Medicine that Moves: The Effect of Dance on Parkinson’s disease

Studies have found that about one in five hundred people suffer from Parkinson’s disease, a chronic illness damaging and deteriorating the nerves in a person's brain. It leads to both motor and cognitive symptoms including tremors, slow movements, motor impairments, poor or weak posture, and bowel disorders. Furthermore, neurons responsible for releasing dopamine, a type of neurotransmitter, are harmed as well, causing patients to have lethargic feelings, affective disorders, and/or decreased mood, focus, attention, or memory (Ismail et al.). However, symptoms do not end there. They affect almost all aspects of a person’s life—including motor, cognitive, emotional, and even social. As reported in the article “Dance Training Reduces Parkinson's Progression, Study Suggests,” Parkinson's disease inhibits the performance of many elementary motor skills often causing patients to develop insecurities about themselves—not wanting to see friends or constantly staying in their homes—and may lead to feelings of loneliness, anxiety, and depression (Brooks). With no cure for Parkinson’s disease, patients have received various kinds of therapy in an attempt to slow the progression and counter symptoms of Parkinson’s disease. 

In standard therapy, common practices include patients working on various kinds of balancing exercises and motion training. For example, in a hall, patients may abruptly change their walking direction based on auditory cues (De Natale et al. 142). Researchers analyzed the cognitive and motor abilities (such as cognitive function, balance, and memory) of patients before and after standard therapy; however, as discussed in their paper “Dance Therapy Improves Motor and Cognitive Functions in Patients with Parkinson’s Disease,” they found that there was not a statistically significant difference in patients before and after therapy as patients showed high levels of entropy in various tests (De Natale et al. 142). Additionally, because standard therapy specifically targets the improvement of motor abilities, it may not address the social and emotional symptoms. 

Even so, exercise, whether performed through standard therapy or sports, is crucial for patients with Parkinson’s disease as it helps train the muscles that are primarily affected by decreased motor abilities. Sheila Ward, a member of the Journal of Physical Education, Recreation, and Dance (JOPERD) Editorial Board, elaborates that the cardio components of exercise cause people to get in shape, lower obesity rates, improve heart health, and even lower risks of certain cancers such as colon or breast. Exercise also releases endorphins, another kind of neurotransmitter, providing pain relief. Yet, even though exercise has many benefits reaching beyond strengthening muscles and increasing mobility for those with Parkinson’s disease, the majority of people with Parkinson’s disease belong to older generations above sixty years old. Since exercise and sports are most often played competitively, they may be considered more strenuous on older bodies. Furthermore, Ward explains that people tend to be more fearful when participating in sports as there is a higher risk of falling and getting hurt. Consequently, despite exercise’s necessity for Parkinson’s disease patients, new practices are needed that are more accomodating for the older generations. Additionally, as aforementioned, standard therapy also has much room for improvement regarding the levels and quantities of symptoms targeted. As a result, some organizations have set up to combat Parkinson’s disease with a different kind of therapy: dance, a type of exercise and art that combines physical, mental, emotional, and social components. From numerous studies conducted, dance may provide a reasonable and holistic approach to slowing the progression of Parkinson’s disease. 

Morris, Mark. “Harriman-Jewell Series.” Harriman-Jewell Series, 8 Feb. 2020, www.hjseries.org/events/2020/02/08pd. Accessed 5 June 2022.

Dance, as Ward explains, is also composed of cardio aspects in addition to flexibility aspects. Consequently, benefits of the cardio aspects of dance may reap the same benefits as cardio in traditional exercise while the flexibility components of dance may strengthen the body, causing people to feel more comfortable in their skin. Because of this, dance has been shown to increase control over motor abilities leading to a lower risk of falling, the number one cause of death from unintentional injuries in older generations. A study conducted by Edoardo Rosario De Natale, a neurologist from the University of Exeter, and other researchers support the results, finding moderate yet statistically significant improvements before and after dance classes in decreased risk of falls as well as balance. For example, assuming an alpha of 0.05, the Timed Up and Go Test (TUG), a test evaluating functional mobility, had a significant p-value of 0.007  (143). In another study, Dr. Joseph DeSouza, the associate professor of System Neuroscience, Center for Vision Research, and Karolina Bearss found that after Parkinson’s disease patients took classes once a week at Canada's National Ballet School for over two-in-a-half years, the patients who danced showed a 9.2 reduction in UPDRS scores compared to a score of 28.27. Consequently, the dancers had a significant slope of 0.000146 for their UPDRS score, meaning that there was no decline in their abilities and strong evidence that dance can inhibit symptoms of Parkinson's disease from becoming more severe (Brooks). Because patients also aren't always able to give their full, undivided attention to simply walking as they dance, this often challenges them, stimulating real-world situations. The art of learning how to multitask is particularly beneficial as multitasking is one of the main reasons someone may fall (De Natale et al. 143). Numerous other studies also confirm the moderate improvement of motor abilities (Brooks; De Natale et al.; Ismail et al.; Krotinger and Psyche; McRae et al.) 

Furthermore, dance may be a more apt fit for older patients with Parkinson's since they execute difficult movements in a more controlled environment (with the assistance of the choreographer in case something does go wrong) rather than when someone, for instance, plays sports. Regardless, motor symptoms, perhaps some of the most noticeable signs, may impede the function of the day-to-day life of a person with Parkinson’s disease more than any other symptom patients face. Therefore, any kind of therapy must at least provide moderate yet significant improvements in motor skills. 

Another benefit of dance for patients with Parkinson’s disease involves the cognitive improvements of dance. De Natale and other researchers' studies found that dance was confirmed to have both motor and non-motor benefits for those with Parkinson's disease as memory and decision-making functions showed significant improvements. These improvements did not go away after the follow-up check-up buttressing the idea that the benefits of dance may have long-term effects. Additionally, the researchers propose that dance classes may better teach patients how to manage day-to-day life with Parkinson's. For example, patients are multi-taking as they follow the movements of the choreographer, execute their dance steps, and maintain the pace with the rhythm of the music (143). This process is what Dr. Sophia Rasheeqa Ismail, one of the winners of the Merdeka Award Grant for International Attachment in 2017, and other researchers call “mirroring.” Dance stimulates mirror neurons from the exercise of repeating dance steps and choreography from the instructor as a way to learn. This leads to cognitive benefits as mirror neurons are responsible for changes in the endocrine gland and enhance different parts of the brain. Similarly, De Natale explains that on top of the activation of mirror neurons, the decision-making function of the brain was enhanced as well. For example, when patients tangoed together, one of the dance types studied in the research, they had to make spontaneous decisions about the next set of movements they will perform with their partner (143). As a dancer myself, I have experienced the cognitive engagements of remembering choreography, especially during fast-paced conventions. On top of that, dancing is not just executing the given movements but rather adding emotion and personal style to the choreography. Because dance fuses art and exercise, it feels as if I am multitasking while dancing—remembering all the steps yet pushing myself to think beyond simply executing the possés and pirouettes and pinwheels. 

“Dance for PD» Dance for PD at Home with the APDA.” Danceforparkinsons.org, 2015, danceforparkinsons.org/resources/dance-at-home/dance-for-pd-at-home-apda. Accessed 5 June 2022.

Dance, however, has another way to combat other aspects of Parkinson’s disease. Dr. DeSouza explains that dance may "train neural network nodes that [help] either strengthen networks damaged or [build] neural road maps that pass the damage" (qtd. in Brooks). The strengthening of cognitive function is buttressed in the paper “Rhythm and Groove as Cognitive Mechanisms of Dance Intervention in Parkinson's Disease” as researchers found that patients with dance intervention prevented the deterioration and death of neurons. Not only could this result from the intense memory training and activation of mirror neurons engaged throughout dance, but this could also occur from the incorporation of music within this exercise. Researchers explain that when someone has Parkinson's disease, they may experience difficulties in moving or coordinating their legs and other muscles, talking, interpreting music, or experiencing stiffness, trembling, and weaker signals transmitted in the brain. These symptoms may all be byproducts of the worsening coordination between auditory signals and responses or dopamine loss—two other cognitive symptoms of Parkinson's disease (Krotinger and Loui). Because these symptoms are rooted in the brain, specifically in the parts that impact music cues, different types of intervention that engage those aspects of the brain, like dance, may counteract Parkinson’s disease. Similar to traditional therapy, when someone dances, their movements typically should correspond to the music or rhythms in some way (of course, the way they align varies from each style of dance). However, dancing takes this a step further than standard therapy or exercise due to all the various aforementioned factors involved while someone dances. The researchers compared the effects of dance and music (with and without prior experience or knowledge) on patients with Parkinson’s disease. From their study they found that dance may not only improve functions of Parkinson's disease such as balance, walking, and retention-span, but also lead to increased happiness, focus, and day-to-day life, many of these benefits not found in exercise Krotinger and Loui). This may suggest that because dance combines music with motions—sight and hearing with choreography—and therefore engages parts of the brain not used during exercise, it may be a more holistic intervention for Parkinson’s disease. Infact, after running UPDRS I, II, III, and IV on patients with no prior experience before and after dance classes, the UPDRS scores showed a decrease of 0.8 in mood and behavior, a 2.39 score decrease in daily activities, a 4.52 score decrease in motor functioning, and a 0.35 score decrease in therapy complications. From these results from the various tests run before and after dance intervention, the researchers found that both patients with and without prior experience of dancing showed a slowed progression of the disease (as indicated with lower UPDRS scores). In fact, the main differences between those with and without prior experience occurred in the tapping test, in which Parkinson's disease patients with dance experience showed more consistent results while patients with no experience had a larger increase in accuracy. For example, assuming an alpha of 0.001, patients with no prior experience showed a statistically significant difference in "time-points," the measurement used in the tapping tests, with a p-value of approximately 0.000106. These positive results indicate that enhanced coordination between the sensory and motor system, control and awareness over movements, and neurological benefits of mirroring occur in patients regardless of dance experience. Many of these improvements were not found in other groups studied (Krotinger and Loui). Though researchers have not conducted many long term studies regarding the effects of dance on Parkinson’s disease, the positive and consistent results of patients with prior dance experience suggest that dance may not only hinder the progression of Parkinson’s disease but prevent the damaging of neurons in the first place, therefore reducing the risk of developing Parkinson’s disease. Furthermore, another study also found that patients who had danced for over one year reported a higher level of benefits, supporting the idea that dance may have long-term benefits that accumulate over time (McRae et al.). For patients who already have Parkinson’s disease, the exercise aspects of dance may improve symptoms in the short term, but the cognitive stimuli dance provides may prevent additional damage to nerves to help Parkinson’s disease patients in the long term. 

Finally, along with the life-changing symptoms of Parkinson’s disease, the disease can impact emotional and social well-being. Researchers conducted a study in which Parkinson's disease patients participating in the Dance for Parkinson's Disease (DfPD) Program in New York filled out various surveys regarding emotional and physical well-being. These surveys included questions regarding patients' opinions about their life, if they believe dance has affected them in the real world, and their confidence levels in fields like motion or stability. Researchers then used Cronbach's alpha to analyze the data and compared their findings to similar surveys used for Parkinson's disease patients. Because of the many different variables involved in the duration of dance classes taken (including the time patients started dancing upon realizing they had the disease, the length of time they had been dancing, and how frequently they visited the studio), the researchers divided the results from the survey by patients with and without a year of dancing, the average amount of time in the classes, then employed a bootstrap technique to identify and analyze patients thoughts on dance’s influence on the improvement of the disease and how their confidence in recovery shaped their day-to-day life experiences (McRae et al.). ​​From the surveys, researchers found that patients with dance training primarily felt an increase in happiness, mood, confidence, and other emotional benefits. On average, patients ranked motor improvements below emotional improvements as shown in the tables below.  

Source: McRae, Cynthia et al. “Long-Term Effects of Dance for PD® on Self-Efficacy Among Persons with Parkinson’s Disease.” Arts and Health, vol. 10, no. 1, 2017, pp. 85–96., https://doi.org/10.1080/17533015.2017.1326390. 

 Interestingly, researchers found that confidence may be critical in recovery. They concluded that from the analyses of responses, a patient's determination and confidence in themselves to recover from Parkinson's disease may play an essential role that can lead to patients feeling as if they are living better lives. Because dance often creates a sense of pride in accomplishments (such as motor improvements), a joy of learning, and a supportive dance group, dance often leads to increased levels of confidence. In turn, this confidence may explain the many non-motor benefits of dance (McRae et al.). Furthermore, when patients find something that they truly enjoy, such as dance, they may have more determination to recover and ultimately show higher signs of recovery. In fact, when patients responded to questions regarding their experience in the dance program, they wrote that they enjoyed the “'[c]ommunity, laughter, [and a] chance to see friends’” or how “‘[i]nspiring, exhilarating, energizing, joyous, freeing, and motivating’” dance made them feel. Some patients who had experience with standard therapy or exercise intervention commented that dance intervention was different because of the “‘'[c]ontinuity of relationships with peers and teachers’” and the music (qtd. in McRae et al.). In any life-threatening disease, patients must reflect on how they have spent their life rather than the number of years they have lived since this helps patients find happiness and enjoy their time living despite the adversities in their lives. For example, one patient explains, dance “‘[m]akes me feel alive and forget my limitations because of PD [Parkinson’s disease]’” while another patient describes, “'I don’t always feel like a patient, [sic] but a person who happens to have PD, and [I] can still have fun and enjoy life'” (qtd. in McRae et al.). In a way, dance helped them cope with Parkinson’s disease, making them feel as if they are in “‘Carnegie Hall compared to Bellevue Hospital'” (qtd. in McRae et al.). Though dance may not fit the likings of everyone, these patients found an enjoyable way to combat their disease as well as develop a community of people similar to them, perhaps alleviating feelings of loneliness or certain affective disorders and helping them develop confidence in themselves. 

Despite the confidence patients have in themselves, dance is a relatively new mechanism to combat Parkinson’s disease, so in all studies, there were limitations. These limitations often included risk of bias, survey bias, small sample sizes, or a non-randomized group of participants, leading to lower levels of certainty of results (Brooks; De Natale et al.; Ismail et al.; Krotinger and Psyche; McRae et al.). Additionally, many confounding factors, such as patients’ other activities and treatment outside of the dance programs, may have also altered the results. 

“Dance for Parkinson’s | ComForCare | Santa Cruz County, CA.” Comforcare.com, 2022, www.comforcare.com/california/santa-cruz-county/senior-care-services/dance-for-parkinsons.html. Accessed 5 June 2022.

Even with these limitations, dance still has shown significant improvements for many symptoms of Parkinson’s disease, suggesting that along with the need for larger-scale research, perhaps physical therapists could offer this more often as a treatment option. Unlike standard therapy or exercise, dance may be an enjoyable way to learn and train the body to combat motor and non-motor symptoms. As for now, there is no known cure or cause for Parkinson’s disease, and we do not have control over our acquisition of the disease. However, we can control our response—the research and time we dedicate to developing then testing new treatments or therapies for them to become more and more effective or the communities and emotional support we offer to patients whose lives have been drastically changed. Whether or not dance results as the best kind of intervention for those with Parkinson’s disease, seems to be a step in the right direction. And surely, people with Parkinson’s disease should at least have the opportunity to take on a new skill that could not only provide them with improvements to the progression of the disease but a new experience to find a source of joy in their lives. 

Works Cited 

Brooks, Megan. "Dance Training Reduces Parkinson's Progression, Study Suggests." Internal Medicine News, vol. 54, no. 8, Aug. 2021, pp. 11+. Gale General OneFile, link.gale.com/apps/doc/A677353100/GPS?u=tlc201825818&sid=bookmark-GPS&xid=53b69d19. 

De Natale, Edoardo Rosario, et al. “Dance Therapy Improves Motor and Cognitive Functions in Patients with Parkinson’s Disease.” NeuroRehabilitation, vol. 40, no. 1, 2017, pp. 141–144., IOS Press Content Library, https://doi.org/10.3233/nre-161399. 

Ismail, Sophia Rasheeqa, et al. "Evidence of Disease Severity, Cognitive and Physical Outcomes of Dance Interventions for Persons with Parkinson's Disease: A Systematic Review and Meta-Analysis." BMC Geriatrics, vol. 21, no. 1, 22 Sept. 2021. Gale Academic OneFile. http://dx.doi.org/10.1186/s12877-021-02446-w. 

Krotinger, Anna, and Psyche Loui. "Rhythm and Groove as Cognitive Mechanisms of Dance Intervention in Parkinson's Disease." PLoS ONE, vol. 16, no. 5, 6 May 2021. Gale In Context: Science, link.gale.com/apps/doc/A660916605/GPS?u=tlc201825818&sid=bookmark-GPS&xid=f758f38e. 

McRae, Cynthia, et al. “Long-Term Effects of Dance for PD on Self-Efficacy Among Persons with Parkinson’s Disease.” Arts and Health, vol. 10, no. 1, 2017, pp. 85–96, Taylor and Francis Group, https://doi.org/10.1080/17533015.2017.1326390. 

Ward, Sheila A. "Health and the Power of Dance." Journal of Physical Education, Recreation, and Dance, vol. 79, no. 4, Apr. 2008, pp. 33-36. eLibrary, https://explore.proquest.com/elibrary/document/215755988?accountid=25270.