Ballroom Dancing Intervention for Parkinson's disease: A Case Study


Abstract

The purpose of this fictional case study is to investigate the effect of ballroom dancing as a treatment for gait and balance disturbances in late onset, idiopathic Parkinson’s disease. The case study is focused on a patient who has moderate Parkinson’s disease symptoms, who sought out physiotherapy to improve his gait, balance, independence for his ADLs, and quality of life. Dance is a treatment technique for Parkinson’s patients which focuses on improving social participation, gait, and balance with the use of visual and auditory cues [1]. A dance intervention was implemented along with traditional physiotherapy techniques 2x a week for 10 weeks. Dance sessions were 60 minutes in length and progressed from low to high intensity over the 10 week period. 

The physiotherapy treatment plan was developed to improve body structure/function impairments, activity limitations, and participation restrictions. This was based on patient centred goals, an objective exam, and outcome measure results including Unified Parkinson’s Disease Rating Scale (UPDRS), Parkinson’s Disease Questionnaire (PDQ-8), Timed Up and Go (TUG), Berg Balance Scale, Activities-Specific Balance Confidence (ABC) Scale, and Sit to Stand. After the 10-week intervention, small improvements were seen in the UPDRS, PDQ-8, TUG, Berg Balance Scale, Sit to Stand, and ABC Scale. The UPDRS met the MCID for minimal change indicated by a 3 point improvement on the motor scale, and 5 points overall for the total score[2]. The ABC improvement with the rollator showed more than the minimal detectable change of 11 points[3]. Maintenance was observed in the TUG cognitive. These outcome improvements were meaningful as they helped with maintenance of symptoms, improving patient participation, and overall quality of life. 

Introduction

The following case will be focused on the assessment and treatment of a 65-year-old male with late onset idiopathic Parkinson’s disease. 

Parkinson’s disease is a progressive neurodegenerative disease due to a degeneration of the dopaminergic neurons in the substantia nigra of the basal ganglia. The reason for the loss of the cells is unknown but is thought to be due to a combination of environmental factors mixed with a genetic predisposition [4]. This disease involves progressive motor and non-motor symptoms where patients face increasing difficulties with activities of daily living (ADLs), cognitive symptoms, gait, transfers, balance, and posture [5]. As a result, these symptoms contribute to a lack of independence, activity, and social participation[6]. The cardinal signs of Parkinson’s disease include the presence of tremor, rigidity, and bradykinesia [7].

Physiotherapy helps to maximize independent function and minimize secondary effects of the disease via education, physical rehabilitation, and supporting the individual by addressing body structure/function impairments, activity limitations, and participation restrictions.  

Goals of physiotherapy for these individuals include improving quality of life by helping preserve patient independence, safety, and overall well-being[6]. Additionally, dance interventions have previously shown improvements in movement initiation, balance, gait, and improved sit to stand performance in people with Parkinson’s disease[8] Therefore, the objective of this case is to explore an intervention approach focused on incorporating dance training in addition to traditional physiotherapy techniques to manage and delay progression of this disease.

Client Characteristics

John is a 65-year-old male, retired teacher who previously participated in ballroom dancing lessons with his wife twice a week. He lives with his wife and has a 30-year-old son who lives a 15-minute drive away. He was diagnosed 5 years ago with late onset idiopathic Parkinson’s disease and at 2 years post-diagnosis was prescribed carbidopa-levodopa for his symptoms. John has no other comorbid conditions. He has had two recent falls and has noticed a worsening resting tremor, difficulty turning, initiating movement, and fatigue in the mornings. He has been referred for physiotherapy due to the recent worsening of symptoms making activities of daily living more difficult, as well as his increased fear of falling. 

Examination Findings

Subjective

John reports being diagnosed with late onset idiopathic Parkinson’s disease 5 years ago based on his presentation of the cardinal signs and a positive response to levodopa treatment. At first, John noticed that he was losing his sense of smell and his handwriting had become unusually small. Now, he realizes that he has developed a resting tremor in the upper extremities, his movements have slowed dramatically, and that he has difficulty getting up and going about his day. He finds himself feeling more fatigued in the morning and takes more naps than he used to.

John’s chief concerns are his loss of independence, significant fatigue with activities of daily living, and fear of falling. He reports difficulty getting dressed and reaching for things in the cupboards because of his limited shoulder mobility. Consequently, John relies heavily on his wife who lives at home with him in a bungalow that has four steps at the front door but no other steps inside. John states that his feet “feel heavy” and feels more confident walking when his wife is beside him. He is unable to walk more than a few minutes at a time and has a difficult time stopping, as well as turning.  He reports that these deficits in walking have stopped him from performing many activities like going to the grocery store with his wife and participating in ballroom dancing which is very upsetting to him.

For medication, John takes trihexyphenidyl (2mg, 3 times per day), ropinirole (3mg, 3 times per day), and carbidopa-levodopa which he has been taking for 3 years at a 60mg dose, 3 times per day. John reports taking his dose of carbidopa-levodopa a few hours before his physiotherapy assessment, so the effects have worn off.

Objective

John presents with hypomimia, mild hypophonia, mild dysarthria, but no observable cognitive deficits. He exhibits a forward head posture and kyphosis of the thoracic spine with mild lateral deviation towards the left. He also stands with slight hip flexion and with his elbows flexed bilaterally. John breathes shallowly, with increased laterocostal and apical involvement. His static and dynamic sitting balance are within normal limits but had deficits with dynamic standing (see outcome measures). Dermatomes and myotomes are normal, and UMN/LMN reflexes are intact. John presents with bradykinesia, and resting tremor primarily in the upper extremity (UE). Moderate rigidity is observed bilaterally in upper extremities throughout range of motion (ROM) and strength testing. Mild rigidity is seen in lower extremities (LE), and marked rigidity is seen in neck and trunk muscles.

Relevant Passive Range of Motion (PROM) Scores

Lower Body Upper Body
Movement PROM (degrees) Movement PROM (degrees)
Hip Extension L: 10 R: 15 Cervical Rotation L: 20 R: 20
Knee Extension L: -5 R: -5 Shoulder Flexion L: 85 R: 90
Ankle Dorsiflexion L: 5 R: 5 Shoulder Abduction L: 80 R: 90
Ankle Plantar Flexion L: 35 R: 40 Elbow Extension L: -5 R: -5

(-) indicates short of full extension. Also observed limited thoracic extension and axial rotation.

Relevant Manual Muscle Testing (MMT) Scores

Lower Body Upper Body
Movement Grade Movement Grade
Plantar Flexion L: 3 R: 3+ Elbow Extension L: 3+ R: 3+
Dorsiflexion L: 2+ R: 2+ Elbow Flexion L: 3+ R: 3+
Knee Extension L: 3 R: 3 Shoulder Flexion L: 3- R: 3-
Hip Extension L: 3- R: 3 Shoulder Abduction L: 2+ R: 2+

Outcome Measures:

  • TUG (Timed Up and Go):
    • 19.5 seconds [9]
    • at increased risk of falls [10]
  • TUG-cognitive (counting backwards by 3’s):
    • 27 seconds [11]
    • at increased risk of falls.
  • Sit to Stand (Time for 5 reps):
    • 21.8 seconds for 5 repetitions[12].
  • Berg Balance Scale:
    • 41/56 [13]
    • at increased risk of falls and may benefit from mobility aid[14].
  • ABC (Activities-Specific Balance Confidence) Scale:
    • 67/100 [15]
    • at higher risk for falls in the next 12 months[16].
  • Single Leg Stance:
    • R = 16.4 seconds , L =9.8 seconds [17]
  • UPDRS (Unified Parkinson’s Disease Rating Scale):
    • Total Score = 66
    • Motor Score = 32
    • Non motor score = 34
      • section 1= 8
      • Section 2 = 26[18].
  • Parkinson’s Disease Questionnaire-8 (PDQ-8):
  • Hoehn and Yahr Scale:
    • Stage 3
      • mild to moderate bilateral disease
      • some postural instability
      • physically independent [20].

Gait Analysis:

John presents with decreased walking speed, increased time in double-limb support, reduced stride length, and reduced step width. He has a reduction in arm swing bilaterally and reduced truncal rotation. He also exhibits a stooped over posture, festination, and freezing of gait (FOG) when attempting to make a turn. When he does turn, John hesitates before moving forward and takes an increased amount of steps. John walks with reduced hip and knee flexion, limited ankle dorsiflexion, and an absent heel strike resulting in shuffling steps.

Primary & Secondary Symptoms of Parkinson's disease

Primary Symptoms of Parkinson's Disease Secondary Symptoms of Parkinson's Disease
Freezing of gait (FOG) Forward head posture
Bradykinesia Increased kyphosis in thoracic spine
Slow turns Loss of joint flexibility
Decreased arm swing when walking Decreased LE ROM: knee extension, ankle dorsiflexion
Festination of gait Decreased UE ROM: elbow extension, shoulder flexion, shoulder abduction
Loss of balance Muscle weakness
Rigidity/hypertonia Shallow breathing pattern
Resting tremor Reduced axial rotation
Speech: mild dysarthria, mild hypophonia

Clinical Impression

Physiotherapy Diagnosis:

Patient is a previously independent 65-year-old male, diagnosed with late onset idiopathic Parkinson’s disease 5 years ago who presents with moderate resting tremor, moderate festinating gait, marked rigidity in the axial trunk and neck, decreased balance, increased fear of falling, difficulty with dressing, reduced L/E and U/E strength, reduced ROM bilaterally, and reduced cervical rotation. Patient lives in a bungalow and needs to climb four stairs to get into his house. Patient is a good candidate for physiotherapy to help increase strength, improve gait pattern, decrease fatigue, increase balance, and improve participation in meaningful activities. Chief concern is recent multiple falls and difficulty with gait.

Problem list:
  • Decreased dynamic standing balance
  • Forward head posture, increased kyphosis and lateral deviation towards the left
  • Increased risk of falls (Berg score 41/56)
  • Inefficient breathing pattern
  • Bilateral effects with postural instability
  • Increased double leg stance time
  • Reduced shoulder ROM, cervical rotation, and lower extremities (all bilaterally)
  • Moderate rigidity in the upper extremities, mild rigidity seen in lower extremities, marked rigidity in neck and axial trunk
  • Reduced upper extremity strength (shoulder flexion and abduction) and lower extremity strength (dorsiflexion and hip extension)
  • Reduced functional mobility based on TUG score of 19.5 seconds
  • Increased difficulty with dual task
  • Fear of falling (ABC score 67/100)
  • Increased FOG, festination and difficulty initiating and stopping; reduced bilateral arm swing
  • Difficulty reaching overhead for items in the cupboard

Intervention

Short-term Goals:

Body Structure Function-related Goals:
  • Increase left and right shoulder flexion ROM by 10° in 4 weeks (increasing right shoulder flexion to 100° and left shoulder flexion to 95°).
  • Improve sit to stand by successfully completing 5 repetitions in 19 sec in 4 weeks.
  • Improve bilateral hip extension strength to 3+ in 4 weeks.
Activity Goals:
  • Reduce TUG time to 17.5 seconds from 19.5 seconds in 3 weeks (reduce to 12.5 seconds with use of a 4-wheeled walker).
Participation Goals:
  • Be able to walk with his wife to the grocery store 5 minutes away, using a 4- wheeled walker in 4 weeks.

Long- term Goals:

Activity Goals:
  • Successfully complete internal perturbations in dynamic standing with minimal supervision compared to initial moderate assistance before 6 weeks in order to reach cups in the cupboard.
Participation Goals:
  • Return to a 60-minute ballroom dance class with his wife once per week in 10 weeks.

Management Program

Dance Intervention:

For John, we used ballroom dance as a rehabilitation intervention to improve balance, coordination and gait. In addition to traditional physiotherapy techniques, studies show that dance has a positive impact on Parkinson’s patients by treating classic symptoms, and has shown improvements in the UPDRS, and Berg Balance Scale[21]. It does this through use of external auditory and visual cueing, working to improve cognition while challenging the patient’s balance, strengthening muscles and improving joint mobility[22].  Freezing of gait is addressed by using visual and auditory cues via the use of the dance partner's foot, and music[23].

Ballroom dance includes both tango and waltz which will be used during the dance intervention. Effective dose of treatment recommends dance twice per week, 1-hour duration for 10- 13 weeks [22][24] Group dance lessons will be held in a studio located within the physiotherapy clinic and will include other patients with Parkinson’s disease.

Week 1 & 2:

  • Frequency: 2 times per week
  • Intensity: low intensity
  • Type: ballroom dancing
  • Time: 60 minutes

Week 3 & 4:

  • Frequency: 2 times per week
  • Intensity: moderate intensity
  • Type: ballroom dancing
  • Time: 60 minutes

Week 5 & onwards:

  • Frequency: 2 times per week
  • Intensity: high intensity
  • Type: ballroom dancing
  • Time: 60 minutes

When designing this intervention, we made sure to focus on fatigue prevention, while still making room in the physical therapy schedule for other interventions during the week. We decided on 1 hour dance classes to limit fatigue[22]. Studies have shown that music can be used to limit the perception of fatigue in patients with PD[25]. The intensity of the workout is based on the tempo of the music and the patient’s motor skill level[24]. Therefore we slowly increased the intensity and the tempo to ensure patient safety. John’s current rating on the Hoehn and Yahr Scale is Stage 3 (mild to moderate bilateral disease), which makes him an appropriate candidate for dance therapy[22]. The Physiotherapist will work with a dance instructor to lead the class. Although we are prescribing a 4-wheeled walker to reduce falls, he will not use the gait aid for dance lessons. Instead, the physiotherapist will offer manual balance support during these sessions as the dance partner.

[26]

Dance helps to improve quality of life, is an enjoyable form of exercise, and improves self esteem[27]. For our patient, this intervention was directly related to his long term goal of returning to ballroom dance with his wife. This helped to promote social participation, and increased John’s motivation for exercise.

Traditional Physiotherapy Sessions:

Gait Aid Prescription:

For this patient, we prescribed a 4-wheeled rollator walker for longer term walking. The purpose of this was because he has been experiencing falls recently, so it is important to try and prevent falls where possible. A rollator can also improve his ability to ambulate for longer distances, as well as within the community.[28]

Laser with Rollator Use:

We instructed John on how to use a laser device attached to his walker to improve gait speed at home and in the community. The laser provides a visual cue for the foot to reach via a horizontal line helping the patient with making turns, preventing FOG, and improving gait and cadence.[29]

[30]

Balance training:

Standing Static Balance:

  • Stage 1:
    • Begin with hip-width base of support on firm surface, eyes open
    • goal of 30 seconds, 2x a week, Week 1
  • Stage 2
    • Hip-width base of support on firm surface, eyes closed
    • goal of 10 seconds, 2x a week, Week 2
  • Stage 3
    • Hip-width base of support on foam, eyes open
    • goal of 20 seconds, 2x a Week 3
  • Stage 4:
    • Hip-width base of support on foam, eyes closed
    • goal of 5 seconds, 2x a week, Week 4
  • Stage 5:
    • Repeat Stages 1-4, just with a narrow base of support
    • Same time goal in seconds per each stage throughout Week 5 & 6.

Internal Perturbation Training:

  • Stage 1:
    • Target placed out in front, within arms reach
    • 5 reaches per side, 2x a week
  • Stage 2:
    • Target out to the side, within arms reach
    • 5 reaches per side, 2x a week
  • Stage 3:
    • Target out behind, within arms reach
    • 5 reaches per side, 2x a week
  • Progression of Stages 1-3:
    • Increase distance to reach for each stage to incorporate weight shifting
    • Complete in weeks 4-6

Walking endurance:

Graded walking activity was introduced to his program with the rollator to improve exercise endurance and walking tolerance. Rest breaks were provided to avoid fatigue with  frequency and duration of rest documented for each session. 1 minute progressions were added per week (10 sec every day), to increase tolerance to reach the  goal of 5 minutes required to walk to the grocery store with his wife in 4 weeks.

  • Week 1: 2 minutes walking with rollator.
  • Week 2: 3 minutes walking with rollator.
  • Week 3:  4 minutes walking with rollator.
  • Week 4 + Onwards : 5 minutes per session walks with rollator.

Home Exercise Program:

Bridging:

  • Frequency: 2 times per week
  • Intensity: body weight against gravity
  • Type: muscle hypertrophy
  • Time: 3 sets of 10 repetitions

Sit to Stand:

  • Frequency: 2 times per week
  • Intensity: body weight against gravity
  • Type: muscle strength
  • Time: 2 sets of 6 repetitions

Supine Shoulder Active Assisted Range of Motion (AAROM) with cane:

  • Frequency: 5-6 times per week
  • Intensity: point of mild discomfort indicating initial resistance point.
  • Type: dynamic AAROM
  • Time: 2 sets of 10 repetitions

Wall Crawl for Shoulder AAROM:

  • Frequency: 5-6 times per week
  • Intensity: point of mild discomfort- indicating initial resistance point
  • Type: dynamic AAROM
  • Time: 2 sets of 10 repetitions

Metronome:

Teach John how to use a metronome application on his smartphone along with wireless earphones to help manage his gait and walking speed. Metronomes produce audible sounds that create a rhythm which acts as an external auditory cue for the Parkinson’s patient. Normal cadence for John’s age and sex is 81–125 steps/minute.[31] The metronome can be set at 60 steps/ minute and slowly increased through time.

Outcome

Small improvements were seen in the UPDRS, PDQ-8, TUG, Berg, Sit to Stand, and ABC Scale. The UPDRS met the MCID for minimal change indicated by 3 point improvement on the motor scale, and 5 point overall for the total score[2]. The ABC improvement with the rollator showed more than the minimal detectable change of 11 points.[3] Maintenance was seen in the TUG cognitive, and the Single Leg Stance. All outcomes were measured in "OFF" medication state in order to be comparable to the initial assessment.

  • UPDRS
    • Pre-Intervention:
      • Total Score = 66
      • Motor Score = 32
      • Non motor score
        • section 1= 8, Section 2 = 26
    • Post-Intervention:
      • Total Score = 61
      • Motor Score : 29
      • Non Motor Score
        • Section 1 = 8, Section 2 = 24
  • PDQ-8
    • Pre-Intervention: 52
    • Post-Intervention: 48
  • TUG
    • Pre-Intervention: 19.5 seconds
    • Post-Intervention: 17.5 seconds without walker, 12.5 seconds with rollator
  • TUG (Cognitive)
    • Pre-Intervention: 27seconds
    • Post-Intervention: 27.5s without walker, 25 seconds with rollator
  • Berg Balance Scale
    • Pre-Intervention: 41/56
    • Post-Intervention: 45/56
  • Sit to Stand
    • Pre-Intervention: 5 in 21.8 seconds
    • Post-Intervention: 5 in 19 seconds
  • ABC Scale
    • Pre-Intervention: 67/100 (no aid)
    • Post-Intervention: 80/100 with the rollator.
  • Single Leg Stance
    • Pre-Intervention: R = 16.4 s , L =9.8
    • Post-Intervention: R = 15.9s, L = 10.1s

Discharge plan:

Patient should continue with home exercise program, use of metronome for gait and is encouraged to continue participation in dance intervention therapy.  If the patient or his wife notice any major changes, they should contact physiotherapy again to reevaluate. Patient will be referred to a speech language pathologist regarding his mild dysarthria, an occupational therapist for home evaluation, and to continue follow up with his neurologist for understanding disease progression over time.

Discussion

This case study presented a 65-year-old male who was diagnosed 5 years ago with late onset idiopathic Parkinson’s disease. The objective of the case study was to show a typical presentation of an individual with Parkinson’s disease and identify effective assessment and treatment strategies to help with challenges the patient experienced in everyday life. Our patient presented with the cardinal signs of Parkinson’s disease, as well as common changes that occur throughout disease progression such as freezing of gait, fatigue, difficulty initiating movement, and increased number of falls.

We provided an assessment and treatment including 10 weeks of traditional physiotherapy and dance intervention techniques. The intervention focus was to improve balance, gait, strength, and ROM deficits as well as address activity limitations and participation restrictions the patient experienced. Outcomes either had small improvements or were maintained in the 10 week intervention. In summary, there was a post-intervention improvement observed in Sit to Stand, PDQ-8, Berg Balance Scale, TUG, ABC Scale, and the UPDRS. There was a clinically significant change with the UPDRS Scale meeting the MCID for minimal change indicated by 3 point improvement on the motor scale, and 5 point overall improvement for the total score[2]. The original ABC score was 67/100 which is predictive of recurrent falls based on a prospective 12-month follow up[32]. Updated ABC score with the walker showed more than the minimal detectable change of 11 points[3]. The pre-intervention scores of TUG cognitive and Single Leg Stance were maintained.

This case study has clinical implications for patients with late onset Parkinson’s disease with moderate dysfunction. We hope the assessment and treatment measures used can assist other students and physiotherapists find useful information to improve patient well being. In addition, we believe that dance interventions can provide physiotherapists and students with novel ideas to help patient independence, balance, and gait, which can be incorporated alongside traditional physiotherapy techniques. The benefits obtained from dance interventions can be demonstrated in other populations as well, including multiple sclerosis (MS) and stroke patients. Dance can help patients with MS improve balance, motor coordination, and achieve greater postural control in addition to improving their emotional state.[33] In stroke patients, dance was shown to be a feasible intervention which had low risk, can be performed in a limited space, easy to be sustained over time, and promoted social interaction.[34]

Physiotherapy in combination with prescription medications should aim to maintain autonomy and quality of life through reducing activity limitations, participation restrictions, and the cardinal signs of Parkinson’s disease by maintaining/improving function, posture, balance, loss of ROM, and gait throughout the stages of the disease.[35][36]

Self-Study Questions

The correct answer is underlined for the three questions below.

1. Which is true regarding Parkinson’s disease?

  • It is more prevalent in women compared to males
  • Early onset is younger than 40 years old
  • There is a longer swing time in gait
  • Clinical symptoms don’t show up until 60% loss of dopaminergic cells

2. State which is false regarding the UPDRS?

  • It has a motor and non motor components
  • It is not related to the Hoehn and Yahr
  • It is specific to Parkinson’s population
  • A higher score is worse

3. Dance therapy as an intervention for patients with Parkinson’s disease works to improve:

  • Balance
  • Stride length
  • Motivation
  • All of the above

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