A High Dose Tango Intervention for People with Parkinson’s disease (PwPD)

Background Dance has been used extensively to help supplement ongoing therapies for people with PD, most commonly on a weekly or biweekly basis. A daily dose, however, may provide additional benefits. This study examines the dose effect of a dance intervention delivered within a clinic for movement disorders in which PwPD are paired with experienced studio tango dancers. Objective The current study aims to examine the dose effects of daily dance for PwPD on motor and non-motor functions directly within a movement disorders clinic. Design within-subject, pre-post-intervention, mixed-methods evaluation including UPDRS III. Setting The intervention was held at the Movement Disorders Department of a General Hospital in Buenos Aires, Argentina over two-weeks. Subjects The class had 21 people in total attendance per class. Two were expert tango dancers and instructors, nine were advanced tango dancers (volunteers), two were caregivers and eight were people with mild and moderate severity [Hoehn and Yahr (H&Y) scale 1-2] idiopathic Parkinson’s disease. Intervention Ten dance lessons, each 90-minutes daily within a two-week period. Outcome measures The Movement Disorders Society Unified Parkinson’s Disease Rating Scale (UPDRS) part III was used for pre- and post-motor assessment. Psychological questionnaires, a Likert scale examining symptoms, and a pictorial scale were used to assess non-motor aspects. Semi-structured interviews were conducted to assess the impact of the dance intervention on participants’ experience. Results Our study found a significant 18% amelioration in motor symptoms as measured by UPDRS III. We also found improvements on activities of daily living (ADL), sleep, Psychological Needs variables - post high dose dance intervention in Likert Scale. Conclusions A high dose short-term tango intervention for PwPD improved motor and non-motor aspects of PD such as ADL and sleep with high levels of adherence (97.5%) and enjoyment reported by participants. This dance intervention also improved participant’s perception of their own skills. The frequency or dosage of dance in rehabilitation suggests that an increased dose from once per week to 5 times per week can ameliorate many symptoms of PD and could be used as a short-term intervention.

Improvisation showed improvements in balance, functional mobility and overall improvement in quality 9 9 of life (Marchant, Sylvester & Earhart, 2010). Both of these studies offered 10 dance lessons in a two-1 0 0 week period. The benefits of increased frequency of dance rehearsal have been observed and are shown to The future goal of this study is to assess the effects of tango class as a non-pharmacological intervention 1 1 1 which may significantly help regulate internal rhythms, coordination, balance and mood, contributing to 1 1 2 participants personal and social resources which may momentarily relieve symptoms of PD. The autonomy, competence and relatedness as proposed in self-determination theories can be nurtured 44,45 . On 1 1 8 the basis of self-determination theory (Ryan and Deci 45 ), we hypothesize that tango classes will foster or 1 1 9 nurture basic psychological needs that are the basis of the elevated sense of vitality and enjoyment most 1 2 0 participants in dance based rehabilitation programs encounter 46 . In fact, the sense of vitality is one of the 1 2 1 high predictors of an elevated perceived quality of life, and therapies based on dance seem to promote an 1 2 2 increased sense of vitality 47 . Thus, this study will also aim to assess changes in psychological needs as a 1 2 3 function of tango classes. Few dance programs have assessed the characteristics of partner dancing and its role in dance with PwPD. diagnostic criteria followed the UK Parkinson's Society brain bank guidelines of bradykinesia, muscular 1 5 0 rigidity, rest tremor, and postural instability (UK, Brain Bank Diagnostic Criteria). All patients were on 1 5 1 Levadopa (L-dopa) medication. They took the medication one to two hours prior to the start of dance counted on the participation of non-PD volunteers, with most being in a tango teaching program (7), 1 6 0 while others were relatives or caregivers (2). The intervention consisted of ten 90-minute classes held over a duration of 2 weeks at the Abnormal 1 6 4 Disorders section within the Neurological department of a General Hospital in Buenos Aires, Argentina.

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PwPD always danced with a partner without PD, most often with an experienced tango dancer. Every   (Table 1). Partners rotated during the class to allow all participants to interact with different 1 7 3 volunteers and tango teachers. Classes were held in a 6 x 4-meter room, which usually functions as a 1 7 4 medical gathering or conference room. Participants brought food to share during the 10-minute rest, 1 7 5 halfway into the dance class. The hospital provided beverages such as water, tea and coffee at every class.  Hospital the week following completion of classes and were self-administered. The scale included items 1 9 0 that represent important concerns for this population such as mobility, ease of walking, and performance of ADL as well as mood, sleep quality, and psychological variables related to autonomy, confidence, and 1 9 2 relatedness (basic psychological needs).
1 9 3 1 9 4 The impact of dancing on the subjective experience of participants were explored using individual semi-1 9 5 structured interviews. A pictorial test consisting of a sequence of 5 pictures showing different degrees of 1 9 6 dance abilities was used as a pilot project to assess PwPD's self-perception of their ability to dance. A 1 9 7 similar design of 5 sequential pictures was used to measure perceived stage of Parkinson's symptoms at 1 9 8 their current or present moment. Both tests were assessed with participants prior to the study to validate 1 9 9 that the pictorial test graphics clearly represented a scale of dance abilities and different stages in 2 0 0 Parkinson's symptoms. This study consisted of a within-subjects design, pre-and post-longitudinal intervention and using 2 0 5 mixed-methods evaluation. This project is the initial phase of a planned 4-year intervention.  Changes in motor symptoms were assessed using the UPDRS pre and post scores and a student's paired t-2 1 4 test was used at the significance level of (p < 0.05) for a one-tailed test -since the literature has shown that 2 1 5 daily dance reduces motor symptoms. All participants completed the two-week intervention consisting of 90-minutes daily Argentine tango 2 2 0 classes. None of them dropped out of the program and only two of them missed one class (2/80 total 2 2 1 scores of the group), each for personal activities not related to PD or the program. In both cases, they let 2 2 2 researchers and tango teachers know about their absence in advance and regretted missing the class.

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Attrition rates were as follows: 6 participants attended all the classes, 2 participants attended 90% of Interview/Questionnaires 2 2 7 None of the participants reported being tired or unable to complete the program even though half the 2 2 8 participants commuted 60-90 minutes each way on the public transportation to attend classes. On the 2 2 9 contrary, they felt very enthusiastic and energetic as the program progressed. They all reported 2 3 0 improvements such as better quality of walking, ability to move, sleep, energy and mood. They also 2 3 1 expressed how energized they felt by meeting with the group every day. None of them reported negative 2 3 2 outcomes or side effects, although some reported their concerns with regards to the moment that the 2 3 3 activity would stop, particularly how it will affect their daily enthusiasm, motivation, mood and exercise 2 3 4 levels. performed. However, trends in patient's responses were observed and are presented in this paper for 2 5 7 future research.
PANAS: All participants completed the mood scale questionnaire prior to the intervention. Only six 2 5 9 participants completed the post-intervention questionnaire. There was a moderate improvement in 2 6 0 positive mood after completion of the program as well as a decrease in negative mood in four patients.

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One patient showed equal results for both pre and post measures, and one showed a very small increase in 2 6 2 negative mood (1-point increase).

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Vitality: Five patients showed improvements in vitality scores after completion of the program. One 2 6 4 patient showed no differences between pre and post scores.   Partner dance: As a pilot project, assessments for Psychological Needs, Vitality, and self-perceived 2 7 7 competences were measured after a 10-minute practice in solo dancing compared with 10-minute partner 2 7 8 dancing (which was always performed with a more skilled person). We used the same 3-item 2 7 9 Psychological Needs Scale and 7-item Vitality Scale for pre and post intervention which asked, "how did This study aimed to assess the impact and potential of dance in rehabilitation for PwPD in high doses. We 2 9 2 assessed the effects of an intensive short-term intervention using Argentine tango on motor and non-2 9 3 motor symptoms. As expected, our results showed significant improvements on MDS-UPDRS III scale.

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On average, these improvements represent an 18% decrease in PD symptoms on this scale. These results 2 9 5 are distributed as follows: 4 patients showed major improvements between 30% -50% (2 of whom had 2 9 6 not participated in previous dance programs for neurorehabilitation), 2 patients showed good 2 9 7 improvements between 18%-30%; and the remaining were the same (1 patient showed only a 1 point  with improvements in their ability to walk, perform ADL, sleep as well as be in a more positive mood.

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There was also significant improvement of psychological needs such as relatedness, competence and 3 0 6 autonomy. These results suggest that the dance intervention is perceived as a very enjoyable activity, Semi-structured interviews: During the semi-structured interviews participants expressed the importance 3 2 4 of the group and camaraderie, the relevance of dancing with the teachers and with skilled dancers, and the 3 2 5 importance of focusing on their movement, balance, and abilities instead of exclusively focusing on the 3 2 6 things they were not able to do. They expressed the importance of the classes strengthening their 3 2 7 motivation and providing a sense of challenge for attending the program daily. They felt fortunate to have 3 2 8 the chance to participate in the program and the fact that dancing helped them to better cope with the 3 2 9 disease and associated symptoms. This longitudinal study had a small sample size (n=8). There was no control group and the instructors all 3 3 3 knew who the people with PD were. All participants had the desire to take dance classes and this could be 3 3 4 a bias for the success rate or improved vitality or enjoyment of the activity. Another limitation of this 3 3 5 study was the self-administered questionnaires with most baseline tests administered in a group setting.

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The Likert questionnaire is a self report and as such, is subject to the inherent biases in all self report 3 3 7 questionnaires. These questions are framed such that they suggest that the patients should feel better after  program showed improvements in perceived mobility, ability to walk, and performance of ADL as well as better quality and quantity of sleep and improved mood. It also shows that the activity fosters 3 5 6 Psychological Needs such as competence, relatedness and autonomy. This study also aimed to investigate 3 5 7 the nuances of partner dancing. PwPD showed improvements in their self-perceived skills after rehearsing 3 5 8 with a more experienced dancer in comparison with a solo dance practice. This is in line with former weekly tango class as well as those who had never taken classes before. As previously stated, dance is a 3 6 6 non-pharmacological approach that helps maintain health through physical activity and cognitive training,

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offering an enriched environment in which to socialize and learn new skills. As a form of rehabilitation in 3 6 8 PD our findings present hope for the possibility of decreasing the rate of progression of the disease.    L  i  k  e  r  t  s  c  o  r  e  s  f  o  r  t  h  e  p  o  s  t  t  i  m  e  w  h  i  c  h  h  a  d  t  h  e  7  8  d  a  n  c  e  c  l  a  s  s  e  s  f  o  r  t  h  e  8  p  a  r  t  i  c  i  p  a  n  t  s  b  e  t  w  e  e  n  5  5  5  t  h  e  p  r  e  -/  p  o  s  t  s  e  s  s  i  o  n  s  o  v  e  r  1  2  d  a  y  s  .  E  a  c  h  l  i  n  e  r  e  p  r  e  s  e  n  t  s  t  h  e  P  w  P  D  g  r  o  u  p  '  s  d  a  t  a  f  o  r  L  i  k  e  r  t  q  u  e  s  t  i  o  n  n  a  i  r  e  5  5  6  a  s  p  e  r  c  e  n  t  a  g  e