spatiotemporal gait parameters, Berg Balance Scale scores, Timed Up and Go test and six-minute walk test that were similar to or greater than those previously reported in a review of dance for individuals with Parkinson's disease.

CONCLUSIONS

There is emerging evidence to support the use of dance as a feasible intervention for adults with neurological conditions. Further investigation of the effects of dance with randomized controlled trials using larger sample sizes and better reporting of the intervention, participant tolerance, and adverse events is warranted.

The Embodied Self in Parkinson's Disease: Feasibility of a Single Tango Intervention for Assessing Changes in Psychological Health Outcomes and Aesthetic Experience

Background: Dance is an embodied activity with benefits for mobility, balance, and quality of life (QoL) of persons affected by Parkinson's Disease (PD). It is enjoyable and likely to support adherence to movement prescriptions. The objective of this study was to assess the feasibility of measuring changes in psychological outcomes, specifically well-being, body self-efficacy, outcome expectations, and experienced beauty after a single Argentine Tango intervention in a workshop format. To anchor experienced beauty in a theory, the article introduces a model of embodied aesthetics featuring active art-making as a central aspect of healing in arts-based interventions.

Methods: In a single-group pre–post design, we tested the feasibility of measuring psychological changes of 34 PD patients from Southern Germany after an introductory workshop in Argentine Tango. They participated in a 90 min Tango for PD intervention and completed the Heidelberg State Inventory (HSI-24; (Koch et al., 2007)), the Body Self-Efficacy Scale (BSE; (Fuchs and Koch, 2014)) with a sub-dimension on aesthetic experience, and the Credibility-Expectancy Questionnaire (CEQ; (Devilly and Borkovec, 2000)) before and after the intervention. A subgroup completed the therapeutic factors of arts therapies-scale, a new measure to elaborate on the aesthetic experience. We analyzed pre–post-differences with a t-test for paired samples.

Results and Discussion: The study supports the feasibility of measuring health-related psychological changes from a single Argentine Tango intervention for PD patients, as well as acceptance and appropriateness of the intervention for the patient group. After the tango intervention, well-being, body self-efficacy, and outcome expectancies increased. Participants also experienced an increase in beauty of their movements and other aesthetic aspects. We suspect that, in addition to the functional and psychological factors identified so far, the aesthetic experience in dance may be an important therapeutic factor mediating several outcomes of dance and other arts-based interventions. A controlled study for evidence-based testing of targeted variables can now follow to examine the new hypotheses.

Sensorimotor integration is enhanced in dancers and musicians

Studying individuals with specialized training, such as dancers and musicians, provides an opportunity to investigate how intensive practice of sensorimotor skills affects behavioural performance across various domains. While several studies have found that musicians have improved motor, perceptual and sensorimotor integration skills compared to untrained controls, fewer studies have examined the effect of dance training on such skills. Moreover, no study has specifically compared the effects of dance versus music training on perceptual or sensorimotor performance. To this aim, in the present study, expert dancers, expert musicians and untrained controls were tested on a range of perceptual and sensorimotor tasks designed to discriminate performance profiles across groups. Dancers performed better than musicians and controls on a dance imitation task (involving whole-body movement), but musicians performed better than dancers and controls on a musical melody discrimination task as well as on a rhythm synchronization task (involving finger tapping). These results indicate that long-term intensive dance and music training are associated with distinct enhancements in sensorimotor skills. This novel work advances knowledge of the effects of long-term dance versus music training and has potential applications in therapies for motor disorders.

A Pilot Study: examining the effects and tolerability of structured dance intervention for individuals with multiple sclerosis

PURPOSE

The aims of this pilot were to examine dance as a feasible intervention for persons with multiple sclerosis (MS), specifically to examine issues of tolerability and its longitudinal effects on participants. Dance is an enjoyable physical activity that has been investigated in other neurodegenerative populations but has yet to be studied in MS.

METHOD

A 4-week, two 60-min classes per week, pilot salsa dance intervention was administered to eight individuals with MS. The outcomes measured were effects on gait, balance, self-efficacy, motivation, physical activity and MS symptoms. They were administered at baseline, immediately post-intervention and at 3- and 6-month follow-ups.

RESULTS

Statistically significant pre-post intervention gains were found for the Timed Up and Go Test (TUG), Dynamic Gait Index (DGI), Activities-specific Balance Confidence Scale and Godin Leisure Time Questionnaire. Significant improvements were also found for the TUG, DGI and MS Walking Scale between baseline and 3-month follow-up assessments. Participants did not report any problems with fatigue or intolerability with the 60-min suggestions, further supporting the feasibility for the concept of a dance intervention.

CONCLUSIONS

This study suggests that dance for persons with MS may have promise for improving physical activity, gait and balance.

IMPLICATIONS FOR REHABILITATION

Although structured dance has reported benefits in elderly populations and in individuals with cardiovascular and neurological impairments, there is virtually nothing known regarding dance in the MS population. This pilot salsa dance study shows that structured dance demonstrates promise of being well-tolerated, safe and effective at promoting physical activity in people with MS without increased fatigue. A 12-week study has been initiated to test the robustness of initial observations and further examine factors influencing participants' physical activity adherence and behavioral change.