Date of receipt: 04/26/2021 / Revision date: 05/12/2021 / Date of acceptance: 05/21/2021

Introduction

Parkinson's disease (PD) is a progressive neurodegenerative disorder that affects dopamine-producing cells in the substantia nigra, within the basal ganglia (Lötzke et al., 2015; Poewe et al., 2017; Pereira et al., 2019). Other cell groups in the central and peripheral autonomic nervous system are also affected. It is the second most common neurodegenerative disorder in the elderly and it is projected that by 2030 more than 9.3 million people will be diagnosed (Poewe et al., 2017). Given its epidemiological importance, the disease can be considered a public health problem (Tillmann et al., 2017). Its main clinical diagnosis is based on bradykinesia, referred to as slowness and difficulty in moving (Lötzke et al., 2015; Poewe et al., 2017).

This disease is associated with deficits in motor, cognitive, and emotional domains, impairing the quality of life of people who suffer from it (Ventura et al., 2016). Among the main motor symptoms are postural instability, tremors, lack of balance, as well as difficulties in the gait pattern, symptoms highly related to falls in this type of population, which generate devastating consequences, such as hip fractures, immobility, reduced quality of life and high medical expenses (Duncan & Earhart, 2014; Lötzke et al., 2015). Freezing of gait is the motor deficit that promotes the highest risk of falls in PD patients, potentially causing death or even psychological trauma resulting in fear of further falls (Pereira et al., 2019). Regarding non-motor symptoms, according to Bognar et al., (2017), fatigue, cognitive changes, as well as mood disorders are noteworthy. People with PD also cope with psychosocial aspects of chronic diseases, such as social isolation, decreased self-efficacy, and depression, affecting these symptoms to health-related quality of life (Sharp & Hewitt, 2014; Bognar et al., 2017).

It should be noted that as the disease progresses, the person's ability to perform activities of daily living (ADLs) may be impaired, leading to dependence on others (Foster et al., 2013). As mentioned above, the risk of falls is present in the lives of these people, so postural instability is a major risk factor for disability, worsening their health and leading to an increased risk of long-term hospitalization (De Natale et al., 2017).

More than half of the general population does not achieve the recommended daily levels of physical activity, and activity levels in people with Parkinson's disease are lower than in healthy older adults (McNeely et al., 2015b). Currently, sedentary lifestyles are a leading cause of death, as well as a high-risk factor for many chronic diseases, making this a major problem (McNeely et al., 2015b). (Kruk, 2014). This has become a global public health problem in the 21st century (Kruk, 2014; Gaetano, 2016). It is therefore necessary to raise public awareness of the negative effects of physical inactivity on health and the development of diseases (Gaetano, 2016). Participation in physical-sports activities is positively correlated with functional status and life satisfaction. (Foster et al., 2013). It also protects against physical and cognitive deterioration as people get older, this aspect being more relevant in people with Parkinson's disease. (Foster et al., 2013).

Often people with PD reduce their level of physical activity due to impaired mobility, fear of falling, or low outcome expectations (Lötzke et al., 2015). However, physical activity has been an effective adjunct to PD treatments, but sometimes the practice of some activities or exercises may not be sufficiently engaging or socially appealing (Duncan & Earhart, 2014). Consequently, approaches to therapies for people with Parkinson's disease aim to counteract the physical impairments and impairments of the disease, but often do not take into account what kind of exercises or activities are interesting for the target group and how to increase long-term participation (Lötzke et al., 2015).

Therefore, according to Duncan & Earhart, (2014), it is necessary to look for innovative activities that arouse the interest of the target group. To this end, dance can be seen as a nonpharmacological alternative (Bearss et al., 2017), as older adults believe that dance is more enjoyable than traditional exercise, and in turn promotes adherence and motivation (Duncan & Earhart., 2014).

Since ancient times, dance has had a therapeutic connotation, which today is still present in some cultures (Valverde Guijarro & Flórez García, 2012), keeping this discipline related to wellness and different healing rituals, tracing these aspects to the history of mankind. (Kalyani et al., 2019). Nowadays, dance is considered a form of expression and movement that contains elements of rhythm and corporal action. (Sanchez et al., 2011). It is characterized by its way of exercising the body and mind simultaneously, activating the organism to optimal effort thresholds and stimulating the memory by remembering certain sequences. (Sanchez et al., 2011). Nowadays, dance is also understood as a form of expression and/or communication in many societies around the world. (Kalyani et al., 2019).. However, there is great ignorance about the contributions of dance in the health and quality of life of people, not only physically but also psychologically (Sanchez et al., 2011).

Dance is a physical activity that can challenge gait and balance impairment in people with PD. Many dance styles include walking as a primary step, which encourages task-specific practice. Dynamic balance challenges are often incorporated into dance, as the subject has to adapt to a constantly changing environment while moving (Duncan & Earhart, 2014). Dance can improve motor and cognitive performance, as well as facilitate long-term physical activity compliance because it incorporates exercise and socialization which helps motivate individuals with PD to engage in physical activity. (De Natale et al., 2017; (Prewitt et al., 2017).

As an enjoyable activity, dance combines a number of factors that benefit PD patients through: auditory cues, aerobic and strength exercises, stretching, and a supportive social community (Sowalsky et al., 2017). This is a multidimensional activity that offers auditory, visual, and sensory stimulation, as well as a musical experience, increased social interaction, and enhanced motor development (Sharp & Hewitt, 2014). Tillmann et al., (2017), state that activities that have a cultural aspect to the population in question, and are enjoyable, allow participants to engage in the long term. According to McNeely et al., (2015b), the contributions of this discipline to patients suffering from Parkinson's disease can generate numerous benefits when it comes to counteracting their symptoms, and thus improving their quality of life.

It is necessary to emphasize that music plays a primordial role in dance, being one of the most universal forms of expression of humanity (Welch et al., 2020). It is present in the daily lives of people of all ages and from all cultures around the world (Welch et al., 2020). When the body is in movement, and we follow a music, a relationship between both is created, because our body seeks to accompany that rhythm and the music facilitates the realization of controlled and rhythmic movement. (Sanchez et al., 2011). Movement therapy based on dance and music for patients with PD combines cognitive movement strategies, balance, and physical activity, while focusing on the enjoyment of movement to the rhythm of the music. (Lötzke et al., 2015; Fragnani & Bezerra, 2018).

Each discipline and/or style of dance presents different characteristics and qualities; however, the contributions of each of them in patients with PD are currently unknown, as well as the lack of consensus on the durations of dance classes and whether any particular modality generates greater benefits with respect to others (Bearss et al., 2017).

Therefore, the objective of this review is to determine the benefits of a dance program in patients with Parkinson's disease, as well as to determine if there are differences depending on the dance modality used.

Method

A systematic review was carried out, conducting the search during the months of February and March 2020. The following databases were used to explore the articles: Google Scholar, Pubmed, and Dialnet. The Spanish keywords used for the search were: "danza", "párkinson", "baile terapéutico", "tango en párkinson" and "enfermedad de párkinson", as well as the English terms: "dance", "Parkinson", "therapeutic dance", "tango in Parkinson" and "Parkinson disease".

As for the inclusion/exclusion criteria, we selected those articles no more than 10 years old and those that related Parkinson's disease to different dance programs and their benefits.

A total of 61 articles were identified in the initial search. After a first analysis, 4 articles that were repeated were eliminated, leaving 57 articles for further screening. After title/abstract analysis, 13 records were eliminated, leaving 41 articles selected for full-text analysis. Fourteen studies were included, which met the inclusion/exclusion criteria. In this last analysis, 3 articles were discarded because they did not meet the inclusion criteria.

Results

In total, 469 participants (233 women and 236 men) were analyzed in the studies present in this review. Table 1 describes the objectives of each intervention, participants, scales used, methodology, and main results. Of these, seven articles investigated the effects of dance on PD using only one dance modality; tango (Duncan & Earhart, 2012; McKay et al.,2016; Holmes & Hackney, 2017; Rawson et al., 2019; Poier et al., 2019), dance therapy (Michels, et al., 2018) and Thai dance (Khongprasert et al., 2012). The rest of the studies used more than one style of dance; Latin, ballroom, ballet, jazz, contemporary, or Zumba (Hackney & Earhart, 2010; Heiberger et al., 2011; Hashimoto et al., 2015; Delextrat et al., 2016; Kunkel et al., 2017; Hulbert et al., 2017; Kunkel et al., 2018). Two studies compared during their intervention a dance program with another type of physical activity; tango, stretching, and treadmill (Rawson et al., 2019) tango and Tai Chi (Poier et al., 2019). All interventions had objectives focused on finding benefits at the level of motor control, cognitive functions, and quality of life.

Discussion and conclusions

Dancing simultaneously affects motor function, cognitive function, and mental symptoms (Hashimoto et al., 2015; Holmes & Hackney, 2017). Notably, dance is associated with improvements in balance, freezing of gait, walking performance, and well-being (Aguiar et al., 2016), so dance therapy appears to be a complementary tool in treatment with PD (Hashimoto et al., 2015).

During dance programs, there is a risk of falls; however, partner dancing is potentially a safe intervention as subjects can serve as a support and has been shown not to create dependence or loss of balance, in addition having a dance partner fosters social support and self-perceived improvement (Hackney & Earhart, 2010; De Dreu et al., 2015; Poier et al.,2019). It is important during dance classes, the rhythm of the music, since when strong and marked rhythms are used, it provides a time frame, allowing precise synchronization of movements similar to external auditory signals (De Dreu et al., 2015; Hashimoto et al., 2015; Aguiar et al.,2016).

Within the different dance modalities, the tango modality has proven to be one of the most beneficial for this type of disease, increasing the speed of movement and balance. (McKay et al., 2016). The tango includes great variety of movements; walking backwards, speed changes, frequent stops, and starts (McNeely et al., 2015a). Tango movements, following a well-defined and precise rhythm, are associated with increased activation of neural areas that are not normally activated in PD patients and with stimulation of cortical activation by increasing motor skills (Hashimoto et al., 2015; De Dreu et al.,2015; Tillmann et al.,2017; Michels et al., 2018). Another of the most effective modalities, is the samba, due to the fact that its lateral steps, forward and backward, performed rhythmically, can stimulate cortical activation, as in tango, increasing attention and concentration (Tillmann et al.,2017). Highlighting that the two most challenging dances were the waltz (due to the crossing of the feet and changes of direction) and the cha-cha-cha (due to its speed and less holding) (Kunkel et al., 2017). Understanding the similarities and differences in the impacts of different dance styles on motor function may be important to inform the development of PD-based dance programs (McNeely et al., 2015a).

The European guideline for Parkinson's disease recommends dancing as a meaningful approach to improve functional mobility and balance (De Dreu et al., 2015). However, at present, there is no clear consensus on program durations, but several studies agree that a duration of 60-90 minutes per session twice a week for a period of 10-12 weeks is adequate for this type of subject. (Hackney & Earhart, 2010; Khongprasert et al., 2012; Hashimoto et al., 2015; McNeely et al., 2015b; Kunkel et al., 2017; Holmes & Hackney, 2017).

This review has analyzed the effects of dancing in patients with PD. The information provided is of great interest since improvements in health and quality of life can be observed, especially when the tango modality is used. However, there is a need for continued research and analysis of this type of alternative therapy, as well as a prior assessment of the patient's condition and disease, in order to offer a treatment according to their needs using the optimal durations and modalities for their condition.

As for the limitations encountered during the development of the work, it is worth highlighting the lack of studies that directly compare different dance modalities in their intervention, as well as studies with longer durations, which could determine whether the benefits can last over time.

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