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“Dance Therapy” as a psychotherapeutic movement intervention in Parkinson’s disease
Accepted Manuscript Title: “Dance Therapy” as a Psychotherapeutic Movement Intervention in Parkinson’s Disease Authors: Kristi Michels, Ornella Dubaz, Erica Hornthal, Danny Bega PII: DOI: Reference:
S0965-2299(18)30417-5 https://doi.org/10.1016/j.ctim.2018.07.005 YCTIM 1872
To appear in:
Complementary Therapies in Medicine
Received date: Revised date: Accepted date:
6-5-2018 8-6-2018 6-7-2018
Please cite this article as: Michels K, Dubaz O, Hornthal E, Bega D, “Dance Therapy” as a Psychotherapeutic Movement Intervention in Parkinson’s Disease, Complementary Therapies in Medicine (2018), https://doi.org/10.1016/j.ctim.2018.07.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
DANCE THERAPY IN PD Title: “Dance Therapy” as a Psychotherapeutic Movement Intervention in Parkinson’s Disease Authors: Kristi Michels1, Ornella Dubaz, MD2, Erica Hornthal, MA3, Danny Bega, MD, MSCI4*
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Affiliations: 1Northwestern University Feinberg School of Medicine,2Northwestern Memorial Hospital, Department of Neurology, 3Chicago Dance Therapy,4Northwestern University Feinberg School of Medicine, Department of Neurology *Corresponding author: Danny Bega, MD, MSCI 710 N Lake Shore Dr, Room 1124 Chicago, IL 60611 Phone: 312-503-5706 [email protected]
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Running title: Dance Therapy in PD
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Highlights Dance therapy is the psychotherapeutic use of movement to improve physical, emotional, cognitive, and social wellbeing. 13 subjects with PD were randomized 2:1 to dance therapy or support group control. All participants in dance therapy enjoyed the classes and most felt they were beneficial. Pre-determined feasibility goals were met. Clinical outcomes were explored and warrant further study in a powered study with groups matched for disease severity.
Abstract Background: Previous studies in Parkinson’s Disease (PD) have described benefits of dance for motor and non-motor outcomes, yet few studies specifically look at Dance Therapy (DT) as a specific psychotherapeutic model for PD. DT is the psychotherapeutic
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DANCE THERAPY IN PD use of movement to improve physical, emotional, cognitive, and social integration and wellbeing. Objective: 1) Explore the safety and feasibility of a 10-week DT program for PD. 2) Collect pilot data on efficacy of DT.
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Design/Methods: Prospective, randomized-controlled study in subjects with PD. 13 participants randomized 2:1 to DT (n=9) or support group (n=4). Assessments were completed 1-2 weeks prior to the first session and after the final session, and included attendance, Hoehn and Yahr Scale (H&Y), Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Montreal Cognitive Assessment, Timed Up and Go, Berg Balance Scale, Beck Depression Inventory, Fatigue Severity Scale, Visual Analog Fatigue Scale, Parkinson’s Disease Questionnaire-39, and an exit satisfaction survey.
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Results: All participants completed the study. The control group was older and had a higher mean baseline MDS-UPDRS III score (27.56 dance vs. 40.75 control) and H&Y score (2.11 dance vs. 2.50 control). 7 of 9 in DT and all control subjects attended at least 70% of classes. All participants in DT enjoyed the classes and most felt they were beneficial. The greatest improvement in motor measures was in MDS-UPDRS III (-4.12 (dance) vs. -1.75 (control)). Non-motor outcomes were explored as well.
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Conclusions: DT is introduced as an enjoyable mind-body intervention for PD. Further studies powered for efficacy and with groups matched for disease severity are warranted.
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Keywords: dance therapy; Parkinson’s disease
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Introduction: Parkinson’s Disease (PD) is a neurodegenerative movement disorder characterized by a constellation of motor symptoms such as tremor, bradykinesia, rigidity, and impaired gait and balance.1,2 Pharmacological PD treatments focus on improving these motor symptoms but over time patients can develop treatment-resistant symptoms and motor complications.3 Non-motor manifestations of PD are also common and include cognitive impairment, fatigue, autonomic changes, mood disorders, and sleep disturbances.1,4,5 Non-motor symptoms can be disabling and lead to a significant decrease in quality of life.5 Non-motor problems may limit the pharmacological treatment of motor symptoms and effective treatments for non-motor symptoms are not always available.2,6 For these reasons, there is increasing interest among patients and providers in pursuing mind-body interventions, such as Dance Therapy, which have the potential to simultaneously address motor and non-motor symptoms of PD.4,7,8 Dance involves the practice of fluid movements, postures, and body control, which may address the rigidity, bradykinesia, and postural instability associated with PD.8-11 Tango specifically addresses movement initiation, as well as directional and speed changes that may help with bradykinesia in PD.7,8 Dance is proposed to offer cognitive and social benefits as well. The activity requires planning movements,
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DANCE THERAPY IN PD
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following music and signals, and remembering choreography.9,12 The sense of community and enjoyment that comes from dancing and listening to music with other people may also address common problems such as depressed mood, fatigue, and isolation.4,7,8,12,13 Numerous studies of dance interventions show positive effects on gait and balance in PD. We previously conducted a systematic review of dance studies in PD and found 6 randomized controlled trials involving a total of 254 participants demonstrating improvements in gait and balance tango, waltz/foxtrot, and Irish dance.2 Dance also appears to have a positive effect on non-motor symptoms. In a review of 6 studies involving a total of 146 participants using tango, ballroom, Irish dance or a combination of aerobic, jazz, tango and ballet, dance appeared to improve cognition, apathy and showed a mild trend to improved fatigue.14 Dance/movement Therapy (DT) is a specialized form of dance that differs from traditional dance instruction because it not only speaks to the aesthetic, educational, and recreational parts of dance, but it also incorporates the bio-psychosocial development of an individual. According to the American Dance Therapy Association, “Dance Therapy is the psychotherapeutic use of movement to further the emotional, cognitive, physical and social integration of the individual.”15 A “Dance Therapist” focuses on movement behaviors as they emerge in the therapeutic relationship and environment. The therapist uses movement to facilitate a compassionate relational opportunity within each session in a holistic body-centered approach to promoting health and wellness.15 In DT, participants are encouraged to express emotions through movement. Body awareness and mobility is addressed as in other dance programs, but with a unique emphasis on social support and emotional recognition. In this way, DT marries traditional “talk therapy” with a body-centered approach to health and wellness. The psychosocial benefits of dance are well recognized in the dance community and many dance classes incorporate elements of DT into their programs. A study in PD using structured interviews demonstrated the positive influences of socialization and communication in decreasing participant isolation and quality of life.16 Similar psychosocial benefits have been described in other populations including cancer patients and patients with cerebral palsy.17,18 We were interested in how the PD community would receive a DT intervention, and how the intervention would impact both motor and non-motor aspects of the disease. We explored the feasibility of DT in patients with PD and collected pilot data on efficacy of DT on motor and non-motor symptoms of PD compared to a control support group.
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Methods: This was a prospective, randomized controlled study designed to assess the feasibility, safety, and participant satisfaction with DT compared to a traditional talk therapy support group in patients with PD. Exploratory analysis of motor and non-motor PD outcomes, with fatigue being of particular interest due to lack of effective treatment strategies, was also performed for pilot data on the efficacy of DT. Participants were randomized 2:1 to a customized group DT session or a support group control. The study aimed to recruit 15-20 participants based on what the instructors felt was a feasible class size and instructor-to-participant ratio. Romenets et al showed improvement in motor and non-motor measures of PD with a 12-week Tango dance intervention.12 We elected to conduct sessions for 60 minutes weekly over 10 weeks due to instructor availability. The study received research ethics approval from the institutional review board. Participants were recruited from the Northwestern Parkinson’s Disease and Movement Disorders Center. Dance therapy and talk therapy classes took place at a movement studio located inside the Chicago Sports Institute in a northern suburb of Chicago. All
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DANCE THERAPY IN PD
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classes were facilitated and supervised by the same board-certified dance therapists and licensed clinical counselors. Participants included in the study were adults with a diagnosis of idiopathic PD as determined by a movement disorders expert. Subjects were included regardless of their Hoehn & Yahr (H&Y) stage or disease severity. All participants had to be on a stable PD medication regimen for at least one month prior to the study and continue that regimen without any changes throughout the course of the study. Participants were excluded if they participated in any therapeutic dance intervention within the three months before the start of the study or initiated any new PD treatments or involvement in other PD-focused interventions throughout the course of the study. Participants were also excluded if they had significant cognitive impairment determined by a Montreal Cognitive Assessment score (MoCA) less than 24, or were under the age of 18, due to inability to provide informed consent. Eligible participants were randomized using a computer block design in a 2:1 ratio to DT or a support group. All DT sessions were led by the same instructor, a board-certified dance therapist with experience working with patients with PD as well as other neurological disorders. Dance exercises were catered to the individual in order to accommodate different levels of functional capacity. The intervention was organized by the dance therapist based on her anecdotal success with classes offered to the PD community. The DT sessions emphasized: 1) an understanding of how movement influences mood and mental health; 2) balance, gait, and coordination; 3) expression of thoughts, feelings, and emotions through movement and dance. The dance therapist also led the support group which involved education about how movement influences mood and mental health, ways to incorporate movement and dance into daily life, and exploration of feelings and emotions in a supportive group environment. The control group practiced no actual physical exercises or techniques. The sessions are outlined in greater detail in Table 1. The primary aim of the study was to explore whether a 10-week, weeklycustomized course of DT was safe, feasible, and enjoyable for patients with idiopathic PD at any stage. Class attendance was measured, and an exit survey on satisfaction of the program was administered after the final week. The instructor and research coordinator logged adverse events each week. The primary feasibility goal was predetermined as at least 70% of participants attending at least 70% of the classes. Exploratory efficacy outcomes included motor and non-motor assessments. These assessments were completed under the supervision of a trained movement disorders specialist who was blinded to class assignment 1-2 weeks prior to the program (baseline) and repeated 1-2 weeks after its conclusion (final). Motor outcome measures assessed included the changes in the H&Y, Movement Disorder Society Unified Parkinson’s Disease Rating Scale (MDS UPDRS), Berg Balance Scale (BBS), and Timed Up and GO (TUG). Non-motor measures were administered by the study coordinator and included the MOCA, Parkinson’s Disease Quality of Life Scale (PDQ39), Beck Depression Inventory (BDI), Fatigue Severity Scale (FSS), and Visual Analog Fatigue Scale (VAFS). Assessments took a total of 30 minutes to complete. Descriptive statistics were calculated for all variables of interest. Results: 14 participants were screened and 13 met eligibility criteria and were enrolled in the study. 1 participant was excluded for a MOCA score below 24. 9 participants were randomized to DT and 4 to the control group. All participants completed the study. Baseline characteristics are shown in table 2. There were 6 male and 7 female participants, most of whom were white. The mean age of the cohort was 69.2 (SD 8.7), and the mean UPDRS part III score was 31.6 (SD 12.2). The control group was older
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DANCE THERAPY IN PD and had a higher mean baseline MDS-UPDRS III score (27.56 dance vs. 40.75 control) and H&Y score (2.11 dance vs. 2.50 control).
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Safety and Feasibility: There were no serious adverse events related to the study’s intervention or control sessions. One participant in the DT group developed low back pain, which was characterized as mild and kept the participant from participating in one session. It was unclear to the investigators if this was related to the study intervention. The predetermined attendance outcome was met with 7 of 9 subjects in the dance group and 4 of 4 subjects in the control group who attended at least 70% of the classes. Reasons for absences included conflicting commitments, travel plans, illness, and trouble with travel arrangements.
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Satisfaction: The program satisfaction measures are illustrated in figure 1 and 2. All participants in the DT group enjoyed the classes and 7 of 9 felt that they benefited from them, while the other 2 felt neutral. The only participant in the study who did not enjoy or feel they benefited from the classes was in the control group and indicated that they were disappointed to not be in the DT group. 6 of the 9 participants in the DT group and 2 of the 4 participants in the control group stated they would attend similar classes in the future and recommend the program to other patients with PD.
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Exploratory outcomes related to motor and non-motor function: The mean change in motor measures included MDS-UPDRS II (-0.11 dance vs. 0.25 control), MDS-UPDRS III (-4.12 dance vs. -1.75 control), MDS-UPDRS IV (-1.33 dance vs. -3.25 control), TUG (-0.57 dance vs. -0.31 control), BBS (2.55 dance vs. 5.25 control), and PDQ-39 (6.78 dance vs. 4.75 control), with the greatest improvement being in MDS-UPDRS III. The mean change in non-motor measures included MDS-UPDRS I (0.45 dance vs. -0.75 control), MoCA (0.44 dance vs. -0.50 control), BDI (2.55 dance vs. 5.25 control), FSS (0 dance vs. -5.50 control), VAFS (-0.03 dance vs. 1.50 control), and PDQ-39 (6.78 dance vs. 4.75 control). The study was not powered to assess whether any of these differences were statistically significant.
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Discussion: This is the first study of DT as a psychotherapeutic movement intervention in PD. The study met all three primary aims showing that DT is safe, feasible, and enjoyable in patients with PD regardless of disease severity. Pre-determined attendance criteria were met, with 85% of subjects attending over 70% of the classes, and no participants withdrew from the study. Strong participant adherence to the program may indicate acceptance of DT as an adjuvant treatment for PD patients, although we acknowledge that self-selection for the study has an impact on this. Every participant who completed the program enjoyed the DT intervention and the majority felt that they benefited from these classes. Most participants stated they would recommend the program to a friend and attend more classes if they were offered. The control group was given the opportunity to complete 10 DT sessions similar to the programs’ original 10 sessions after the end of the study and showed similar enthusiasm and enjoyment. Enough participants in both groups appreciated and enjoyed the classes persuading the dance therapist in charge of the intervention to hold another 10-week session after the study completed. Similar findings in reviews of mostly tango studies by Shanahan and Lotzke, including high attendance rates, requests to continue the classes
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DANCE THERAPY IN PD
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and satisfaction with the classes, indicate that dance may facilitate long-term compliance.19-21 Recruitment was challenging limiting the sample size. Some participants could not commit to the study because of a lack of proximity to, or foreseen difficulty traveling to, the Chicago Sports Institute. Future studies may be more successful by offering classes in multiple locations or providing transportation for participants. Results of exploratory analysis of motor and non-motor variables are demonstrated in Table 2, though the study was not powered to determine whether these differences are significant. The DT group and the control group were not well matched for age and H&Y despite randomization due to a limited sample size. For these reasons, a larger study powered to determine significant changes would be needed in order to determine efficacy of the therapeutic intervention and provide for successful randomization. This pilot study suggests that DT has the potential to improve motor symptoms in people with PD. Improvement in UPDRS III scores were seen in our DT group although results were non-significant. Improvements in these scores have also been demonstrated in multiple tango/ballroom dance studies.22-24 Dance may be effective in targeting motor symptoms of PD because it incorporates the stretching and strengthening of muscles and increases flexibility throughout the body, which may help maintain balance in people with PD.7 Another possibility is that practice of dance may activate areas of the brain that normally show reduced activation in PD.7 PET studies have shown that blood flow to the cerebellum increases when dance steps are performed.25 Calvo-Merino et al found that primary motor regions and motor-planning regions, including pre-motor and supplementary motor areas, were activated while participants learned complex dance sequences, and suggested that dance impacts motor and pre-motor networks in the brain.26 Sacco et al found similar results with Tango lessons.27 It has been hypothesized that dance may change underlying neural mechanisms in PD by improving functional connectivity in motor networks resulting in improved motor performance, including gait and balance.28 The non-motor benefits of dance have previously been described for cognition.14 depression, apathy and quality of life.4 DT is a more holistic, mind-body approach to dance. Body awareness is emphasized more so than during a regular dance class and participants are counseled to make the connection between their thoughts and their body movements.29 Participants are also encouraged to link their movement to what they are experiencing emotionally or physically and even express that emotion through movement. DT combines the benefits of mobility with social support and the expressive process.30 Improvements in mood are therefore plausible through this expression of emotion. Community dance classes often incorporate elements of psychosocial therapy and studies in various populations have described specific psychosocial benefits of dance interventions.17,18 Subjective reports of improvements in social isolation and quality of life have been reported in PD with other dance interventions.16 Both of our groups received education on the benefits of DT, and both may have benefited from the therapeutic aspect and social interaction of the weekly sessions. It is possible that we would have seen more significant differences between our DT and control groups if our control would have been a no contact control group. As a social activity performed with others, DT shares elements of a support group.9 The intervention in this study was limited to once a week for 10 weeks. We might have seen more promising trends with sessions than ran more frequently or for a longer period of time. Most dance studies involve twice-weekly sessions of 60-90 minutes duration that span a period of 6-12 weeks.7 Natale et al recorded significant
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improvement of motor function and cognitive skills with a twice-weekly tango dance intervention over a 10-week period.31 The unique ability of a trained dance therapist to facilitate the intervention in patients of any stage of PD makes DT an appealing and likely beneficial adjuvant therapy for improving motor and non-motor symptoms in PD. An obstacle in studying the potential benefits of DT is accessibility to a dance therapist. However, if DT is found to be more beneficial than informal community dance classes or support groups, accessibility to therapists and classes may expand. Further studies would be necessary to reveal any advantage of DT in PD over a community based dance class or support group. Conclusion: This study explores the psychotherapeutic use of DT as a potential mind-body intervention for PD. This study supports the feasibility of a DT intervention in patients with PD. Classes were well attended, safe and participants enjoyed the intervention. A schematic for Dance Therapy class progression is introduced. Further studies powered for efficacy and with groups matched for disease severity are warranted.
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Authors’ Roles: Kristi Michels: Research project: Conception, organization, execution | Data Analysis: Design, execution, and creation of tables and figures | Manuscript: Writing of the first draft and revising later drafts Ornella Dubaz, MD: Manuscript: Review, critique, and helping to research and write the background section Danny Bega, MD, MSCI: Research project: conception, organization, execution | Data Analysis: Design, review, and critique | Manuscript: Review and critique
Financial disclosures: Kristi Michels has no financial disclosures Ornella Dubaz, MD has no financial disclosures
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Danny Bega, MD, MSCI has received royalties from the British Medical Journal. He has served as a contractor for Medscape, LLC. He is on the speaker’s bureau for Neurocrine, Adamas, and Teva Pharmaceuticals.
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Funding sources for study: N/A
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5. Balestrino R, Martinez-Martin P. Neuropsychiatric symptoms, behavioural disorders, and quality of life in Parkinson's disease. Journal of the neurological sciences. Feb 15 2017;373:173-178.
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DANCE THERAPY IN PD 6. Ventura MI, Barnes DE, Ross JM, Lanni KE, Sigvardt KA, Disbrow EA. A pilot study to evaluate multi-dimensional effects of dance for people with Parkinson's disease. Contemporary clinical trials. Nov 2016;51:50-55.
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7. Earhart GM. Dance as therapy for individuals with Parkinson disease. European journal of physical and rehabilitation medicine. Jun 2009;45(2):231238.
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Tango for treatment of motor and non-motor manifestations in Parkinson's disease: A randomized control study. Complementary therapies in medicine. 2015;23:175-184.
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DANCE THERAPY IN PD Table 1: A breakdown of the dance therapy and the talk therapy/support group (control) interventions by week Dance Therapy
Control - Group introductions - Discussion about dance/movement therapy and how it differs from typical dance - Each participant discussed how they currently use movement in their lives
Week 2 - Facilitator led group in repetitive and rhythmical movements
- Discussion of the Brain Dance program - Participants discussed their PD
Week 3 - Exploration of different rhythms and movement qualities such as time, rhythm, and weight, individually and collectively - Cool down and discussion about the experience as well as impressions of the different qualities
- Discussion of PD and Tai Chi - Discussion of leading research on Tai Chi - Demonstration of hand motions to get feel for the flow and tempo of tai chi class
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Week 1 - Seated warm up – head to toe improvisational movements – activate mind-body connection (this was repeated each week). - Across the floor steps and rhythms, led by facilitator - Balance check: rise onto toes, lift alternating legs, balance on one leg - Participants created a “dance” using movements that expressed something about themselves - Discussion of the experience
- Discussion of 7 ways to combat and prevent fatigue in PD - Participants discussed what affects their fatigue and what exercises can aid in symptom management
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Week 4 - Exploration of body attitude - Body attitude experiential exercise where participants took on another person’s body attitude/posture - Cool down and processing of the experience
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Week 5 - Discussion of the dance therapy experience thus - Discussion of yoga in PD far - Discussion of participants’ experiences with yoga and other forms of exercise - Discussion about benefits of Tango and PD - Participants engaged with and counted out the tango beat
Week 7 - Across the floor exercises - Small combination (4 counts of 8) - Focus on balance, coordination, and gait
- Discussion of PD medications - Discussion of current symptoms, management, and current medications
Week 8 - Across the floor exercises - Small combination (4 counts of 8) - Focus on balance, coordination, and gate
- Discussion of PD medications - Discussion of current symptoms, management, and current medications
Week 9 - Learned 3 different ballroom dance rhythms (foxtrot, tango, and waltz) - Cool down and discussion of the experience
- Group discussion on effects of Tango dance on PD
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Week 6 - Chacian dance therapy - Explored Tango rhythms and movement - Cool down and discussion of the experience
Week 10 - Similar balance check as week 1 - Participants reflected on the past 10 weeks - Participants created a “dance” using movements - Brief recap on previous discussions and that expressed what the program meant to them – topics movements were pieced together to create choreography that was then performed - Discussion of the10-week experience
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Final Dance
Mean Change Dance
Baseline Control
Final Control
Mean Change Control
Age
66.44
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---
75.50
---
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H&Y
2.11 (SD 0.33)
2.11 (SD 0.33)
0
2.50 (SD 1.00)
2.50 (SD 1.00)
0
11.89 (SD 5.44)
11.44 (SD 5.36)
-0.45*
10 (SD 3.65)
9.25 (SD 6.24)
-0.75*
10.78 (SD 5.69)
10.67 (SD 6.52)
-0.11*
10.75 (SD 3.50)
11.00 (SD 5.29)
+0.25
27.56 (SD 11.57)
23.44 (SD 10.61)
-4.12*
40.75 (SD 8.66)
39.00 (SD 11.97)
-1.75*
5.22 (SD 4.09)
3.89 (SD 2.80)
-1.33*
4.25 (SD 2.87)
1.00 (SD 2.00)
-3.25*
55.44 (SD 15.88)
49.44 (SD 15.86)
-6.01*
65.75 (SD 13.07)
60.25 (SD 18.39)
-5.50*
MoCA
27.00 (SD 2.18)
27.44 (SD 2.40)
25.25 (SD 1.5)
24.75 (SD 0.96)
-0.50
TUG
8.41 (SD 1.57)
7.84 (SD 1.62)
-0.57*
14.43 (SD 8.97)
14.12 (SD 10.09)
-0.31*
BBS
51.78 (SD 2.64)
54.33 (SD 1.66)
+2.55*
42.75 (SD 11.90)
49.00 (SD 6.68)
+5.25*
BDI
9.56 (SD 6.67)
10.89 (SD 5.53)
+1.33
4.00 (SD 1.41)
5.50 (SD 2.38)
+1.50
FSS
34.22 (SD 10.93)
34.22 (SD 14.01)
0
33.00 (SD 8.45)
27.50 (SD 14.66)
-5.50*
VAFS
6.56 (SD 1.94)
6.11 (SD 2.47)
-0.03*
6.50 (SD 2.65)
8.00 (SD 1.63)
+1.50
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MDSUPDRS I MDSUPDRS II MDSUPDRS III MDSUPDRS IV MDSUPDRS Total
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Baseline Dance
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Table 2: Mean baseline, final, and change in variable measures for dance therapy and control groups.
30.89 37.67 +6.78 25.50 (SD 14.80) 30.25 (SD 16.78) +4.75 (SD 17.39) (SD 15.85) * = change in direction of improvement, H&Y = Hoehn and Yahr, UPDRS = Unified Parkinson’s Disease Rating Scale, MoCA = Montreal Cognitive Assessment, TUG = Timed Up and Go, BBS = Berg Balance Scale, BDI = Beck Depression Inventory, FSS = Fatigue Severity Scale, VAFS = Visual Analog Fatigue Scale, PDQ = Parkinson’s Disease Questionnaire
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PDQ-39
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Figure 1: Shows participant’s responses to the exit survey statement “I enjoyed the class” to assess participant satisfaction of both the dance therapy and control interventions.
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Figure 2: Shows participant’s responses to the exit survey statement “I felt I benefited from the class” to assess participant’s perceived value of both the dance therapy and control interventions.
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S0965-2299(18)30417-5 https://doi.org/10.1016/j.ctim.2018.07.005 YCTIM 1872
To appear in:
Complementary Therapies in Medicine
Received date: Revised date: Accepted date:
6-5-2018 8-6-2018 6-7-2018
Please cite this article as: Michels K, Dubaz O, Hornthal E, Bega D, “Dance Therapy” as a Psychotherapeutic Movement Intervention in Parkinson’s Disease, Complementary Therapies in Medicine (2018), https://doi.org/10.1016/j.ctim.2018.07.005 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
DANCE THERAPY IN PD Title: “Dance Therapy” as a Psychotherapeutic Movement Intervention in Parkinson’s Disease Authors: Kristi Michels1, Ornella Dubaz, MD2, Erica Hornthal, MA3, Danny Bega, MD, MSCI4*
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Affiliations: 1Northwestern University Feinberg School of Medicine,2Northwestern Memorial Hospital, Department of Neurology, 3Chicago Dance Therapy,4Northwestern University Feinberg School of Medicine, Department of Neurology *Corresponding author: Danny Bega, MD, MSCI 710 N Lake Shore Dr, Room 1124 Chicago, IL 60611 Phone: 312-503-5706 [email protected]
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Running title: Dance Therapy in PD
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Highlights Dance therapy is the psychotherapeutic use of movement to improve physical, emotional, cognitive, and social wellbeing. 13 subjects with PD were randomized 2:1 to dance therapy or support group control. All participants in dance therapy enjoyed the classes and most felt they were beneficial. Pre-determined feasibility goals were met. Clinical outcomes were explored and warrant further study in a powered study with groups matched for disease severity.
Abstract Background: Previous studies in Parkinson’s Disease (PD) have described benefits of dance for motor and non-motor outcomes, yet few studies specifically look at Dance Therapy (DT) as a specific psychotherapeutic model for PD. DT is the psychotherapeutic
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DANCE THERAPY IN PD use of movement to improve physical, emotional, cognitive, and social integration and wellbeing. Objective: 1) Explore the safety and feasibility of a 10-week DT program for PD. 2) Collect pilot data on efficacy of DT.
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Design/Methods: Prospective, randomized-controlled study in subjects with PD. 13 participants randomized 2:1 to DT (n=9) or support group (n=4). Assessments were completed 1-2 weeks prior to the first session and after the final session, and included attendance, Hoehn and Yahr Scale (H&Y), Unified Parkinson’s Disease Rating Scale (MDS-UPDRS), Montreal Cognitive Assessment, Timed Up and Go, Berg Balance Scale, Beck Depression Inventory, Fatigue Severity Scale, Visual Analog Fatigue Scale, Parkinson’s Disease Questionnaire-39, and an exit satisfaction survey.
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Results: All participants completed the study. The control group was older and had a higher mean baseline MDS-UPDRS III score (27.56 dance vs. 40.75 control) and H&Y score (2.11 dance vs. 2.50 control). 7 of 9 in DT and all control subjects attended at least 70% of classes. All participants in DT enjoyed the classes and most felt they were beneficial. The greatest improvement in motor measures was in MDS-UPDRS III (-4.12 (dance) vs. -1.75 (control)). Non-motor outcomes were explored as well.
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Conclusions: DT is introduced as an enjoyable mind-body intervention for PD. Further studies powered for efficacy and with groups matched for disease severity are warranted.
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Keywords: dance therapy; Parkinson’s disease
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Introduction: Parkinson’s Disease (PD) is a neurodegenerative movement disorder characterized by a constellation of motor symptoms such as tremor, bradykinesia, rigidity, and impaired gait and balance.1,2 Pharmacological PD treatments focus on improving these motor symptoms but over time patients can develop treatment-resistant symptoms and motor complications.3 Non-motor manifestations of PD are also common and include cognitive impairment, fatigue, autonomic changes, mood disorders, and sleep disturbances.1,4,5 Non-motor symptoms can be disabling and lead to a significant decrease in quality of life.5 Non-motor problems may limit the pharmacological treatment of motor symptoms and effective treatments for non-motor symptoms are not always available.2,6 For these reasons, there is increasing interest among patients and providers in pursuing mind-body interventions, such as Dance Therapy, which have the potential to simultaneously address motor and non-motor symptoms of PD.4,7,8 Dance involves the practice of fluid movements, postures, and body control, which may address the rigidity, bradykinesia, and postural instability associated with PD.8-11 Tango specifically addresses movement initiation, as well as directional and speed changes that may help with bradykinesia in PD.7,8 Dance is proposed to offer cognitive and social benefits as well. The activity requires planning movements,
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following music and signals, and remembering choreography.9,12 The sense of community and enjoyment that comes from dancing and listening to music with other people may also address common problems such as depressed mood, fatigue, and isolation.4,7,8,12,13 Numerous studies of dance interventions show positive effects on gait and balance in PD. We previously conducted a systematic review of dance studies in PD and found 6 randomized controlled trials involving a total of 254 participants demonstrating improvements in gait and balance tango, waltz/foxtrot, and Irish dance.2 Dance also appears to have a positive effect on non-motor symptoms. In a review of 6 studies involving a total of 146 participants using tango, ballroom, Irish dance or a combination of aerobic, jazz, tango and ballet, dance appeared to improve cognition, apathy and showed a mild trend to improved fatigue.14 Dance/movement Therapy (DT) is a specialized form of dance that differs from traditional dance instruction because it not only speaks to the aesthetic, educational, and recreational parts of dance, but it also incorporates the bio-psychosocial development of an individual. According to the American Dance Therapy Association, “Dance Therapy is the psychotherapeutic use of movement to further the emotional, cognitive, physical and social integration of the individual.”15 A “Dance Therapist” focuses on movement behaviors as they emerge in the therapeutic relationship and environment. The therapist uses movement to facilitate a compassionate relational opportunity within each session in a holistic body-centered approach to promoting health and wellness.15 In DT, participants are encouraged to express emotions through movement. Body awareness and mobility is addressed as in other dance programs, but with a unique emphasis on social support and emotional recognition. In this way, DT marries traditional “talk therapy” with a body-centered approach to health and wellness. The psychosocial benefits of dance are well recognized in the dance community and many dance classes incorporate elements of DT into their programs. A study in PD using structured interviews demonstrated the positive influences of socialization and communication in decreasing participant isolation and quality of life.16 Similar psychosocial benefits have been described in other populations including cancer patients and patients with cerebral palsy.17,18 We were interested in how the PD community would receive a DT intervention, and how the intervention would impact both motor and non-motor aspects of the disease. We explored the feasibility of DT in patients with PD and collected pilot data on efficacy of DT on motor and non-motor symptoms of PD compared to a control support group.
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Methods: This was a prospective, randomized controlled study designed to assess the feasibility, safety, and participant satisfaction with DT compared to a traditional talk therapy support group in patients with PD. Exploratory analysis of motor and non-motor PD outcomes, with fatigue being of particular interest due to lack of effective treatment strategies, was also performed for pilot data on the efficacy of DT. Participants were randomized 2:1 to a customized group DT session or a support group control. The study aimed to recruit 15-20 participants based on what the instructors felt was a feasible class size and instructor-to-participant ratio. Romenets et al showed improvement in motor and non-motor measures of PD with a 12-week Tango dance intervention.12 We elected to conduct sessions for 60 minutes weekly over 10 weeks due to instructor availability. The study received research ethics approval from the institutional review board. Participants were recruited from the Northwestern Parkinson’s Disease and Movement Disorders Center. Dance therapy and talk therapy classes took place at a movement studio located inside the Chicago Sports Institute in a northern suburb of Chicago. All
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classes were facilitated and supervised by the same board-certified dance therapists and licensed clinical counselors. Participants included in the study were adults with a diagnosis of idiopathic PD as determined by a movement disorders expert. Subjects were included regardless of their Hoehn & Yahr (H&Y) stage or disease severity. All participants had to be on a stable PD medication regimen for at least one month prior to the study and continue that regimen without any changes throughout the course of the study. Participants were excluded if they participated in any therapeutic dance intervention within the three months before the start of the study or initiated any new PD treatments or involvement in other PD-focused interventions throughout the course of the study. Participants were also excluded if they had significant cognitive impairment determined by a Montreal Cognitive Assessment score (MoCA) less than 24, or were under the age of 18, due to inability to provide informed consent. Eligible participants were randomized using a computer block design in a 2:1 ratio to DT or a support group. All DT sessions were led by the same instructor, a board-certified dance therapist with experience working with patients with PD as well as other neurological disorders. Dance exercises were catered to the individual in order to accommodate different levels of functional capacity. The intervention was organized by the dance therapist based on her anecdotal success with classes offered to the PD community. The DT sessions emphasized: 1) an understanding of how movement influences mood and mental health; 2) balance, gait, and coordination; 3) expression of thoughts, feelings, and emotions through movement and dance. The dance therapist also led the support group which involved education about how movement influences mood and mental health, ways to incorporate movement and dance into daily life, and exploration of feelings and emotions in a supportive group environment. The control group practiced no actual physical exercises or techniques. The sessions are outlined in greater detail in Table 1. The primary aim of the study was to explore whether a 10-week, weeklycustomized course of DT was safe, feasible, and enjoyable for patients with idiopathic PD at any stage. Class attendance was measured, and an exit survey on satisfaction of the program was administered after the final week. The instructor and research coordinator logged adverse events each week. The primary feasibility goal was predetermined as at least 70% of participants attending at least 70% of the classes. Exploratory efficacy outcomes included motor and non-motor assessments. These assessments were completed under the supervision of a trained movement disorders specialist who was blinded to class assignment 1-2 weeks prior to the program (baseline) and repeated 1-2 weeks after its conclusion (final). Motor outcome measures assessed included the changes in the H&Y, Movement Disorder Society Unified Parkinson’s Disease Rating Scale (MDS UPDRS), Berg Balance Scale (BBS), and Timed Up and GO (TUG). Non-motor measures were administered by the study coordinator and included the MOCA, Parkinson’s Disease Quality of Life Scale (PDQ39), Beck Depression Inventory (BDI), Fatigue Severity Scale (FSS), and Visual Analog Fatigue Scale (VAFS). Assessments took a total of 30 minutes to complete. Descriptive statistics were calculated for all variables of interest. Results: 14 participants were screened and 13 met eligibility criteria and were enrolled in the study. 1 participant was excluded for a MOCA score below 24. 9 participants were randomized to DT and 4 to the control group. All participants completed the study. Baseline characteristics are shown in table 2. There were 6 male and 7 female participants, most of whom were white. The mean age of the cohort was 69.2 (SD 8.7), and the mean UPDRS part III score was 31.6 (SD 12.2). The control group was older
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DANCE THERAPY IN PD and had a higher mean baseline MDS-UPDRS III score (27.56 dance vs. 40.75 control) and H&Y score (2.11 dance vs. 2.50 control).
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Safety and Feasibility: There were no serious adverse events related to the study’s intervention or control sessions. One participant in the DT group developed low back pain, which was characterized as mild and kept the participant from participating in one session. It was unclear to the investigators if this was related to the study intervention. The predetermined attendance outcome was met with 7 of 9 subjects in the dance group and 4 of 4 subjects in the control group who attended at least 70% of the classes. Reasons for absences included conflicting commitments, travel plans, illness, and trouble with travel arrangements.
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Satisfaction: The program satisfaction measures are illustrated in figure 1 and 2. All participants in the DT group enjoyed the classes and 7 of 9 felt that they benefited from them, while the other 2 felt neutral. The only participant in the study who did not enjoy or feel they benefited from the classes was in the control group and indicated that they were disappointed to not be in the DT group. 6 of the 9 participants in the DT group and 2 of the 4 participants in the control group stated they would attend similar classes in the future and recommend the program to other patients with PD.
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Exploratory outcomes related to motor and non-motor function: The mean change in motor measures included MDS-UPDRS II (-0.11 dance vs. 0.25 control), MDS-UPDRS III (-4.12 dance vs. -1.75 control), MDS-UPDRS IV (-1.33 dance vs. -3.25 control), TUG (-0.57 dance vs. -0.31 control), BBS (2.55 dance vs. 5.25 control), and PDQ-39 (6.78 dance vs. 4.75 control), with the greatest improvement being in MDS-UPDRS III. The mean change in non-motor measures included MDS-UPDRS I (0.45 dance vs. -0.75 control), MoCA (0.44 dance vs. -0.50 control), BDI (2.55 dance vs. 5.25 control), FSS (0 dance vs. -5.50 control), VAFS (-0.03 dance vs. 1.50 control), and PDQ-39 (6.78 dance vs. 4.75 control). The study was not powered to assess whether any of these differences were statistically significant.
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Discussion: This is the first study of DT as a psychotherapeutic movement intervention in PD. The study met all three primary aims showing that DT is safe, feasible, and enjoyable in patients with PD regardless of disease severity. Pre-determined attendance criteria were met, with 85% of subjects attending over 70% of the classes, and no participants withdrew from the study. Strong participant adherence to the program may indicate acceptance of DT as an adjuvant treatment for PD patients, although we acknowledge that self-selection for the study has an impact on this. Every participant who completed the program enjoyed the DT intervention and the majority felt that they benefited from these classes. Most participants stated they would recommend the program to a friend and attend more classes if they were offered. The control group was given the opportunity to complete 10 DT sessions similar to the programs’ original 10 sessions after the end of the study and showed similar enthusiasm and enjoyment. Enough participants in both groups appreciated and enjoyed the classes persuading the dance therapist in charge of the intervention to hold another 10-week session after the study completed. Similar findings in reviews of mostly tango studies by Shanahan and Lotzke, including high attendance rates, requests to continue the classes
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and satisfaction with the classes, indicate that dance may facilitate long-term compliance.19-21 Recruitment was challenging limiting the sample size. Some participants could not commit to the study because of a lack of proximity to, or foreseen difficulty traveling to, the Chicago Sports Institute. Future studies may be more successful by offering classes in multiple locations or providing transportation for participants. Results of exploratory analysis of motor and non-motor variables are demonstrated in Table 2, though the study was not powered to determine whether these differences are significant. The DT group and the control group were not well matched for age and H&Y despite randomization due to a limited sample size. For these reasons, a larger study powered to determine significant changes would be needed in order to determine efficacy of the therapeutic intervention and provide for successful randomization. This pilot study suggests that DT has the potential to improve motor symptoms in people with PD. Improvement in UPDRS III scores were seen in our DT group although results were non-significant. Improvements in these scores have also been demonstrated in multiple tango/ballroom dance studies.22-24 Dance may be effective in targeting motor symptoms of PD because it incorporates the stretching and strengthening of muscles and increases flexibility throughout the body, which may help maintain balance in people with PD.7 Another possibility is that practice of dance may activate areas of the brain that normally show reduced activation in PD.7 PET studies have shown that blood flow to the cerebellum increases when dance steps are performed.25 Calvo-Merino et al found that primary motor regions and motor-planning regions, including pre-motor and supplementary motor areas, were activated while participants learned complex dance sequences, and suggested that dance impacts motor and pre-motor networks in the brain.26 Sacco et al found similar results with Tango lessons.27 It has been hypothesized that dance may change underlying neural mechanisms in PD by improving functional connectivity in motor networks resulting in improved motor performance, including gait and balance.28 The non-motor benefits of dance have previously been described for cognition.14 depression, apathy and quality of life.4 DT is a more holistic, mind-body approach to dance. Body awareness is emphasized more so than during a regular dance class and participants are counseled to make the connection between their thoughts and their body movements.29 Participants are also encouraged to link their movement to what they are experiencing emotionally or physically and even express that emotion through movement. DT combines the benefits of mobility with social support and the expressive process.30 Improvements in mood are therefore plausible through this expression of emotion. Community dance classes often incorporate elements of psychosocial therapy and studies in various populations have described specific psychosocial benefits of dance interventions.17,18 Subjective reports of improvements in social isolation and quality of life have been reported in PD with other dance interventions.16 Both of our groups received education on the benefits of DT, and both may have benefited from the therapeutic aspect and social interaction of the weekly sessions. It is possible that we would have seen more significant differences between our DT and control groups if our control would have been a no contact control group. As a social activity performed with others, DT shares elements of a support group.9 The intervention in this study was limited to once a week for 10 weeks. We might have seen more promising trends with sessions than ran more frequently or for a longer period of time. Most dance studies involve twice-weekly sessions of 60-90 minutes duration that span a period of 6-12 weeks.7 Natale et al recorded significant
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improvement of motor function and cognitive skills with a twice-weekly tango dance intervention over a 10-week period.31 The unique ability of a trained dance therapist to facilitate the intervention in patients of any stage of PD makes DT an appealing and likely beneficial adjuvant therapy for improving motor and non-motor symptoms in PD. An obstacle in studying the potential benefits of DT is accessibility to a dance therapist. However, if DT is found to be more beneficial than informal community dance classes or support groups, accessibility to therapists and classes may expand. Further studies would be necessary to reveal any advantage of DT in PD over a community based dance class or support group. Conclusion: This study explores the psychotherapeutic use of DT as a potential mind-body intervention for PD. This study supports the feasibility of a DT intervention in patients with PD. Classes were well attended, safe and participants enjoyed the intervention. A schematic for Dance Therapy class progression is introduced. Further studies powered for efficacy and with groups matched for disease severity are warranted.
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Authors’ Roles: Kristi Michels: Research project: Conception, organization, execution | Data Analysis: Design, execution, and creation of tables and figures | Manuscript: Writing of the first draft and revising later drafts Ornella Dubaz, MD: Manuscript: Review, critique, and helping to research and write the background section Danny Bega, MD, MSCI: Research project: conception, organization, execution | Data Analysis: Design, review, and critique | Manuscript: Review and critique
Financial disclosures: Kristi Michels has no financial disclosures Ornella Dubaz, MD has no financial disclosures
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Danny Bega, MD, MSCI has received royalties from the British Medical Journal. He has served as a contractor for Medscape, LLC. He is on the speaker’s bureau for Neurocrine, Adamas, and Teva Pharmaceuticals.
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Funding sources for study: N/A
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3. Muller T. Current and investigational non-dopaminergic agents for management of motor symptoms (including motor complications) in Parkinson's
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5. Balestrino R, Martinez-Martin P. Neuropsychiatric symptoms, behavioural disorders, and quality of life in Parkinson's disease. Journal of the neurological sciences. Feb 15 2017;373:173-178.
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DANCE THERAPY IN PD 6. Ventura MI, Barnes DE, Ross JM, Lanni KE, Sigvardt KA, Disbrow EA. A pilot study to evaluate multi-dimensional effects of dance for people with Parkinson's disease. Contemporary clinical trials. Nov 2016;51:50-55.
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9. Hashimoto H, Takabatake S, Miyaguchi H, Nakanishi H, Naitou Y. Effects of
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Tango for treatment of motor and non-motor manifestations in Parkinson's disease: A randomized control study. Complementary therapies in medicine. 2015;23:175-184.
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DANCE THERAPY IN PD Table 1: A breakdown of the dance therapy and the talk therapy/support group (control) interventions by week Dance Therapy
Control - Group introductions - Discussion about dance/movement therapy and how it differs from typical dance - Each participant discussed how they currently use movement in their lives
Week 2 - Facilitator led group in repetitive and rhythmical movements
- Discussion of the Brain Dance program - Participants discussed their PD
Week 3 - Exploration of different rhythms and movement qualities such as time, rhythm, and weight, individually and collectively - Cool down and discussion about the experience as well as impressions of the different qualities
- Discussion of PD and Tai Chi - Discussion of leading research on Tai Chi - Demonstration of hand motions to get feel for the flow and tempo of tai chi class
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Week 1 - Seated warm up – head to toe improvisational movements – activate mind-body connection (this was repeated each week). - Across the floor steps and rhythms, led by facilitator - Balance check: rise onto toes, lift alternating legs, balance on one leg - Participants created a “dance” using movements that expressed something about themselves - Discussion of the experience
- Discussion of 7 ways to combat and prevent fatigue in PD - Participants discussed what affects their fatigue and what exercises can aid in symptom management
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Week 4 - Exploration of body attitude - Body attitude experiential exercise where participants took on another person’s body attitude/posture - Cool down and processing of the experience
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Week 5 - Discussion of the dance therapy experience thus - Discussion of yoga in PD far - Discussion of participants’ experiences with yoga and other forms of exercise - Discussion about benefits of Tango and PD - Participants engaged with and counted out the tango beat
Week 7 - Across the floor exercises - Small combination (4 counts of 8) - Focus on balance, coordination, and gait
- Discussion of PD medications - Discussion of current symptoms, management, and current medications
Week 8 - Across the floor exercises - Small combination (4 counts of 8) - Focus on balance, coordination, and gate
- Discussion of PD medications - Discussion of current symptoms, management, and current medications
Week 9 - Learned 3 different ballroom dance rhythms (foxtrot, tango, and waltz) - Cool down and discussion of the experience
- Group discussion on effects of Tango dance on PD
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Week 6 - Chacian dance therapy - Explored Tango rhythms and movement - Cool down and discussion of the experience
Week 10 - Similar balance check as week 1 - Participants reflected on the past 10 weeks - Participants created a “dance” using movements - Brief recap on previous discussions and that expressed what the program meant to them – topics movements were pieced together to create choreography that was then performed - Discussion of the10-week experience
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Final Dance
Mean Change Dance
Baseline Control
Final Control
Mean Change Control
Age
66.44
---
---
75.50
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H&Y
2.11 (SD 0.33)
2.11 (SD 0.33)
0
2.50 (SD 1.00)
2.50 (SD 1.00)
0
11.89 (SD 5.44)
11.44 (SD 5.36)
-0.45*
10 (SD 3.65)
9.25 (SD 6.24)
-0.75*
10.78 (SD 5.69)
10.67 (SD 6.52)
-0.11*
10.75 (SD 3.50)
11.00 (SD 5.29)
+0.25
27.56 (SD 11.57)
23.44 (SD 10.61)
-4.12*
40.75 (SD 8.66)
39.00 (SD 11.97)
-1.75*
5.22 (SD 4.09)
3.89 (SD 2.80)
-1.33*
4.25 (SD 2.87)
1.00 (SD 2.00)
-3.25*
55.44 (SD 15.88)
49.44 (SD 15.86)
-6.01*
65.75 (SD 13.07)
60.25 (SD 18.39)
-5.50*
MoCA
27.00 (SD 2.18)
27.44 (SD 2.40)
25.25 (SD 1.5)
24.75 (SD 0.96)
-0.50
TUG
8.41 (SD 1.57)
7.84 (SD 1.62)
-0.57*
14.43 (SD 8.97)
14.12 (SD 10.09)
-0.31*
BBS
51.78 (SD 2.64)
54.33 (SD 1.66)
+2.55*
42.75 (SD 11.90)
49.00 (SD 6.68)
+5.25*
BDI
9.56 (SD 6.67)
10.89 (SD 5.53)
+1.33
4.00 (SD 1.41)
5.50 (SD 2.38)
+1.50
FSS
34.22 (SD 10.93)
34.22 (SD 14.01)
0
33.00 (SD 8.45)
27.50 (SD 14.66)
-5.50*
VAFS
6.56 (SD 1.94)
6.11 (SD 2.47)
-0.03*
6.50 (SD 2.65)
8.00 (SD 1.63)
+1.50
U
N
+0.44*
M
D
TE
EP
MDSUPDRS I MDSUPDRS II MDSUPDRS III MDSUPDRS IV MDSUPDRS Total
SC RI PT
Baseline Dance
A
Table 2: Mean baseline, final, and change in variable measures for dance therapy and control groups.
30.89 37.67 +6.78 25.50 (SD 14.80) 30.25 (SD 16.78) +4.75 (SD 17.39) (SD 15.85) * = change in direction of improvement, H&Y = Hoehn and Yahr, UPDRS = Unified Parkinson’s Disease Rating Scale, MoCA = Montreal Cognitive Assessment, TUG = Timed Up and Go, BBS = Berg Balance Scale, BDI = Beck Depression Inventory, FSS = Fatigue Severity Scale, VAFS = Visual Analog Fatigue Scale, PDQ = Parkinson’s Disease Questionnaire
A
CC
PDQ-39
14
D
M
A
N
U
SC RI PT
DANCE THERAPY IN PD
A
CC
EP
TE
Figure 1: Shows participant’s responses to the exit survey statement “I enjoyed the class” to assess participant satisfaction of both the dance therapy and control interventions.
15
TE
D
M
A
N
U
SC RI PT
DANCE THERAPY IN PD
A
CC
EP
Figure 2: Shows participant’s responses to the exit survey statement “I felt I benefited from the class” to assess participant’s perceived value of both the dance therapy and control interventions.
16