Hot Topic: Argentine tango in the rehabilitation of persons with Parkinson's disease

I'm so thankful to be joined by Assistant Professor Hae-Young Hawong, Movement disorders neurologist at the Yale School of Medicine, Doctor of Osteopathic Medicine, and I believe you also trained in neuro-ophthalmology and you speak fluent Korean.

Is that correct?

Prof. Hae-Young Hawong: Yes.

Ms. Nicole Duff: Quite amazing. As I was going through your biography, I was like, "Wow, is there any more to add onto that?" Quite amazing.

[00:01:00] So when diving into this hot topic, dance has some of the strongest evidence as a rehabilitation therapy alongside aquatherapy and Tai Chi as an example.

And then amongst all the dance styles, Argentinian tango has by far the highest level of evidence with regards to efficacy, and that has led us to you. So I know that you have a background in ballet, but what led you to Argentinian tango?

Prof. Hae-Young Hawong: Thank you so much for your kind introduction and thank you for this opportunity. Yeah. My specialty is actually deep brain stimulation. And while we are quite effective at treating tremor, rigidity, bradykinesia with the DBS and levodopa pharmacotherapy, but gait and balance can be very challenging.

And we usually focus primarily on disease and motor symptoms, [00:02:00] and we forget patients as a whole, their quality of life, mood, cognition, and social connection. That realization made me ask simple question, what more can I offer my patients? And I have background in Argentine tango, so that it was natural for me to think beyond the traditional therapies and look at Argentine tango.

But why Argentine tango? There are many studies, clinical trials, systemic review, meta-analysis already show UPDRS, Time Up Go, and it's good, it's evident, reduce fall risk. But why? Argentine tango integrates the multiple domains simultaneously. Structured physical movement, rhythmic auditory stimulation through music, and rich social interaction through partner dance.

The combination address not only [00:03:00] motor impairments, but also improve emotional and social aspect of the disease. And through tango, patients are not just practicing movement, they're engaging in meaningful, enjoyable activity that promotes confidence, connection, and sense of identity beyond the illness.

But again, why tango? So tango is a unique feature we also call walking dance. It incorporates rhythmic walking, intentional stepping, walking patterns that help patients to relearn gait and improve balance, particularly the heel-to-toe concept, that transition we always tell our patients, that's actually a fundamental dance technique in Argentine tango.

And with consistent practice, the brain can form new neural pathways, supporting more learning, improving movement through neuroplasticity. And tango is a partner dance, [00:04:00] which provides both physical support and external cueing. This shared movement allows patient to practice walking in safer, more guided way, improving confidence and stability.

Another unique feature of Argentine tango is the concept of, this is my favorite part, connection. This is achieved through the embrace, meaning how you hold each other. This connection is physical, emotional, and nonverbal, a dynamic dialogue between partners that allows them to move as one system. This aspect of tango extends beyond the movement and plays an important therapeutic role.

Up to 64% patients with Parkinson disease report feeling socially isolated, 38% depression, 37% report [00:05:00] apathy. Adaptive tango therapy has demonstrated improvement in mood, depression, and apathy. And when we first teach tango close embrace, we start with hugging. A nice, big, warm hug, dancing while hugging each other.

So the embrace and shared connection foster a sense of belonging and community. This positively influence motivation, self-efficacy, and emotional wellbeing. Okay, let's talk about science. If I explain in a neurobiological perspective, music and dance activate multiple dopaminergic pathway. We know that Parkinson is nigrostriatal dopaminergic pathways impacted and we are all familiar with that.

But there are also mesolimbic reward system, mesolimbic dopaminergic neurons. Engagement with the rhythm and music can enhance the activity in nucleus accumbens, and this increase the dopamine [00:06:00] release and reinforce the motivation and pleasure. Emotional resonance during dance may also promote the prolactin release, and prolactin contribute to feeling of comfort, bonding, and joy.

This parallels the concept of connection in Argentine tango. And what about rhythmic walking? Another unique feature of Argentine tango is rhythmic walking. The rhythm is critical as gait itself is a highly complex neural process. Gait is regulated by striatal thalamocortical network integrating cortical, subcortical, brainstem structures.

The key component of prefrontal cortex, we also-- PFC, supports executive control and attention. Supplementary motor area, SMA, responsible for motor planning and initiation. Primary motor cortex m1, [00:07:00] which generates voluntary movements by the corticospinal tract. This cortical region interacts closely with the basal ganglia, which plays central role in motor adjustment, automatic movement, and internal cueing, which is impacting Parkinson disease.

And the studies show in healthy older adults, they have increase in PFC activation during walking, suggesting compensatory mechanism and greater reliance on cognitive control when automatic motor pathways declined. So this is where the tango comes. In Parkinson disease, dysfunction of the basal ganglia disrupts the motor adjustment, action selection, initiation, and automatic movements.

Adaptive tango therapy helps bypass this impaired circuits by providing strong external cue. The auditory cues from music, [00:08:00] rhythm, and beats. Visual cues from steps and spatial orientation. Somatosensory inputs, weight shifting, proprioception, and sensation from the partners. The partner feedback through embrace and shared movements.

These inputs engage alternative neural pathways and facilitate movement through external guidance rather than impair the internal cueing in Parkinson disease. And these reinforcing movement patterns and enabling the formation of new neural connection, this process reflects neuroplasticity, the brain's capacity to reorganize and form new functional circuits.

Ms. Nicole Duff: I can feel your passion for the project that you have created, and you've laid it out so beautifully. Thank you. Just highlighting the different facets of Tango and the neuro [00:09:00] biological components where it impacts. And for me, when I think of Tango, I always think of that flair, that we see people with.

And and for me, that must also create a sense of creativity within the person performing the Tango, even if they're not physically able to create that movement. I would imagine within the brain, they're imagining perhaps the kind of movements that they would want to create. And would that be doing something within the brain structure as well?

Prof. Hae-Young Hawong: Yes. Yes. So that's why when I have Parkinson's adaptive tango therapy program structure if I may talk about how I do the structure. It's a led structure adaptive tango therapy program consists of 12 weekly session. Each lasting 90 minutes. The program is delivered as group intervention with two instructor.

Participants dance with trained [00:10:00] volunteers or their own partners, creating supportive and interactive environment. So I start with the warm-up, two songs that prevents... I do a lot of warm-up because that prevents the injury and increase range of motion, and this is where I work on the rigidity and body awareness and mindfulness.

And then I do musicality exercise. For the creativity, I work on musicality. So I introduce rhythm, timing using auditory cues, teach to recognize beats, clapping, toe-tapping, weight shifting, walking. We teach to recognize beats and then go to the use the beat and now clapping with the beat, toe-tapping with the beat, weight shifting with the beat, walk with the music.

Then I do cognitive dual task exercise. Walk with the partner, learn to walk with the partner in synchrony, integrating movement with the cognitive [00:11:00] challenges, spelling backwards while walking with the partner. So work on the attention, sequencing, memory tasks to improve executive function and motor coordination.

I will answer your question soon. Getting there. And then I work on the adaptive tango step and sequences. Tango movement sequences are tailored to optimize motor function, balance and gait, while minimizing fall risk. And then I do games on interactive exercise. We do connectivity game, balance exercise, so with eyes closed but with the music only, they feel the movement of the partners by different contacts.

And then sometime we play red light and green light in "Squid Game." Have you seen the "Squid Game"? Yes. And we work on motor control and timing through this game. So this activity is designed to enhance partner connection, balance, and [00:12:00] responsiveness in a dynamic and engaging way. And then we do sequence building and progression.

We review and repeat the sequence we learn, then adding a variation where they can be creative. Review of learned material with guided, gradual additional complexity, introducing variation and building confidence in movement patterns. Then we do mini practica. Participants practice freely, encouraging creativity and autonomy in movement.

You are right on. Tanda in Argentine tango is a set of two to four songs. We dance with one partner with one set of the song, then we switch, and this is why this is social dance. And in Argentine tango etiquette, final tanda is typically danced with the caregiver and [00:13:00] partners to strengthen the emotional connection and reinforce the learned skills, and they can be creative with the music, with the emotion.

And then we do cool down, which is gentle stretching and relaxation to conclude the session. So yes, creativity in the movement is very important, and that's what I emphasize on my tango program as well.

Ms. Nicole Duff: Your program is just tailored to focus on so many different areas within Parkinson's disease. And, you know, I had some questions here on how will it affect non-motor and motor, but you've gone so far beyond that to thinking around quality of life and connections with carers, and it's really quite mind-blowing how detailed you've gone within the program.

And have you replicated at all in other facilities, or is it something that you think could be replicated? Because seeing your passion I would [00:14:00] imagine it would be something that unless you find someone with the same level of passion might be difficult to replicate. But is it something that you think in the future might be able to be done?

Prof. Hae-Young Hawong: Yes, definitely. This can be done. There's a tango therapy project organization called Tango Therapy Project in Philadelphia. They're also doing this tango therapy program. And I'm in contact-- I'm starting a tango therapy project in New York City with collaborator who's a professional tango dancer.

This is well done in many places in Argentine. So yes, this is feasible. Just give me a call, contact me. I will train you. We can have a training together. I can show you how, and there's a training done by Dr. Hackney, and this is where I actually got trained as well.

Ms. Nicole Duff: That is I mean, such exciting possibilities, research possibilities [00:15:00] going forward. Out of interest, do patients have to meet certain criteria to be part of the group?

Prof. Hae-Young Hawong: Yes. Usually we want Hoehn and Yahr stage of one to three, but I have patient stage four. I recommend HY stage one to three, but I do accept stage four, and I tailor exercise individually with him during group session for the safety. Because I have-- volunteers are all trained.

I do orientation in advance and train them with the safety. And I have another tango instructor, and actually a lot of volunteers are tango dancers. So I have enough people. So I do accept stage four and do individualized exercise. But recommendation would be stage one to three.

Ms. Nicole Duff: Thank you. And what sort of feedback have you been getting from the patients? Not just seeing improvements, subjectively or objectively from you, but [00:16:00] hearing from them. What are they saying?

Prof. Hae-Young Hawong: I got a testimony from one of my patient, if I can share. He wrote a whole letter, and I wanna share this part. It kinda made me feel... it touched my soul. "My experience with the tango reminds me of study I read some time ago about a PD patient, Parkinson patient, whose symptoms seemingly disappear when they were on a bike.

Similarly, I've discovered that practicing the tango box step significantly improve my mobility. Whenever I experience mobility issues or rigidity, performing the box step brings noticeable relief. The more I practice this step daily, the less frequently these Parkinson's symptoms seem to occur. This is my personal story of how the miracle of tango has improved my quality of life.

To my [00:17:00] fellow Parkinson patients, I sincerely hope that you might consider trying tango and potentially experience similar positive results." So this is what he wrote, and I remember I parked my car to go to tango therapy program. I saw him in the side of the parking lot practicing tango box, and then I saw this testimony.

Yeah.

Ms. Nicole Duff: That's what makes it all worthwhile, Hae. All the thinking and planning and putting everything together and just seeing how patients' quality of life is changed. What I think stands out to me a lot from that testimony is the carryover between sessions that, sometimes within sessions we see a lot of improvement and then they come back the next week and unfortunately they've returned to their previous level of baseline.

But he's speaking about how he's getting carryover during the week, about how he's still seeing, and it's what you're [00:18:00] talking about, that neuroplasticity that there's so many facets that are feeding into the brain the dopaminergic pathways that are just being flooded with all the different facets that you've put into place and I think that's what's quite remarkable 'cause a lot of other therapies don't always have that carryover and I think that it's really something that is different from many other therapies.

Prof. Hae-Young Hawong: Yes. And it just-- it's not just helping patients. This work also shaped my role as a physician. I get to observe my patients in dance setting and assess their movements, their motor function during 90-minute session than standard 30-minute clinic visits. For example, I noticed one patient, while dancing, she had a open and close movement during the session, and that prompted me to adjust medication dosing to improve her dyskinesia.

In another case, I had a [00:19:00] patient he came off dragging his foot. The thing is, patient don't recognize that. They're not able to give us these histories. And I was able to change the timing of the medication to improve his symptom. And dancing with the patient weekly base, that foster sense of community and strengthens the doctor-patient relationship.

And this shared experience creates informal support group , benefiting both patients and myself. And as a physician, I find this work deeply rewarding. It provides a sense of purpose that I am able to help my patients, reinforces altruistic motivation, reminds me of my mission, and serve as a meaningful way that it actually mitigates burnout.

Ms. Nicole Duff: You, you're right. It's as you said, it benefits the patient as much as us, and I think that's such a [00:20:00] beautiful way of framing it. It gets our dopaminergic pathways firing as much as theirs. So out of interest, you said that you work mainly within DBS, and with that you saw that postural instability and, gait and balance aren't benefited as much through DBS.

So are a lot of your patients in the Argentinian tango group DBS, or is it a complete mix?

Prof. Hae-Young Hawong: Mix.

Ms. Nicole Duff: Mix. Okay. And do you see that one group or one-- a patient with DBS or not DBS improving more than the other?

Prof. Hae-Young Hawong: That's a very good question. That would be very good research idea.

Ms. Nicole Duff: There we go. Thoughts for the future. Thoughts for the future. Thank you so much for your time. I've just loved hearing your passion. I've loved hearing the intricacies of everything you've put into the program and how it feeds into every aspect of Parkinson's, and I sincerely hope [00:21:00] people just start reaching out to you, and we can get programs going.

From here in South Africa, I am certainly excited to see if we can get something up and running with you that benefits our patients so much. And just thank you so much for your time. I really appreciate it.

Prof. Hae-Young Hawong: Thank you so much. And before we end, I do want to thank Dr. Hackney for her research in this field, and she formalized all this tango therapy structure. So thank you so much.

Ms. Nicole Duff: Thank you too.

Prof. Hae-Young Hawong: If anyone have a question, please feel free to reach me.

Ms. Nicole Duff: We'll put your details underneath the podcast on the website.

Prof. Hae-Young Hawong: Thank 

Ms. Nicole Duff: Thank you.

Bye [00:22:00]