Dance as a group-based treatment for Parkinson’s disease (PD) incorporates physical exercise, cognitive tasks, sensory experience (music), emotional expression, and social interaction. As such a multidimensional activity, dance has the potential to address many of the challenges faced by patients. Indeed, in addition to significant motor and cognitive impairment, patients are troubled by mood changes and social isolation. Therefore, dance may highly impact the quality of life in patients with PD.
The therapeutic benefits of dance have been studied for at least a decade yielding interesting findings, but additional clinical trials are necessary to strengthen the evidence in support of this treatment for PD. To discuss the therapeutic use of dance in PD, we have invited experienced professionals, Drs. Earhart, Hackney and Postuma, as well as the Founder and Executive Director of Dancing with Parkinson’s (DWP), Ms. Robichaud. Finally, an expert in Movement Disorders, Dr. Fox, will provide the concluding remarks.
What has research revealed about the effects of dance in PD?
Over the past decade, there has been an explosion of information about the effects of dance in PD. A quick search of PubMed for ‘Parkinson and dance’ returns nearly 100 articles published within the last 10 years. Much of the early work focused on tango, but many other forms of dance have also been studied. The majority of these studies analyzed the impact of dance on movement and have shown that dance improves balance and walking. There is also evidence for overall improvement of motor deficits as assessed by the Unified Parkinson’s Disease Rating Scale (UPDRS). However, fewer studies have addressed the impact of dance on non-motor symptoms of PD, and their results are inconsistent. According to some studies, dance may positively impact mood, cognition, and quality of life. Yet, many potential effects of dance such as improving cardiovascular health, muscle strength, body composition, flexibility, and proprioception remain to be formally examined.
Studies in the last 10 years have shown some forms of dance to be beneficial for mobility, balance, and psychosocial health in PD. Many different types of dance have been researched, including contemporary dance in the form of Mark Morris Dance Group's Dance for PD®, Irish step dancing, ballet, contact improvisation, ballroom dancing, and Argentine tango. It is exciting that there has been such diverse interest from multiple dance fields. It is also important to note that many patients have postural instability and other mobility difficulties that preclude them from doing some types of dancing without modifications, and therefore the adapted forms of these dance genres seem to be the most beneficial.
Although recent research suggests that dance affects the neural mechanisms underlying motor function, I believe dance could also be thought of as a form of cognitive rehabilitation because it certainly involves executive function, attention, visuospatial function, working memory, and long-term memory. There is some evidence that cognitive function, in particular visuospatial function, is positively impacted by dance. Dance also involves the cognitive aspects of interpreting a musical beat and coordinating movement to the rhythm. Clearly, more research is needed to determine the role that music plays in the beneficial effects of dance in PD.
Independent of supporting research data, do you recommend dance to your patients with PD?
By all means, I often recommend this for my PD patients. The key is to get exercise. I do not think there is any one exercise that is clearly better than the others. Therefore, any way that patients can enjoy themselves, as long as it is sufficiently vigorous, is fine. If patients enjoy the exercise, then compliance improves. In addition, I think most PD patients can participate in dance. I would hold back on recommending dance to those with severe loss of balance; dance requires patterned steps, which can result in falls if balance is sufficiently impaired. Those with dementia will have trouble learning new steps, but this does not necessarily imply that they cannot participate.
Dance has several advantages. First, it is a good exercise for balance; people can practice walking backwards and forwards while supported by their partner. The patterning of the movements, in conjunction with music, can help unblock freezing. Depending on the type of dance, it is a good level of workout for patients with PD at the more moderate-advanced stages of disease. Finally, it is fun. It is especially good for couples as a source of bonding and shared enjoyment. In the face of all challenges and stresses of PD, it can be one means by which the disease can introduce something positive in the relationship. Finally, many patients get a pleasant break in their day by attending the dance class. The patients believe that they are better. Although I am a scientist and eager to demonstrate objective evidence of improvement, knowing that people enjoy the classes and feel hope, is perhaps the true end result to go for.
What are the key components of your dance class for people with PD?
Dancing with Parkinson’s (DWP) is a Canadian charitable organization that creates and delivers specialized dance classes specifically designed for all patients living with PD in Ontario, Canada. The DWP dance classes are based on the Dance for PD® program developed by David Leventhal and John Heginbotham from the Mark Morris Dance Group. The classes are a multidimensional and multidisciplinary artistic activity that incorporates physical exercise, cognitive tasks, social interactions, music, and expression. No previous dance experience is required or expected of our dance students. At the start of the class, PD students and care givers are welcomed into the dance studio by trained, skilled, and enthusiastic volunteers and instructors who create a safe, artistic, and inclusive environment. The class begins with the students seated and the instructor leading them through a series of warm up dances aiming to increase range of motion, core strength, coordination, musicality, posture, and expression. The class then progresses to dancers standing (depending on their ability and individual limitations) to learn both stationary and travelling steps and choreography. All dances are done to music, which is an important component of the classes.
Dance instructors expose the students to varying styles of dance and modify choreography when needed for those in wheelchairs and using walkers so that everyone can fully participate to their own potential. Other key component of the class is the various techniques of imaginary representation used to teach the dances, which help dancers initiate, sustain, and develop their movement. The number of volunteers is also important for the students to feel well supported and cared for throughout the class, and typically the ratio of volunteers to students is 1:4. The set of choreography and improvisations executed in class, whether seated or standing, promote creativity, expression, connectivity, musicality, and a sense of joy in being in control of one’s own movement.
What important issues need to be addressed in clinical trials to provide high quality evidence to support the therapeutic use of dance for PD?
The MDS Evidence Based Medicine (EBM) Committee develops and publishes EBM reviews on treatments for movement disorders with 3 reviews of treatments for PD already published. EBM is a strategy for the critical evaluation and uniform comparison of clinical trial data with conclusions based on predetermined efficacy criteria. In clinical practice, EBM offers guidance that must be integrated with the physician’s experience and judgment, patient preference, expert opinion, and medical economic determinants to arrive at a final therapeutic recommendation. EBM reviews also help to identify areas where specific evidence is lacking so future research can focus on unmet needs.
Exercise, including dance, is an area of interest for clinical researchers and has seen an exponential growth in the number of studies published. The quality of these studies has improved considerably over the past decade, however, inequity between the designs, and thus quality rating given to clinical trials evaluating a drug or surgical intervention vs dance persists. Some of these issues are inherent in the intervention itself such as the lack of blinding of a patient. However, there are factors that can be improved and addressed to improve the evidence. The most important factor is to ensure the patients and control groups are equally matched in all clinical aspects of PD including doses and type of drugs, presence and severity of fluctuations, etc. The ideal design is to have two control groups: one as an active control group, participating in a group-setting, patterned exercise-related activity (to control for the type of dance) and another control group optimized on best medical therapy, without exercise, but participating in a social group activity, to control for underlying clinical features of PD related to medications and fluctuations. The outcomes measured also need to use a clinically-relevant scale that has been validated in the PD population. This also allows for more accurate power calculations to give statistical validity. The use of an independent rater to evaluate the primary endpoint blind to the groups also reduces bias.
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