Griffith University (GU), Queensland Ballet (QB), and the Gold Coast University Hospital (GCUH) were involved in initial collaborator discussions to propose formative ideas and assess interest. Discussions occurred during face-to-face meetings in September 2022, October 2022, and February 2023. In attendance were members from the medical and research team (including senior and middle management of the organizations and the GU PhD candidate).

Each party discussed their specific requirements. The university included a PhD candidate who had been involved in the earlier community-based proof-of-concept study—Ballet for Brain Injury (BFBI; a collaboration between Citrine Sun Entertainment, QB, and GU). GCUH required a recreation program that could run on Saturday mornings within their recreation activity program (RAP) using nursing staff to assist. The program needed to be designed for a heterogeneous group of people with acquired brain injuries. The neuroscience rehabilitation ward has a high turnover of patients, so each class needed to be independent from previous and subsequent sessions. It was noted that strict procedures for patients to participate would be necessary. For example, the medical team would need a process to determine who can participate and what movements they could be asked to do. Their procedures required consistent dance teachers throughout the program, with formalized class plans developed ahead of the sessions.

QB preferred a partnership model rather than being contracted to run the program. They proposed including their physiotherapist and expressed concerns about how ballet might be perceived as elite or daunting in a noncreative environment. As a result, they proposed moving away from the term ballet, rather using the more approachable term “dance.”

All collaborators noted resource availability challenges of some nature. Availability of two teaching artists (dance teachers) on a weekend was challenging for QB given their existing weekend program. Similarly, neurosciences ward allied health staffing was restricted on weekends. Funding limitations also restricted the scope and duration of the program.

The literature was searched for useful evidence to support the design of programs for people with neurological impairments. A meta-analysis by Mogan et al [21] concluded that moving in synchrony is beneficial for positive affect and prosocial behavior. A multisensory experience is beneficial following stroke [46], and meditative movement and mindfulness may reduce fatigue in people with brain injury [47]. Regarding movement function, systematic reviews suggest that movement to the beat is beneficial to facilitate motor movements in people with brain injury [48,49] and action observation (observing an action while performing the action) can lead to improvement in movement function [50]. Thus, these concepts became the initial building blocks of the program.

Available dance literature specifically for people with brain injury was reviewed to determine what techniques were currently being used, how dance was being taught, what modifications were used, and if they were effective. This review identified a scoping review on dance with people with stroke [30], but there were no reviews on dance for people with TBI. Therefore, a scoping review was conducted on this topic (D Pretty et al, unpublished data, August 2024). These reviews identified challenges associated with previous neurological dance programs including difficulties initiating movement [34,51,52], risk taking and disinhibition [52], tailoring the intervention (eg, stimulating a stroke-affected side in a heterogeneous class [34]), inappropriate movements during improvisation [34], and the potential that dance increases fatigue [27,29].

A proof-of-concept study, BFBI, was conducted in 2021 (D Pretty et al, unpublished data, December 2024). Follow-up questionnaires were sent to all participants with brain injury and their carers post-BFBI program participation. Responses indicated that people with a brain injury and their carers were satisfied with how the pilot program was delivered. The majority agreed it improved their quality of life and their emotional and mental well-being. Perceived benefits included improved perceived fitness and a sense of social connection, which was linked to positive emotion. Participants reported that the classes were well facilitated and scaffolded. They highlighted the usefulness of movement repetition and the tailored speed of the class to suit the needs of people with brain injury. When asked what could improve the program, one person suggested increased options to suit varying ability levels, and another suggested recapping the previous week due to memory limitations (D Pretty et al, unpublished data, December 2024).

The author DP audited the adapted dance classes throughout the proof-of-concept BFBI study and had informal discussions with the participants and therapists following sessions. These observations highlighted a need to reduce the burden on those assisting participants perform the movements. Specifically, helpers struggled with not knowing what movements were coming next. It was also challenging to maneuver participants (eg, changing sides on the ballet barre). Thus, it was decided that the teaching model required slight modifications to support those assisting dancers and ensure less effort was required.

This phase was concluded with a face-to-face workshop in May 2024 with QB teaching artists, research team members including the QB physiotherapist, and the GU researcher/dance teacher (DP). Initial ideas for addressing the program-related challenges were discussed. Optimal approaches for including those with hemiparesis were workshopped. The use of improvisation was also discussed, and consideration was given to how this could be safely implemented.

Two allied health clinicians (a physiotherapist and an occupational therapist) attended a 1.5-hour focus group in mid-August 2024. The clinicians had between 8 years and 19 years of experience in neuroscience rehabilitation, one with and one without previous experience with dance. Example topics in the focus groups were the barriers and enablers to dance, potential benefits of dance, safety concerns, and movements that should be omitted.

Example recommendations made by therapists were that movements be gentle and stay within their base of support (no leaning forwards or sideways) and that exercises avoid the need for arms or legs moving at the same time (eg, feet marching without arms or arms extended without feet marching). The need for modifications to language such as slowed pace of instruction, the additional use of gestures, and using language sensitive to those who have had a limb amputated were suggested. Views on the appropriateness or inappropriateness of patients performing movements standing if able were raised, and a safety modification of no passive assistance for those with hemiparesis was recommended.

Concerns were raised regarding dance teachers’ lack of medical knowledge or medical training and how this might impact patients. For example, if teachers would instruct patients to “stretch” when this would be contraindicated for them or if they would give unsolicited advice regarding what would be beneficial for patients from a rehabilitation perspective. The onsite location of the dance classes was also discussed. For example, concerns included the impact of using the therapy room on a weekend; logistical challenges such as transporting the patients to and from the location; and equipment safety and staffing limitations on the weekend. These important topics raised were then discussed with the medical team, and a plan of action for each topic raised was devised. This involved medical emergency team call procedures and processes for the research nurse to provide dance teachers with information regarding what movements patients are and are not cleared to do or any specific necessary precautions.

A 60-minute focus group was attended by 3 neurosciences ward inpatients with acquired brain injuries (56-77 years old; 2 women, 1 man) in mid-August 2024. Questions pertained to what they wanted to achieve, what would help them feel safe, what type of dance movements and music they wanted, and what barriers there would be to participating. Patients were given the questions earlier in the day to allow time to plan their answers. Issues raised included the desire for simple movements (such as percussion) for inclusivity, repetition, and improvisation. They discussed that having themes would be fun and something to look forward to with certainty. When discussing music, the patients reminisced about music, dance halls, and music from their younger years. It became apparent that music selection from relevant eras could be an important element to the adapted dance classes.

Three other salient topics patients raised included agency, boredom, and safety. Patients discussed that, during inpatient care, every element of their day is chosen for them, from what time they shower to what time they eat. The opportunity to choose and have influence over decisions such as the opportunity to create movements or choose music was important. The desire to break the boredom of “staring at the ceiling” was also relished. Regarding safety, patients discussed the desire for clinicians to be involved in their lessons. They also described potential barriers of fatigue, pain, and sickness.

Based on clinician opinions regarding the need to tailor communication for people with brain injury, specialist support was sought from a speech pathologist at GCUH through a 60-minute virtual meeting in early September 2024. Suggestions included the use of both verbal cues and gestures to communicate, using repeated simple instructions on repeated movements (eg, arms, arms, arms), and the use of concrete descriptions free of jargon. Suggestions to support attentional processes included having only one main speaker for each section, using a consistent technique to get attention, and keeping distractions to a minimum.

Advice for supporting cognitive disorders included segmenting teaching, where one teaches the more complex version and one teaches a simpler version instead of demonstrating both options and allowing the patient to choose. Given the potential challenges associated with the use of improvisation and movement creation, it was suggested that a contingency plan be developed for the improvisation section including alternative facilitation strategies.

Two workshops were conducted with QB teaching artists, a QB physiotherapist, and the GU researcher/dance teacher (DP) in August 2024 and October 2024 to consolidate all information learned. Together, this information was used to develop the what and how of the program and classes. Teaching techniques were refined and practiced at these workshops. The structure of the class was determined, and fundamental movements to be included in the movement bank were decided.

The safety of the preliminary devised movements was assessed through feedback from the medical research team. A video bank, consisting of prototypical movements from each section of the class (ie, mindful warmup, percussion, arms and legs) was shared, along with the corresponding cueing styles. The videos included a range of potential movements of differing degrees of challenge, by difficulty (levels 1, 2, and 3).

In late September 2024, feedback on the movement bank was given through an online meeting with members of the medical research team who had also consulted other specialist rehabilitation team members. This feedback was predominately on providing additional modifications for those in wheelchairs and for those with upper limb mobility challenges. Other modifications included the use of headset microphones for the hearing impaired and the requirement of additional stability aids if some patients were to be standing. The expected proportion of patients who would be able to participate in certain exercises or not was also discussed for dance teacher knowledge.

Final program design based on this feedback occurred in a 2-hour face-to-face workshop in late September 2024. Further cues for the creative section were mapped out, as were the themes and design of the repertoire section. Music options were discussed, and a music bank was initiated for quick selection over the weeks in case any in vivo adaptations needed to be made to the song tempo. Following this, the TIDieR [35] was completed, and preliminary weekly class plans (which included cueing and any precautions) were devised collaboratively online between the QB and GU team members then sent to the hospital team for final approval.

Further feedback on the program was given (such as the removal of neck movements (eg, slow looking sideways). Standing exercises were removed for the first week of the program.

The proposed pilot is not a clinical trial and, therefore, has not been registered. Any future evaluative research on the DAN-CER program will be registered.

This project is a Brain and Enriched Environment Laboratory (BEEHive) project. As described by Norwood et al [11], the BEEHive is a multidisciplinary team situated within The Hopkins Centre, GU, that investigates how an enriched environment can assist neurological rehabilitation. Specifically, the BEEHive aims to develop (using a participatory research approach), test (including piloting and acceptability and efficacy testing), and deliver novel solutions to enrich the neurorehabilitation environment.

DAN-CER operates at the GCUH neuroscience rehabilitation unit as part of their RAP. This is a 28-bed unit in which the hospital team provides intensive inpatient rehabilitation throughout weekdays and recreational activities occur on weekends. The classes are held on the neuroscience ward on Saturday mornings at 10 AM for 6 weeks and began in mid-October 2024.

The study uses a mixed methods design. Mixed methods were chosen to generate comprehensive insights that may be used to inform further adaptations of the DAN-CER intervention and methodology. The mixed methods design includes semistructured interview questions, field notes, and quantitative data (eg, questionnaires and count data). Regarding quantitative data, the study incorporates a single-case, 1-phase (B phase), nonexperimental design with replication across 3 participants. Interparticipant replication is chosen for intensive study at the individual level to capture different characteristics of brain injury. This approach provides a detailed understanding of any potential impact of the program while also assessing how variable outcomes are from day to day and differences between participants. The chosen methodology (as opposed to an A-B or multiple baselines study) is due to a range of contextual factors such as the average patient length of stay, the available time for running the classes, and funding. In addition, restricting enrichment in a group of people that have minimal other activity options (due to delivery of the adapted dance program occurring on the weekend when no therapy is available) could raise ethical concerns in terms of potential negative emotional impacts [53], which we aimed to avoid. Given the pilot nature of the case study methodology, there is no control group and therefore no randomization nor blinding. Results will give an indication of how to proceed with future iterations of the study.

By using a mixed methods pilot, any issues with data collection (eg, due to logistical or communication barriers, time pressures, fatigue) and program implementation can be evaluated and used to inform the design of future research methodology, including outcome measures (for example, determining if a single-case experimental design is feasible) and any further program modifications needed. See Figure 2 for the schematic diagram of the study process and Table 1 for the schedule of assessments.

The study includes 2 groups of participants, as follows: (1) patients at the GCUH who sustained a brain injury and are residing on the neurosciences ward and (2) neurosciences ward staff who assist with program delivery. The group of patients will primarily consist of people who have experienced a stroke, TBI, or neoplasm. A research nurse provides information about the project to the patients. As a pilot study, the adapted dance classes are adjunct to participants’ other therapies. For the staff group, any staff member present during the adapted dance sessions receives information about the follow-up interview at the end of the day. All participants are adults (>18 years) who can communicate in English.

Patients residing on the neurosciences ward are considered a special population necessitating additional ethical considerations, as discussed in the following paragraphs.

Regarding cognitive impairments, to be eligible, patient participants must demonstrate sufficient cognitive capacity to understand the study’s purpose and provide informed consent. Eligibility requires completion of the University of California, San Diego Brief Assessment of Capacity to Consent (UBACC) [54], with a passing score. Further, a patient consent form modified with assistance from a speech therapist is used to ensure that the language used is appropriate.

For recruitment considering the dependent relationship with hospital staff, eligible patients are approached by a research nurse, who obtains verbal consent to allow a university researcher to provide further information.

Patient data are maintained in accordance with an approved data management plan to ensure confidentiality and security. When required, essential data are securely transferred to co-investigators via password-protected links, granting access to the individual research files stored in a secure system.

The sample size required for the study is not derived statistically but rather determined by feasibility and pragmatic considerations. The sample size is constrained by class size parameters for safety (a maximum of 6 participants per session) and an expected high turnover of patients during the 6-week period (due to discharge from the ward). Accrual data are gathered from all patients on the ward, and qualitative data are gathered from up to 10 patients and nursing staff who participated in the program.

The intervention is outlined in Table S3 in Multimedia Appendix 1 in accordance with the TIDieR checklist [35]. Several potential challenges to implementation are anticipated and addressed. The most likely concern is staff shortages due to sickness. In such instances, a contingency plan is in place to reduce the number of participants in each class, ensuring that the appropriate staff-to-patient ratio is maintained. Additionally, if logistical issues such as transportation difficulties arise, the class is relocated to the dining room, which is closer to patient rooms.

Another key consideration involves the burden on clinical staff to conduct patient clearances. This challenge is minimized by aligning the clearance process with the existing procedure for granting weekend leave. To facilitate this, the lead author developed a proforma document for completion.

To align the research questions with the quantitative and qualitative data sources, a data source table has been developed. This is presented in Table S4 in Multimedia Appendix 1. Further descriptions are provided in the following sections where necessary.

Approaches to analysis will differ depending on the data type. Pre- and postsession PANAS and VAS-F will simply be plotted and visually displayed. For the pre-and postprogram well-being data, a reliable change index will be calculated (change score divided by the standard error of the two measurement scores) [65]. Recruitment and attendance will be displayed in a flowchart, showing the total number admitted to the ward during the study period, the number deemed eligible and offered the program, the number consenting to participate, and those who attended. The average number of classes attended over the 6 weeks will also be presented.

Interviews will be transcribed verbatim and deidentified for analysis. Interview transcripts will be analyzed thematically using the method proposed by Braun and Clarke [66] to devise themes concerning participants’ perceptions of the adapted dance program. DP and MN will initially read and reread interview transcripts to immerse themselves in the data. Initial codes, along with example raw data, will then be presented in a team meeting for team level discussion and code refinement. Themes will be collaboratively developed by the research team.

As recommended by Aschbrenner et al [44], a joint display table will be produced where rows represent each aspect of feasibility (ie, accrual, retention, attendance, safety, and acceptability) as well as pilot efficacy and measurement and design feasibility. Columns will represent quantitative data (including count data and reliable change index), qualitative data (stratified via stakeholder) including dance teacher and research nurse notes, and themes raised in the semistructured interviews. The final column will be the point of intersection or integration of quantitative and qualitative data including a comment on where the data diverge or are in agreement.

In the case study write-up, qualitative data will be used to expand on the quantitative data in a side-by-side write-up where the patient-specific qualitative data can add value to the quantitative data.