Ballroom Dancing for Community-dwelling Older Adults: A 12-month Study of the Effect on Well-being, Balance and Falls Risk

ABSTRACT Physical activities that involve muscle strengthening, balance and coordination skills such as ballroom dancing are encouraged for older adults to assist with the maintenance of functional autonomy and prevention of falls. Twenty-three community-dwelling older adults engaged in regular ballroom dancing completed a 12-month study assessing well-being, falls risk and balance using a set of clinical outcome measures. Those attending ballroom dancing classes were more likely to be active older adults, with lower levels of BMI and obesity compared to the general population. Participants scored lower in the falls risk tests than normative values. Some of the results suggest a possible substantive finding for clinical practice and indicate ballroom dancing is an activity with good attrition and adherence rates among community-dwelling older adults that can improve well-being, balance and reduce falls risk as part of an active lifestyle.


Introduction
The World Health Organization (WHO, 2016) predicts that between 2000 and 2050 the world's population of adults over the age of 60 years will double from 11% to 22%. In the United Kingdom (UK), the percentage of over 65-year-olds has risen from 15% in 1984 to 18% in 2014, and the number of adults in the 'oldest old' age bracket, above 80 years, has risen from 19% of the over-65 population in 1984 to 22% in 2014 (Office for National Statistics, 2015). There is an acknowledged age-related risk of many chronic health conditions, such as coronary heart disease, type 2 diabetes and cancer (Department of Health, Physical Activity, Health Improvement and Protection, DHPAHIP, 2011) and progressive functional decline due to aging may have a significant impact on many individuals' quality of life. Amongst those aged 75 years and over, it is thought that around 25% live in ill-health and are, therefore, particularly at risk of poor mental health and well-being or social exclusion issues (Allen, 2008).
Evidence suggests that promoting a healthy aging process is dependent upon multiple factors including appropriate policies at national level to combat the known risks associated with aging, such as those highlighted above. For example, in the UK, "social prescribing" aims to use networks commissioned by Clinical Commissioning Groups (CCGs) and local councils to link health service users with community groups to provide non-medical interventions that aim to reduce social isolation, loneliness and improve physical and mental health (Department of Health, 2019), an example being referral to community-based physical activity classes. In relation to falls, the National Health Service's (NHS) National Service Framework (NSF) for Older People highlighted 'falls prevention' as a priority. Introduced in 2001, the NSF suggested that integrated falls services involving local authorities and health and social care provision are needed, as this has been shown to reduce the number of falls and their negative impact by up to 30% (Department of Health, 2003, p. 8). However, NHS falls pathways tend to be fairly short-lived meaning upon discharge, individuals need to then self-manage conditions and transition to community-based physical activity programs to maintain the benefits of physical activity and avoid return to one's physical state pre-rehabilitation (Hawley, 2009). Falls are a leading cause of both injury and death in the over 65-year-old age group (Lueckenotte & Conley, 2009;Mitty & Flores, 2007;Perell et al., 2001) and over 75-year-old age group (DH, 2003) and can lead to increased need for long-term care amongst older adults (Campbell & Robertson, 2003). The National Institute for Health and Care Excellence (NICE, 2013) estimates the cost of falls to the NHS to be £2.3 billion per year, and it is predicted that the incidence of falls will rise 2% each year with increasing numbers of people aged 60 and over (McMillan, 2012).
The American Geriatrics Society/British Geriatrics Society (AGS/BGS) has also echoed the importance of falls prevention programs, and suggest, given the consequences of hospitalization, functional decline and reliance on nursing home care, that falls prevention is "an important public health objective" (AGS/ BGS, 2011, p. 148). The AGS/BGS also emphasizes the effectiveness of multifactorial fall intervention programs for community-dwelling older adults when they include an exercise component that varies in intensity and includes resistance, balance, gait and coordination training of more than 12 weeks' duration (American Geriatrics Society/British Geriatrics Society, 2011, p. 151). Therefore, transition from NHS-led pathways and uptake of community-based physical activities for older adults must be encouraged by health-care professionals.

Physical activity for older adults
Maintaining physical activity for older people is important in encouraging social interaction, preventing chronic diseases, decreasing cognitive decline and maintaining physical independence (Wurm, Tomasik & Tesch-Romer, 2010). Whilst research promotes the importance of physical activity to support successful aging (Flynn & Stewart, 2013) and guidelines for exercise 'dose' exist for older adults from associations such as the American College of Sports Medicine (ACSM, 2009), the specific types of exercise or activity that are recommended for community-dwelling older-adults are less clear. There is some suggestion that walking, jogging, cycling and gardening are suitable activities but there is criticism that this remains 'vague' (Paterson & Warburton, 2010) and that the methodologies reviewed contained insufficient details on the minimum volume of physical activity recommended to enable any strong conclusions to be formed. Stevens et al. (2014) acknowledge that all of the physical activity interventions in the studies they reviewed were left to participants to organize; and as the studies were heterogeneous in design and at times poorly reported, the types and quantity of activity were difficult to compare for the most beneficial interventions.
Aerobic and strengthening exercises were found to be of benefit for older adults in the studies considered by Paterson and Warburton (2010), and included alongside these guidelines were the inclusion of balance and resistance exercise. The Department of Health, Physical Activity, Health Improvement and Protection (DHPAHIP, 2011) guidelines also recommend that older adults perform a physical activity to improve muscle strength, balance and co-ordination (particularly if at risk of falls) on at least two days a week. As ballroom dancing includes steps and routines that would improve muscle strength, balance and coordination, it is proposed as a specific physical activity that has the potential to assist with physical improvements and a reduction in falls risk, with the additional benefit of enhancing the social and mental health components that are also important for successful aging.

Social ballroom dancing and health in older adults
Evidence in the literature on ballroom dancing as an intervention for health improvements tends to include ballroom dancing classes for periods of time ranging from 2 weeks (Hackney & Earhart, 2009a) to ongoing involvement in dancing classes and competitions (Kattenstroth, Kalisch, Kolankowska, & Dinse, 2011). A short-duration feasibility study undertaken by Hackney and Earhart (2009a) revealed significant findings for positive changes in balance, concentration and reaction times. The majority of studies reviewed included intervention programs of around 2 to 3 months' duration. During such an intervention period, positive results were found for significant improvements in function and gait measurements, motor, cognitive and perceptual performance, cardiac efficiency, balance and physical performance, functional autonomy, a reduction in depression and improvements in self-esteem and observations of increased physical participation (Belardinelli, Lacalaprice, Ventrella, Volpe, & Faccenda, 2008;Gomes da Silva Borges et al., 2012;Haboush, Floyd, Caron, LaSota, & Alvarez, 2006;Hackney & Earhart, 2009b;Hackney, Kantaorovich, Levin & Earhart, 2007;McKinley et al., 2008). However, these studies largely used clinical populations and the lack of detail in some studies of baseline measurements, the plethora of different ballroom dances studied and the heterogeneous quantitative outcome measures and qualitative research methodologies used within each of these studies make comparison and interpretation of findings across the studies problematic.

Falls risk assessment
There has been much debate about the relevance of formal 'falls' risk assessments for community-dwelling individuals or inpatients in hospital settings (Donoghue, Graham, Gibbs, Mitten-Lewis, & Blay, 2003;Muir, Berg, Chesworth, Klar, & Speechley, 2010;Scott, Votova, Scanlan, & Close, 2007). An accurate method of assessment is important to predict those at risk of falls and for an appropriate prevention program to be implemented, but Scott et al. (2007) suggest that there is no single test that can be recommended for implementation in all settings as assessments, whilst shown to be valid and reliable in some settings, have yet to be tested in more than one setting. Therefore, questions remain regarding the inter-rater reliability, validity and specificity of the numerous tests that have been suggested. Indeed, some authors have found there to be no difference between the accuracy of some validated tests, which are time-consuming to complete, and nurses' own clinical judgments (Eagle et al., 1999cited by Donoghue et al., 2003 or even the self-reporting of balance problems (Muir et al., 2010). The numerous outcome measures with their different indications for use mean that careful consideration is needed prior to their implementation. Ambulatory capacity, age, balance, lower limb strength and range of joint motion have been cited as risk factors for falls and the chosen tests in this study assessed some of these intrinsic factors (Donoghue et al., 2003;Hansma, Emmelot-Vonk & Verhaar, 2010;Lueckenotte & Conley, 2009;Mitty & Flores, 2007;Perell et al., 2001;Scott et al., 2007;Wolfe, Lourenco & Mukland, 2010). The outcome measurement tests used, as outlined below, are all commonplace in clinical practice.
In summary, social ballroom dancing is an activity that can provide older adults with improvements in functional independence, balance, cognitive performance and sociality, even over relatively short durations of time. Kattenstroth et al. (2011, p. 7) suggest that dance can enrich the environment for individuals due to its, "unique combination of physical activity, rhythmic motor coordination, emotion, affection, balance, memory, social interaction and acoustic stimulation." Given its popularity, there remains a paucity of literature supporting the use of ballroom dancing as an engaging activity beneficial to physical and social health and mental wellbeing in communitydwelling, non-symptomatic older adults.
The aim of this study was to investigate the effect of social ballroom dancing on well-being, balance and falls risk outcome measures in communitydwelling older adults.

Participants
A purposive sample of 26 older adults were recruited from a population of community-dwelling 'older people' who participated in social ballroom dance at least once a week, via approaches made to local dance tutors leading community-based ballroom dance classes. Inclusion criteria were: aged 58 years and over (to allow for the inclusion of partners of those aged 60 years and above; on which many outcome measures were based); living in their own home (not residing in assisted living or nursing home accommodation); and participating in ballroom dancing at least 1 hour per week. Exclusion criteria included those with diagnosis of a dementia-related pathology. The aims of the study and the commitment required from individuals to participate were explained on a detailed information sheet and there was an opportunity for potential participants to have any questions answered.

Data collection
Participants completed the physical tests at baseline, 3 months, 6 months, 9 months and 12 months after baseline. If a participant felt unable to continue any of the tests on that day for health reasons, the tests were not carried out, or if started, ceased immediately. Following each session, participants were contacted via e-mail or telephone to arrange a convenient time for the next visit.
The age, height and weight of all participants were collected at baseline. Information relating to known medical problems, any diagnosis of dementia or dementia-related illness, current medication use, any history of falls, frequency of ballroom dancing and participation in any other form of exercise was collected at baseline and updated at subsequent visits.

Well-being, falls risk and balance outcome measures
Clinical wellbeing was measured using the Clinical Outcomes in Routine Examination (CORE-GP); a 14-item measure including questions covering issues such as general well-being, depression, anxiety, self-esteem and risk and life/social functioning which has been validated for use within a non-clinical general population (CORE-IMS, 2014). Higher scores indicate greater levels of distress. The scale boundaries for the CORE-GP test are 0-20 are considered to be a "healthy" range, with 21-33 depicting a "low level of client distress" and a national "clinical cutoff" has been established as a score of 10 (CORE-IMS, 2014). Falls risk was measured using the Falls Efficacy Scale-International (FES-I); a 16-item commonly used measure with questions focussing on social activities and the impact of a fear or concern of falling upon one's social life (Yardley et al., 2005). Balance was measured using the Timed Up and Go test (TUGT), designed to assess elements of functional ability, motor performance, balance, gait and transfers (Fawcett, 2007) for older adults in a variety of settings; and via an Overall Stability Index (OSI) of dynamic balance obtained from the Biodex Balance System SD (BBS) (Biodex Medical Systems Inc., Shirley, New York). For each participant, this latter measure was compared to age-dependent normative data, with scores higher than normative values being suggestive of deficiencies in strength, proprioception, vestibular or vision and therefore, individuals being at risk of falls (Biodex Medical Systems Inc, n.d. b). All physical tests were performed at a university exercise laboratory on five occasions over the course of a 12-month period.
The CORE-GP, FES-I, TUGT and Biodex Overall Stability Index instruments used in the study are all validated instruments with demonstrably high reliability (CORE-IMS, 2014; Dawson, Dzurino, Karleskint, & Tucker, 2018;Fawcett, 2008;Yardley et al., 2005). The TUGT has been validated as a suitable functional outcome measure to predict falls in community-dwelling older adults and is commonly used in clinical practice (AGILE, n.d.).

Rejected tests
Additional testing procedures considered included the Functional Reach Test; the Performance Orientated Assessment of Mobility (POAM) (Mitty & Flores, 2007;Perell et al., 2001;Raîche, Herbert, Prince, & Corriveau, 2000;Wolfe et al., 2010) and the Four Square Step Test (FSST) (Dawson et al., 2018) to measure dynamic standing balance in an adult population. These tests were found to show poor discriminative capability between participants and were rejected from further consideration.

Statistical analysis
The sample was summarized descriptively. Mean and standard deviation (SD) values were derived for numerical measures at baseline and after 12 months' dancing activity. The significance of any differences from baseline in key outcome measures was assessed using paired-samples t-testing. The significance of any differences in functional outcome study data from age-standardized normative data was assessed using singlesample t-testing.

Ethical issues
Ethical approval was sought and gained from the University's School Research Ethics Panel to ensure compliance with regulations for the use of human subjects and data storage. Written informed consent was obtained from all participants and all data were anonymized. Any risks of harm during physical testing procedures were mitigated; for example, due to the positioning of crash mats around the testing equipment where participants might have been at risk of falling off the testing equipment.

Demographic data
Twenty-six participants agreed to participate in the study. Three participants withdrew after the data collection at baseline; with analysis conducted on the remaining 23 participants (88%) who completed all 5 data collection sessions at baseline and at 3, 6, 9 and 12 months. Of these participants, 18 were either married or life partners dancing together, and 5 were single. Participant characteristics are summarized in Table 1.

Outcome Measures
Outcome measures recorded at baseline and 12 months are summarized in Table 2. The range of scores for the CORE-GP was 0-24 points, indicating at worst low-level client distress. Low-level distress was indicated on only 3 of 115 measurement occasions (2.61%) and 'healthy' values were recorded on 112 of 115 occasions (97.4%). Mean scores for the TUGT were almost within the normative values in all age groups.

Significance testing
A paired samples t-test conducted on CORE-GP scores of completing dancers at baseline and 12 months revealed no evidence of a significant effect at the 5% significance level (p = .07; 95% confidence interval for the difference (−0.17, 3.36)). However, the change of 1.6 points (25% reduction from baseline) suggested an improvement of substantive importance.
Normative values for the falls risk OSI for individuals aged 54 to 71 years of age were 2.3 (SD = 1.4) and for those aged 72 to 89 were 3.0 (SD = 1.0) (Biodex, n.d. b). At baseline, the mean score for the 54-to 71-year-old age group was 1.23 (SD = 0.53) and the mean score for the 72-to 89-year-old age group was 1.88 (SD = 1.07). At 12 months, corresponding OSI scores were 1.17 (SD = 0.489) for the 54-to 71-year-old age group and 1.96 (SD = 1.17) for the 72-to 89-year-old age group. Between testing at baseline and 12 months, there was no consistent increase or decrease at an individual level in the falls risk OSI scores. The mean difference between the observed and normative values was 0.99 (95% CI (0.74, 1.24)) in the 54-to 71-year-old age group and 0.14 (95% CI (0.165 to 2.12)) in the 72-to 89-year-old age group. Single-sample t-tests revealed these differences to be statistically significant at the 5% significance level (p < .001 for the 54 to71year-old age group; p = .030 for the 72 to 89 year-old age group). However, under the application of a Bonferroni correction for multiple comparisons, this latter result would not be considered significant.

Discussion
The quantitative element of this study was performed in the context of a feasibility study and thus not powered to detect significant effects. Therefore, significant differences were not particularly expected due to the small sample size. Nonetheless, some significant effects were observed; alongside effects that did not reach significance at standard significance levels but appeared to be of some substantive importance. Tests were performed to potentially identify 'promising' effects even in small sample sizes and have demonstrated that the data are amenable to the form of testing if repeated in future, larger-scale studies.

Effect of dancing and concomitant activities
It appears that ballroom dancing attracts people who are 'active' in their lifestyle, and is an activity which, once taken up, is generally maintained: 17 of the 23 participants continued dancing consistently for the 12-month period; and those who did not maintain the activity constantly over the 12-month period reported factors unrelated to dancing, such as worsening illness or injury to be the cause of stopping and this also meant their partners stopped dancing. These adherence rates are slightly higher than those found in the systematic review of community-based group exercise programs by Farrance, Tsofliou, and Clark (2016) who found adherence rates at 6 to 12 months of 69.1% in adults with a mean age of 73.8 years. While the majority of participants (20; 87%) reported being involved in other forms of exercise at the start of the trial, participation in these other exercises was generally not as regularly attended as the weekly ballroom dancing, for which consistent attendance of a constant weekly frequency was recorded. The low attrition rate recorded in this study is consistent with the findings of other studies (Belardinelli et al., 2008;Hackney & Earhart, 2009a;Pinniger, Brown, Thorsteinsson, & McKinley, 2012). As ballroom dancing is a partnered activity, the act of being in a 'couple,' as well as being in the group as a whole, might help to enhance the social aspect of dance. Therefore, the sociality of ballroom dancing may assist with improving one's emotional and social health status, a reduction in social isolation as well as providing physical assistance for more frail older adults.
This sample suggests that those attending dancing classes were more likely to be more active older adults, as their levels of participation in physical activity were greater than those previously reported by Flynn and Stewart (2013) who suggested only 13% of 65 to 74 year-olds and 6% of over 75 yearolds participate in vigorous physical activity, with ballroom dancing previously being classified as such (Blanksby & Reidy, 1988;Lima & Vieira, 2007). The study sample comprised individuals with lower levels of BMI and a lower proportion of obese participants compared with the general population in which adult obesity levels are around 26.9% in England (Public Health England, 2015). Aydoğ, Bal, Tolga, Aydoğ and Çakei (2006) note than in individuals with Rheumatoid Arthritis, age and BMI were the most important factors affecting postural dynamic balance. Furthermore, Greve, Alonso, Bordini, and Camanho (2007) have previously found a link between increased BMI and reduced postural balance in adults with a BMI greater than 30 kg/m 2 . Calculations for this were not performed within this sample population as there was only 1 participant with a BMI over 30 kg/m 2 .
There is no evidence that the study sample is systematically different from the age strata of the population from which it was drawn. Twenty-one participants (91%) were taking regular medication; similar to reported figures for the incidence of medication use by older adults in the UK, whereby 75% of 65 to 74 year-olds and 84% of those aged 75 plus were taking regular medication (Chen, Dewey & Avery, 2001). At baseline, 5 of the 23 participants had reported having a previous fall with a further 8 falls reported in 6 participants over the course of the study (26% of participants falling over the 12-month period). Yoshida (2007) noted similar findings in community-dwelling older adults over the age of 64, with 28-35% falling each year and in those of 70, 32-42% fall each year.

Well-being measures
For the CORE-GP test, 97.4% of participant scores were within a healthy mental well-being range. Three of the possible 115 scores were between 21 and 33, indicating a low-level client distress. The mean scores for all participants at each testing period were always less than 10, indicating a healthy range of well-being throughout the study. The lack of statistical significance between CORE-GP scores at baseline and at 12 months is likely to be because the sample was generally already in a healthy range of well-being at baseline and no participants were diagnosed with a mental health condition. Also, as mentioned above, as a feasibility study the population was not powered to detect significant changes and significant differences were not really expected.
Some of the higher scores recorded in the FES-I questionnaire appeared to be seasonal, in that participants were more concerned about walking outside during the heavy snow and ice periods that occurred during the course of the study and this did coincide with higher scores for certain individuals. However, possibly of note is the reduction of the mean FES-I scores from baseline to the end of the follow-up period of 1.40 points, representing a reduction of about 7% from baseline values.
Whilst there were no significant findings or changes over the 12-month study period in the FES-I outcome measure, Oliver et al. (2008, p. 626) note that one should be cautious at the use of falls risk prediction tools and clinicians should not be "seduced by the attractiveness of an 'off the shelf' solution to the problem of falls" and they suggest that the most successful falls risk programs involve post-fall assessment and treatment plans rather than the use of falls-risk indicators.

Biodex Balance System measures
There is a paucity of evidence for normative data for the BBS equipment. That which does exist has often been performed in small numbers or with younger participants; for example, Akbari, Karimi, Farahini and Faghihzadeh (2006) who studied 30 symptomatic male athletes, aged 20 to 35 with ankle sprains; Testerman andGriend (1999, cited by Aydoğ et al., 2006) who studied 10 individuals under 30 years of age with ankle sprains, Aydoğ et al. (2006) who evaluated dynamic postural balance using the BBS with participants with rheumatoid arthritis and Dawson et al. (2018) who studied 105 healthy subjects with a mean age of 24.5 years. Whilst the Biodex manual provides normative mean and ranges for data for the falls risk test, at present, there are no standard guidelines for other tests, other than suggesting that it in terms of a person's overall stability, proprioception and dynamic balance, it is better to have a lower overall stability index (OSI) (Biodex Medical Systems Inc, n.d. b). This is perhaps because the BBS provides a number of levels of difficulty for each test and hence normative data are likely to be varied at each level and for each age-group.
The BBS user's manual suggests reliability levels of platform stability settings such as those provided by Lephart, Pincivero and Henry (n.d., cited by Biodex Medical Systems Inc, n.d. a). These guidelines suggest a bilateral stance platform level setting of 8 and that two test trials are performed for participants to familiarize themselves with the BBS and that after this, all data can be assumed reliable (Lephart et al., n.d., cited by Biodex Medicial Systems Inc, n. d. a). However, their study was only performed using 10 university-aged students and on one platform setting. Whilst there might have been a learning effect involved in the present study, the tests were performed using the default 3 attempt settings for each set of the balance tests performed and the authors suggest any more than 3 attempts at each test would have led to results being affected by elements of fatigue, given the age of participants and their subjective feedback that it was not an easy test to perform. In addition, the platform stability settings were considered after the pilot study and after discussions with the clinical technician staff, it was decided to use a mid-range, 'moderate' setting of 6. A higher setting might have been easier for participants and produced different results, however, OSI scores in this participant sample were better than those suggested in the normative data on the more difficult settings used within this study. Finn, Alvarez, Jett, Axtell & Kemler (1999, cited by Biodex Medical Systems Inc, n.d. a: 3-8) studied 200 participants (106 males and 94 females) aged between 18 and 89 years old. In 54 to 71 year-olds, the mean OSI was 2.57 (SD 0.78) and in 72 to 89 year-olds it was 2.70 (SD 0.80). In a further study (Finn, 2010, cited by Biodex Medical Systems Inc, n.d. b) the normative OSI was 2.3 (SD 1.4) in 50, 54 to 71 year-olds and 3.0 (SD 1.0) in a sample of 17, 72 yearolds or above (with no defined upper age limit). In the current study, the platform was set at 6-2 for the majority of participants; therefore, this trial's settings required a greater balance skill level. Despite this, and the small sample size of the study, the mean OSI score for study participants was significantly lower in both age groups, suggesting a beneficial effect of dancing on balance.

Future research and implications for professional practice
With regard to the future feasibility of a larger randomized controlled trial into the physical health benefits of ballroom dancing for community-dwelling older adults, this study demonstrated promising findings in terms of attrition and adherence to both ballroom dancing and the 12-month study length itself. Larger participant numbers would need to be sought from additional dancing classes to increase the sample size but preliminary findings from this study indicate the potential for a significantly better balance and hence a lower falls risk in older adults who participate in ballroom dancing. Further work is needed to establish normative values measured by the Biodex Balance System equipment to provide more workable comparisons with a general population.
Overall participants were found to be performing tests to higher levels of function; thus, a ceiling effect was evident with scores. The CORE-GP test demonstrated healthy well-being scores and a decline of 1.4 points over the 12month follow-up period in the FES-I test. Although no statistical significance was revealed, the findings over 12 months suggest a reduction in scores that might be a substantive finding in clinical practice.
Whilst these tests were unable to discriminate between the participants in this sample, since they are previously validated and commonly used measures in clinical practice, it is suggested they are of some worth in terms of ethical practice value; that is they might be used as a baseline 'family of outcome tests' to illustrate homogeneity within a sample and be used to demonstrate the participants' risk levels for inclusion in a study. The issue of sensitivity does create a wider issue of the use of outcome measures in clinical practice in terms of cost-effectiveness. As noted previously above, Oliver et al. (2008, p. 626) note clinicians should be cautious at the use of falls risk prediction tools. Perera, Mody, Woodman, and Studenski (2006) also question what constitutes a clinically meaningful change in the field of clinical geriatrics. They argue if this was known, it would be useful to plan, evaluate and compare treatment interventions that use outcome measures and that this information could be used to form power calculations for sample sizes in research trials. This point might have had an impact upon this study; if clinically meaningful change parameters were known, power calculations might have been made to formulate an ideal sample size for this study. It is of note that the normative data scores for the TUGT are single figures and not a range of 'normative' figures, thus meaning it is harder to interpret the findings for individuals who lie even 0.1 seconds either side of the normative scores.
In addition, clinicians should be mindful that it is not possible to totally separate the effects of some of the confounding variables of the study. For example, in dancing pairs, the amount of dancing is dependent on each individual being willing and able to participate; if one person were to fall ill and not attend dancing, their partner would also be unlikely to attend for that duration.

Conclusions
This research study aimed to explore the influence of ballroom dancing on health and well-being for older, community-dwelling adults over a 12-month period. Specifically, it aimed to assess well-being and functional activity in terms of balance and falls risk.
The results of this study appear to indicate positive findings in comparison to normative data. However, the sensitivity of these outcome measures for an older adult population is difficult to establish in this specific group of active older adults. Although these tests are validated for an older adult, communitydwelling population (AGILE, n.d.), findings suggest that a ceiling effect may have been reached in the study sample, with participants generally scoring at or just under the best scores for these tests. This may limit the predictive value of these tests in the study population.
The economic burden of the aging population worldwide has led to a sense of 'moral obligation' for older adults to maintain or improve their health and remain physically active. A central role of the present-day healthcare professional working with older adults is to promote health and encourage individuals to realize their potential and remain functionally independent for as long as possible by means of tailoring physical activity programs to an individual's personal interest. The findings of this study suggest that ballroom dancing is an activity that is pursued by healthy older adults; they are naturally active individuals, with healthy levels of wellbeing, low anxiety of falling and are of a low falls risk than normative data for the parent population.