# Exercise as it relates to Disease/The Effect of dance on symptoms of Parkinson's Disease
## What is Parkinson's Disease?

Parkinson’s Disease (PD) is a progressive, degenerative neural condition. It affects more than 1 million people in the US, and onset can range from 40–70 years of age. PD is caused by a progressive loss of substantia nigra neurons which produce dopamine, a neurotransmitter associated with conduction of signals for voluntary movement, motivation, sleep, mood and attention. The deficiency in dopamine causes neurotransmitter imbalances which affects movement, mood and cognitive function affecting the person’s ability to perform activities of daily living (ADL). The cause of PD is unknown, however, genetics and the environment are thought to be factors.

## Symptoms

Symptom type, number, severity and progression vary between individuals. Some symptoms include:
| Symptom | Description |
| Tremor at rest | Present in 70% - 80% of all patients and typically appears in the arm, leg or chin. |
| Rigidity | Velocity-independent increase in tone - when moved passively, the patient’s limb may seem to repeatedly catch and release. |
| Bradykinesia | Slowness in movement exhibited by spontaneous body gestures, difficulty with motor initiation or performing sequential movements. |
| Gait problems and postural instability | Flexed posture, decreased arm swing and a shortened stride. |
| Dysphagia | Difficulty or discomfort in swallowing. |
| Sialorrhea | Excessive production of saliva or increased amount of saliva in the mouth, which may also be caused by decreased clearance of saliva – result of dysphagia. |
| Hypophonia | Soft speech, often as a result of poor coordination in the vocal musculature. |
| Micrographia | Unusually small, cramped handwriting. |
| Hypomimia | Reduced facial expression caused by motor impairment. |
| Dystonia | Abnormal muscle tone resulting in muscular spasm and abnormal posture. |
| Hypokinesia | Decreased body movement, characterized by a partial or complete loss of muscle movement. Individual may have muscle rigidity and an inability to produce movement. |

## Problems Associated with Parkinson's Disease

Depression, combined with motor symptoms of PD and fear of falling, often leads to the individual staying indoors, reducing participation in physical activities and thus adopting a sedentary lifestyle. As a result, individuals with PD can enter a state of decline in mobility which causes progressive deficits in the capacity to undertake ADL resulting in poor quality of life (QoL), loss of independence and development of secondary diseases such as osteoporosis.

## The Effect of Dance on Symptoms of Parkinson's Disease

Dance has been shown to improve or prevent a decline in motor symptoms when compared to controls and has demonstrated greater improvements than traditional exercises, such as walking. Dancing has led to improvements or prevented decline in rigidity, bradykinesia, balance, walking velocity, dual task walking velocity, motor control, aerobic capacity, facial expression, fine motor skills and depression and anxiety.

## How Does Dance Improve Symptoms of Parkinson's Disease?

* It has been proposed the Tango may assist due to walking being the basic step, acting as a way of focusing attention on walking, which can improve walking performance in people with PD. With practice, the walking movements become more automatic.
* People with PD can utilize cues to improve movement capabilities. Music serves as an auditory cue, which has previously improved gait speed, initiation and cadence in a laboratory session. It is proposed that auditory cues my bypass the dysfunctional basal ganglia to the supplementary motor area via the thalamus. Stepping over the foot of the partner serves as a visual cue.
* Dance incorporates functional movements that people with PD struggle with, for example, walking backwards and turning. People with PD also have difficulty walking while performing a secondary task but practice of multitasking can improve performance. Dance involves multitasking as the person must complete steps while navigating other people on the dance floor and attending to the music.
* Tango includes pauses, which means movement initiation is repeatedly practiced. Tango also incorporates steps that are similar to strategies used for freezing of gait, such as stepping over the foot of their partner.
* Rigidity is decreased immediately after the dance class which may be due to increased proprioception achieved through dance and it’s sustained movement repetition with verbal and visual (reflection in the mirror) feedback.
* Hand and finger movements improve, possibly as a result of better movement initiation and execution or activation of the motor system or by motor learning effects.
* Endurance is improved by aerobic exercise provided by dance. Waltz elicits cardiovascular benefits equal to treadmill training, while Tango elevated heart rate to 70% of maximum which is appropriate range for aerobic training.
* Dance incorporating emotional expression and theatrical pantomime leads to improvements of facial expression.
* Dance is enjoyable and engaging, which improves motivation for regular participation, a high compliance and little drop out. Dance has been reported to increase the concentration of serotonin “the happy hormone”, improving participants mood, who report their mood ‘lightens’ and anxiety decreases.

## Recommendations for Exercise

* Individuals with PD should participate in dance classes 3 days per week, each class should be minimum of 30 – 60min in duration, according to the individuals capabilities, and the individual should work at 40%-<60% VO2.
* People with PD should attend a class led by a supportive instructor, rather than dancing at home, as self-guided programs aren’t as effective and it may be unsafe.
* Where possible, individuals should participate in Argentine Tango, as it has been demonstrated to have the most amount of benefit.
* Dance classes should form part a multidisciplinary approach to treatment incorporating medication, flexibility, strength training and functional training.

## Further reading

For further information regarding Parkinson’s Disease and dance as a treatment contact your health care professional or visit:
* National Parkinson’s Foundation: http://www.parkinson.org/#
* ABC Health and Wellbeing, the Pulse: http://www.abc.net.au/health/thepulse/stories/2013/08/21/3829855.htm
* Dance for Parkinson’s Australia: http://danceforparkinsonsaustralia.org/

## References

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* ↑ Speelman AD, van de Warrenburg BP, van Nimwegen M, Petzinger GM, Munneke M, Bloem BR. How might physical activity benefit patients with Parkinson disease?. Nature Reviews Neurology. 2011;7(9):28-534.
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* ↑ Schrag A, Jahanshahi M, Quinn N. How does Parkinson’s disease affect quality of life? A comparison with quality of life in the general population. Movement Disorders. 2000;15(6):1112-1118.
* 1 2 3 4 5 6 Heiberger L, Maurer C, Amtage F, Mendez-Balbuena I, Schulte-Monting J, Hepp-Reymond MC, Kristeve R. Impact of a weekly dance class on the functional mobility and on the quality of life of individuals with Parkinson’s disease. Frontiers in Aging Neuroscience. 2011;3(14)
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* ↑ Jacobson AC, McKinley PA, Leroux A, Rainville C. Argentine tango dancing as an effective means for improving cognition and complex task performance in at-risk elderly: A feasibility study. Society for Neuroscience Abstract Viewer/757.7. 2005.
* ↑ Hackney ME, Kantorovich S, Levin R, Earhart GM. Effects of tango on functional mobility in Parkinson's disease: a preliminary study. Journal of Neurologic Physical Therapy. 2007;1(4):173-179.
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* ↑ Morris, ME, Iansek R, Matyas TA Summers JJ. Stride length regulation in Parkinson's disease normalization strategies and underlying mechanisms. Brain. 1996;119(2):551-568.
* 1 2 Dibble LE, Nicholson DE, Shultz B, MacWilliams BA, Marcus RL, Moncur C. Sensory cueing effects on maximal speed gait initiation in persons with Parkinson's disease and healthy elders. Gait & Posture. 2004;19(3):215-225.
* ↑ Nieuwboer A., Feys P, Weerdt WD, Dom R. Is using a cue the clue to the treatment of freezing in Parkinson's disease?. Physiotherapy Research International. 1993;2(3):125-132.
* ↑ Galletly R, Brauer SG. Does the type of concurrent task affect preferred and cued gait in people with Parkinson's disease?. Australian Journal of Physiotherapy. 2005;51(3):175-180.
* ↑ Rochester L, Hetherington V, Jones D, Nieuwboer A, Willems AM, Kwakke G, Van Wegen E. Attending to the task: interference effects of functional tasks on walking in Parkinson’s disease and the roles of cognition, depression, fatigue, and balance. Archives of Physical Medicine and Rehabilitation 2004;85(10):1578-1585.
* ↑ Brichetto G, Pelosin E, Marchese R, Abbruzzese G. Evaluation of physical therapy in parkinsonian patients with freezing of gait: a pilot study. Clinical Rehabilitation. 2006;20(1):31-35.
* ↑ Fallik, D. Finding new life through movement: how a modern dance academy helps Parkinson’s disease patients loosen tight joints and lift spirits. Neurology. 2007;3(1):30-33.
* ↑ Westheimer O. Why dance for Parkinson’s disease. Topics in Geriatric Rehabilitation. 2008;24(2):127-40.
* ↑ Leste A, Rust J. Effects of dance on anxiety. Perceptual and Motor Skills. 1984;58(3):767-772.
* ↑ American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription. Lippincott Williams & Wilkins; 2013. Parkinson’s Disease; p. 322 -330.
* ↑ Dereli EE, Yaliman A. Comparison of the effects of a physiotherapist-supervised exercise programme and a self-supervised exercise programme on quality of life in patients with Parkinson’s disease. Clinical Rehabilitation. 2010;24(4):352–362.