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Effects of contemporary dance and physiotherapy intervention on balance and postural control in Parkinson’s disease

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Abstract

Purpose To describe the effects of a contemporary dance program, combined with conventional physiotherapy, on postural control, satisfaction and adherence in mild-moderate Parkinson’s disease (PD) patients. Methods A withdrawal/reversion test with three intervention periods. Each period lasts for two months: physiotherapy, physiotherapy + dance and withdrawing dance and continuing with the physiotherapy sessions. Berg Balance Scale (BBS), Timed Up & Go test (TUG), Sensory Organization Test (SOT), Motor Control Test (MCT) and Rhythmic Weigh Shift (RWS) were assessed at T1 (baseline), T2 (post-physiotherapy treatment), T3 (post-physiotherapy and dance) and T4 (post-physiotherapy). A satisfaction questionnaire and adherence were registered. Results 27 patients (67.32 ± 6.14 yrs) completed the study. Statistical analysis revealed differences between T2-T3 (p = 0.027), T2-T4 (p = 0.029), T1-T3 (p = 0.010) and T1-T4 (p = 0.008) for BBS; and between T1-T2 (p = 0.037), T1-T3 (p = 0.005), T1-T4 (p = 0.004), T2-T3 (p = 0.022) and T2-T4 (p = 0.041) for TUG. Significant differences for CES (p < 0.001), VEST (p = 0.024) and strategy (p = 0.011) were observed, but not for MCT. Lateromedial velocity (p = 0.003) and anteroposterior velocity (p < 0.001) were significant for RWT. Patients showed a high level of satisfaction and adherence. Conclusions A short 8-weeks contemporary dance program plus combined physiotherapy shows benefits in functional mobility and balance, with a high degree of satisfaction and adherence in PD. • IMPLICATIONS FOR REHABILITATION • Contemporary dance, combined with physiotherapy, is a useful therapeutic tool to treat balance disorders and postural control in people with PD. • A short 8-weeks contemporary dance program plus combined physiotherapy shows high satisfaction in people with PD. • Contemporary dance, combined with physiotherapy, shows high adherence in people with mild-moderate PD to treat postural control.

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... Regarding the changes in postural sway as tested by tracing the COP in different standing situations, no significant treatment effects were shown for all the test parameters. This is entirely unexpected and inconsistent with the related studies that examined the efficacy of dance in older adults [35][36][37]. One potential reason for this could be related to the health status of participants. ...
... Participants in this study were apparently healthy and free from any restrictions in exercising. They may not have been able to gain exercise benefits in postural control to the same extent as those who were suffering from Parkinson's disease [35,38] or who were at risk of falling [39,40]. Alternatively, the other potential reason could be related to differences in postural control assessment (dynamic postural control assessments in previous studies vs. static postural control assessments in the current study). ...
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... This concept was concordant with recent systematic reviews on dance practice in populations with neurological disorders that reported improvements in balance and gait performance with dance that entailed movement with music, rhythm, and movement exploration (11,45,46). Similarly, intervention studies investigating the effect of dance (tango, waltz, salsa, tap dance, modern dance) on balance and mobility in the neurological population agreed that multiple sensory inputs, such as the music, partner, various steps at different spatial levels, and changing directions (including backward walking), resulted in the improvement in balance and gait performance (21,22,47,48). ...
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Parkinson's disease is a prevalent neurodegenerative disorder for which only symptomatic treatment exists. Gait and balance disturbance is common in Parkinson's disease and is a major contributor to increased disability and decreased health-related quality of life and survival. Balance and gait deficits in Parkinson's disease are notoriously difficult to treat and are not significantly helped by pharmacological or surgical treatment. The last two decades have seen a dramatic increase in the research and clinical interest in using exercise as a treatment for mobility problems in people with Parkinson's disease. With exciting advances in basic science research suggesting neurochemical and neuroplastic changes after exercise, an increasing number of high-quality studies are documenting particular aspects of mobility improving after exercise. Exercise has the potential to help both motor (gait, balance, strength) and nonmotor (depression, apathy, fatigue, constipation) aspects of Parkinson's disease as well as secondary complications of immobility (cardiovascular, osteoporosis). This perspective article focuses primarily on recent evidence on the effects of exercise in improving mobility while highlighting the importance of targeted exercise intervention for maximizing the benefits of exercise. Suggestions for exercise guidelines, adherence issues, and directions for future research are provided. © 2013 International Parkinson and Movement Disorder Society.
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Background: Parkinson's is a neurological disease that is physically debilitating and can be socially isolating. Dance is growing in popularity for people with Parkinson's and claims have been made for its benefits. The paper details a mixed-methods study that examined a 12-week dance project for people with Parkinson's, led by English National Ballet. Methods: The effects on balance, stability and posture were measured through the Fullerton Advanced Balance Scale and a plumb-line analysis. The value of participation and movement quality were interpreted through ethnographic methods, grounded theory and Effort analysis. Results: Triangulation of results indicates that people were highly motivated, with 100% adherence, and valued the classes as an important part of their lives. Additionally, results indicated an improvement in balance and stability, although not in posture. Conclusions: Dancing may offer benefit to people with Parkinson's through its intellectual, artistic, social and physical aspects. The paper suggests that a range of research methods is fundamental to capture the importance of multifaceted activity, such as dance, to those with Parkinson's.
Article
Objective: To investigate the ability of the Timed Up & Go test to identify patients with Parkinson's disease at risk for a fall. Design: Cross-sectional cohort study. Setting: Sixteen participating National Parkinson's Foundation Centers of Excellence. Participants: A query yielded a total of 2985 records (1828 men and 1157 women). From these, 884 were excluded because of a lack of crucial information (age, diagnosis, presence of deep brain stimulation, disease duration, inability of performing the Timed Up & Go test without assistance) at the time of testing, leaving 2097 patients included in the analysis. Interventions: Not applicable. Main outcome measures: The primary outcome measure for this study was falls. The chief independent variable was the Timed Up & Go test. Results: The initial model examined the prediction of falls from the Timed Up & Go test, adjusting for all study covariates. The estimated models in the imputed data sets represented a significant improvement above chance (χ(2) range [df=17], 531.29-542.39, P<.001), suggesting that 74% of participants were accurately classified as a faller or nonfaller. The secondary model in which the question of whether the effect of Timed Up & Go test was invariant across disease severity demonstrated 75% of participants were accurately classified as a faller or nonfaller. Additional analysis revealed a proposed cut score of 11.5 seconds for discrimination of those who did or did not fall. Conclusions: The findings suggest that the Timed Up & Go test may be an accurate assessment tool to identify those at risk for falls.
Article
OBJECTIVES: To investigate the discriminative ability and diagnostic accuracy of the Timed Up and Go Test (TUG) as a clinical screening instrument for identifying older people at risk of falling. DESIGN: Systematic literature review and meta-analysis. SETTING AND PARTICIPANTS: People aged 60 and older living independently or in institutional settings. MEASUREMENTS: Studies were identified with searches of the PubMed, EMBASE, CINAHL, and Cochrane CENTRAL data bases. Retrospective and prospective cohort studies comparing times to complete any version of the TUG of fallers and non-fallers were included. RESULTS: Fifty-three studies with 12,832 participants met the inclusion criteria. The pooled mean difference between fallers and non-fallers depended on the functional status of the cohort investigated: 0.63 seconds (95% confidence (CI) = 0.14-1.12 seconds) for high-functioning to 3.59 seconds (95% CI = 2.18-4.99 seconds) for those in institutional settings. The majority of studies did not retain TUG scores in multivariate analysis. Derived cut-points varied greatly between studies, and with the exception of a few small studies, diagnostic accuracy was poor to moderate. CONCLUSION: The findings suggest that the TUG is not useful for discriminating fallers from non-fallers in healthy, high-functioning older people but is of more value in less-healthy, lower-functioning older people. Overall, the predictive ability and diagnostic accuracy of the TUG are at best moderate. No cut-point can be recommended. Quick, multifactorial fall risk screens should be considered to provide additional information for identifying older people at risk of falls.
Article
Brooklyn Parkinson Group (BPG) in collaboration with Mark Morris Dance Group (MMDG), a renowned modern dance company, developed dance classes for persons with Parkinson's disease (PD), friends, and family. In 5 years, classes have increased from 2 to 9 participants once a month, to weekly classes of 20 to over 30 participants. Professional dancers teach the classes in a large dance studio with live piano accompaniment. This article explains the rationale of dance for PD, describes teaching methods, and includes participants' observations. Perceived benefits noted by 15 participants with PD to a validated questionnaire are discussed.
Article
Falls are the leading cause of injury deaths in older adults (Murphy 2000), and they can lead to fear of falling, reduced quality of life, withdrawal from activities, and injury. Changes in joint ranges of motion, strength, sensory processing, and sensorimotor integration all contribute to reduced balance stability with increasing age and these changes are paralleled in those with Parkinson Disease (PD). Interventions, such as traditional exercises tailored specifically for seniors and/or individuals with PD, have addressed balance and gait difficulties in an attempt to reduce fall rates with mixed, undocumented results. Argentine tango dancing has recently emerged as a promising non-traditional approach to ameliorating balance and gait problems among elderly individuals. The goal of this study was to determine whether the functional mobility benefits noted in elders following a tango dancing program might also extend to older individuals with PD. We compared the effects of tango to those of traditional exercise on functional mobility in individuals with and without PD. We predicted that the functional mobility and quality of life gains noted with Argentine tango would be greater than those noted with traditional strength/flexibility exercise. Thirty-eight subjects (19 control and 19 with PD) were assigned to 20 hour-long exercise or tango classes that were completed within 13weeks. Although all groups showed gains in certain measures, only the Parkinson Tango group improved on all measures of balance, falls and gait. Moreover, upon terminating the program the Parkinson Tango group was more confident about balance than the Parkinson Exercise group. In psychosocial terms, both groups largely enjoyed their experiences because the classes fostered community involvement and became a source of social support for the members. Our results suggest that Argentine tango is an appropriate, enjoyable, and beneficial activity for the healthy elderly and those with PD and that tango may convey benefits not obtained with a more traditional exercise program.
Article
Psychiatric symptoms are important non-motor features in PD, which occur at high frequency and have significant impact on health related quality of life. This review concentrates on the prevalence, pathophysiology, diagnosis and treatment of depression, anxiety, apathy and psychosis. The pathophysiology of these disorders is complex, reflecting the widespread brainstem and cortical pathology in PD, with involvement of several neurotransmitters, including dopaminergic, serotonergic, noradrenergic and cholinergic systems. The diagnosis of psychiatric conditions, in particular affective disorders, is challenging because of the overlap of somatic features of psychiatric disorders and underlying movement disorder. The pathogenesis is likely to differ considerably from non-PD patients, and treatments used in general psychiatry services may not be as effective in PD and will require clearer clarification in well-designed clinical studies. Management strategies include adjustment of dopaminergic medication, use of psychotropic treatments and behavioural and psychological approaches. However, the future challenge will be to develop treatments developed specifically for the pathogenesis of these disorders in PD.
Article
Former studies on the effects of physical exercise, physical and occupational therapy (PT, OT) and speech and swallowing therapy (ST, SwT) in Parkinson's disease (PD) have demonstrated little or uncertain effects. New pathophysiological concepts have been developed. Recent controlled high-level studies demonstrate improvement of mobility and balance after training of muscular strength and endurance, trunk control, and amplitude and rhythmicity of movements (treadmill). Attentional and cognitive strategies were found to enforce body awareness and improve movement sequences. Dance, sensory (auditory, visual, tactile) and cognitive cueing are effective for problems of gait and balance. Whether PT and OT reduce the risk of falls remains uncertain. ST including Lee Silverman Voice Treatment has been shown to relieve speech problems. SwT and OT are frequently applied, however, further studies are necessary. Therapeutic interventions need to be evaluated with regard to consistency, intensity, frequency, duration, side effects, home versus institution based and standardized versus individualized training, quality standards, practicability in real life, and cost-effectiveness. Parkinson patients should resume or continue physical exercise as long as possible. There is hope that regular sport may modify PD risk and progression.
Article
This study explored the feasibility and possible benefits of contact improvisation (CI) as an exercise intervention for individuals with PD. This was an uncontrolled pilot study. Eleven people with PD (H&Y=2.4 ± 0.4) participated in a workshop of 10 1.5-h CI classes over 2 weeks, dancing with previously trained student CI dancers. Measures of disease severity, balance, functional mobility, and gait were compared 1 week before and after the workshop. Participants demonstrated improvements on the Unified Parkinson Disease Rating Scale-Motor Subsection and Berg balance scores, along with increased swing and decreased stance percentages during walking. Backward step length also increased. Participants expressed a high level of enjoyment and interest in taking future CI classes. This pilot study supports the feasibility of CI as an intervention to address mobility limitations associated with PD.
Article
Patients with Parkinson's disease (PD) improve gait after treadmill training and while they are walking over the treadmill. However, the mechanisms of these improvements have not been addressed. We designed a treadmill simulator without a belt that could move on a walkway in a constant speed, in order to explore the mechanism underlying treadmill walking improvements in PD. All subjects were tested in three different sessions (treadmill, simulator(assisted) and simulator(not assisted)). In each session, subjects first walked overground and then walked using the treadmill or simulator with the hands over the handrails (simulator(assisted)) or with the hands free (simulator(not assisted)). Step length, cadence, double support time, swing time, support time and the coefficient of variation (CV) of step time and double support time were recorded. Over the treadmill PD patients increased their step length and reduced significantly their cadence and CV of double support time in comparison with overground walking. In the simulator(assisted) condition PD patients reduced significantly the CV of double support time in comparison with overground walking. With the simulator(not assisted) both groups decreased their step length and increased their cadence and CV of double support time, compared with walking overground. These findings suggest that the step length improvement observed in PD patients, walking over a treadmill, is due to the proprioceptive information generated by the belt movement, since no improvement was reported when patients using a treadmill simulator.
Article
Many authorities have drawn attention to the difficulties in clinically distinguishing Parkinson's disease (PD) from other parkinsonian syndromes. We assessed the clinical features of 100 patients diagnosed prospectively by a group of consultant neurologists as having idiopathic PD according to their pathologic findings. Seventy-six percent of these cases were confirmed to have PD. By using selected criteria (asymmetrical onset, no atypical features, and no possible etiology for another parkinsonian syndrome) the proportion of true PD cases identified was increased to 93%, but 32% of pathologically confirmed cases were rejected on this basis. These observations suggest that studies based on consultant diagnosis of PD, using standard diagnostic criteria, will include cases other than PD, thus distorting results from clinical trials and epidemiologic studies. The strict use of additional criteria can reduce misdiagnosis but at the cost of excluding genuine PD cases.
Article
Evaluation of balance, gait changes, sexual functions, and activities of daily living in patients with total hip replacement in comparison with healthy subjects. A total of 30 patients were included in the study after total hip replacement. Balance was examined using dynamic posturography, and gait evaluation was done clinically. Sexual functions and activities of daily living were also assessed. A total of 30 healthy subjects of comparable age and sex served as a control group. Dynamic balance and gait differed significantly in both the groups. Despite capsulectomy, no significant difference was observed on testing proprioception. In the sensory organization tests with difficult tasks, patients needed more sensory input from vision and vestibular sense, despite normal proprioceptive sense. Significant difference was observed for limits of stability, rhythmic weight shifts, and for gait variables other than walking base. Some of the patients had major difficulties with sexual functions and activities of daily living. Compared with the healthy age- and sex-matched controls, patients with total hip replacement did not have any proprioceptive deficit. Patients required extrasensory input, and there was a delayed motor response. Gait and dynamic balance results also indicated the motor deficit and required a compensatory strategy. Restoration of the postural control in these patients is thus essential. Necessary training is required for balance, gait, and activities of daily living, and proper sexual counseling is necessary in postoperative care.
Article
To assess internal consistency and validity of measures of balance (Berg balance scale, BBS), postural changes (postural changes scale, PCS) and fear of falling (fear of fall measure, FFM) in 70 ambulant Parkinson's disease (PD) persons, these instruments were matched with performance-based balance and mobility tests, and other clinical, functional and quality of life PD-specific measures. The BBS, PCS and FFM showed a good internal consistency, moderate to good inter-correlation, and a significant correlation with measures of both disability (UPDRS-ADL, Schwab and England scale) and--to a lesser extent--impairment/severity of symptoms (UPDRS-ME, Hoehn and Yahr Scale). Tandem Romberg, Single-Limb Stance, Functional Reach, and the Timed Up & Go test correlated slightly better with BBS than with PCS and FFM. This study shows that problems of balance and postural control in PD patients result from complex interactions between motor impairment, functional abilities and fear of falling.
Article
Human dance was investigated with positron emission tomography to identify its systems-level organization. Three core aspects of dance were examined: entrainment, meter and patterned movement. Amateur dancers performed small-scale, cyclically repeated tango steps on an inclined surface to the beat of tango music, without visual guidance. Entrainment of dance steps to music, compared to self-pacing of movement, was supported by anterior cerebellar vermis. Movement to a regular, metric rhythm, compared to movement to an irregular rhythm, implicated the right putamen in the voluntary control of metric motion. Spatial navigation of leg movement during dance, when controlling for muscle contraction, activated the medial superior parietal lobule, reflecting proprioceptive and somatosensory contributions to spatial cognition in dance. Finally, additional cortical, subcortical and cerebellar regions were active at the systems level. Consistent with recent work on simpler, rhythmic, motor-sensory behaviors, these data reveal the interacting network of brain areas active during spatially patterned, bipedal, rhythmic movements that are integrated in dance.