Parkinson's and Dance

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History of Dance as Treatment for Individuals with Parkinson's Disease

Parkinson's disease (PD) is a progressive neurodegenerative disease. Common symptoms of PD are resting tremor, bradykinesia, rigidity, mask face, and difficulties with gait.[1] Gait difficulties include short and shuffling steps, festination and/or freezing of gait, difficulty turning or walking backward, and impaired ability to perform dual tasks when walking. [2] Individuals with PD are also at an increased risk of falls.[3]

Medical treatments for PD, including medications, do not fully address gait and balance issues[4] and so exercise has become an important part of treatment. Four key areas of focus when designing exercise programs for PD as recommended by Keus et al.[5] are:

  1. Cueing strategies to improve gait,[5]
  2. Cognitive movement strategies to improve transfers,[5]
  3. Exercises to improve balance,[5] and
  4. Training of joint mobility and muscle power to improve physical capacity.[5]

Dance address each of the previously mentioned key areas[5] in the following ways, as suggested by Earhardt[2]:

  • The use of music to accompany dance movement can act as an external cue to facilitate movement.[2]
  • The use of specific movement strategies when teaching the dance steps.[2]
  • The need to control dynamic balance and respond to perturbations when interacting with other participants facilitates balance exercises.
  • Dance helps enhance strength and flexibility. It may also improve cardiovascular functioning if done at a sufficient intensity.[2]

The first study that examined the potential benefits of dance for individuals with PD was completed in the late 1980s by Westbrook et al. [6] comparing dance/movement therapy with a traditional exercise program over a 6-week period of time. Later in 2001, Olie Westheimer, the Founder and Executive Director of the Brooklyn Parkinson Group teamed up with the Mark Morris Dance Group, a modern dance company that had recently opened a dance centre in Brooklyn.[7] Two dancers from the Mark Morris Dance Group, John Heginbotham and David Leventhal, started leading monthly classes, offered free of charge to individuals with PD.[7] In 2004 the Mark Morris Dance Group began leading their classes in cities where the company was touring.[7] Mark Morris Dance Group subsequently developed a training program for dance teachers and began offering free demo classes and teacher training workshops.[7] The original Brooklyn program now serves as a model for Parkinson's dance classes in 30 U.S. states and ten countries: Australia, Canada, England, Germany, Holland, India, Israel, Italy, Mexico, and Scotland.[7]

Other studies have focused on studying the benefits of partnered dance forms, with an emphasis on Argentine tango in the literature.[8] These studies demonstrated that not only was functional capacity improved but that participants were more likely to continue with a dance class than a traditional exercise program. 

The cognitive and functional benefits of dance in patients with PD is continuously researched, however it is important to note the additional benefit of creating engaging and active Parkinson's communities where none previously existed. 

Potential Benefits of Dance in Individuals with PD

Motor Benefits

Dance is shown to benefit individuals with Parkinson's disease by enhancing motor function through stretching, stepping and balance.[9] Individuals who participated in a dance intervention ranging from 90 minutes of dance per week for 8 weeks, to 2 hours, two times per week for 2 years, showed improvements in various outcome measures, notably Berg Balance Scale, when compared to a regular exercise group.[10][11] The motor improvements could be due to repetition, direction change, and step sequencing that are inherent in dance and transfer into effective, regular gait patterns.[9] Furthermore, basal ganglia may be activated during rhythmic movements, and enhanced by the auditory cues in the music accompanying dance.[12]

Dos Santos Delabary et al in a systematic review, that included 159 patients has found that dance leads to significant improvements on Unified PD Rating Scale III and decreased Timed Up and Go Test in comparison with other types of exercise. It was also significant improvements in motor scores in dance practice compared to the absence of intervention[13].

Cognitive Benefits

The changing visual and auditory stimuli, unique to dance, facilitate cognitive improvements when compared to regular exercise programs for PD patients.[9] A dance class creates an environment where individuals must control continuously changing patterns of movement to match the instructor. Dance has been shown to reduce time taken to correctly complete the MRT (Mental Rotation Task) as dance aids in imagery formation and judgement.[9] The attention required to anticipate movements, and respond to changes in music or instruction is unique to dance and can enhance the activity of the basal ganglia loops and frontal lobes.[12] This is supported by greater improvement in FAB (frontal assessment battery).[9] When compared to traditional rehabilitation (balance exercises, gait training) there were moderate improvements in cognitive test scores at the 8 week follow up, supporting dance therapy as being able to impact higher cortical functions in the long term.[14]

Mental Health Benefits

Mental health benefits for individuals with Parkinson's disease are exclusive to dance when compared to control and regular exercise treatment.[9] Improvement shown in mood, motivation and enjoyment can be related to feelings of unity. There are improved AP (apathy scale) and SDS (self-rating depression scale) scores after dance intervention in patients with PD.[9] It has been suggested that dance therapy can decrease fear of falling through practicing position changes in a controlled environment.[1] Overall, health related quality of life and emotional well-being has been increased through dance for people living with PD.[1]

Additional Benefits

When compared to regular exercise and control groups, dance for PD yields greater gains in UPDRS (Unified Parkinson's Disease Rating Scale).[9] Please note that research is required to determine the optimal types of dance and parameters (i.e. frequency, intensity, duration) of dance to address specific motor impairments patients with PD experience. Personal, cultural, and social preference need to be considered to improve adherence to treatment program.[11]

Types of Dance and PD Outcomes

Style of Dance and Effects on PD

The style of dance most prominently researched in patients with PD is the tango. Tango is thought to target major functional impairments in people with PD, such as walking backwards, starting and stopping gait, turning, and changing tempo.[11][15] In a comparison of Argentine tango to American ballroom (waltz and foxtrot) both groups had significant improvement in balance, locomotion, and motor control. The benefits were greater in the tango group which also showed significant improvement in freezing of gait.[8] In both a meta-analysis and systematic review, investigation into comparing different forms of dance to determine whether tango really does provide more benefits is recommended.[15][11]

Below is a list of benefits specific to particular dance styles:

  • Irish step dancing significantly improved freezing in patients with PD, while tango did not significantly improve freezing (as mesured using the Freezing of Gait Questionnaire).[11] 
  • Turkish Folkloristic dance improved muscle strength and endurance (as measured using the 5 Times Sit to Stand).[11]
  • Tango, waltz, and foxtrot improved scores in the 6 Minute Walk Test.[11]
  • Balance improvement is consistent in the literature, regardless of dance type.[11][15]

Partnered Versus Non-Partnered Dance's Effect on PD

In a study of partnered versus non-partnered tango interventions for people with PD, both groups improved in cadence, Berg Balance Scale scores, and comfortable and fast-as-possible walking speed.[16] Patients in the partnered class reported having more motivation to continue with the program and more enjoyment partaking in the class.[16] To date, research comparing partnered to nonpartnered dance is limited.[10]

Additional Resources

For more information on the Mark Morris Dance Group and Brooklyn Parkinson Group dance classes: Dance for PD

For more information on Canada's National Ballet School's dance classes for people with Parkinson's: Sharing Dance.

Video about joint research between Canada's National Ballet School, York University, and Ryerson University:


Why Dance for PD:

References

  1. 1.0 1.1 1.2 Ventura, MI, Barnes, DE, Ross, JM, Lanni, KE, Sigvardt, KA, Disbrow, EA. A pilot study to evaluate multi-dimensional effects of dance for people with Parkinson's disease. Contemp Clin Trials 2016;51:50-55.
  2. 2.0 2.1 2.2 2.3 2.4 Earhart, GM. Dance as therapy for individuals with Parkinson disease. Eur J Phys Rehabil Med 2009;45:231-8.
  3. Pickering, RM, Grimbergen, YA, Rigney, U, Ashburn, A, Masibrada, G, Gray, P, Bloem, BR. A meta-analysis of six prospective studies of falling in Parkinson's disease. Mov Disord 2007;22:1892-1900.
  4. Gage, H, Storey, L. Rehabilitation for Parkinson's disease: a systematic review of available evidence. Clin Rehabil 2004;18:463-482.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Keus, SH, Bleom, BR, Hendriks, EJ, Bredero-Cohen, AV, Munneke, M. Practice recommendations development group evidence-based analysis of physical therapy in Parkinson's disease recommendations for practice and research. Mov Disord 2007;22:451-460.
  6. Westbrook, BK, McKibben, H. Dance/movement therapy with groups of outpatients with Parkinson's disease. Amer J Dan Ther 1989;11:27-38.
  7. 7.0 7.1 7.2 7.3 7.4 Dance for PD. About Us. http://danceforparkinsons.org/about-the-program (accessed 4 May 2017).
  8. 8.0 8.1 Hackney, ME, Kantorovich, S, Levin, R, Earhart, GM. Effects of tango on functional mobility in Parkinson's disease: a preliminary study. 2007 J Neurol Phys Ther;31:173-9.
  9. 9.0 9.1 9.2 9.3 9.4 9.5 9.6 9.7 Hashimoto, H, Takabatake, S, Miyaguchi, H, Nakanishi, H, Naitou, Y. Effects of dance on motor functions, cognitive functions, and mental symptoms of Parkinson's disease: a quasi-randomized pilot trial. Complement Ther Med 2015;23:210-9.
  10. 10.0 10.1 Aguiar, LPC, da Rocha, PA, Morris, M. Therapeutic dancing for Parkinson's disease. Int J Gerontol 2016;10:64-70.
  11. 11.0 11.1 11.2 11.3 11.4 11.5 11.6 11.7 McNeely, ME, Duncan, RP, Earhart, GM. A comparison of dance interventions in people with Parkinson's disease and older adults. Matirutas 2015;81:10-16.
  12. 12.0 12.1 Hackney, ME, Earhart, GM. Effects of dance on movement control in Parkinson's disease: a comparison of Argentine tango and American ballroom. J Rehabil Med 2009;41:475-481.
  13. Dos Santos Delabary M, Komeroski IG, Monteiro EP, Costa RR, Haas.Effects of dance practice on functional mobility, motor symptoms and quality of life in people with Parkinson's disease: a systematic review with meta-analysis.Aging Clin Exp Res 2018 Jul;30(7):727-735.
  14. de Natale, ER, Paulus, KS, Aiello, E, Sanna, B, Manca, A, Sotgiu, G, Deriu, F. Dance therapy improves motor and cognitive functions in patients with Perkinson's disease. NeuroRehabilitation 2017;(Preprint):1-4.
  15. 15.0 15.1 15.2 Sharp, K, Hewitt, J. Dance as an intervention for people with Parkinson's disease: a systematic review and meta-analysis. Neurosci Biobehav Rev 2014;47:445-56.
  16. 16.0 16.1 Hackney, ME, Earhart, GM. Effects of dance on gait and balance in Parkinson's disease: a comparison of partnered and nonpartnered dance movement. Neurorehabil Neural Repair 2010;24:384-92.