# Exercise as it relates to Disease/Gait and balance for Parkinsons through dance

Parkinson's Disease is the second most common neurological degenerative disease, following Alzheimer's. It is a progressive disease caused by neurons in the substantia nigra, being unable to produce dopamine. As a whole, Parkinson's impedes on an individuals activities of daily living. At first, the most obvious signs are gross movement problems such as tremors or shaking, rigidity, slowness of movements and postural instability. In worse cases of Parkinson's, it may affect the patient not only physically but mentally as well. Parkinson's Disease is more prevalent in those over 60 years of age, with 4% of people with PD being over 50. and 1 in 7 patients under the age of 50. There is no cure to Parkinson's disease so there is a large focus on slowing down the degeneration. Exercise, and in particular Dance, has had substantial evidence that it is effective in slowing down the degeneration and provides greater balance, gait, confidence and enjoyment to the patients.

## Prevalance & Cost

In 2011, approximately 64,000 Australians had Parkinson's Disease with estimations that one in every 350 people were living with it. Worldwide, an estimated 10 million people are living with Parkinson's disease every day. On average in Australia, the cost of Parkinson's per year is around $7,599. Overall costs of Parkinson's disease in 2011 was approximately $775.4 million in Australia with a direct cost to the health system of $478.5 million per year.

## Signs & Symptoms

There are four cardinal signs associated with Parkinson's Disease that can help with identification - TRAP.
| T | Tremors - shaking of the extremities at rest or in action |
| R | Rigidity - within the joints and therefore movement |
| A | Akinesia (or Bradykinesia) - slowness of movement |
| P | Postural Instability |
Other symptoms may include:
* Hypomimia - reduced facial expression
* Dysarthria - unclear articulation in speech
* Dysphagia - difficulty or discomfort when swallowing
* Sialorrhoea - hypersalivation
* Micrographia - decreased size of handwriting
* Shuffling Gait - more steps taken, but the length of the steps or shortened
* Festination - all joints (knees, hips, ankles) are flexed when walking, limited full extension occurs
* Freezing - temporarily unable to move without choice
* Glabellar reflexes - reptitive tapping on the forehead
* Anosmia - loss of smell
* Autonomic system dysfunction
* Cognitive/neurobehavioral abnormalities
* Sleep disorders
* Pain

## Cause

Parkinson's Disease is a degeneration of the dopamine producing nuerons within the substantia nigra (in the midbrain). Approximately 50-80% of these neurons will die in Parkinson's patients. As the neurons die, less dopamine is produced and taken to the striatum, the area of the brain that co-ordinates movement. Although a lot of research has been undertaken in the past, the exact cause of the degeneration of the dopamine neurons is still unclear. What is now clear is that there are many triggers for the neural degeneration causing Parkinson's.

## Treatment

With no cure, there are few pharmaceutical products that can alleviate symptoms such as levodopa (L-DOPA). L-DOPA is the natural precursor to Dopamine, so it helps to provide a greater amount of dopamine to the necessary pathways. L-DOPA is only effective during the early stages of Parkinson's disease though. If there are not enough neurons in the substantia nigra to be able to produce the dopamine with assistance from L-DOPA, it becomes ineffective. There are also some surgical treatments available but these are for the most sever cases of Parkinson's
Exercise has been evident in slowing down the degeneration. Gait and balance are of a large concern for Parkinson's patients. Their gait cycle tends to consist of more steps of a shorter length and a wider stance in order to maintain balance during the transition of each step. In the most severe of cases, patients will have a shuffling action more so than a typical walking pattern. So exercise and movement in any form is a good measure to take in terms of preventative measures.

## Dance for Parkinson's

Dance has many beneficial elements towards Parkinson's disease in assisting the slowing of degeneration. In many cases it has been shown that it can even improve the balance, gait, coordination, enjoyment and activities of daily living. Partnered and non-partnered dancing has been observed and although both have seen improvements, the partnered dancing has seen the more significant trends. Waltz, Foxtrot, Tango & Argentine are common styles which have been proven time again to show improvements. It has also been looked at in both mild cases of Parkinson's and in severe cases showing positive improvements for both.
| Tango | Improvements in Balance, Gait, Walking Velocity, Upper Extremity Function, Single Leg stance, balance Confidence, Perceived Happiness, perceived improvement in Activities of Daily Living and Teamwork |
| Waltz/Foxtrot | Improvements in Balance, Gait, Motor Control, Enjoyment and Teamwork. |
| Ballet | Improved Quality of Life (questionnaires) |
| Tai Chi | Improved Balance, Improve Up and Go Test Scores and a Higher Score of Wellbeing |
| No Interventions | Decreases in most motor movements, difficulty increases in activities of daily living, risk of falls due to unstable balance, reduced quality of life, |
Those with Parkinson's use external cues to focus their attention to be able to move with normality. With partnered dancing such as Tango/Waltz/Foxtrot, the individual has cues such as the music and their partner that they can focus their attention to. Using specific movement patterns, they can focus on moving towards or with their partner to maximize movement and the choreography provided can be very specific to improving movement and so in such fine intrinsic movement, like used in the Tango, it can improve the coordination and balance of the patient.
Common results show that the most improvement in balance, gait, motor control and activities of daily living, will come from 1 hour classes 2-4 times per week with a focus on short amounts of high activity.

## References

* 1 2 de Lau, L.M.L, Breteler, M.M.B, (2006). Epidemiology of Parkinson’s Disease. The Lancet Neurology, 5:525–35.
* ↑ Gibrat, C, Saint-Pierre, M, Bousquet, M, Lévesque, D, Rouillard, C & Cicchetti, F, (2009). Differences between subacute and chronic MPTP mice models: investigation of dopaminergic neuronal degeneration and α-synuclein inclusions. Journal of Neurochemistry, 109:1469-1482..
* ↑ Selkoe, D.J & Lansbury. Jr, P.J, (1999). Alzheimer’s Disease Is the Most Common Neurodegenerative Disorder. Basic Neurochemistry: Molecular, Cellular and Medical Aspects. 6th Edition. Philadelphia: Lippincott-Raven. Available from http://www.ncbi.nlm.nih.gov/books/NBK27944/.
* ↑ Bertram, L & Tanzi, R.E., (2005). The genetic epidemiology of neurodegenerative disease. Journal of Clinical Investigation, 115(6):1449-1457.
* 1 2 3 Jankovic, J, (2008). Parkinson’s disease: clinical features and diagnosis. Journal of Neurology, Neurosurgery & Psychiatry, 79:368-376.
* 1 2 Marieb, E.N & Hoehn, K (2013). Human Anatomy & Physiology. 6th Edition Pearson Education Inc. United States.
* 1 2 Parkinson’s Disease Foundation, (2014). Statistics on Parkinson’s. Viewed 30 September 2014, available at http://www.pdf.org/en/parkinson_statistics.
* ↑ Findley, L.J, (2007). The economic impact of Parkinson’s disease. Parkinsonism & Related Disorders, S8-S12.
* 1 2 3 Earhart, G.M, (2009). Dance as Therapy for Individuals with Parkinson Disease. European Journal of Physical and Rehabilitation Medicine 45(2):231-238.
* 1 2 3 Hackney, M.E. & Earhart, G.M (2010). Effects of dance on balance and gait in severe Parkinson disease: A case study. Disability and Rehabiliation, 23(8):679-684.
* 1 2 3 Duncan, R.P & Earhart, G.M, (2012). Randomized Controlled Trial of Community-Based Dancing to Modify Disease Progression in Parkinson Disease. Neurorehabilitation and Neural Repair, 26:132-145.
* 1 2 3 4 Hackney, M.E. & Earhart, G.M (2010). Effects of Dance on Gait and Balance in Parkinson Disease: A Comparison of Partnered and Non-Partnered Dance Movement. Neurorehabilitation and Neural Repair, 24(4):384-392.
* 1 2 Parkinson’s Australia, (2011). Living with Parkinson's Disease – update. Deloitte Access Economics. Available at http://www.parkinsons.org.au/ACT/AEReport_2011.pdf .
* ↑ The Michael Stern Parkinson's Research Foundation, (2013). What causes Parkinson’s Disease?. Viewed 29 September 2014, available at http://www.parkinsoninfo.org/about-parkinsons-disease/what-causes-parkinsons/.
* ↑ Walkinshaw, G & Waters, C.M, (1995). Induction of Apoptosis in Catecholaminergic PC12 Cells by L-DOPA: Implications for the Treatment of Parkinson's Disease. Journal of Clinical Investigation, 95:2458-2464.
* ↑ Goetz, C.G, Poewe, W, Rascol, O & Sampaio, C, (2005). Evidence-Based Medical Review Update: Pharmacological and Surgical Treatments of Parkinson's Disease: 2001 to 2004. Movement Disorders, 5:523-539.
* ↑ Morris, M.E, Huxham, F, McGinley, J, Dodd,K & Iansek, R, (2001). The biomechanics and motor control of gait in Parkinson disease. Clinical Biomechanics, 16:459-470.
* ↑ Yousefi, B, Tadibi, V, Khoei, A.F & Montazeri, A, (2009). Exercise therapy, quality of life, and activities of daily living in patients with Parkinson disease: a small scale quasi-randomised trial. Trials, 10:67.
* ↑ Baatile, J, Langbein, W.E, Weaver, F, Maloney, C & Jost, M.B (2000). Effect of exercise on perceived quality of life of individuals with Parkinson's disease. Journal of Rehabilitation Research & Development, 37(5):529-34.
* 1 2 3 4 Hackney, M.E. & Earhart, G.M (2009). Effects of Dance on Movement Control in Parkinson's Disease: A Comparison of Argentine Tango and American Ballroom. Journal of Rehabilitation Medicine, 41(6):475-481.
* ↑ Hackney, M.E & Earhart, G.M, (2009). Short duration, intensive tango dancing for Parkinson disease: an uncontrolled pilot study. Complementary Therapies in Medicine, 17(4)ː203-207.
* 1 2 Hackney, M.E, Kantorovich, S & Earhart, G.M, (2007). A Study on the Effects of Argentine Tango as a Form of Partnered Dance for those with Parkinson Disease and the Healthy Elderly. American Journal of Dance Therapy, 29(2)ː109-127.
* ↑ Westheimer, O, (2007). Why Dance for Parkinson’s Disease. Topics in Geriatric Rehabilitation, 1-13.
* ↑ Hackney, M.E & Earhart, G.M, (2008). Tai Chi Improves Balance and Mobility in People with Parkinson Disease. Gait Posture, 28(3)ː456-460.
* 1 2 Hackney, M.E & Earhart, G.M, (2009). Health-related quality of life and alternative forms of exercise in Parkinson disease. Parkinsonism and Related Disorders, 15ː644-648