# Dance Is an Accessible Physical Activity for People with Parkinson’s Disease

Authors: Sara Emmanouilidis; Madeleine E. Hackney; Susan C Slade; Hazel Heng; Dana Jazayeri; Meg E. Morris
Journal: Parkinson’s Disease
 (2021)

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## Abstract

Objective. To evaluate the outcomes of face-to-face, digital, and virtual modes of dancing for people living with Parkinson’s disease (PD). Design. Systematic review informed by Cochrane and PRIMSA guidelines. Data Sources. Seven electronic databases were searched: AMED, Cochrane, PEDro, CINHAL, PsycINFO, EMBASE, and MEDLINE. Methods. Eligible studies were randomised controlled trials (RCT) and other trials with quantitative data. The PEDro scale evaluated risk of bias for RCTs. Joanna Briggs Institute instruments were used to critically appraise non-RCTs. The primary outcome was the feasibility of dance interventions, and the secondary outcomes included gait, balance, quality of life, and disability. Results. The search yielded 8,327 articles after duplicates were removed and 38 met the inclusion criteria. Seven were at high risk of bias, 20 had moderate risk of bias, and 11 had low risk of bias. There was moderately strong evidence that dance therapy was beneficial for balance, gait, quality of life, and disability. There was good adherence to digital delivery of dance interventions and, for people with PD, online dance was easy to access. Conclusion. Dancing is an accessible form of exercise that can benefit mobility and quality of life in people with PD. The COVID-19 pandemic and this review have drawn attention to the benefits of access to digital modes of physical activity for people living with chronic neurological conditions.


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## Body

## 1. Introduction

Parkinson’s disease (PD) is a debilitating and progressive condition that currently has no cure. People living with PD can experience movement disorders and nonmotor symptoms that compromise their levels of physical activity [1] and quality of life [2–5]. Movement slowness [6], balance impairment [7], falls [8, 9], and gait disturbance often occur [10]. These movement disorders, coupled with anxiety, depression, or lethargy, can be major barriers to maintaining long-term engagement in physical activity [1].Structured exercises and physical activities can assist people with chronic diseases to keep moving and to stay engaged in social activities and recreational sports [1]. One of the challenges for practitioners is keeping people with Parkinson’s motivated to adhere to regular physical activities over long periods of time [1]. People typically live with PD for 7–25 years [11, 12], and clinical guidelines recommend daily physical activities for at least 30–45 minutes per session [13]. For progressive conditions such as PD, it is recommended that a range of therapeutic exercises is available, to maintain long-term exercise adherence and compliance [1, 14]. There is evidence that people in the early to midstages of Parkinson’s can benefit from progressive resistance strength training [8, 15, 16], cueing [10,15], aqua therapy [17], physiotherapy [18, 19], aerobic exercises [20], Nordic walking [21], community walking [22], assisted cycling [23], boxing [24], and tai chi [25]. Therapeutic dancing is another option, given that it is engaging and can be done in groups or individually [26–28].Dancing for people with PD aims to improve movement, wellbeing, and quality of life, as well as social engagement and exercise capacity [29–32]. Dance also allows for creative expression and can take the focus off the disease and onto movement to music and social connection [31,33,34]. A study by Dos Santos Delabary et al. [35] reported that dance sometimes has greater benefits for functional mobility and motor symptoms than usual care. Likewise, Shanahan et al. [36] noted that participation in dance can improve endurance, motor impairment, and balance for those with mild to moderate PD. Berti et al. [37] reported that adapted tango dance programs are an effective intervention for individuals with PD with a range of abilities and balance limitations.Given the need for people with Parkinsonism and related disorders to have a range of evidence-based exercise choices, the primary aim was to evaluate the outcomes of face-to-face, online, and virtual modes of therapeutic dancing as an accessible physical activity for people living with PD. The outcomes of particular interest were balance, gait, disability, and quality of life.


## 2. Methods

We conducted a systematic review of the literature followinga priori methods. Two independent reviewers (SE, HH) were involved in the selection of studies into the review and two independent reviewers (SE, DJ) completed the data extraction to ensure that all relevant studies were identified, and that data were extracted reliably and consistently [38]. The review was informed by Cochrane guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist [39].The search was conducted using seven electronic databases: AMED, Cochrane, PEDro, CINHAL, PsycINFO, EMBASE, and MEDLINE. The search terms included: Parkinson disease or Parkinson’s disease or Parkinson∗, movement disorders and dance therapy or dancing or dance based or danc∗ or foxtrot or tango or waltz or “Irish set” or ballroom or dance movement therapy or contemporary salsa or cultural and telerehabilitation or telemedicine or telehealth or tele or remote or online or web-based or virtual or in-person or pre-recorded or live or synchronous or asynchronous or partnered or on-partnered and quality of life or balance or gait or disability. The MEDLINE strategy was adapted to the other databases and search strategies are available on request. An example of the Medline search strategy is in Table1. The searches were conducted by a health sciences librarian up until June 2020, saved in each database, and downloaded into the bibliographic management software program Endnote [40, 41]. Search yields were combined into one Endnote library, and duplicates were deleted prior to application of the eligibility criteria to the titles.Table 1
Medline search.
Search ID#Search termsSearch notesResults1Exp Parkinson disease, secondary/or exp Parkinson disease/709952Parkinson∗.mp.1279203Exp stroke/or exp stroke rehabilitation/1364334(Stroke or strokes).mp.2953255Exp Multiple sclerosis/581986“Multiple sclerosis”.mp.8251571 or 2 or 3 or 4 or 5 or 65193768Exp dance therapy/3599Exp dancing/284810(Dance∗ or dance-based or dancing).mp.734511(Foxtrot or tango or Waltz or “Irish set” or ballroom or ballet).mp.211312Or/8–11Dance related terms834813Exp exercise movement techniques/811614physiotherap∗.mp.2612415Exp exercise therapy/5013016Exp exercise/19292617exercis∗.ti,ab.29008618Or/13–17Exercise/physio related terms4313321912 or 18Included dance and physio/exercise terms43807720Exp telemedicine/or exp telerehabilitation/2795021telerehabilitation.mp.93322tele.mp.317323(Remote adj3 rehabilitat∗).mp.8724telehea∗.mp.492225app.mp.2573626((Exercise or mode) adj2 delivery).mp.837627virtual.mp.5900828video.mp. or exp video recording/or tape recording/or videotape recording/14894729(Online or “online”).ti,ab.13740330telemedicine.mp.2755631Exp telemedicine/2795032(Telemonitor∗ or tele-monitor∗).mp.170633Internet.mp.10250134((Tele∗ adj2 coach∗) or telecoach∗).mp.37435videoconferenc∗.mp.284336ipad.mp.130037computer.mp.69352838Exp internet/or exp internet-based intervention/7840639Mobile applications/568340(Apps or “mobile applications”).mp.1063141zoom.mp.160042webinar∗.mp.56943(Live adj2 stream∗).mp.14844Web-based.mp.3009745Pre-record∗.mp.36346(Dvd adj2 deliv∗).mp.3147Or/20–461110851487 and 19 and 47Final results190349recorded.mp.52583150synchronous.mp.3523151asynchronous.mp.99885249 or 50 or 51566263537 and 19 and 52Testing results for synchronous/asynchronous.Or recorded1204Inclusion and exclusion criteria were firstly applied to the titles to exclude studies that were clearly ineligible. We then applied the eligibility criteria to the titles and abstracts (SE, HH). Two reviewers (SE, HH) independently read in full the remaining articles to determine whether they met the eligibility criteria. A third reviewer (SS) was consulted to reach consensus if needed. Remaining discrepancies were resolved through consensus by two final reviewers (MM, MH) to determine the final included studies.


### 2.1. Inclusion Criteria

#### 2.1.1. Study Designs

The study designs included randomised controlled trials (RCT) and nonrandomised trials that contained data. We deliberately included both randomised and nonrandomised trials, to extend the findings of systematic reviews, which were confined to RCTs (e.g., 35–37). The full text had to be available and accessible in English. Systematic reviews, meta-analyses, protocol papers, letters to the editor, conference posters, opinion pieces, and abstracts were excluded.


#### 2.1.2. Participants

Participants had to have a diagnosis of PD. Other chronic neurological, musculoskeletal, or respiratory conditions were excluded, as well as dementia and Alzheimer’s disease. Individuals were at any stage of PD classified by the modified Hoehn and Yahr Scale [42] and living in residential care or the community. Adults of all ages, genders, and many cultures were included.


#### 2.1.3. Interventions

Studies were included if they used dance as an exercise intervention or form for physical activity or physiotherapy. All genres of dance were eligible, including Irish-set dancing, tango, waltz, tap, jazz, salsa, ballroom, ballet, mixed genre, and creative dancing. Classes could be delivered partnered or nonpartnered, group or one to one and with or without music. The mode of delivery was in-person, digitally (also known as online), or using virtual tools. Online delivery was via platforms such as Zoom® or Microsoft Teams®. Some of the dance interventions were delivered by dance teachers and others were delivered using “virtual” tools such as Wii (Nintendo Inc., Japan) or Sony Play Station® video game systems. The criteria for comparison or control interventions were any “usual care” or “usual physical activity” condition or any other therapeutic intervention.


#### 2.1.4. Outcomes

Studies were selected if they included baseline and after intervention outcomes for any of the following variables: gait, balance, movement, mobility, movement disorders, nonmotor symptoms, disability, participation, quality of life, wellbeing, or social participation. Feasibility studies were also reviewed.


#### 2.1.5. Risk of Bias

The PEDro scale was used to determine the risk of bias for RCTs [43]. PEDro was selected as it is a valid and reliable appraisal instrument for RCTs [44, 45]. Joanna Briggs Institute (JBI) instruments were used to critically appraise nonrandomised studies and to determine their risk of bias [46, 47]. Risk of bias assessments were completed independently by two reviewers (SE, SS), and consensus was reached by consultation with the research team (MM, MH).


#### 2.1.6. Data Extraction

Reviewers (SE, DJ,) independently extracted data into a pretested spreadsheet under headings such as study, participant and intervention characteristics, and outcome data. The data were independently screened and confirmed (SS, MEM). Outcome data were extracted for short-, medium-, and long-term follow-up assessments when reported.


#### 2.1.7. Data Analysis

For quantitative data, summary statistics were calculated. For the RCTs, the reported means and standard deviations were tabulated, and the Hedge’s g, bias-corrected effect size (ES) index was used to estimate the effects of dancing compared to another intervention or no therapy [48]. In some cases, the ES was already reported as a standardized mean difference (SMD) or Cohen’s d [49, 50] which we used. The Hedge’s g and Cohen’s d are similar; the Hedge’s g tends to perform better with sample sizes lower than 20. Whenever possible, a 95% confidence interval (95% CI) was calculated around the SMD for an estimate of the range of intervention effects [51]. Median scores and interquartile ranges (IQR), reported by the study authors, were also tabulated [52]. To facilitate comparisons across studies, median scores were entered into SMD calculations as best estimates of mean scores [53]. For non-RCTs, within-group mean differences and change scores were reported and effect sizes calculated whenever possible.


## 2.1. Inclusion Criteria

### 2.1.1. Study Designs

The study designs included randomised controlled trials (RCT) and nonrandomised trials that contained data. We deliberately included both randomised and nonrandomised trials, to extend the findings of systematic reviews, which were confined to RCTs (e.g., 35–37). The full text had to be available and accessible in English. Systematic reviews, meta-analyses, protocol papers, letters to the editor, conference posters, opinion pieces, and abstracts were excluded.


### 2.1.2. Participants

Participants had to have a diagnosis of PD. Other chronic neurological, musculoskeletal, or respiratory conditions were excluded, as well as dementia and Alzheimer’s disease. Individuals were at any stage of PD classified by the modified Hoehn and Yahr Scale [42] and living in residential care or the community. Adults of all ages, genders, and many cultures were included.


### 2.1.3. Interventions

Studies were included if they used dance as an exercise intervention or form for physical activity or physiotherapy. All genres of dance were eligible, including Irish-set dancing, tango, waltz, tap, jazz, salsa, ballroom, ballet, mixed genre, and creative dancing. Classes could be delivered partnered or nonpartnered, group or one to one and with or without music. The mode of delivery was in-person, digitally (also known as online), or using virtual tools. Online delivery was via platforms such as Zoom® or Microsoft Teams®. Some of the dance interventions were delivered by dance teachers and others were delivered using “virtual” tools such as Wii (Nintendo Inc., Japan) or Sony Play Station® video game systems. The criteria for comparison or control interventions were any “usual care” or “usual physical activity” condition or any other therapeutic intervention.


### 2.1.4. Outcomes

Studies were selected if they included baseline and after intervention outcomes for any of the following variables: gait, balance, movement, mobility, movement disorders, nonmotor symptoms, disability, participation, quality of life, wellbeing, or social participation. Feasibility studies were also reviewed.


### 2.1.5. Risk of Bias

The PEDro scale was used to determine the risk of bias for RCTs [43]. PEDro was selected as it is a valid and reliable appraisal instrument for RCTs [44, 45]. Joanna Briggs Institute (JBI) instruments were used to critically appraise nonrandomised studies and to determine their risk of bias [46, 47]. Risk of bias assessments were completed independently by two reviewers (SE, SS), and consensus was reached by consultation with the research team (MM, MH).


### 2.1.6. Data Extraction

Reviewers (SE, DJ,) independently extracted data into a pretested spreadsheet under headings such as study, participant and intervention characteristics, and outcome data. The data were independently screened and confirmed (SS, MEM). Outcome data were extracted for short-, medium-, and long-term follow-up assessments when reported.


### 2.1.7. Data Analysis

For quantitative data, summary statistics were calculated. For the RCTs, the reported means and standard deviations were tabulated, and the Hedge’s g, bias-corrected effect size (ES) index was used to estimate the effects of dancing compared to another intervention or no therapy [48]. In some cases, the ES was already reported as a standardized mean difference (SMD) or Cohen’s d [49, 50] which we used. The Hedge’s g and Cohen’s d are similar; the Hedge’s g tends to perform better with sample sizes lower than 20. Whenever possible, a 95% confidence interval (95% CI) was calculated around the SMD for an estimate of the range of intervention effects [51]. Median scores and interquartile ranges (IQR), reported by the study authors, were also tabulated [52]. To facilitate comparisons across studies, median scores were entered into SMD calculations as best estimates of mean scores [53]. For non-RCTs, within-group mean differences and change scores were reported and effect sizes calculated whenever possible.


## 2.1.1. Study Designs

The study designs included randomised controlled trials (RCT) and nonrandomised trials that contained data. We deliberately included both randomised and nonrandomised trials, to extend the findings of systematic reviews, which were confined to RCTs (e.g., 35–37). The full text had to be available and accessible in English. Systematic reviews, meta-analyses, protocol papers, letters to the editor, conference posters, opinion pieces, and abstracts were excluded.


## 2.1.2. Participants

Participants had to have a diagnosis of PD. Other chronic neurological, musculoskeletal, or respiratory conditions were excluded, as well as dementia and Alzheimer’s disease. Individuals were at any stage of PD classified by the modified Hoehn and Yahr Scale [42] and living in residential care or the community. Adults of all ages, genders, and many cultures were included.


## 2.1.3. Interventions

Studies were included if they used dance as an exercise intervention or form for physical activity or physiotherapy. All genres of dance were eligible, including Irish-set dancing, tango, waltz, tap, jazz, salsa, ballroom, ballet, mixed genre, and creative dancing. Classes could be delivered partnered or nonpartnered, group or one to one and with or without music. The mode of delivery was in-person, digitally (also known as online), or using virtual tools. Online delivery was via platforms such as Zoom® or Microsoft Teams®. Some of the dance interventions were delivered by dance teachers and others were delivered using “virtual” tools such as Wii (Nintendo Inc., Japan) or Sony Play Station® video game systems. The criteria for comparison or control interventions were any “usual care” or “usual physical activity” condition or any other therapeutic intervention.


## 2.1.4. Outcomes

Studies were selected if they included baseline and after intervention outcomes for any of the following variables: gait, balance, movement, mobility, movement disorders, nonmotor symptoms, disability, participation, quality of life, wellbeing, or social participation. Feasibility studies were also reviewed.


## 2.1.5. Risk of Bias

The PEDro scale was used to determine the risk of bias for RCTs [43]. PEDro was selected as it is a valid and reliable appraisal instrument for RCTs [44, 45]. Joanna Briggs Institute (JBI) instruments were used to critically appraise nonrandomised studies and to determine their risk of bias [46, 47]. Risk of bias assessments were completed independently by two reviewers (SE, SS), and consensus was reached by consultation with the research team (MM, MH).


## 2.1.6. Data Extraction

Reviewers (SE, DJ,) independently extracted data into a pretested spreadsheet under headings such as study, participant and intervention characteristics, and outcome data. The data were independently screened and confirmed (SS, MEM). Outcome data were extracted for short-, medium-, and long-term follow-up assessments when reported.


## 2.1.7. Data Analysis

For quantitative data, summary statistics were calculated. For the RCTs, the reported means and standard deviations were tabulated, and the Hedge’s g, bias-corrected effect size (ES) index was used to estimate the effects of dancing compared to another intervention or no therapy [48]. In some cases, the ES was already reported as a standardized mean difference (SMD) or Cohen’s d [49, 50] which we used. The Hedge’s g and Cohen’s d are similar; the Hedge’s g tends to perform better with sample sizes lower than 20. Whenever possible, a 95% confidence interval (95% CI) was calculated around the SMD for an estimate of the range of intervention effects [51]. Median scores and interquartile ranges (IQR), reported by the study authors, were also tabulated [52]. To facilitate comparisons across studies, median scores were entered into SMD calculations as best estimates of mean scores [53]. For non-RCTs, within-group mean differences and change scores were reported and effect sizes calculated whenever possible.


## 3. Results

Of the initial yield of 17,122, there were 8,327 remaining after duplicates were removed. Screening of the articles was conducted by two independent reviewers (SE, HH) with 34 articles initially assessed for eligibility. A third reviewer (SS) was consulted to check the findings and reach consensus and 13 additional articles were added by members of the research team (MM, MH). From the articles read in full, 9 were excluded because they did not meet the eligibility criteria. Final consensus was reached in consultation with MM and MH, yielding a total of 38 articles. Figure1 shows the PRISMA-compliant flowchart for selection of studies [39]. Of the included studies, 17 were RCTs [26, 27, 30, 54–67]. One of these was a sequential RCT [66], one was a quasi-RCT [67], and one was an RCT with a crossover design [63] (Table 2). Of the trials, 21 had nonrandomised designs [28, 68–87], and one of these was a quasiexperimental study [81]. One used mixed methods design [82] for which quantitative data were extracted and analysed. Also, one was an exploratory trial [87] and there was an additional single case study [88]. (Table 2).Figure 1
PRISMA flow diagram.Table 2
Study characteristics.
First author, yearStudy designSample sizeInterventionsAge (years) mean ± SDSex (M, F)H&Y mean ± SD, range, or median (IQR)Session length, frequency, intervention durationMedicationsOutcome measuresRandomised studiesDuncan and Earhart, 2012 [62]RCT62Argentine Tango69.3 ± 1.9M: 15, F: 112.6 ± 0.11 hr class, 2/week, 12 monthsNot reported but tested in the “off phase”UPDRS-II, UPDRS-III, FOG, 6MWT, MiniBEST, gait velocityControl, no dance69.0 ± 1.5M: 15, F: 112.5 ± 0.1Duncan and Earhart, 2014 [54]RCT10Argentine Tango67.8 ± 8.72M: 4, F: 12.41 hr, 2/week, 2 yearsLevodopaUPDRS-I, UPDRS-II, UPDRS-III, MiniBEST, gait velocity, TUG, dual-task TUG, 6MWT, FOGQControl, no dance66 ± 11.0M: 4, F: 12.3Kunkel et al., 2017 [55]RCT51Dance (mixed genre)71.3 ± 7.7M: 19, F: 171–31 hr, 2/week, 10 weeksNot reportedBBS, SS180, TUG, 6MWT, Phone-FITT, EQ-5D, ABCControl, no dance69.7 ± 6.0M: 6, F: 91–3Hackney and Earhart, 2010 [60]RCT39Partner dancing69.6 ± 8.5M: 13, F: 62-31 hr, 2/week, 10 weeksLevodopaUPDRS-III, BBS, tandem stance, one leg stance, TUG, 6MWT, gait measuresNonpartner dancing69.6 ± 9.5M: 15, F: 52-2.6Hackney and Earhart, 2009 [61]RCT58Waltz/foxtrot66.8 ± 2.4M: 11, F: 62.0 ± 0.21 hr, 2/week, 13 weeksLevodopaUPDRS-III, BBS, TUG, 6MWT, gait measures, FOGQTango68.2 ± 1.4M: 11, F: 32.1 ± 0.1Control, no dance66.5 ± 2.8M: 12, F: 52.2 ± 0.2Hackney et al., 2007 [59]RCT19Tango72.6 ± 2.20M: 6, F: 32.3 ± 0.71 hr, 2/week, 13 weeksPD medicationsUPDRS-III, BBS, gait velocity, TUG, FOGQGroup exercise class69.6 ± 2.1M: 6, F: 42.2 ± 0.6Hashimoto et al., 2015 [67]Quasi-RCT46PD dance67.9 ± 7.0M: 3, F: 12Score 2 (11)60 min class, 1/week, 12 weeksNot reportedTUG, BBS, UPDRS, SDS, FAB, Mental Rotation Task, Apathy ScalePD exercise62.7 ± 14.9M: 2, F: 15Score 3 (33)60 min class, 1/week, 12 weeksControl, usual care69.7 ± 4.0M: 7, F: 7Score 4 (2)Lee et al., 2015 [57]RCT20Virtual reality dance68.4 ± 2.9M: 5, F: 5Not reported30 mins, 5/week, 6 weeksNot reportedBBS, BDI, MBIControl70.1 ± 3.3M: 5, F: 5Lee et al., 2018 [63]RCT with cross-over design32Qigong dance65.8 ± 7.2M: 10, F: 151–360 min, 2/week, 8 weeksNot reportedUPDRS, PDQL, BBS, BDIControl, wait list65.7 ± 6.4M: 7, F: 91–3McKee and Hackney, 2013 [66]Sequential RCT33Tango68.4 ± 7.5M: 12, F: 122.3 (2.0-2.6)90 mins, 20 sessions, 12 weeksPD medicationsUPDRS-III, Four-Square Step Test, TUG, dual-task TUG, PDQ-39, FOGQ, SFHS-12Lecture series74.4 ± 6.5M: 8, F: 12.0 (2.0- 2.0)Michels et al., 2018 [30]Pilot RCT13Dance therapy69.2 ± 8.7 (total)M: 6, F: 7 (total)2.11 ± 0.332.5 ± 1.0060 mins, 1/week, 10 weeksStable PD medication regimenUPDRS, MOCA, TUG, BBS, BDI, FSS, Visual Analog Fatigue Scale, PDQ-39Control, support groupPoier et al., 2019 [64]Pilot RCT29Argentine Tango68.50 ± 8.07M: 9, F: 5Not reported60 min class, 1/week, 10 weeksNot reportedPDQ-39, BMLSS, ICPHControl, Tai Chi68.87 ± 10.96M: 3, F: 12Rocha et al., 2018 [27]Pilot RCT21Argentine Tango70.2 ± 5.5M: 4, F: 61–4In-person: 1 hour, 1/weekHome: 40 mins, 1/week, 8 weeksPD medicationTUG, BBS, functional gait assessment, FOGQ, UPDRS-II and -III, PDQ-39Mixed dance72.9 ± 5.5M: 4, F: 7Rio Romenets et al., 2015 [58]RCT33Argentine Tango63.2 ± 9.9M: 12, F: 62 ± 0.51 hr, 2/week, 12 weeksNot reportedUPDRS-III, UPDRS, MiniBEST, TUG, dual-task TUG, BDI, Apathy Scale, KFSS, PDQ-39, CGI-C, FOGQ, Falls Questionnaire, MOCAControl64.3 ± 8.1M: 7, F: 81.7 ± 0.6Shanahan et al., 2017 [26]RCT41Set dancing69 ± 10M: 13, F: 71.25 ± 1In-person: 1 hr, 1/weekNot reportedUPDRS-III, 6MWT, MiniBEST, PDQ-39Control, usual care and ADL69 ± 8M: 13, F: 82 ± 1Home: 20 mins, 3/week, 10 weeksSolla et al., 2019 [56]RCT20Sardinian folk dance67.8 ± 5.9M: 6, F: 42.1 ± 0.690 mins, 2/week, 12 weeksPD medicationsUPDRS-III, 6MWT, BBS, TUG, Parkinson’s Disease Fatigue Scale, BDI, Starkstein Apathy Scale, MOCAControl, usual care67.1 ± 6.3M: 7, F: 32.3 ± 0.4Volpe et al., 2013 [65]RCT: single blind, parallel group24Intervention: Irish set dancing61.6 ± 4.5 M: 7, F: 52.2 ± 0.490 min classes, 1/week, 6 monthsLevodopa (n=24)I: 725.0 mg ± 234C: 645.0 ± 216Also, pramipexole,ropinirole, rotigotine,rasagiline, entacaponeUPDRS-III, BBS, FOG, PDQ-39Control: physiotherapy (balance, cueing, gait training, strength)65.0 ± 5.3M: 6, F: 62.2 ± 0.490 mins, 1/week, 6 months, 1 hr weekly home videoNonrandomised studiesAlbani et al., 2019 [68]Single group, pre-post design, feasibility10Tango-based home exercises and group sessions63.1 ± 9.25M: 6, F: 42-3Home: 1 hr, 4/week, 5 weeksGroup session: 2 hr 1/ week, 5 weeksNot reportedGait measures (fully cued visual four-choice reaction-time tasks, simple reaction-time task, an uncued task, two partially cued tasks), UPDRSBatson, 2010 [77]Single group, pre-post design11Modern dance72.7 + 8.7M: 5, F: 61-2.585 min class 3/week, 3 weeksSinemet n=7,Azilect n=1, Requip n=1,No med n=2TUG, FABBlandy et al., 2015 [70]Single group, pre-post design6Argentine Tango64 ± 6.28M: 3, F: 32 (2-2)1 hr, 2/week, 4 weeks“ON” phase of medicationEQ-5D, Visual Analogue Scale, BDIDahmen-Zimmer and Jansen, 2017 [69]Pre-post design, pilot trial37Karate (Shotokan)68.87 ± 7.24M: 13, F: 31–31 hr, 1/week, 30 weeksNot reportedMultidimensional Mood State Questionnaire, Hospital Anxiety and Depression Scale, CEDS Depression Scale, SFHS-12, Short Scale Of General Self-EfficacyDance (mixed genre)72.33 ± 6.69M: 6, F: 3Control (waitlist)70.42 ± 10.07M: 8, F: 4Delextrat et al., 2016 [71]Single group, pre-post design, feasibility11Zumba64.0 ± 8.1M: 5, F: 6<345 mins–1 hr, 1/week, 6 weeksNot reportedEnjoyment, change in physical activity, exercise intensity (accelerometry), heart rate, rated perceived exertionHackney and Earhart, 2009 [72]Single group, pre-post design14Argentine Tango67.2 ± 9.6M: 9, F: 52.4 (25%:2.0; 75%:2.5)1.5 hrs, 5/week, 2 weeksNot reportedUPDRS-III, BBS, TUG, 6MWT, gait measuresHackney and McKee, 2014 [28]Single group, pre-post, pilot trial88Argentine Tango (PD)68.4 ± 7.5M: 13, F: 121–31.5 hrs, 2/week for 12 weeksPD medicationUPDRS-III, BBS, TUG, gait speed assessment, 30 second chair stand, tandem stanceOlder adults (non-PD)82.3 ± 8.8M: 49, F: 14Heiberger et al., 2011 [78]Single group, pre-post design11Mixed genre dance71.3 ± 8.4M: 5, F: 6Moderate to severe 2.5–41/week class, 8 monthsL-Dopa or dopamine agonistsUPDRS-III, TUG, QOLS, Westheimer QuestionnaireKalyani et al., 2019 [81]Quasiexperimental design33Dance (mixed genre)65.24 ± 11.88M: 3, F: 141.65 ± 0.791 hr, 2/week, 12 weeksNot reportedUPDRS-I, UPDRS-II, PDQ39Control66.50 ± 7.70M: 10, F: 61.56 ± 0.81Listewnik and Ossowski, 2018 [75]Single group, pre-post design10Dance69.9 ± 6.47M: 5, F: 5—70 mins, 2/week for 12 weeksNot reportedTinetti POMA Test, TUG, 6MWTMcGill et al., 2018 [85]Non-RCT32Ballet69.83 ± 4.55M: 9, F: 102.32 ± 0.481.25-1.5 hrs, 1/week for 1 yearNot reportedStep and stride variability, ABCControl73.25 ± 8.09M: 6, F: 72.15 ± 0.55McKay et al., 2016 [80]Single group study22Adapted Tango65.4 ± 12.8M: 7, F: 151–490 mins, 15 lessons over 3 weeksNot reportedUPDRS, dyskinesia, BBS, Dynamic Gait Index, FAB, musculoskeletal health, 6MWT, single and dual-task TUG, fast and preferred cadence, ABC, FOGQMcNeely et al., 2015 [74]Pre-post design16Dancing for PD (mixed genre)Tango68.25 ± 10.90M: 4, F: 42.25 ± 0.271 hr group class, 2/week, 12 weeksLevodopaUPDRS-III, MiniBEST, TUG, dual-task TUG, 6MWT, gait velocity67.66 ± 8.62M: 4, F: 42.13 ± 0.58McRae et al., 2018 [87]Exploratory study, surveys61Dancing for Parkinson’s Disease (mixed genre)67 ± 13M: 21, F: 401–41-2/week, 12 months (6months–2 years), session length unknownNot reported36-Item Short Form Health Survey, Self-Efficacy Scale, functional mobilityMarchant et al., 2010 [79]Single group, pre-post design11Improvisation dance71.2 ± 6.1M: 4, F: 72.4 ± 0.410 1.5-hour classes, 2 weeksPD medicationUPDRS-III, BBS, TUG, gait measures, Five Times Sit-to-Stand Test, 6MWT, FOGQ, ABC, PDQ-39Rawson et al., 2019 [86]Nonrandomised controlled96Tango vs treadmill vs control (stretching)67.2 ± 8.9M: 56, F: 401–41 hr class, 2/week, 12 weeksLevodopaUPDRS-III, PDQ-39, 6MWT, MiniBEST, gait measuresSeidler et al., 2017 [84]Non-RCT26Telerehab dance68.1 ± 7.9M: 4, F: 61–31 hr, 2/week, 12 weeksNot reportedMiniBEST, UPDRS-III, gait velocityIn-person dance68.9 ± 9.4M: 5, F: 5Shanahan et al., 2015 [76]Single group, pre-post pilot trial10In-person and home-based dance programs66.66 ± 5.87M: 7, F: 31.5 ± 0.5In-person: 1.5 hrs. 1/weekHome: 20 mins, 2/week, 8 weeksNot reportedUPDRS, 6MWT, BBSTillmann et al., 2020 [83]Non-RCT47Brazilian samba67 ± 9.2n=231.8 ± 0.71 hr, 2/week, 12 weeks4 months stable medicationPDQ-39, PDSS, BDI, FSS, UPDRS-IControl69.6 ± 9.5n=24Tunur et al., 2020 [73]Pre-post -mixed methods7Google glass dance modules69 ± 5.5M: 3, F: 42–33+ modules/day, 3 weeks. Session length not reportedNot reportedMiniBEST, one leg stance, TUG, dual-task TUG, ABC, BDI, PDQLZafar et al., 2017 [82]Pre-post design88Adapted Tango (PD)68.4 ± 8M: 13, F: 121–390 min, 2/week, 12 weeksPD medicationFear of falling, quality of life, composite physical function, MOCA, BDI, UPDRS-III, gait velocity, Impact on Participation and Autonomy QuestionnaireAdapted Tango (non-PD)82.3 ± 9M: 14, F: 49Note: 6MWT, Six-Minute Walk Test; ABC, Activities-Specific Balance Confidence Scale; BBS, Berg Balance Scale; BDI, Beck Depression Inventory; EQ-5D, EuroQol-5 Dimension; FAB, Fullerton Advance Balance Scale; FOGQ, Freezing of Gait Questionnaire; FSS, Fatigue Severity Scale; HADS, Hospital Anxiety and Depression Scale; KFSS, Krupp Fatigue Severity Scale; MiniBEST, Mini-Balance Evaluation Systems Test; MBI, Modified Barthel Index; MOCA, Montreal Cognitive Assessment; PDQ-39, Parkinson’s Disease Questionnaire-39; PDSS, Parkinson's Disease Sleep Scale; RCT, Randomised Controlled Trial; SDS, Self-Rating Depression Scale; SFHS-12, Short Form Health Survey-12; SS180, Standing-Start 180° Turn Test; Tinetti POMA Test, Tinetti Performance-Oriented Mobility Assessment Test; TUG, Timed Up and Go; UPDRS, Unified Parkinson’s Disease Rating Scale.The included studies ranged in sample size from 6 to 96 participants (Table2). Only 3 studies included either telehealth [84] or technology-based interventions that included virtual reality dancing [57] or dance Google glass modules [73]. Dance interventions included tango [27, 28, 54, 55, 58, 59, 60–62, 64, 66, 68, 70, 72, 80, 82, 86], Sardinian folk dancing [56], Irish set dancing [26, 65], waltz/foxtrot [55, 61], ballet [85], Brazilian Samba [83], Zumba [71], Qigong dance [63], improvisation dance [79], or mixed dance genres [27, 55, 62, 66, 67, 77, 78], with three studies including home-based dance programs [27, 68, 76]. The duration of interventions ranged from two weeks to two years with frequency per week varying from once a week to daily. The intervention session length was usually 1 hour, although it ranged from 30 minutes to two hours.Method quality and risk of bias assessments were conducted for all studies. Table3 shows that the risk of bias for five of the RCTs was high [54, 57, 59, 61, 66]. It was also high for two of the nonrandomised studies [72, 75]. In addition, 20 were at moderate risk of bias (eight RCTS, 12 nonrandomised studies) [26, 28, 30, 55, 56, 58, 65, 67, 69–71, 73, 74, 76–79, 84, 87, 88] and 11 were at low risk of bias (four RCTs, seven nonrandomised studies) [27, 62–64, 68, 81–83, 85, 86, 80]. For RCTs, blinding of the participants and therapists was generally not possible due to the nature of dance therapy. A large number of RCTs did not include intention to treat analysis [26, 30, 54–57, 59, 61, 65–67], concealed allocation [30, 54–61, 66], or reporting of outcomes for more than 85% of participants at each time point [26, 54, 57, 59–62, 65–67]. These omissions increased the risk of bias (Table 3). Non-RCT studies were identified as having increased risk of bias as there was no control group [28, 68, 70–74, 75–80, 84, 87], or they did not receive similar treatment or care [28, 68–75, 80, 81, 84, 87], or they did not conduct a follow-up [69–72, 74–76, 83–85, 87].Table 3
Method quality appraisal of included studies.
Randomised controlled trials (PEDro Scale)First author, yearRandom allocationConcealed allocationBaseline-similarBlinded participantBlinded therapistBlinded assessorMeasures for >85% sampleITTBetween group analysisOutcome measure dataScore/10Duncan and Earhart, 2012 [62]YYYNNYNYYY7Duncan and Earhart, 2014 [54]YNYNNYNNYY5Hackney and Earhart, 2010 [88]YNYNNYNYYY6Hackney and Earhart, 2009 [61]YNYNNYNNYY5Hackney et al., 2007 [59]YNYNNYNNYY5Hashimoto et al., 2015 [67]YYYNNYNNYY6Kunkel et al., 2017 [55]YNYNNYYNYY6Lee et al., 2015 [57]YNYNNNNNYY4Lee et al., 2018 [63]YYYNNYyYYY8McKee and Hackney, 2013 [66]NNYNNYNNYY4Michels et al., 2018 [30]YNYNNYYNYY6Poier et al., 2019 [64]YYYNNYYYYY7Rocha et al., 2018 [27]YYYYYYYYYY10Rios Romenets et al., 2015 [58]YNYNNNYYYY6Shanahan et al., 2017 [26]YYYNNYNNYY6Solla et al., 2019 [56]YNYNNYYNYY6Volpe et al., 2013 [65]YYYNNYNNYY6Nonrandomised studies (JBI Appraisal Tool)First author, yearCause effectParticipants similarComparisons similarControl groupMultiple measuresFollow-upConsistent measurementReliable measurementStatistical analysisScore/9Albani et al., 2019 [68]YYNNYYYYY7Batson, 2010 [77]YYYNNYYYN6Blandy et al., 2015 [70]NYNNYNYYY5Dahmen-Zimmer and Jansen, 2017 [69]YNNYYNYYY6Delextrat et al., 2016 [71]YYNNYNYYY6Hackney and Earhart, 2009 [72]YNNNYNNYY4Hackney and McKee, 2014 [28]YNNNYYNYY5Heiberger et al., 2011 [78]YNYNYYYYN6Kalyani et al., 2019 [81]YYNYYYYYY8Listewnik and Ossowski, 2018 [75]YNNNNNYNY3McGill et al., 2018 [85]YYYYYNYYY8McKay et al., 2016 [80]YYNNYYYYY7McNeely et al., 2015 [74]YYNNYNYYY6McRae et al., 2018 [87]YNNNYNYYY5Marchant et al., 2010 [79]YNYNNYYYY6Rawson et al., 2019 [86]YYYYYYYYY9Seidler et al., 2017 [84]YYNNYNYYY6Shanahan et al., 2015 [76]YNYNYNYYY6Tillmann et al., 2020 [83]YYYYNNYYY7Tunur et al., 2020 [73]NYNNYYYYY6Zafar et al., 2017 [82]YNYYYYYYY8Note: Y=yes; N=no.Data analysis is presented in Tables4 and 5. Overall, the results showed moderate to large benefits from therapeutic dance for people with mild to moderate PD (Table 4). RCTs demonstrated significant short-term benefits for balance with the Berg Balance scale (BBS) [30, 56, 57, 59–61, 67], significant reduction in disability measured by the Unified Parkinson’s Disease Rating Scale (UPDRS) [26, 30, 56, 59, 61, 62, 65, 67], significantly improved mobility measured by Timed Up and Go (TUG) [56, 58, 59, 61], significantly improved endurance measured by the 6 Minute Walk Test [56, 61], significantly reduced gait freezing measured by the Freezing of Gait scale [59, 61, 65], and significantly reduced depression measured by the Beck Depression Inventory [57]. Meta-analysis was not conducted due to intervention and outcome measure heterogeneity.Table 4
Data analysis for randomised controlled trials.
Author (lead), yearDependent variableOutcome measureEffect size95% Confidence interval (CI)Dose of interventionDuncan and Earhart (2012) [62]: tango vs. usual careDisability-motorUPDRS-motor 3−2.71−3.40 to −2.021 hr class, 2/week, 12 monthsHackney and Earhart (2010) [60]: partnered tango vs. nonpartnered danceBalanceBerg balance scale−0.33−0.96 to 0.301 hr, 2/week, 10 weeksMobilityTimed up and go0.52−0.12 to 1.16Hackney and Earhart (2009) [61]: waltz/foxtrot vs. control argentine tango vs. controlDisabilityUPDRSWF: −2.61−3.53 to −1.701 hr, 2/week, 13 weeksT: −2.44−3.37 to −1.51BalanceBerg balance scaleWF: 2.541.64 to 3.44T: 2.521.57 to 3.46MobilityTimed up and goWF: -1.74−2.25 to −0.95T: −2.14−3.02 to −1.25Endurance6 minute walk testWF: 1.861.05 to 2.66T: 2.391.47 to 3.31Freezing of gaitFreezing of gaitWF: 0.850.14 to 1.55T: 0.760.03 to 1.49Tango vs. waltz/foxtrotDisabilityUPDRS0.55−0.17 to 1.27BalanceBBS−0.09−0.80 to 0.61MobilityTUG−0.75−1.48 to −0.02Endurance6MWT1.750.92 to 2.58Freezing of gaitFOG−0.08−0.79 to 0.63Hackney et al. (2007) [59]: partnered argentine tango vs. group exercise classDisability (motor)UPDRS–Motor 31.530.51 to 2.551 hr, 2/week, 13 weeksBalanceBerg balance scale3.522.09 to 4.96MobilityTimed up and go−4.78−6.54 to −3.01Freezing of gaitFreezing of gait1.560.54 to 2.59Gait velocityGait velocity m/s−1.01−1.97 to −0.05Dual taskingVelocity of dual walking task m/s−1.11−2.08 to −0.05Hashimoto et al. (2015) [67]: PD dance vs. PD exMobilityTime up and go0.29−0.40 to 0.99Dance: 60 min class (dance), 1/week, 12 weeks Exercise: 60 min class (stretching, strengthening), 1/week, 12 weeksBalanceBerg balance scale1.490.71 to 2.28DisabilityUPDRS−0.89−1.62 to −0.16DepressionSelf-rating depression scale−0.18−0.88 to 0.51PD dance vs. control (usual care)MobilityTime up and go−0.22−0.95 to 0.51Dance: 60 min class, 1/week, 12 weeksBalanceBerg balance scale1.050.27 to 1.83DisabilityUPDRS−1.19−1.98 to −0.40DepressionSelf-rating depression scale−0.71−1.46 to 0.04Kunkel et al. (2017) [55]: dance vs. controlBalanceBerg balance scale−0.01−0.62 to 0.591 hr, 2/week, 10 weeksMobilityTimed up and go0.37−0.24 to 0.97Endurance6 minute walk test−0.26−0.87 to 0.34Quality of lifePDQ-390.13−0.47 to 0.73Lee et al. (2015) [57]: virtual reality vs. controlBalanceBerg balance scale1.090.15 to 2.0330 mins, 5/week, 6 weeksActivities of daily livingModified Barthel index1.120.18 to 2.07DepressionBeck depression inventory−1.30−2.26 to −0.34Lee et al. (2018) [63]: Qigong dancing vs. wait listDisabilityUPDRS−0.36−1.00 to 0.2760 min, 2/week, 8 weeksQuality of lifePD quality of life0.55−0.09 to 1.19BalanceBerg balance sale0.38−0.25 to 1.01DepressionBeck depression inventory0.33−1.22 to 0.06McKee and Hackney (2013) [66]: tango vs. educationDisability (motor)UPDRS–Motor 3−0.66−1.45 to 0.1290 mins, 20 sessions, 12 weeksBalanceAdvanced balance scale0.32−0.45 to 1.09MobilityTimed up and go−0.07−0.83 to 0.70Quality of lifePDQ-390.16−0.61 to 0.93Freezing of gaitFreezing of gait−0.27−1.00 to 0.53Michels et al. (2018) [30]: dance therapy vs. controlDisability (motor)UPDRS–Motor 3−1.32-2.60 to −0.0360 mins, 1/week, 10 weeksDisabilityUPDRS–Total−0.61−1.81 to 0.59BalanceBerg balance scale1.320.03 to 2.60MobilityTimed up and go−1.07−2.32 to 0.18DepressionBeck depression inventory1.03−0.21 to 2.27Poier et al. (2019) [64]: argentine tango vs. tai chiQuality of lifePDQ-39−0.14−0.87 to 0.5960 min class, 1/week, 10 weeksSatisfactionBMLSS-life satisfaction0.18−0.55 to 0.91Rocha et al. (2018) [27]: argentine tango vs. mixed genre danceMobilityTimed up and go−0.61−1.49 to 0.27In-person: 1 hour, 1/week Home: 40 mins, 1/week, 8 weeksFreezing of gaitFreezing of gait0.26−0.60 to 1.12BalanceBerg balance scale0.43−0.44 to 1.30Quality of lifePDQ-39−0.75−1.64 to 0.14Disability (motor)UPDRS 3 (R)−0.01−0.87 to 0.85Disability (motor)UPDRS 3 (L)0.14−0.72 to 0.99Rio Romenets et al. (2015) [58]: partnered tango vs. self-directed exerciseDisabilityUPDRS-total−0.50−1.19 to 0.201 hr, 2/week, 12 weeksDisability (motor)UPDRS 3−0.60−1.30 to 0.11Quality of lifePDQ-390.11−0.57 to 0.80MobilityTimed up and go−1.00−1.73 to −0.28MobilityDual timed up and go0.28−0.41 to 0.97Freezing of gaitFreezing of gait−0.34−1.03 to 0.35Shanahan et al. (2017) [26]: Irish set dancing vs. usual careDisability (motor)UPDRS 3−1.13−1.79 to −0.47In-person: 1 hr, 1/week Home: 20 mins, 3/week, 10 weeksEndurance6 minute walk test0.13−0.48 to 0.74Quality of lifePDQ-390.00−0.61 to 0.61Solla et al. (2019) [56]: Sardinian folk dance vs. usual careDisability (motor)UPDRS–Motor 3−1.16−2.11 to −0.2190 mins, 2/week, 12 weeksEndurance6 minute walk test2.571.38 to 3.75BalanceBerg balance scale1.990.92 to 3.07MobilityTimed up and go−1.81−2.85 to −0.77Volpe et al. (2013) [65]: Irish set dancing vs. physiotherapyDisability (motor)UPDRS-motor−0.99−1.84 to −0.14Dance: 90 min classes, 1/week, 6 months PT: 90 mins, 1/week, 6 months, 1 hr weekly home videoBalanceBerg balance scale0.81−0.02 to 1.64Freezing of gaitFreezing of gait−1.45−2.43 to −0.55Quality of lifePDQ-39−0.58−1.43 to 0.23PDQ-39: Parkinson’s Disease Questionnaire-39; PT: physiotherapy; UPDRS: Unified Parkinson's Disease Rating Scale. Analyses were for baseline and after intervention data within groups, unless otherwise specified.Table 5
Data analysis for nonrandomised trials.
Author (lead), yearDependent variableOutcome measureMean difference (within group: baseline to after intervention)95% confidence interval (CI)Dose of interventionAlbani et al. (2019) [68] : home exercise + tangoDisabilityUPDRS−3.33N/AHome: 1 hr, 4/week, 5 weeksGroup session: 2 hr, 1/week, 5 weeksQuality of lifePDQ-39−3.57N/ABatson (2010) [77] :  modern danceMobilityTimed up and go0.70N/A85 min class, 3/week, 3 weeksBalanceFullerton Advanced Balance Scale3.1N/ABlandy et al. (2015) [70] :  tango classQuality of lifeEurQol-5D0.06 (median)N/A1 hr, 2/week, 4 weeksDepressionBeck Depression Inventory4.50 (median)N/ADahmen-Zimmer and Jansen (2017) [69] :  dance training versus karateDepressionHospital Anxiety Depression ScaleES (between group) 0.61−0.22 to 1.451 hr, 1/week, 30 weeksWellbeingSF-12ES (between group) −1.02−1.88 to −0.15Delextrant et al. (2016) [71]Aerobic capacityMean heart rateNo significant effect of dance style on heart rate (p = 0.689).N/AUp to 1 hr, weekly, 6 sessionsHackney and Earhart (2009) [72]: Argentine tangoBalanceBerg Balance Scale2.80N/A1.5 hrs, 5/week, 2 weeksDisability (motor)UPDRS-motor 3−4.6N/AMobilityTimed up and go−2.0 (seconds)N/AEndurance6-minute walk test35.90 (metres)N/AHackney and McKee (2014) [28] :  adapted tangoBalanceBerg Balance Scale0.30N/A1.5 hrs, 2/week, for 12 weeksMobilityTimed up and go−0.19N/AHeiberger et al. (2011) [78]: mixed dance for PDDisabilityUPDRS8.2N/A1/week class, 1.5 hrs, 8 monthsMobilityTimed up and go0.7N/AKalyani et al. (2019) [81]: dance class versus controlQuality of lifePDQ39ES (between group) 0.23−0.46 to 0.911 hr, 2/week, 12 weeksDisability (ADL)UPDRS-2ES (between group) −0.13−0.81 to 0.55DepressionHospital Anxiety Depression ScaleES (between group) −0.71−1.41 to 0.00Listewnik and Ossowski (2018) [75]: tango dance classesMobilityTinetti Performance Oriented Mobility Assessment2.15N/A70 mins, 2/week, for 12 weeksMobilityTimed up and go−1.72N/AEndurance6-minute walk test85.20N/AMcGill et al. (2018) [85]: ballet classes versus no danceGaitStep variabilityES (between group) 0.70−0.03 to 1.421.25–1.5 hrs, 1/week, for 1 yearGaitStride variabilityES (between group) 0.62−0.10 to 1.34BalanceActivities-Specific BalanceConfidence ScaleES (between group) 0.24−0.47 to 0.95McKay et al. (2016) [80]: adapted tangoDisability (motor)UPDRS-motor 3−2.90N/A90 mins, 15 lessons over 3 weeksBalanceBerg Balance Scale3.80N/AEndurance6-minute walk test40.80N/AMobilityTimed up and go−1.10N/AFreezing of gaitFreezing of gait0.10N/AMcNeely et al. (2015) [89]:tango vs. mixed danceDisability (motor)UPDRS-motor 3ES (between group) −0.42−1.41 to 0.571 hr group class, 2/week, 12 weeksQuality of lifePDQ-39ES (between group) −0.25−1.23 to 0.74MobilityTimed up and goES (between group) 0.2−0.78 to 1.19MobilityDual task timed up and goES (between group) 0.42−0.57 to 1.41Endurance6-minute walk testES (between group) −0.39−1.38 to 0.60McRae et al. (2018) [87]: dance classesQuality of lifeShort-Form Health Survey3.84N/A1-2/week, 12 months (6 months–2yrs), session length unknownMarchant et al. (2010) [79]: improvisation danceDisability (motor)UPDRS-motor 35.4N/A10 1.5 hour classes, 2 weeksEndurance6-minute walk test−3.8N/AMobilityTimed up and go−0.5N/ABalanceBerg Balance Scale3.0N/ARawson et al. (2019) [86] tango vs. treadmillDisability (motor)UPDRS-motor 3ES (between group) 1.350.83 to 1.871 hr class, 2/week, 12 weeksEndurance6-minute walk testES (between group) 0.29−0.19 to 0.76Quality of lifePDQ-39ES (between group) 0.44−0.04 to 0.92Tango vs control (stretching)Disability (motor)UPDRS-motor 3ES (between group) 1.070.56 to 1.57Endurance6-minute walk testES (between group) −0.80−1.29 to −0.31Quality of lifePDQ-39ES (between group) 1.140.63 to 1.65Seidler et al. (2017) [84]: tele-rehabilitation group (tango versus in-person group)Disability (motor)UPDRS-motor 3ES (between group) 0.22−0.66 to 1.101 hr, 2/week, 12 weeksShanahan et al. (2017) [76] :  Irish set dancingDisability (motor)UPDRS-motor 3−2.0 (median)N/AIn person: 1.5 hrs, 1/week Home: 20 mins, 2/week, 8 weeksQuality of lifePDQ-39−4.03 (median)N/AEndurance6-minute walk test0.0N/ABalanceBerg Balance Scale1.0N/ATillmann et al. (2020) [83] :  Brazilian samba versus controlBeck Depression InventoryES (between group) 1.170.55 to 1.791 hr, 2/week, 12 weeksTunur et al. (2020) [73] :  Google glass dancingMobilityTimed up and go0.5N/A3+ modules/day, 3 weeks. Session length not reportedMobilityDual task timed up and go−0.5N/AZafar et al. (2017) [82] :  adapted tango for PD versus AT for older adultParticipationParticipation and Autonomy ScaleES (between group) 0.32−0.20 to 0.8390 min, 2/week, 12 weeksNote: ES, effect size; PDQ-39, Parkinson’s Disease Questionnaire-39; UPDRS: Unified Parkinson’s Disease Rating Scale Analyses were for baseline and postintervention data within groups, unless otherwise specified.The effects of dancing for PD reported in non-RCTs demonstrated end of intervention benefits for people with mild to moderately severe disease (Table5). There were improvements in balance (BBS) [28, 72, 77, 80], disability (UPDRS) [68, 72, 78, 80, 86], mobility (TUG) [28, 72, 73, 75, 80] and Tinetti Mobility Scale [75], depression [70, 83], and quality of life [26, 68–70, 86, 87]. Key studies on digital delivery modes for dancing with PD (e.g., [57, 73, 84]) showed that virtual technologies can be an accessible and beneficial method of physical activity for some people living with this chronic and progressive disease.


## 4. Discussion

This systematic review of the global literature showed that dancing for individuals with mild to moderately severe PD could be a beneficial and accessible form of physical activity for some people, whether delivered face-to-face or using an online telemedicine platform or “virtual dance” video-gaming tools. The findings support mounting evidence that therapeutic dance can, in the short term, significantly improve balance, mobility, gait, disability, and quality of life in PD [26, 68, 70, 86, 87, 89]. Although the recruitment levels in the reviewed studies did not always meet clinical trial targets, attendance and adherence to dance classes were generally high. The duration of the dancing classes and session lengths varied, and improvements were seen in interventions running for two weeks [72] up to 2 years [54]. There were significant improvements when session lengths ranged from 30 to 90 minutes per day. Although previous systematic reviews of dance for Parkinson’s disease were conducted by Shanahan et al. (2017) [36], Carapellotti et al. [31], Berti et al. [37], and Rocha et al. [90], all of those were confined to randomised controlled clinical trials. By conducting a more recent search and extending our analysis to RCTs and non-RCT quantitative studies, our review captured more of the therapies currently being implemented in clinical practice.Our review suggests good attendance for the telehealth mode of delivery in chronic diseases, possibly because digital delivery reduces geographical, environmental, economic, and commute barriers [91]. Some technological difficulties can be encountered with digital delivery [84] such as Internet and usability problems and the need for training and guidance in how to operate the technology. Nevertheless, the reviewed articles did not directly analyse the risk of falls with online delivery or when using video modes. For people with moderate to advanced disease, postural instability and falls can be problematic. Precautions need to be taken to ensure that people at home have strategies to prevent and manage falls, should they occur.There are several clinical implications of this systematic review. Dancing was shown to be clinically feasible, with high levels of adherence by participants and considerable interest in future classes. Many of the publications that we reviewed supported the need to increase access to community dance classes to improve exercise capacity and wellbeing, as well as to increase the opportunity for people living with Parkinsonism to socialise. For face-to-face dance classes, there is a need to determine how to reduce barriers to participation, including transportation, access, and cost, (please see [1, 92]). For digital modes of dancing, clinical protocols are needed to support safe and sustainable implementation and guidance in the use of technology. In addition, it could be argued that a need exists for credentialing programs for dance teachers and practitioners, to ensure evidence-based and effective delivery of this form of structured exercise [93] as well as protocols for clinicians and dance teachers to ensure safe and effective delivery. In the current global context of the COVID-19 pandemic, there is arguably a need to further explore digitally delivered dance and other forms of physical activity for people living with chronic neurological conditions [91, 94].Despite the systematic review being informed by the Cochrane guidelines, there were several limitations. Most studies included people with mild-moderate disease. The findings might not generalise to people with end-stage disease or very old people, or those who cannot access face-to face classes or digital technologies. Many trials did not control for the effects of levodopa or other Parkinson’s medications. Intervention duration and frequency were reported; however, none of the studies documented the intensity of dance therapy. Although some large, significant effects were demonstrated, these need to be considered in light of the moderate to high risk of bias in many studies, especially those that were not randomised trials. Although dance and music were shown to have benefit for people living with PD, the most effective dance genre or music type require further exploration [95]. Quality of life can be adversely affected by Parkinsonism [3, 5], and the mechanisms by which arts-health therapies such as dance and music can improve health-related quality of life warrant further exploration [95]. Also, the reviewed articles were in the English-language, limiting generalisability to non-English speaking cultures and their associated dance genres.To conclude, dance is safe and feasible for some people in the early to midstages of PD, provided that safety precautions and training are incorporated into design and delivery. There are positive associations between therapeutic dancing and improvements in gait, balance, movement disorders, and disability. For some individuals, there can be improvements in quality of life. There was preliminary evidence that delivery of dancing for PD online is beneficial for some people, although there is a need to verify the efficacy and safety of this modality, especially for people who are frequent fallers.



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