Healthy-Steps

An increasing number of women are living with breast cancer and adjusting to the changes that accompany survivorship. Many factors can profoundly affect quality of life for survivors, such as disturbances in body image, reduced range of motion in the shoulder hindering full engagement in everyday activities, and changes in psychological well-being. Women with breast cancer report distress, depression, and anxiety at greater rates, and these symptoms may persist for years following treatment. Another challenge is the occurrence of lymphedema, a chronic and progressive swelling of the arm, shoulder, neck, or torso from physical disruption or compression of the axillary lymphatic channels from surgery or radiation therapy.  Though reduced in frequency with advances in surgical procedures, the condition still occurs with extensive surgery and axillary lymph node dissection. There is a growing recognition among health care providers, breast cancer survivors, and public policymakers that more attention and research need to focus on life after diagnosis and treatment. 

Healthy-Steps is a dance and movement program based on The Lebed Method, Focus on Healing Through Movement and Dance developed by Lebed-Davis, which was designed to restore shoulder range of motion, reduce lymphedema, and bring a renewed sense of body symmetry, femininity, sexuality, and grace through dance and arm movements.  For the Healthy-Steps program, the Lebed Method is designed to help improve quality of life, body image, and shoulder function in breast cancer survivors.  Sessions are led by a registered dance/movement therapist who is also a certified Lebed Method instructor. The program is 12 weeks in duration, with two sessions per week for the initial 6 weeks and one session per week for an additional 6 weeks. Each session consists of a warm-up, core exercises, dance movements, water breaks, and a wrap-up. The warm-up exercises include deep breathing, head and neck stretches, shoulder rotations, torso contractions, side-to-side arm extensions, torso lengthening, and large arm circles. The warm-up is usually done sitting in a circle, to percussion music orchestrated to the movements. This is followed by stretching exercises in a standing position with a chair for support. The core exercises include upper and lower body movements to music and imagery to help increase range of motion. 

The core movements are followed by 25-30 minutes of dance movement designed to address challenges that women report following the diagnosis and treatment of breast cancer, including body image, sexuality, sense of control, meaning in life, grief, and loss. The dance movements are simple and designed for women with no dance experience, or with poor balance or low self-confidence. The dances are drawn from a variety of musical traditions, including Celtic, American, jazz, Afro-Cuban, reggae, Middle-Eastern, and Cajun. Props such as a tubular stretch band of jersey and long pieces of silk are used to help provide an external focus and decrease anxiety. The session leader strives to create a safe and accepting environment that encourages each participant to engage at her level of comfort, with a focus on positive expression, recovery, and celebration.  Each session closes with a seated ritual using gentle stretching, meditative movements, and focused breathing to soothing music. When the music ends, the session leader asks how participants are feeling and whether they have questions. Participants are then given time to share their thoughts and feelings. 

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

The Healthy-Steps program includes 3 days of training for instructors who administer the program to breast cancer survivors. The program is 12 weeks in duration, with two sessions per week for the initial 6 weeks and one session per week for an additional 6 weeks, for a total of 18 sessions. Each session consists of 10-15 minutes of warm-ups, 10 minutes of core exercises, 25-30 minutes of dance movements, 5-7 minutes for water breaks, and 10 minutes for the wrap-up. 

Healthy-Steps is designed for adult women who have undergone diagnosis and surgical treatment for breast cancer. 

Healthy-Steps was evaluated in an out-patient and community setting. It has also been implemented in health centers, and churches.

To administer the Healthy-Steps program, the following materials are needed:

-Healthy-Steps Implementation Guide
-Lebed Method Instructor Training Web site, http://training.gohealthysteps.com

Healthy-Steps was evaluated using a randomized control trial, with a wait-list control and crossover at 13 weeks.  The study was conducted with the collaboration of the Cancer Care Partnership of MidState Medical Center (CT) and the University of Connecticut Cancer Center. Patients from the centers who had received treatment for breast cancer in the prior 18 months received an invitation to join the program. Both health centers also promoted the program through newsletters and brochures, and the program was also announced in the local print media.

Because of the difficulty in recruiting a sufficient number of participants using the initial criterion, eligibility was expanded to include women who had surgery within the past 5 years.  Women with metastatic breast cancer or an inability to stand independently for 3 minutes were excluded from participation. Volunteers who met inclusion criteria and completed baseline testing were randomized to either the intervention group or the wait-list control group. The wait-list control group was asked to maintain their usual activities during weeks 1 through 12. At week 14, the wait-list control group crossed over and participated in the movement program during weeks 14 through 25, while the intervention group continued their usual activities.  Participants ranged in age from 38 to 82 years, with a mean age of 61. A total of 38 women met entry criteria, completed baseline testing, were randomized and began exercising. Thirty-seven subjects completed measurements at 13 weeks, and 35 completed measures at 26 weeks (19 in the intervention group and 16 in the wait-list control group).

• FACT-B (Functional Assessment of Cancer Therapy, Breast), the breast cancer-specific, health-related, quality-of-life measure, improved significantly in the intervention group compared to the control group (p= .008). 
  
  
• During weeks 13 to 26, the wait-list group received the dance/movement program. At 26 weeks, the wait-list group's FACT-B score had increased 7.4 points, while the FACT-B score in the intervention group held stable. At 26 weeks, the overall sample had significant improvement in FACT-B scores from baseline (p= .003).

Sandel SL, Judge JO, Landry N, Faria L, Ouellette R, Majczak M. (2005). Dance and movement program improves quality-of-life measures in breast cancer survivors. Cancer Nursing, 28 (4), 301-309.