Tango for Treatment of Motor and Non-motor Manifestations in Parkinson's Disease.
Tango for Treatment of Motor and Non-motor Manifestations in Parkinson's Disease.
Parkinson's disease involves many motor difficulties as well as non-motor ones. Recent
 research has strongly suggested that exercise is very important for Parkinson's disease. We
 are interested especially in dance as a form of exercise, because it combines physical
 movements with balance tasks, social engagement, and mental stimulation. Therefore, we think
 dance classes may be a very beneficial exercise for Parkinson's disease; the purpose of this
 study is to see if Argentinean Tango classes might improve motor and non-motor manifestations
 of Parkinson's disease.
There is accumulating evidence for positive effects of exercise on gait speed, strength,
 balance, and quality of life for people with PD. Habitual physical activity can lower risk
 for developing PD. In toxin-induced animal models of PD, exercise may decrease neuronal
 injury. The key components of an exercise program in PD include: 1) cueing strategies to
 improve gait; 2) cognitive movement strategies to improve transfers; 3) exercises to improve
 balance, and 4) training of joint mobility and muscle power to physical capacity. Traditional
 exercise programs can meet these needs but often they are not very appealing for older adults
 including patients with PD. Unfortunately more than half of individuals with PD does not meet
 the recommended daily level physical activity.

 There is a connection between music and level of Dopamine, which is pivotal for establishing
 and maintaining behavior. According to recent study music-induced emotional states can
 increase dopamine release, partially explaining how musical experiences are so valued and why
 music is an especially potent pleasurable stimulus for most people, and is frequently used to
 affect emotional states.

 The development of interventions which combine exercise, with accessibility, enjoyability,
 good motivation to practice regularly improving mood and stimulating cognition would be ideal
 for individuals with PD. Dance may provide all of these characteristics, and so may be an
 affective useful and accessible intervention to improve motor impairments. Dance requires
 dynamic balance and permanent adjustment to the environment at the same time. It promotes
 enjoyment and encouragement interest in continuing participation. Habitual social dancers
 have superior balance, gait function, and reaction times compared with age-matched
 nondancers. Regular dancing improves balance and functional mobility, and increases
 motivation to continue healthful exercise-related behaviours in older adults.

 There is also evidence that exercise has a positive impact on cognitive function in
 vulnerable populations. Musical exercise improved cognitive function in residents of long-
 term care facilitations without diagnosis of dementia and in patients with established
 Alzheimer's disease. Particularly dance produces clinically important changes in measures of
 mental status and behaviour in patients with moderate to severe dementia.

 Social isolation is an important cause of the development of depression in the older
 population and it may be caused by numbers of factors, including mobility limitations:
 medical illness, and economic difficulties. The relationship between social isolation and
 depression is clear, as is the link between social engagement and improved mood and perceived
 quality of life. There is also an important link between social disengagement, depression and
 cognitive decline in elderly population. Dance classes occur in a group setting and it is
 forced social interaction, which may produce noticeable improvement in mood and subsequently
 decrease cognitive decline.

 There is currently an insufficient body of literature on dance for PD and much additional
 work is needed. Most studies on dance in PD have used small sample sizes and assessed
 short-term effects and long-term effects of dance intervention only focused in motor
 manifestations of PD. Consequently, the effect of dance on cognition, mood and motivation has
 not been yet explored in PD. There is insufficient literature about what type of dance is
 more beneficial for motor and non-motor manifestations in PD.

 Why Argentinean tango?

 Better improvements of balance and complex gait were observed in elderly participants in
 tango lessons compared with a walking group. Beneficial effect of Argentine tango was also
 suggested, compared to traditional exercise for improving balance and functional mobility in
 patients with PD. Furthermore, a positron emission tomography (PET) study has shown increased
 activity in the basal ganglia when tango movements were performed with a metered and
 predictable beat. Tango requires particular motor skills, including frequent initiation and
 cessation, a variety of movement speeds, rhythmic variation, and spontaneous multidirectional
 perturbations. These features target motor impairments with movement initiation, turning, and
 bradykinesia. Interesting, tango could also effectively address freezing of gait (FOG),
 because some step patterns mimic the rehabilitation exercises designed for those with FOG.
 Visual cues, such as a foot to step over, can improve FOG. Tango technique which involve
 stepping over a partner's foot, tapping a partner's foot, or crossing one foot over another,
 are steps similar to conventional rehabilitation for FOG. In addition, tango involves
 rhythmic rocking, or alternating shift of center of mass from foot to foot, which can be
 another good strategy for freezing. Tango appeared to have a larger effect on freezing
 compared to other styles of dancing (waltz/foxtrot). Tango involves the practicing of control
 of movement speed and size, which may improve walking velocity and stride length. It also
 adds slow and quick steps of varying lengths and requires continual adjustment of these
 features. Tango may be especially beneficial for addressing backward walking, a critical area
 given the tendency for falls in the backward direction in PD6. Surprisingly in a recent
 study, tango even significantly improved upper extremity function, which it may be reflective
 of a global impact of exercise on bradykinesia. Better improvements of balance and complex
 gait were observed in elderly participants in tango lessons compared with a walking group. No
 studies have examined the effect of tango on cognitive function, mood and motivation in
 patients with PD.
Inclusion Criteria:

 -  Patients will be eligible for inclusion if they have a diagnosis of idiopathic PD.

 -  The subjects must speak either English or French sufficiently to fill out
 questionnaires and understand the instructions for dance classes (classes will be
 bilingual).

 Exclusion Criteria:

 1. Patients who cannot stand for at least 30 min and walk for ≥3 m without an assistive
 device.

 2. Individuals with Hoehn and Yahr stage IV- V (severe and nonambulatory)

 3. Dementia, defined according to PD dementia criteria as MMSE< 26/30 and ADL impairment
 secondary to cognitive loss, or inability to understand consent process60

 4. Serious hearing and vision problems that could affect the participation in dance
 classes.

 5. Change to dopaminergic therapy over the preceding three months, or changes to
 antiparkinsonian medication are anticipated during the study protocol

 6. Serious medical conditions, including cardiac disease or evidence of musculoskeletal
 problem which precludes dancing or can be worsened by exercise

 7. History of frequent falls, with more than 3 falls in the last 12 months