The Effects of Argentine Tango on Balance and Quality of Life in Subjects with Traumatic Brain Injury" (2019)

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2019 The ffecE ts of Argentine Tango on Balance and Quality of Life in Subjects With Traumatic Brain Injury Pamela Marie Peterson

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This Thesis is brought to you for free and open access by the Graduate School at ScholarWorks at University of Montana. It has been accepted for inclusion in Graduate Student Theses, Dissertations, & Professional Papers by an authorized administrator of ScholarWorks at University of Montana. For more information, please contact [email protected]. The Effects of Argentine Tango on Balance and Quality of Life in Subjects With Traumatic Brain Injury

PAMELA MARIE PETERSON

Bachelors of Science Degree, University of Montana, Missoula, Montana, 2014 Associate of Science, Solano Community College, Fairfield, California, 2011

Thesis

presented in partial fulfillment of the requirements for the degree of

Master of Science In Health and Human Performance

The University of Montana Missoula, MT

Official Graduation Date May 2019

Approved by:

Scott Whittenburg, Dean of The Graduate School Graduate School

Dr. Charles Dumke, Chair Health and Human Performance

Dr. Matthew Bundle Health and Human Performance

Ann Stevenson, LCPC

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ABSTRACT

This study investigated the effect of a six-week tango-based intervention on the balance and quality of life on subjects with traumatic brain injury (TBI). Twenty-two men and women were assigned into three groups TBI group (TBI: n=2; 44.5±2.1 years), Treatment control (TC: n=8; 30.9±12.3 years), Control (CG: n=12; 32.8±9.6 years). The TC group showed an improvement in stress levels compared to the CG p<0.05. While all groups improved in most of the feet on foam with eyes closed condition over time, those that participated in tango improved more (time p<0.05). Findings demonstrate that tango improves stress in subjects with TBI, and may improve balance regardless of TBI.

ACKNOWLEDGEMENTS

I would like to thank both of my professors who helped me more than I can say with this project: Dr. Dumke and Dr. Bundle. Thank you to Ann Stevenson as well for her unfailing support for the nature of this endeavor.

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TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION ...... 1

INTRODUCTION ...... 1

STATEMENT OF PROBLEM ...... 2

STATEMENT OF PURPOSE...... 3

RESEARCH HYPOTHESIS ...... 3

SIGNIFICANCE OF THE STUDY ...... 4

RATIONALE OF THE STUDY ...... 4

LIMITATIONS ...... 4

DELIMITATIONS ...... 5

DEFINITION OF TERMS ...... 96

CHAPTER 2: REVIEW OF RELATED LITERATURE ...... 10

EXERCISE ...... 10

MUSIC ...... 10

DANCE ...... 11

SOCIAL INTERACTIONS ...... 13

TANGO ...... 13

SUMMARY ...... 14

CHAPTER 3: METHODOLOGY ...... 15

SUBJECTS ...... 15

RESEARCH DESIGN ...... 15

OUTCOMES ...... 16

iii

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CONSIDERATIONS ...... 19

CHAPTER 4: RESULTS ...... 20

QUALITY OF LIFE ...... 20

BALANCE ...... 22

CHAPTER 5: DISCUSSION ...... 49

QUALITY OF LIFE ...... 49

BALANCE ...... 49

CHAPTER 6: CONCLUSION ...... 52

REFERENCES ...... 53

APPENDICES ...... 63

APPENDIX 1: DASS 21 QUESTIONNAIRE ...... 63

APPENDIX 2: COURSE DESIGN ...... 64

APPENDIX 3: ATTENDANCE SPREADSHEET ...... 68

APPENDIX 4: STATISTICAL ANALYSIS TABLE ...... 69

APPENDIX 5: GRAPHS OF INDIVIDUAL SUBJECT DATA ...... 70

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Introduction: Traumatic brain injury (TBI) is a disruption in the normal function of the brain caused by a blow to the head, violent shaking, or penetration of the brain tissue with varying degrees of severity1,2. Effects of TBI can be long or short term and symptoms can include physical, cognitive, behavioral, and emotional impairments2. Many studies have evaluated different treatment techniques post TBI3. According to the American Academy of Neuroscience review in

2018, people with severe brain injury had lower mortality 3 years post discharge if they had a multidisciplinary approach to their treatment4. A multidisciplinary approach is best to address the complexity of symptoms that vary depending on the severity of injury2,4.

Studies suggest that participating in an exercise regimen after a TBI aids in patient recovery5. Several exercise modalities have been explored for TBI recovery including various aerobic activities6 and progressive strength training techniques7 that showed improvement in motor functions. It has also been suggested that individual choice in the type and intensity of exercise may be more logistically sustainable than regimented exercise protocols for recovery8,9 due to the motivation of the individual to complete the tasks on their own10.

In addition to physical movement, several studies provide evidence that musical interventions have been successful in the treatment and recovery of patients with TBI11,12.

Music therapy is the planned and intentional use of music to address physical, cognitive, social, psychological, and other needs of the individual11,12. It has been shown to reduce circulating stress hormones which improves the efficacy of other therapies done at the same time1,13,14.

Combining the modalities of music and exercise could have an additive effect on gait and balance control in those suffering from TBI. A study by Thornberg et al. used a controlled rhythmic exercise with music and visual inputs such as colors and words to produce movement

Peterson 2019 and verbal recognition in patients after stroke15. In her study, she concluded that activities promoting connection to the body provides a sense of wholeness and allows subjects to add meaning to their lives through social interaction and engagement with the environment and themselves15.

Dance is a modality that combines exercise with music. Tango is a partner dance developed in Argentina in the mid-19th century involving long steps and complex patterns of movement14. One of the few times tango has been examined as an intervention was in a case study by Hackney et al. as a treatment for a patient with chronic stroke16. She found measurable improvements on gait, mobility and balance as well as cognitive factors16.

Recently, there have been studies examining the benefits of dance interventions in people with

Parkinson’s disease3,17,18. In another, larger, study by Madeleine Hackney, it was concluded that tango had more benefit than the Fit ‘n Fun exercise protocols for Parkinson’s disease in a subject’s functional mobility10. This could be the result of the complexity of movement patterns required for tango such as turning, varying speed, and varied direction of movement stimulating areas of the brain controlling balance centers19.

Statement of Problem:

Traumatic brain injuries are common and complex. Because not everyone has behavioral issue or severe impairments as a result of TBI the need for outpatient treatment is generally not warranted1. Though medical intervention is not always prescribed, or the patient has recovered to a point where they no longer need the clinical intervention, patients often have symptoms of disorganized movements and postural problems that persist and cause a loss

Peterson 2019 of quality of life1. Research has been done using interventions such as rhythmic exercise and dance to increase the quality of life for other brain disorders including degenerative balance disorders associated with age13,20–23, Alzheimer’s disease24, stroke16,25 and Parkinson’s disease3,10,17,18,26–28, while one study looked at aerobic dance and TBI29, none have looked at how tango can benefit individuals with TBI.

Statement of Purpose:

The purpose of the study is to investigate the effects of Argentine tango on balance control and quality of life in subjects with traumatic brain injury compared to both a non- traumatic brain injury tango intervention and non-intervention control group.

Research Hypothesis:

There will be no difference between the control group and the Tango groups in Quality of life scores pertaining to Stress as reflected in the Pre and Post DASS-21 Questionnaire.

There will be no difference between the control group and the Tango groups in Quality of life scores pertaining to Anxiety as reflected in the Pre and Post DASS-21 Questionnaire.

There will be no difference between the control group and the Tango groups in Quality of life scores pertaining to Depression as reflected in the Pre and Post DASS-21 Questionnaire.

There will be no difference between the control group and the Tango groups in center of pressure anterior to posterior displacement as reflected in the Pre and Post force platform assessments.

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There will be no difference between the control group and the Tango groups in center of pressure medial to lateral displacement as reflected in the Pre and Post force platform assessments.

There will be no difference between the control group and the Tango groups in center of pressure area as reflected in the Pre and Post force platform assessments.

There will be no difference between the control group and the Tango groups in center of pressure path length as reflected in the Pre and Post force platform assessments.

Significance of the Study:

This is the only study exploring the effects of Argentine tango on balance and quality of life on persons with traumatic brain injury.

Rationale of the Study:

Because Argentine tango is dynamic and improvisational, continuous corrections need to be made without the benefit of anticipated patterns which will, in theory, enhance the balance required for the activities of daily life.

Limitations:

Argentine tango combines the musicality11,12,30,31 and mindfulness32–37 components with the physical to enhance effectiveness. It also has higher adherence rates3,20 which makes it a candidate for a long term intervention for improving physical and mental qualities of life in persons with traumatic brain injury.

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Delimitations:

Studies have already explored various physical therapy modalities for balance or music interventions individually or in conjunction with other mindfulness therapies for traumatic brain injury to great effect. However, unless stipulated by the individual participating in the intervention, they do not combine mindfulness techniques, interpersonal touch, social interactions, physical movements, and rhythmic/ musical stimulation and reflex simultaneously.

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Definition of Terms:

• Traumatic Brain Injury (TBI): “A disruption in the normal function of the brain that can be

caused by a bump, blow, or jolt to the head or a penetrating head injury1.” This definition

has been expanded to include explosive blasts as a cause1.

• Postural Control: complex motor skill involving sensory and motor systems working

together to prevent falls38,39

o Center of Pressure: the location of vertical ground reaction vector on the force

platform40.

o Postural Sway: horizontal movement around the center of gravity41

• Balance: the condition of someone or something in which its weight is equally divided so

that it can stay in one position or be under control while moving42.

• Quality of life: how people see their lives compared to their ideal lives based on societal

norms43–45

o Stress: uncomfortable emotional experience accompanied by predictable

biochemical, physiological and behavioral changes46,47.

o Anxiety: an emotion characterized by feelings of tension, worried thoughts and

physical changes like increased blood pressure48.

o Depression: a common mental disorder with symptoms including: a lack of interest

and pleasure in daily activities, significant weight loss or gain, insomnia or excessive

sleeping, lack of energy, inability to concentrate, feelings of worthlessness or

excessive guilt and recurrent thoughts of death or suicide49.

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o DASS 21: is a 21-item self-report instrument designed to measure the three related

negative emotional states of depression, anxiety and tension/stress50.

• Argentine Tango

o Walking: The lead moves forwards or backwards and the follower moves backwards

or forwards in parallel or crossed system

o Cross system: Occurs whenever the couple are stepping together on his and her

right feet and then on his and her left feet, regardless of direction. The opposite

of parallel system51.

o Parallel system: The natural condition when a couple dance in an embrace facing

each other, the lead stepping on his left, the follower on her right foot, and then the

lead stepping on his right, the follower on her left foot, regardless of direction51.

o Sidesteps: Moving as a unit to the side

o Ochos: (eights) Pivoting on one foot forward or backward with the feet together

during the pivot and extended during the step as in figure eights. Typically executed

with feet together (ankles touching) instead of one foot extended51,52.

o Giros (turn): While follower does molinete, leader turns on one foot placing the toe

of the foot in front and executing a sharp turn52.

o Molinete: Windmill; wheel: A figure in which the follower dances a grapevine

pattern around the leader, stepping in a side-back crossing step-side-forward

crossing pattern as the leader pivots at the center of the figure. This is a very

common figure in tango which challenges both roles to maintain good posture,

balance, and technique51.

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o Rock step: A split weight check and replace, usually led as the leader steps forward

with the left foot interrupting his or her forward step. May also refer to a subtle

shifting of weight from foot to foot in place and in time with the music done by the

lead before beginning a dance to give the follow the rhythm intended to ensure that

the follow will begin on the correct foot51.

▪ Rock step turn: using the rock step to change direction by pivoting on the

forward foot

o Cruzada: Cross; occurs anytime a foot is crossed in front or in back of the other52.

o Calisita: “merry-go-round”53; occurs when the lead circles around a stationary

(pivioting) follow.

o Parada pasada:

▪ Parada (stop) happens when the leader places a foot against a follower's foot

and leads them to stop54.

▪ Pasada (stepover) often follows a parade. It occurs when the follower steps

over the leader's foot often to return to the center herself in front of the

leader54.

o Adorno: ornament, decoration55; a movement in tango that is not led

• Body:

o Axis: The center vertical line around which one's balance is maintained52

o Line of Dance: Moving in a counter clockwise circle with the group of dancers at a

social dance

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• Lead: Traditionally a male role, a lead invites the follow to perform steps and step

sequences

• Follower: Traditionally a female role, a follower “follows” the lead but the role is not

passive. The follow can set the timing and the emotion of the dance based on how they

follow the leader’s invitations.

• Practica: Informal Tango dance practice

• Milonga: Formal Argentine tango dance party

Figure 1: Schematic of the complex interaction of tango

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Chapter 2: Review of Related Literature:

Exercise:

Following the initial physical therapy to return to normal function after traumatic incident, depending on the extent of the injury, can be months to years of additional intensive physical therapies1. Some of the greatest gains during this time can be made in the psychological effects of chronic illness—depression and resultant decrease in cognitive function1. Exercise has been found to be as effective as medications at soothing the dysregulated sympathetic nervous system post TBI6,15,56–60. In addition to being dysregulated, the treatment of depression and anxiety after traumatic brain injury is challenged by increased sensitivity to medications and vulnerability to side effects61.

Exercise mitigates persistent problems with balance and stability. Progress was made toward normalcy and safety for people who live with traumatic injury or other balance disorders using yoga58, monitored circuit training7,9,62,63 and other highly individualized interventions57,64.

Music:

Music is a multi-dimensional tool newly introduced to the world of psychotherapy. It has the power to enhance and destroy motivation and bridge the gaps between brain cells65. In

2009, Altenmüller et al. observed after 15 sessions of music therapy there were not only improvements in motor control and precision of movements over controls, but there was better cortical connectivity in the EEG in the damaged parts of the brain than in the control groups. Neurologic music therapy has huge implications for people with traumatic brain injury for depression and for motor control66–68.

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Emotional regulation is difficult for those with traumatic brain injury. Music therapy can help modulate the peaks and valleys of nervous system dysregulation by stimulating the paralimbic system causing feelings of happiness or satiety69–71. Thaut et al. looked at executive function and emotional adjustment in persons with traumatic brain injury. They found that the treatment group who used percussion instruments to follow patterns led by a therapist were significantly improved in anxiety, depression and sensation seeking and more mentally flexible70.

Adding music to movement therapies that are not dance has shown to have significant improvements to patients’ quality of life and mobility due to a sense of being connected to the whole body15. Two weeks after stroke, adding music to wheelchair-seated arm activities showed greater satisfaction and greater range of motion in the shoulder and elbow in the affected arm compared to the control group72. Pacchetti et al. found a similar phenomenon when adding music to weekly physical therapy in Parkinson’s patients73. His patients saw a decrease in bradykinesia, improvements in activities of daily living and overall happiness factors73. In subjects who completed Dance For Parkinson’s (DFP) protocols, there were no improvements to balance due to the seated nature of the exercise but showed positive improvement in social application and quality of life scores3.

Dance:

In 2002, Dault et al. performed a study involving aerobic dancing compared to muscular training on subjects with traumatic brain injury29. The dancing was individualized slide and step dancing with gradual addition of arms while the muscular training was traditionally prescribed

Peterson 2019 musculoskeletal training using Nautilus equipment. The study concluded, based on force plate analysis, that the dance group benefited more in balance and coordination than the weight training (control) group29.

The older adults also show improvements in postural control with dance-based programs. An eight-week ballroom dance study showed improvement in balance and functional performance using subjective tests such as the Timed up and go, Tinetti test, etc. and objective measures such as force plate data compared to controls23. Kattenstroth et al. found after six months of a weekly dance class, there were significant changes to posture and balance that were tested with both subjective tests and with force plates as well as cognition and quality of life changes that were tested with the everyday competence questionnaire22.

Parkinson’s disease has some of the same hallmarks of instability and resulting deficits in quality of life as persons with traumatic brain injury due to lack of mobility including postural instability, gait difficulties, impaired functional mobility3,10,17,18,26–28, and depression17,18. Several studies have explored dance and how it impacts motor function in people with Parkinson’s disease with mixed results based on modality. Ballet did not show significant balance improvement based on the measurements taken with the explanation being fatigue during the measurements since they were taken directly after the class, but it did show a significant improvement to motor control scores as well as those to quality of life18. Subjects who participated in improvisational28 and modern dance27 showed improvement in balance scores using the Fullerton scale. The case study showing improvement with improvisational dancing was substantiated with changes in fMRI imaging showing the possibility the basal ganglia can reroute to reestablish connections to improve movement patterns28. This finding is also being

Peterson 2019 explored by Hafting et al. in the older adult population as it pertains to dance with the explanation neurons are part of a grid system and even if they are atrophied or missing, they still hold the space—the location they connected to can be reached74 and dancing can help reconnect these pathways13.

Social interactions:

The social interaction of activities is well known to help with depression and anxiety.

Tango goes a step further by combining music and partner using interpersonal touch to alleviate the feelings of isolation and loneliness32,33,35. In a study by Quiroga Murcia et al., the role of hormone was evaluated as were the roles of partner and music33. They found that regular tango decreased cortisol levels which were additive with partner and with music and testosterone fluctuations were mitigated after the second introduction which substantiated previous, self-reported research on the subject of well-being33. It is important to note that this decrease in cortisol is unique to Argentine tango perhaps due to its more casual atmosphere75,76.

Tango:

Hackney et al. in several studies spanning 2007-2010 looked at how tango used as an intervention could improve quality of life in subjects compared to other interventions such as

American Ballroom tango26, and group exercise classes10; as well as a longer term study following a single individual for a duration of 20 weeks17. Overall, she and her colleagues found that when compared to exercise only tango improved on the balance measures, and compared

Peterson 2019 to the other dance modalities the groups participating in tango showed the same if not more improvement in balance according to the Berg Balance scale.

Used as treatment for chronic stroke, there were similar effects. In 2012, Hackney again tested tango as an intervention in a case study showing marked improvement after 20 hours of tango classes in balance and coordination as well as a commitment to continuing the course of treatment16.

Tango has also been used in non-pathological older adults with balance and confidence problems. Patricia McKinley and colleagues in 2005 did a feasibility study that found tango targeted balance and complex task execution better than other modalities specifically compared to a walking program21. She repeated the study in 2008. After the follow-up it was determined both groups were significantly improved, but the attrition rate for the tango group was much less than for the walking group there was only 1 compared to 4 in the walking group which might have more significant ramifications for long-term treatment choices20.

Summary:

The literature shows there is strong evidence Argentine tango can be an effective intervention for generalized traumatic brain injury because it is the integration of movement, music, social interaction and mindfulness practice.

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Chapter 3 Methodology:

Subjects:

Subjects were selected from volunteers in the Missoula, MT and surrounding communities with an interest in learning to dance Argentine Tango. All subjects had no previous dance experience or did not dance regularly within the last year and were between 18 and 50 years of age with the average age of 32 years. Because Argentine Tango is a partner dance, we wanted each group to have 5 males and 5 females to conform to traditional leader and follower roles, we had 6 females and 5 males with the instructors substituting for the absent partner. There were three groups: Tango with TBI, Tango without TBI, and the Control Group.

The TBI group were individuals who have an history of TBI with recovery lasting greater than

1 year and have ambulatory ability (n=2). The severity of TBI in the participants were determined by self-reported acknowledgement of Glasgow Coma Scale scores between 9-12 which are considered moderate77.

The Non-TBI group were individuals with no known TBI (n=12). They participated in the same tango intervention and measurements as the TBI group. Three of the participants elected to remove themselves from the study leaving n=9.

The Control group were individuals without a known TBI who did not participate in the tango intervention (n=12).

Research Design:

All participants from each group participated in pre and post testing of balance and quality of life scores.

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TBI and Treatment Control groups participated in a six-week introductory Argentine tango class once per week provided by Tango Connections, of Missoula, MT. The instructors for the course were Lori Mitchell and Michaela Stockhouse. The class covered basic movements such as walking with a partner in parallel and cross systems and progressed to more complex movements throughout the course. A detailed description of the classes is available in

Appendix 3. Subjects were discouraged to participate in non-tango dancing during the experiment and were required to practice tango one time per week outside of class during organized practicas supervised by members of the tango community and instructors3,18,19,22–

24,27–29,34,35. These were held for one and one-half hours per week on Monday, Thursday and

Friday evenings in various venues in Missoula and the Bitterroot Valley. These were monitored by rollcall by the PI who attended all functions. Subjects were removed from the study if they missed more than one class and one practica. Subject number one was removed from analysis after completing the protocol due to a syncopal episode during the treatment period.

Outcomes:

Postural control evaluation:

Subjects reported to Ed 010 by appointment. Subjects were responsible for ensuring they did not arrive to the laboratory inebriated or otherwise incapacitated. The laboratory portion of the assessment took approximately 15-20 minutes per subject. During data collection subjects performed a cognitive challenge (serial sevens). Data was collected on all subjects within two days of completion of intervention to ensure effect is measured. The entire assessment took about one hour per individual including the survey.

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The assessments included pre and post intervention time points in a modified sensory orientation test in 6 different conditions. Subjects were asked to stand on the force plate for 45 seconds with their:

(1) Feet together and eyes open,

(2) Feet together and eyes closed,

(3) Feet apart and eyes open, and

(4) Standing on foam with feet together and eyes open

(5) Standing on foam with feet together and eyes closed

(6) Standing on foam with feet apart and eyes open

Quality of Life evaluation:

Subjects filled out a survey (DASS-21) to evaluate their mental state of depression, anxiety and stress78 to determine the quality of life impact of the intervention. The surveys were manually scored and the deidentified data were entered into excel for analysis.

Analysis:

Balance evaluation:

In this study we used a BerTec 6040 force platform with a dual pass of a 6-pole, low pass, Butterworth filter producing a zero-lag filter with an effective cutoff frequency of 40 Hz,79 along with the Axoscope 10.2 to analyze postural sway similar to those used in the Dault study29. Each of these conditions was assessed at 1000 Hz for the middle 30 seconds eliminating the step on and off period to ensure steady state. The foam measured 12.7 cm in depth. Readings of Anterior/Posterior and Medial/Lateral Center of Pressure (COP)

Peterson 2019 displacement, COP area, and COP path length were taken from this assessment using

WaveMetrics Inc., Igor Pro 6.34A; OR, USA program. Center of pressure was assessed from the ground reaction force record in accordance with Newton’s first law:

−푀푦 퐶표푃푋 = 퐹푧

푀푥 퐶표푃푌 = 퐹푧

We calculated the center of pressure area by writing a code in Igor to convert the non- simple figure generated by the raw data using the maximum and minimum values to find the perimeter of the figures. We then calculated the area using a modification of Green’s Theorem for a simple closed figure. Where c is the clockwise oriented simple closed curve.

푎푟푒푎 표푓 퐷 = ∬ 푑퐴

1 = ∫푥푑푦 − 푦푑푥 2 퐶

We calculated percent change in the pre to post intervention measurements to remove the variability between subjects. This was calculated by using the formula:

(푝표푠푡 𝑖푛푡푒푟푣푒푛푡𝑖표푛 푑푎푡푎 − 푝푟푒 𝑖푛푡푒푟푣푒푛푡𝑖표푛 푑푎푡푎) 푃푒푟푐푒푛푡 푐ℎ푎푛푔푒 = × 100 푝푟푒 𝑖푛푡푒푟푣푒푛푡𝑖표푛 푑푎푡푎

Quality of Life evaluation:

Quality of life scores were separated into their respective categories and then summed to get each subject’s score before and after the intervention.

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Considerations:

Subjects gave their written informed consent to engage in all measures and activities associated with this study.

Statistical Procedures:

Statistical analysis using 3x2, 2x2 ANOVA and a two-tailed independent t-test for balance measures as well as 3x2 and 2X2 ANOVA for quality of life measures in SPSS.

Significance was set at p<0.05.

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Chapter 4 Results:

Twenty-six subjects participated in pre assessment of quality of life and balance testing consisting of surveys and analysis of balance in six conditions each with twenty- three completing the study for a total of 49 quality of life surveys and 294 balance scores assessed.

Further analysis of these scores broke each of these conditions into ten categories that were evaluated: Center of Pressure Area, Displacement, Anterior-Posterior Displacement, Medial- lateral Displacement, Average Velocity, Peak Velocity, AP Average Velocity, ML Average

Velocity, AP Peak Velocity and ML Peak Velocity.

Each of the subjects participated in weekly practice sessions and dance classes with the duration of each being 1.5 hours. Both TBI participants missed one class and they attended all practice sessions. Of the treatment group four had perfect attendance, two missed a practice session, and three missed both a class and a practice session which was the maximum to miss without being removed from the study.

In the treatment groups there were n=2 with TBI and n=12 without TBI three of which were removed due to non-compliance with attendance protocols. The control group had n=12 subjects. The TBI group had one female aged 43 and one male aged 48. In the treatment control group, there were six females aged 34±12 years and four males aged 27±13years. The control group included six females aged 29±9 years and six males aged 33±8 years.

Quality of Life:

Using the DASS-21, the scale of the data are 0-21 in all categories and the data are without units.

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Quality of Life:

A B C *

Figure 2: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.029 time*group interaction in the stress category for the treatment control group.

Quality of Life:

Depression:

There was not a main effect of time, nor a significant time*group interaction for

depression (Figure 2A).

Anxiety:

There was not a main effect of time, nor a significant time*group interaction for anxiety

(Figure 2B).

Stress:

There was a p=0.029 time*group significant interaction in the treatment control group

(Figure 2C). Post hoc analysis demonstrated that the treatment control group was different

from both the TBI and control group post intervention.

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Balance:

There were six conditions for each of the ten categories: feet together with eyes open

(FTEO), feet together with eyes closed (FTEC), feet apart with eyes open (FAEO), feet together on foam with eyes open (FFTEO), feet together on foam with eyes closed (FFTEC), and feet apart on foam with eyes open (FFAEO). The level of difficulty for the subjects from least to most difficult is as follows: FAEO, FTEO, FFAEO, FTEC, FFTEO, and FFTEC as demonstrated in

Figure 3.

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Figure 3: This Figure represents the control group and is mean ± SD during the pre-assessment phase of the trial and shows the progressive difficulty of the conditions.

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Center of Pressure Area (cm2):

A B C

D E * F

Figure 5:The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.002 time in the FFTEC category for the TBI group.

A B C

Figure 4: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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Center of Pressure Area (cm2):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for center of pressure area (Figure 4A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for center of pressure area (Figure 4B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for center of pressure area (Figure 4C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for center of pressure area (Figure 4D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for center of pressure area (Figure 4E).

Foam Feet Together Eyes Closed

There was a p=0.002 significant main effect of time in the TBI Group (Figure 4F). Post hoc analysis demonstrated that the TBI group was different from both the treatment control and control group post intervention.

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Percent Change scores:

There was no significant percent change across the groups (Figure 5) for center of pressure area.

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Displacement (cm): A B C

D E F * * *

Figure 7:The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.001 time interaction in the FFTEC category for all groups.

A B C

Figure 6: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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Displacement (cm):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for displacement (Figure 6A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for displacement (Figure 6B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for displacement (Figure 6C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for displacement (Figure 6D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for displacement (Figure 6E).

Foam Feet Together Eyes Closed

There was a There was a p=0.001 significant main effect of time for all groups (Figure

6F).

Percent change scores:

There was no significant percent change across the groups (Figure 7) for displacement.

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AP Displacement (cm):

A B C

D E F

Figure 9: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.029 time interaction in the FFTEC category for the treatment control group.

A B C

Figure 8: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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AP Displacement (cm):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP displacement (Figure 8A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP displacement (Figure 8B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for AP displacement (Figure 8C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP displacement (Figure 8D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP displacement (Figure 8E).

Foam Feet Together Eyes Closed

There was a p=0.029 significant main effect of time for the treatment control group

(Figure 8F). Post hoc analysis demonstrated that the effect of time was different for the treatment control group than the TBI and control groups.

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Percent change scores:

There was no significant percent change across the groups (Figure 9) for AP displacement.

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ML Displacement (cm):

A B C

D E F

Figure 10: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

A B C

Figure 11: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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ML Displacement (cm):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 10A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 10B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 10C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 10D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 810E).

Foam Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for ML displacement (Figure 10F).

Percent change scores:

There was no significant percent change across the groups (Figure 11) for ML displacement.

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Average Velocity (cm/s): A B C

D E F

* * *

Figure 13: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.001 time interaction in the FFTEC category for all groups.

A B C

Figure 12: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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Average Velocity (cm/s):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for average velocity (Figure 12A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for average velocity (Figure 12B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for average velocity (Figure 12C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for average velocity (Figure 12D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for average velocity (Figure 12E).

Foam Feet Together Eyes Closed

There was a p=0.001 significant main effect of time for all groups (Figure 12F).

Percent change scores:

There was no significant percent change across the groups (Figure 13) for average velocity.

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Peak Velocity (cm/s):

A B C

D E F * * *

Figure 15: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.000 time interaction in the FFTEC category for all groups.

A B C

Figure 14: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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Peak Velocity (cm/s): Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for peak velocity (Figure 14A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for peak velocity (Figure 14B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for peak velocity (Figure 14C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for peak velocity (Figure 14D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for peak velocity (Figure 14E).

Foam Feet Together Eyes Closed

There was a p<0.001 significant main effect of time for all groups (Figure 14E).

Percent change scores:

There was no significant percent change across the groups (Figure 15) for peak velocity.

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AP Average Velocity (cm/s): A B C

D E F *

Figure 16:The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.008 time interaction in the FFTEC category for the TBI group.

A B C

Figure 17: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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AP Average Velocity (cm/s):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP average velocity (Figure 16A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP average velocity (Figure 16B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for AP average velocity (Figure 16C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP average velocity (Figure 16D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP average velocity (Figure 16E).

Foam Feet Together Eyes Closed

There was a p=0.008 significant main effect of time for the TBI group (Figure 16E). Post hoc analysis demonstrated that the effect of time was different for the TBI group than the treatment control and control groups.

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Percent change scores:

There was no significant percent change across the groups (Figure 17) for AP average velocity.

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AP Peak Velocity (cm/s):

A B C

D E F

Figure 19:The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.014 time interaction in the FFTEC category for the treatment control group.

A B C

Figure 18: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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AP Peak Velocity (cm/s):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP peak velocity (Figure 18A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP peak velocity (Figure 18B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for AP peak velocity (Figure 18C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP peak velocity (Figure 18D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for AP peak velocity (Figure 18E).

Foam Feet Together Eyes Closed

There was a p=0.014 significant main effect of time for the treatment control group

(Figure 18E). Post hoc analysis demonstrated that the effect of time was different for the treatment control group than the TBI and control groups.

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Percent change scores:

There was no significant percent change across the groups (Figure 19) for AP peak velocity.

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ML Average Velocity (cm/s):

A B C

D E F * * *

Figure 21: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.000 time interaction in the FFTEC category for all groups.

A B C

Figure 20: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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ML Average Velocity (cm/s):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML average velocity (Figure 20A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML average velocity (Figure 20B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for ML average velocity (Figure 20C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML average velocity (Figure 20D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML average velocity (Figure 20E).

Foam Feet Together Eyes Closed

There was a p<0.001 significant main effect of time for all groups (Figure 20E).

Percent change scores:

There was no significant percent change across the groups (Figure 21) for ML average velocity.

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ML Peak Velocity (cm/s):

A B C

D E F

* * *

Figure 23: The TBI Group (n=2), Treatment control (n=8), and Control (n=12). There was a p=0.000 time interaction in the FFTEC category for all groups.

A B C

Figure 22: The TBI Group (n=2), Treatment control (n=8), and Control (n=12).

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ML Peak Velocity (cm/s):

Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML peak velocity (Figure 22A).

Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML peak velocity (Figure 22B).

Feet Together Eyes Closed

There was not a main effect of time, nor a significant time*group interaction for ML peak velocity (Figure 22C).

Foam Feet Apart Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML peak velocity (Figure 22D).

Foam Feet Together Eyes Open

There was not a main effect of time, nor a significant time*group interaction for ML peak velocity (Figure 22E).

Foam Feet Together Eyes Closed

There was a p<0.001 significant main effect of time for all groups (Figure 22E).

Percent change scores:

There was no significant percent change across the groups (Figure 23) for ML peak velocity.

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Effect of tango independent of TBI:

Because of the low numbers of TBI patients in this study, data was also analyzed by a 2x2

ANOVA on the TC and CG. This resulted in a significant main effect of time in the areas of center of pressure area (FFAEO) in the treatment control group p=0.025, displacement for the treatment control group (FFTEC) p=0.006 and both groups (FFAEO) p=0.016. The velocity changes were also significantly altered in the areas of: average velocity for both groups (FFAEO) p=0.017, Peak velocity for the treatment control group (FFTEC) p=0.001 and for both groups

(FFAEO) p=0.040, AP average velocity for the treatment control group (FFTEC) p=0.032, AP peak velocity for the treatment control group (FFTEC) p= 0.013, ML average velocity for both groups

(FFTEC) p=0.002, and for the treatment control group (FAEO) p=0.045. There were also several trends for time*group interactions, including COP area (FFTEO) p=0.089 and AP displacement

(FAEO) p=0.070.

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Chapter 5 Discussion:

This is the first study to explore tango as an intervention for traumatic brain injury. The tango groups showed the most improvement in the most areas. The non-intervention control group did show improvements, though those may be explained by the learning effect of testing.

The TBI group improved in seven of the thirteen areas tested and significantly more than the other groups in two of the seven. The treatment control group showed improvement in seven of thirteen areas with significant improvement in three of the seven while the control group only showed improvement in six of thirteen areas with no significance on their own.

Quality of Life:

While there was no significance shown in the reduction of depression or anxiety, the treatment control group who participated in the tango intervention showed significant improvement in stress. These stress findings are consistent with those of Pinniger et al. 2012 whose healthy subjects danced tango and were compared to controls37. Furthermore, anecdotally, several subjects reported they felt better after the tango. One noticed an improvement in online quizzes when taken after tango classes compared to before starting the classes, which is corroborated by studies which examine exercise and learning80–82.

Balance:

In this study, the primary change of interest was how the tango intervention changed subject’s balance measures over time. There were trends of changes with time. While not statistically significant, whether from the variability between the subjects and/or the small sample size, it is apparent from the data that while the control group remains relatively steady, there are consistent improvements in the tango treatment groups. These improvements are

Peterson 2019 consistent with other research on tango compared with other types of movement therapy. In

2011, Ricotti et al. studied 9 year old soccer players and found that break dancing improved their objective balance measures over 6 months of training83. Additionally, Bavli et al. 2016 tested basketball players with an aerobic dance class to ascertain if it would influence their balance and according to their static flamingo test, dance was an effective way to improve these healthy athlete’s balance84.

Figures 7 and 13 and show trends in changes of displacement and average velocity respectively. The percent change of the control group remains relatively consistent, where the percent change of the intervention groups show more improvement especially in the area

FFTEC which is the most difficult of the challenges presented to the subjects. These types of improvements following tango interventions were noted in the studies by Hackney et al. 2007 and 2009 using Berg Balance testing on Parkinson’s patients10,26. While the Berg balance test, in conjunction with the other tests used in their study, is an effective means of establishing a subject’s balance, it is still a subjective measure. Our study was unique in that our measure of balance eliminated the subjectivity of these measures and relied on the objectivity of the force plates. Rodacki et al. (2017) studied ballroom dancing and used both the subjective measures of the timed up and go and six minute walking test as well as the objectivity of force plate analysis. They found that there was a significant change over time and between groups after the dancing intervention in CoP area and displacement. Unlike our study, however, they had very little variability in subjects as they used only older women as their subjects. They also had a longer time interval eight weeks vs six and their subjects met three times per week instead of two.

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TBI

Our small population of subjects with traumatic brain injury showed a significant decrease (54%) in the center of pressure area measure with feet together on foam with eyes closed the treatment control improved only 13% and the control group got worse by 43%. The anterior-posterior velocity was decreased by 27% compared to a decrease of 17% in the treatment control and 4% in the control groups with feet together on foam with eyes closed.

These changes did not reach a significant time*group interaction, however this could be due to the low power by having only an n=2 in our TBI group, or the large variance in our outcomes.

Yet, this remains to our knowledge the first study to evaluate tango as a treatment intervention in TBI sufferers.

Treatment Control:

The treatment control groups improved in anterior-posterior displacement by 21% while the other groups appeared to worsen (TBI, 47%; and CG, 15%) with feet apart eyes open. Peak anterior-posterior velocity was decreased by 21% compared to TBI’s 23% and CG’s 3% decreases with feet together on foam with eyes closed. These changes did not reach a significant time*group interaction, however this could be due to low power, or the large variance in our outcomes. Together, however, despite our more robust measurements of balance this work supports previous investigations utilizing tango as an intervention on the improvement of balance10,16,17,20,21,26,.

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Limitations:

There may have been several reasons why we did not find statistical significance of the tango intervention. The first is the variance in the subjects. Previous studies had a narrow range of ages of their subject pool—usually within seven years while I had a SD of twelve years in the treatment control group. The aging effect on balance85 itself is enough to exacerbate the variability to skew the data. Secondly, the number of subjects was lacking. We did not have enough individuals to have statistical power for the TBI group to show effect. Additionally, the time frame of the treatment was too short. Most studies that evaluated balance were two to four weeks longer than our study10,16,17,23,26.

Chapter 6 Conclusion:

This study shows that tango may have an effect on both individuals with and without traumatic brain injury on balance. Furthermore, tango demonstrated reductions in stress in all the subjects that participated in the intervention.

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References:

1. Report to Congress on Traumatic Brain Injury Epidemiology and Rehabilitation | Concussion

| Traumatic Brain Injury | CDC Injury Center. (2018). Available at:

https://www.cdc.gov/traumaticbraininjury/pubs/congress_epi_rehab.html. (Accessed: 3rd

April 2018)

2. Archer, T., Svensson, K. & Alricsson, M. Physical exercise ameliorates deficits induced by

traumatic brain injury. Acta Neurol. Scand.

3. Westheimer, O. et al. Dance for PD: a preliminary investigation of effects on motor function

and quality of life among persons with Parkinson’s disease (PD). J. Neural Transm. 122,

1263–1270 (2015).

4. American Academy of Neuroscience Practice Guideline Update Recommendations

Summary: Disorders of Consciousness. (2018). Available at:

https://www.aan.com/Guidelines/Home/GuidelineDetail/926. (Accessed: 30th April 2019)

5. Lal, A., Kolakowsky-Hayner, S. A., Ghajar, J. & Balamane, M. The Effect of Physical

Exercise After a Concussion: A Systematic Review and Meta-analysis. Am. J. Sports Med.

46, 743–752 (2018).

6. Deslandes, A. et al. Exercise and Mental Health: Many Reasons to Move.

Neuropsychobiology 59, 191–198 (2009).

7. Tiwari, D., Daly, C. & Alsalaheen, B. Home-based circuit training program for an adolescent

female with severe traumatic brain injury: A case report. Physiother. Theory Pract. 34, 137–

145 (2018).

Peterson 2019

8. Devine, J. M., Wong, B., Gervino, E., Pascual-Leone, A. & Alexander, M. P. Independent,

Community-Based Aerobic Exercise Training for People With Moderate-to-Severe

Traumatic Brain Injury. Arch. Phys. Med. Rehabil. 97, 1392–1397 (2016).

9. Renfro, M., Bainbridge, D. B. & Smith, M. L. Validation of Evidence-Based Fall Prevention

Programs for Adults with Intellectual and/or Developmental Disorders: A Modified Otago

Exercise Program. Front. Public Health 4, (2016).

10. Hackney, M. E., Kantorovich, S., Levin, R. & Earhart, G. M. Effects of Tango on Functional

Mobility in Parkinsonʼs Disease: A Preliminary Study: J. Neurol. Phys. Ther. 31, 173–179

(2007).

11. Magee, W., Clark, I., Tamplin, J. & Bradt, J. Music Interventions for Acquired Brain Injury:

Findings From a Cochrane Review. Arch. Phys. Med. Rehabil. 98, e135 (2017).

12. Dr, W. L. M. Music therapy with patients in low awareness states: Approaches to assessment

and treatment in multidisciplinary care. Neuropsychol. Rehabil. 15, 522–536 (2005).

13. Foster, P. P. How does dancing promote brain reconditioning in the elderly? Front. Aging

Neurosci. 5, (2013).

14. Targhetta, R., Nalpas, B. & Pascal, P. Argentine tango: Another behavioral addiction? J.

Behav. Addict. 2, 179–186 (2013).

15. Thornberg, K., Josephsson, S. & Lindquist, I. Experiences of participation in rhythm and

movement therapy after stroke. Disabil. Rehabil. 36, 1869–1874 (2014).

16. Hackney, M. E., Hall, C. D., Echt, K. V. & Wolf, S. L. Application of Adapted Tango as

Therapeutic Intervention for Patients With Chronic Stroke: J. Geriatr. Phys. Ther. 35, 206–

217 (2012).

Peterson 2019

17. Hackney, M. E. & Earhart, G. M. Effects of dance on balance and gait in severe Parkinson

disease: A case study. Disabil. Rehabil. 32, 679–684 (2010).

18. Heiberger, L. et al. Impact of a Weekly Dance Class on the Functional Mobility and on the

Quality of Life of Individuals with Parkinson’s Disease. Front. Aging Neurosci. 3, (2011).

19. Brown, S., Martinez, M. J. & Parsons, L. M. The Neural Basis of Human Dance. Cereb.

Cortex 16, 1157–1167 (2006).

20. McKinley, P. et al. Effect of a community-based Argentine tango dance program on

functional balance and confidence in older adults. J. Aging Phys. Act. 16, 435–453 (2008).

21. McKinley, P. et al. 18.16 Argentine tango dancing improves balance and complex task

performance in at-risk elderly: A feasibility study. Gait Posture 21, S117 (2005).

22. Kattenstroth, J.-C., Kalisch, T., Holt, S., Tegenthoff, M. & Dinse, H. R. Six months of dance

intervention enhances postural, sensorimotor, and cognitive performance in elderly without

affecting cardio-respiratory functions. Front. Aging Neurosci. 5, (2013).

23. Rodacki, A. L. F., Cepeda, C. P. C., Lodovico, A. & Ugrinowitsch, C. The Effects of a

Dance-Based Program on the Postural Control in Older Women: Top. Geriatr. Rehabil. 33,

244–249 (2017).

24. Lazarou, I. et al. International Ballroom Dancing Against Neurodegeneration: A

Randomized Controlled Trial in Greek Community-Dwelling Elders With Mild Cognitive

impairment. Am. J. Alzheimers Dis. Dementias® 32, 489–499 (2017).

25. Tsaklis, P. V., Grooten, W. J. A. & Franzén, E. Effects of Weight-Shift Training on Balance

Control and Weight Distribution in Chronic Stroke: A Pilot Study. Top. Stroke Rehabil. 19,

23–31 (2012).

Peterson 2019

26. Hackney, M. E. & Earhart, G. M. Effects of dance on movement control in Parkinson’s

disease: a comparison of Argentine tango and American ballroom. J. Rehabil. Med. 41, 475–

481 (2009).

27. Batson, G. Feasibility of an Intensive Trial of Modern Dance for Adults with Parkinson

Disease. Complement. Health Pract. Rev. 15, 65–83 (2010).

28. Batson, G., Migliarese, S. J., Soriano, C., Burdette, J. H. & Laurienti, P. J. Effects of

Improvisational Dance on Balance in Parkinson’s Disease: A Two-Phase fMRI Case Study.

Phys. Occup. Ther. Geriatr. 32, 188–197 (2014).

29. Dault, M. C. & Dugas, C. Evaluation of a specific balance and coordination programme for

individuals with a traumatic brain injury. Brain Inj. 16, 231–244 (2002).

30. Bower, J., Catroppa, C., Grocke, D. & Shoemark, H. Music therapy for early cognitive

rehabilitation post-childhood TBI: An intrinsic mixed methods case study. Dev.

Neurorehabilitation 17, 339–346 (2014).

31. Repp, B. H. Sensorimotor synchronization and perception of timing: Effects of music

training and task experience. Hum. Mov. Sci. 29, 200–213 (2010).

32. Alphen, F. van. Tango and Enactivism: First Steps in Exploring the Dynamics and

Experience of Interaction. Integr. Psychol. Behav. Sci. 48, 322–331 (2014).

33. Quiroga Murcia, C., Bongard, S. & Kreutz, G. Emotional and Neurohumoral Responses to

Dancing Tango Argentino: The Effects of Music and Partner. Music Med. 1, 14–21 (2009).

34. Muro, A. & Artero, N. Dance practice and well-being correlates in young women. Women

Health 57, 1193–1203 (2017).

35. Murcia, C. Q., Kreutz, G., Clift, S. & Bongard, S. Shall we dance? An exploration of the

perceived benefits of dancing on well-being. Arts Health 2, 149–163 (2010).

Peterson 2019

36. Santana, R., Gouveia, M. J. & Carvalheira, A. Demographic and Well-Being Predictors of

Regular and Long-term Practice of Argentine Tango in a Multicultural Sample of

Practitioners. Am. J. Dance Ther. 39, 252–266 (2017).

37. Pinniger R, Brown RF, Thorsteinsson EB & McKinley P. Argentine tango dance compared

to mindfulness meditation and a waiting-list control: A randomised trial for treating

depression. Complement. Ther. Med. 20, 377–384 (2012).

38. Ide, C. et al. P. in Encyclopedia of Neuroscience 3059–3347 (Springer, Berlin, Heidelberg,

2009). doi:10.1007/978-3-540-29678-2_16

39. Horak, F. B. Postural orientation and equilibrium: what do we need to know about neural

control of balance to prevent falls? Age Ageing 35, ii7–ii11 (2006).

40. Chaudhry, H., Bukiet, B., Ji, Z. & Findley, T. Measurement of balance in computer

posturography: Comparison of methods—A brief review. J. Bodyw. Mov. Ther. 15, 82–91

(2011).

41. Chaudhry, H. et al. Measures of postural stability. J. Rehabil. Res. Dev. 41, 713–720 (2004).

42. BALANCE | definition in the Cambridge English Dictionary. Available at:

https://dictionary.cambridge.org/us/dictionary/english/balance. (Accessed: 23rd October

2018)

43. Poradzisz, M. & Florczak, K. L. Quality of Life: Input or Outcome? Nurs. Sci. Q. 26, 116–

120 (2013).

44. Theofilou, P. Quality of Life: Definition and Measurement. Eur. J. Psychol. 9, 150–162

(2013).

45. WHO | WHOQOL: Measuring Quality of Life. WHO Available at:

http://www.who.int/healthinfo/survey/whoqol-qualityoflife/en/. (Accessed: 20th June 2018)

Peterson 2019

46. Understanding chronic stress. http://www.apa.org Available at:

http://www.apa.org/helpcenter/understanding-chronic-stress.aspx. (Accessed: 12th October

2018)

47. Baum, A. Stress, intrusive imagery, and chronic distress. Health Psychol. 9, 653–675 (1990).

48. Anxiety. https://www.apa.org Available at: https://www.apa.org/topics/anxiety/index.aspx.

(Accessed: 12th October 2018)

49. Depression. https://www.apa.org Available at:

https://www.apa.org/topics/depression/index.aspx. (Accessed: 12th October 2018)

50. Depression Anxiety Stress Scales - DASS. Available at: http://www2.psy.unsw.edu.au/dass/.

(Accessed: 23rd October 2018)

51. A Guide to Tango Terminology. Available at: https://www.tejastango.com/terminology.html.

(Accessed: 25th April 2018)

52. Argentine tango dance terms. Available at: http://www.tangoconcepts.com/terms.html.

(Accessed: 25th April 2018)

53. Check out the translation for ‘calesita’ on SpanishDict! SpanishDict Available at:

https://www.spanishdict.com/translate/calesita?utm_source=social&utm_medium=facebook

&utm_campaign=share. (Accessed: 13th May 2019)

54. Paradas and Pasadas (Stepovers). Available at:

http://www.fredosaurus.com/tango/figures/parada.html. (Accessed: 13th May 2019)

55. Adorno - Spanish to English Translation | Spanish Central. Available at:

http://www.spanishcentral.com/translate/adorno. (Accessed: 13th May 2019)

56. Blake, H. & Batson, M. Exercise intervention in brain injury: a pilot randomized study of Tai

Chi Qigong. Clin. Rehabil. 23, 589–598 (2009).

Peterson 2019

57. Kleffelgaard, I., Soberg, H. L., Bruusgaard, K. A., Tamber, A. L. & Langhammer, B.

Vestibular Rehabilitation After Traumatic Brain Injury: Case Series. Phys. Ther. 96, 839–

849 (2016).

58. Schmid, A. A., Miller, K. K., Puymbroeck, M. V. & Schalk, N. Feasibility and results of a

case study of yoga to improve physical functioning in people with chronic traumatic brain

injury. Disabil. Rehabil. 38, 914–920 (2016).

59. Blumenthal, J. A. et al. Exercise and Pharmacotherapy in the Treatment of Major Depressive

Disorder. Psychosom. Med. 69, 587–596 (2007).

60. Esterov, D. & Greenwald, B. D. Autonomic Dysfunction after Mild Traumatic Brain Injury.

Brain Sci. 7, (2017).

61. Fleminger, S. Managing agitation and aggression after head injury. BMJ 327, 4–5 (2003).

62. Peters, D. M. et al. Individuals With Chronic Traumatic Brain Injury Improve Walking

Speed and Mobility With Intensive Mobility Training. Arch. Phys. Med. Rehabil. 95, 1454–

1460 (2014).

63. Ustinova, K. I., Chernikova, L. A., Dull, A. & Perkins, J. Physical therapy for correcting

postural and coordination deficits in patients with mild-to-moderate traumatic brain injury.

Physiother. Theory Pract. 31, 1–7 (2015).

64. Kaski, D., Buttell, J. & Greenwood, R. Targeted rehabilitation reduces visual dependency

and improves balance in severe traumatic brain injury: a case study. Disabil. Rehabil. 40,

856–858 (2018).

65. Altenmüller E., Marco‐Pallares J., Münte T. F. & Schneider S. Neural Reorganization

Underlies Improvement in Stroke‐induced Motor Dysfunction by Music‐supported Therapy.

Ann. N. Y. Acad. Sci. 1169, 395–405 (2009).

Peterson 2019

66. Altenmüller, E. & Schlaug, G. Neurologic music therapy: The beneficial effects of music

making on neurorehabilitation. Acoust. Sci. Technol. 34, 5–12 (2013).

67. Thaut, M. H. Neurologic Music Therapy in Cognitive Rehabilitation. Music Percept.

Interdiscip. J. 27, 281–285 (2010).

68. Gardiner, J. C. & Horwitz, J. L. Neurologic Music Therapy and Group Psychotherapy for

Treatment of Traumatic Brain Injury: Evaluation of a Cognitive Rehabilitation Group. Music

Ther. Perspect. 33, 193–201 (2015).

69. Blood, A. J., Zatorre, R. J., Bermudez, P. & Evans, A. C. Emotional responses to pleasant

and unpleasant music correlate with activity in paralimbic brain regions. Nat. Neurosci. 2,

382–387 (1999).

70. Thaut Michael H. et al. Neurologic Music Therapy Improves Executive Function and

Emotional Adjustment in Traumatic Brain Injury Rehabilitation. Ann. N. Y. Acad. Sci. 1169,

406–416 (2009).

71. Zatorre, R. J., Chen, J. L. & Penhune, V. B. When the brain plays music: auditory–motor

interactions in music perception and production. Nat. Rev. Neurosci. 8, 547–558 (2007).

72. Jun, E.-M., Roh, Y. H. & Kim, M. J. The effect of music-movement therapy on physical and

psychological states of stroke patients. J. Clin. Nurs. 22, 22–31 (2013).

73. Pacchetti, C. et al. Active Music Therapy in Parkinson’s Disease: An Integrative Method for

Motor and Emotional Rehabilitation. Psychosom. Med. 62, 386–383 (2000).

74. Hafting, T., Fyhn, M., Molden, S., Moser, M.-B. & Moser, E. I. Microstructure of a spatial

map in the entorhinal cortex. Nature 436, 801–806 (2005).

Peterson 2019

75. Rohleder, N., Beulen, S. E., Chen, E., Wolf, J. M. & Kirschbaum, C. Stress on the Dance

Floor: The Cortisol Stress Response to Social-Evaluative Threat in Competitive Ballroom

Dancers. Pers. Soc. Psychol. Bull. 33, 69–84 (2007).

76. West, J., Otte, C., Geher, K., Johnson, J. & Mohr, D. C. Effects of hatha yoga and african

dance on perceived stress, affect, and salivary cortisol. Ann. Behav. Med. 28, 114–118

(2004).

77. Teasdale, G. & Jennett, B. ASSESSMENT OF COMA AND IMPAIRED

CONSCIOUSNESS: A Practical Scale. The Lancet 304, 81–84 (1974).

78. Lovibond, S. H., Lovibond, P. F. & Australia, P. F. of. Manual for the depression anxiety

stress scales. (Sydney, N.S.W. : Psychology Foundation of Australia, 1995).

79. Robertson, D. G. E. & Dowling, J. J. Design and responses of Butterworth and critically

damped digital filters. J. Electromyogr. Kinesiol. 13, 569–573 (2003).

80. Hillman, C. H., Erickson, K. I. & Kramer, A. F. Be smart, exercise your heart: exercise

effects on brain and cognition. Nat. Rev. Neurosci. 9, 58–65 (2008).

81. Chen, C. et al. The exercise-glucocorticoid paradox: How exercise is beneficial to cognition,

mood, and the brain while increasing glucocorticoid levels. Front. Neuroendocrinol. 44, 83–

102 (2017).

82. Den Heijer, A. E. et al. Sweat it out? The effects of physical exercise on cognition and

behavior in children and adults with ADHD: a systematic literature review. J. Neural

Transm. 124, 3–26 (2017).

83. Ricotti, L. & Ravaschio, A. Break dance significantly increases static balance in 9 years-old

soccer players. Gait Posture 33, 462–465 (2011).

Peterson 2019

84. Bavlı, Ö. Investigation into the Effects of Eight Weeks of Step Aerobic Dance Practice on

Static Balance, Flexibility and Selected Basketball Skills in Young Basketball Players. J.

Educ. Train. Stud. 4, 233–238 (2016).

85. Lizama, L. E. C. et al. Age effects on mediolateral balance control. PLoS ONE 9, e110757

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Appendix 1:

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Appendix 2:

Day 1

- Entrance, solo walking to music while everyone arrives

- Warm up with where are you standing on your foot and grounding to push off to step

- Tango play

- Practice embrace (arms on chest), slots, simple straight walking

- Slots, walking, pause

- Slots, walking/pause/ sidestep

- Slots, walking with big step vs small step, fast step vs slow step

- Introduction to rock step solo

- Practice embrace (arms on chest), Rock step with partner (forward, side, with rotation)

- Sugar bowl similar Practice embrace (leads hands on follower arms)

- Introduction to line of dance

Forward walking around corner, if working try tight circle

Twisting to Cross walking in parallel (lead steps to outside of followers trailing leg)

Big side step with ankle attitude

Day 2

-Warm up

-Just Walking - halfway thorough song switch who is walking backwards

-Finding your axis

-Calicita drill to feel pivot (shoulders connected to feet)

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-Solo pivot practice with group

-Any steps dance - big steps, super slow

-Little guns

-big guns

-Any steps dance - small steps

-Followers initiate ochos, lead is there for moral support

-Leads lead the ochos

-Any steps dance - Poema

-Cross walking if there’s time

Day 3

-Review of walking, pause, side step, self pivot. Demonstrated rock step.

-Gave them chances for free dance.

-Review and practice of back ocho

-Introduce front ocho

-Lots of drilling and in place practice.

-Introduce walking ochos

-Introduce basic left hand turn

-Ended with general musicality/ movement attitude

A turn -> probably review ochos, introduce front ochos, have a turn occur out of front ochos

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How to keep them engaged (introduce more musicality?), how to help those who are frustrated/struggling from feeling left out.

Day 4

Suggested: Review connection, even compression, and delayed compression (go back to slots and practice embrace again temporarily?) /control while spiraling pivoting/ and being responsible to move oneself (dance with no hands, maybe do this one twice? First and last?),

Introduce molinete, practice what we’ve learned

Day 5

Suggested: Brief review of previous steps and introduce the Quality&Type game (teacher prep: find classical songs that go well with the different qualities and ones that can be interpreted in more than one way), no new “steps” introduced in this class, emphasis on musicality

(specifically classical) MAKE SURE THERE IS A DRY ERASE MARKER WE CAN USE if we can borrow the whiteboard?

Day 6

Suggested: Review as needed, Introduce Parada pasada with sandwich and follower options, practice what we’ve learned and encourage fun

-Review ochos

-give dance

-Review molinete

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-give dance

-Back to ochos, practice

-give dance

-Ochos, slowing down the follower, pausing the follower in the middle of the step, follower is focused on technique while listening to the lead

-give dance

-Ochos, can lead balance mostly on one foot while slowing to pause the follower before collection and then slide their opposite foot to meet the follower trailing foot, sandwich, then invite follower to collect on forward foot. [Teacher Stop there and let them practice for a short moment] Continuing step by follower stepping over and resolving pivot to face lead. Lead has shifted weight to step onto outstretched foot.

-give dance

-Some follower adorno ideas

-Some lead adorno ideas

-Rotate each dance to practice with new people until end of class.

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Appendix 3:

#####

Number ID

TBI

Control

Control C/I

Yes

Yes Conf. Conf.

X Par Q

Consen

DAS

Pre

balan

Pre

n/a

Week 1

Class

Friday

Thurs

Friday

Thurs

Friday

Thurs

n/a

week 1

Practice

n/a

Week 2

Class

Monday

Thurs

Monday

Friday

Monday

Thurs

Friday

Thurs

n/a

week 2

Practice

n/a

Week 3

Class

Thursday

Monday

Thursday

Monday

Friday

Monday

n/a

week 3

Practice

n/a

Week 4

Class

Thursday

Monday

Thursday

Monday

Monday?

Thursday

Monday

Friday

Monday

n/a

week 4

Practice

n/a

Week 5

Class

Monday

Friday

Thursday

Monday

Thursday

Friday

Thursday

n/a

week 5

Practice

n/a

Week 6

Class

Monday

Friday

Monday

n/a

week 6

Practice

DASS

Post Post

Balance

Post Post

191.5

157.5

168

166.5

179.75

165.5

174.5

165

164

170

173

188

157.48

188

170.18

185.42

163.83

180.34

165.1

182.88

167.64

175.26

182.25 Height

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Appendix 4:

2 tailed non paired t 3X2 WITHOUT SUBJECT 1 3X2 WITH SUBJECT 1 2X2 WITHOUT SUBJECT 1 2X2 WITH SUBJECT 1 tests OUTCOMES TIME TIME*GROUP TIME TIME*GROUP TIME TIME*GROUP TIME TIME*GROUP Assumed unassumed DEPRESSION 0.183 0.264 0.173 0.238 0.023 0.15 0.018 0.035 ANXIETY 0.45 0.917 0.409 0.939 0.381 0.688 0.312 0.733 STRESS 0.675 0.029 0.694 0.023 0.059 0.019 0.053 0.016 COP AREA 1 1 1 0.991 1 0.977 0.987 1 0.991 0.137 0.239 1=FTEO COP AREA 2 0.784 0.652 0.805 0.612 0.522 0.826 0.465 0.762 0.714 0.731 2=FTEC COP AREA 3 0.273 0.434 0.35 0.602 0.077 0.235 0.125 0.359 0.083 0.059 3=FAEO COP AREA 4 0.896 0.198 0.765 0.767 0.506 0.089 0.843 0.489 0.233 0.221 4=FFTEO COP AREA 5 0.002 0.094 0.431 0.489 0.061 0.881 0.223 0.256 0.456 0.371 5=FFTEC COP AREA 6 0.752 0.108 0.658 0.121 0.025 0.525 0.037 0.716 0.75 0.791 6=FFTAEO DISPLACEMENT 1 0.556 0.475 0.573 0.483 0.668 0.259 0.711 0.265 0.379 0.384 DISPLACEMENT 2 0.737 0.239 0.674 0.161 0.299 0.123 0.192 0.08 0.09 0.069 DISPLACEMENT 3 0.202 0.668 0.224 0.747 0.124 0.385 0.148 0.461 0.256 0.179 DISPLACEMENT 4 0.142 0.837 0.121 0.546 0.176 0.689 0.073 0.293 0.359 0.299 DISPLACEMENT 5 0.001 0.395 0.165 0.482 0.006 0.791 0.082 0.245 0.259 0.203 DISPLACEMENT 6 0.128 0.823 0.183 0.853 0.016 0.906 0.031 0.81 0.655 0.617 AP DISPLACEMENT 1 0.887 0.742 0.903 0.695 0.634 0.283 0.676 0.437 0.956 0.957 AP DISPLACEMENT 2 0.761 0.709 0.66 0.829 0.095 0.485 0.845 0.606 0.313 0.365 AP DISPLACEMENT 3 0.499 0.166 0.617 0.264 0.093 0.07 0.139 0.119 0.119 0.135 AP DISPLACEMENT 4 0.524 0.566 0.691 0.778 0.991 0.742 0.902 0.551 0.307 0.28 AP DISPLACEMENT 5 0.029 0.297 0.289 0.383 0.143 0.145 0.15 0.183 0.151 0.116 AP DISPLACEMENT 6 0.687 0.566 0.573 0.673 0.861 0.275 0.785 0.798 0.705 0.698 ML DISPLACEMENT 1 0.446 0.156 0.409 0.107 0.118 0.114 0.11 0.037 0.023 0.064 ML DISPLACEMENT 2 0.557 0.277 0.58 0.259 0.291 0.906 0.238 0.778 0.529 0.561 ML DISPLACEMENT 3 0.602 0.913 0.669 0.969 0.621 0.553 0.474 0.859 0.487 0.487 ML DISPLACEMENT 4 0.431 0.313 0.312 0.628 0.764 0.946 0.763 0.669 0.399 0.407 ML DISPLACEMENT 5 0.069 0.314 0.242 0.614 0.161 0.205 0.198 0.349 0.802 0.775 ML DISPLACEMENT 6 0.56 0.42 0.677 0.504 0.064 0.237 0.075 0.883 0.985 0.987 AVERAGE VELOCITY 1 0.556 0.475 0.573 0.483 0.518 0.104 0.711 0.265 0.379 0.384 AVERAGE VELOCITY 2 0.737 0.239 0.674 0.161 0.136 0.157 0.192 0.08 0.09 0.069 AVERAGE VELOCITY 3 0.202 0.668 0.224 0.747 0.128 0.609 0.148 0.461 0.256 0.179 AVERAGE VELOCITY 4 0.142 0.837 0.121 0.546 0.051 0.345 0.073 0.293 0.359 0.299 AVERAGE VELOCITY 5 0.001 0.395 0.173 0.482 0.075 0.213 0.086 0.245 0.259 0.203 AVERAGE VELOCITY 6 0.128 0.823 0.183 0.853 0.017 0.76 0.031 0.81 0.655 0.617 PEAK VELOCITY 1 0.4 0.428 0.433 0.474 0.166 0.223 0.187 0.254 0.303 0.351 PEAK VELOCITY 2 0.493 0.06 0.505 0.044 0.091 0.344 0.063 0.279 0.718 0.762 PEAK VELOCITY 3 0.171 0.463 0.259 0.71 0.051 0.245 0.11 0.438 0.173 0.182 PEAK VELOCITY 4 0.72 0.845 0.544 0.941 0.52 0.611 0.268 0.982 0.866 0.853 PEAK VELOCITY 5 0 0.271 0.05 0.364 0.001 0.37 0.024 0.174 0.186 0.139 PEAK VELOCITY 6 0.258 0.753 0.33 0.769 0.04 0.976 0.065 0.784 0.891 0.898 AP AVERAGE VELOCITY 1 0.747 0.542 0.783 0.567 0.785 0.292 0.855 0.311 0.438 0.4 AP AVERAGE VELOCITY 2 0.977 0.371 0.926 0.277 0.554 0.198 0.459 0.142 0.112 0.078 AP AVERAGE VELOCITY 3 0.253 0.695 0.292 0.796 0.171 0.41 0.129 0.516 0.292 0.216 AP AVERAGE VELOCITY 4 0.496 0.595 0.353 0.343 0.668 0.373 0.314 0.162 0.219 0.176 AP AVERAGE VELOCITY 5 0.008 0.481 0.181 0.47 0.032 0.729 0.096 0.237 0.177 0.12 AP AVERAGE VELOCITY 6 0.336 0.86 0.501 0.967 0.118 0.697 0.276 0.931 0.185 0.166 AP PEAK VELOCITY 1 0.411 0.486 0.442 0.534 0.18 0.263 0.2 0.296 0.816 0.84 AP PEAK VELOCITY 2 0.409 0.033 0.435 0.022 0.06 0.275 0.035 0.198 0.284 0.321 AP PEAK VELOCITY 3 0.255 0.455 0.346 0.661 0.086 0.242 0.155 0.396 0.308 0.332 AP PEAK VELOCITY 4 0.84 0.915 0.674 0.763 0.499 0.912 0.281 0.598 0.484 0.444 AP PEAK VELOCITY 5 0.014 0.563 0.245 0.399 0.013 0.37 0.098 0.196 0.151 0.109 AP PEAK VELOCITY 6 0.289 0.991 0.391 0.928 0.165 0.99 0.287 0.709 0.82 0.817 ML AVERAGE VELOCITY 1 0.28 0.5 0.271 0.485 0.517 0.353 0.513 0.341 0.524 0.593 ML AVERAGE VELOCITY 2 0.502 0.229 0.439 0.148 0.147 0.105 0.094 0.065 0.095 0.102 ML AVERAGE VELOCITY 3 0.184 0.813 0.171 0.801 0.12 0.534 0.102 0.518 0.387 0.327 ML AVERAGE VELOCITY 4 0.068 0.925 0.069 0.727 0.073 0.996 0.034 0.446 0.603 0.544 ML AVERAGE VELOCITY 5 0 0.373 0.174 0.499 0.002 0.912 0.082 0.257 0.422 0.38 ML AVERAGE VELOCITY 6 0.086 0.765 0.075 0.755 0.008 0.765 0.005 0.76 0.922 0.913 ML PEAK VELOCITY 1 0.332 0.438 0.34 0.448 0.308 0.222 0.322 0.228 0.185 0.227 ML PEAK VELOCITY 2 0.43 0.486 0.44 0.493 0.195 0.262 0.195 0.266 0.538 0.591 ML PEAK VELOCITY 3 0.049 0.926 0.079 0.873 0.045 0.894 0.092 0.806 0.339 0.279 ML PEAK VELOCITY 4 0.504 0.647 0.356 0.833 0.203 0.455 0.084 0.952 0.993 0.992 ML PEAK VELOCITY 5 0 0.116 0.026 0.336 0.001 0.406 0.021 0.174 0.192 0.145 ML PEAK VELOCITY 6 0.404 0.574 0.418 0.56 0.047 0.852 0.044 0.768 0.692 0.714

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Appendix 5:

Figures include Subject 1 and show outlier status.

Peterson 2019