June 2015

Adapted tango: bringing artistry to rehabilitation

6Tango-iStock44878978-copy-2By Madeleine E. Hackney, PhD 

Adapted tango, a version of traditional Argentine tango modified to address motor impairments, has been shown to improve balance, mobility, and cognition in older adults and patients with Parkinson disease, with better compliance than conventional rehabilitation.

Individuals with Parkinson disease (PD) experience reduced mobility from postural instability, bradykinesia (extreme slowness of movement), rigidity, turning difficulty, and freezing. These problems frequently lead to falls and withdrawal from society.1,2 A 2004 study showed that 70% of patients fell within a one-year period, and 50% of them fell again the following year.2 In addition, individuals with PD are 3.2 times more likely to sustain a hip fracture than people of similar age without PD.3 Older adults without PD also experience similar problems with walking, balance, and mobility. As pharmacological and surgical methods remain only partially effective in treating symptoms of PD, and fall risk and related injury are prevalent among older adults in this population, additional, nonpharmacol­ogical approaches that address balance and gait impairments are necessary.4

Exercise for older adults with and without PD is crucial for maintaining their health and independence. Habitual participation in physical activity, even when begun late in life, can improve postural and motor control in older individuals. Activities that engage older individuals and sustain interest are especially needed, as approximately 60% of Americans older than 65 years do not achieve the recommended daily amount of physical activity.5 Activity levels in individuals with PD are reduced even further, being roughly 15% lower than that of the same age group without PD.6

Adapted tango has the same spirit and structure as traditional Argentine tango, with aspects thought to be beneficial for patients with PD.

Dance

Rehabilitative programs for postural instability, particularly in individuals with PD, are effective if they incorporate dynamic balance practice and continual adjustment to environmental demands.7 These elements of motor challenge are provided by dance, which appears to be appropriate as a therapy because of its physical and emotional benefits.8 The social aspects of dance in a group setting may motivate older adults to pursue healthy exercise-related behaviors.9 Habitual participation in social dancing over several years is associated with superior balance, postural stability, gait function, and leg reaction times in older dancers compared with age-matched nondancers.10,11 Greater improvements in balance and complex gait tasks were also noted in older adults who participated in an Argentine tango group than in those who participated in a walking group.12 Some evidence suggests dance may improve quality of life (QOL) in older adults with multiple comorbidities.13,14

tango-table1

Adapted Argentine tango as therapy

In 2006, I adapted an Argentine tango dance program for people with PD, called adapted tango. Adapted tango is similar to traditional Argentine tango dancing, but the frame (positioning of partners relative to each other), some steps, and some positions have been modified to address the motor impairments and limitations of some people with PD and older adults. However, adapted tango has the same spirit and the general structure of traditional Argentine tango, which has steps, patterns, music, and partnered aspects thought to be beneficial for specific PD impairments.

Postural instability. In dancing tango, a dancer stands in single-leg support while a partner provides light balance assistance, often for periods that exceed those of normal gait cycles. Because dancers coordinate their timing to music and to choreographic patterns, they use postural control to anticipate center of mass perturbations and to perform requisite weight shifting during succeeding steps. Consistently attending to balance may increase general awareness of postural control and personal mobility.

Bradykinesia. Individuals with PD tend to move slowly in a phenomenon called bradykinesia, which translates from the Greek to “poverty of movement.” Coordinating steps with the musical beat may help increase the pace of movement, as auditory cues can enhance walking speed and step rate.15 Tango practice involves a tempo dictated by an external source as well as the need to maintain rhythm with one’s partner. The tango partner, the music, or the intrinsic rhythm of particular steps, as well as the wide range of tango movement speeds, may encourage dancers to push the boundaries of their perceived speed limitations.

Stride length. Because tango technique employs steps that range from short to long, dancing tango may be ideal for practicing spontaneous adjustments of stride length. In stepping backward, dancers are taught to extend the foot and toe back farther than a normal stride. Rhythmic somatosensory cues, richly provided through the upper limb contact maintained between partners in the frame, may help to regulate and increase stride length.16

Backward locomotion. The limits of stability of individuals with PD are reduced in the backward direction, which can lead to falls.17 In tango, dancers frequently walk backward in a way that allows them to dance comfortably with one another, maintain balance, and adjust quickly to multidirectional perturbations. Given that partners maintain physical connection through the arms and hands (the frame), providing light contact that can enhance balance, backward walking can be performed safely when individuals with PD are instructed properly.

Turning. Individuals with PD use more steps to turn and use less axial rotation during turns than individuals without PD and can experience freezing of gait while turning.8 Some classic Argentine tango turns involve pivoting over a single foot to varying degrees of rotation, which is extremely challenging for some individuals with PD. However, in adapted tango, modified turns are completed with several extra steps, and with little twisting of the hips or ankles. Partners turn in spatiotemporal coordination, following each other’s external cues and the mechanistic breakdown of turning patterns and footwork provided by the instructor.

Multitasking. Dual tasking is impaired with aging and further impaired in individuals with PD.19 Tango has been shown to improve dual task abilities in frail older individuals.12 Adapted tango requires participants to multitask by attending to posture, balance, foot placement, and the upcoming move. Dancers also attend to and control the amount of body weight directed toward their partners through the tactile connection of the frame. Also, dancers contend with other couples within the space of the dance floor and concentrate on trajectories being followed by those couples. Finally, dancers listen to, interpret, and respond to musical rhythms and phrasing while considering aesthetics: body postures, lines, and shapes of movement.

6tangochart-copyFreezing of gait. Walking in small and narrow spaces can often trigger freezing of gait. One dances tango in very close proximity to a partner and frequently among many other couples on the dance floor. Navigation through these couples occurs while traveling around the dance floor and performing intricate steps in place. Therefore, dancing tango offers the opportunity to practice moving in enclosed tight spaces within a safe and structured environment. The use of visual cues, such as a foot to step over, is known to help relieve freezing of gait.20 Tango requires practiced and careful attention to movement initiation; therefore, dancers may develop strategies to use cues such as the partner’s weight shifting and indicated direction of movement or the music’s beat in order to facilitate movement.

Internally guiding movement. In Argentine tango dancing, participants take on one of two roles, which could be thought of as distinct motor training approaches: leading (internally guiding movement plans) or following (responding to external guidance). Qualities of effective rehabilitative programs are found in both internally guided and externally guided training within the context of adapted tango. Specifically, for individuals with PD, having complex movements broken down into simpler elements by the teacher, something that is done in any dance pedagogy, may facilitate motor performance.21 Synchronizing movement to rhythm, which is inherent to dance, may enhance movement speed.15 Dancing with a partner may enhance balance, as even light-touch contact can augment postural control.22

Leading, which uses internally guided cognitive and motor skills, is thought to involve increased focus on movement plans and mentally rehearsing or preparing for movement. Leaders must determine the precise spatiotemporal movement parameters of a dance sequence. As such, leading may pose a challenge for individuals with PD, given that many have deficient executive control specifically related to cognitive processes involved in planning and executing complex goal-directed behavior.23 However, movement strategies involving strong cognitive involvement and planning are associated with mobility improvements in individuals with PD.21 Focusing on critical movement aspects (eg, longer steps, quicker movements) helps individuals with PD achieve nearly normal speed and amplitude.18

Abundant evidence demonstrates benefits of rehabilitative exercise that exploits external cueing and specifically targets neural systems that support balance.24,25 External cueing has improved movement initiation.20,26 People with PD have faster reaction times when externally cued compared with self-initiated movement.27 Importantly, during externally guided partnered movement, the follower receives movement guidance from the leader through tactile and, to a lesser extent, visual cues. Because followers are not devoting attentional resources to planning movement, potentially they attend more to postural control. When following (externally guided training) in adapted tango, participants focus on external cues, which may access cerebellar-thalamo-cortical circuitry and bypass the basal ganglia,28 and therefore benefit movement facilitation in those with PD.

Findings to date

In several studies conducted between 2006 and 2010, we demonstrated that individuals with idiopathic PD who participated in 20 adapted tango dance classes (60 minutes each) improved on measures of functional mobility, balance, gait, and quality of life.29-31 Socialization is important, but our 2013 adapted tango study investigating the efficacy of 20 90-minute classes demonstrated that getting up and moving are very important for motor gains.32 Even a high-dosage intensive tango program of 15 hours within two weeks was feasible, and had low attrition for individuals with mild to moderate PD.33

While the early research described above typically showed improvements in mobility, more recent efforts have evaluated the effects of adapted tango on cognition in individuals with PD. Thirty-three individuals with mild to moderate PD (stage I-III) were assigned to 20 lessons, each 90 minutes, focused on tango (n = 24) or education (n = 9). Disease severity, spatial cognition, balance, and fall incidence were evaluated before and immediately after intervention and 10 to 12 weeks postintervention. Tango participants had significantly more improvement in disease severity (p = .008) and spatial cognition (p = .021) than the education participants. Tango participants also significantly improved in balance (p = .038) and executive function (p = .012). Gains were maintained 10 to 12 weeks postintervention.32

Older adults with visual impairment have also benefitted from the same adapted tango program provided for individuals with PD. Thirty-two individuals with visual impairment (aged 79.3 ± 11 years, range 51-95 years) were assigned to 20 adapted tango or balance and mobility lessons, each 90 minutes, within 12 weeks. Participants underwent assessment of balance, dual-tasking, endurance, gait, and vision-related QOL. The balance reactions of participants in both groups significantly improved (p <.001). Endurance, cognitive dual-tasking, and vision-related QOL improved more for the tango group than the balance and mobility group. Group differences and gains were maintained one month after the program’s end.34

Importantly, we have also begun dissemination and implementation of adapted tango in the community for older adults. We taught a manualized program of adapted tango to nine dance instructor trainees, who then implemented the program in the community at six senior living communities for 62 older adults and 25 adults with PD. The efficacy of the program was demonstrated with mobility, gait, and balance measures. Safety and fidelity of the instructors to the program was also monitored and verified.35

The research described in this article demonstrates dance’s ability to penetrate one of the most challenging human conditions: the gradual degeneration of the ability to move.

Broader clinical implications

Changes noted on both clinical and laboratory measures in the earlier studies characterizing the motor effects of adapted tango may have functional significance and impact the daily lives of individuals with PD (Table 1). Specifically, changes were noted in the Unified Parkinson’s Disease Rating Scale-III,29,30,36 the Berg Balance Scale (BBS),29,30,31,36 six-minute walk test,30,31,36 and gait variables (velocity, stride length, cadence, swing percent).30,31 For example, a .1 m/s increase in velocity is considered a substantial meaningful change, with clinical relevance, in older adults with mild to moderate mobility deficits.37 The minimal detectable change on the BBS in parkinsonism, 2.84 points,38 was exceeded.29,30,31,36 Improved endurance from dance training may have been reflected in increased walking distance in the six-minute walk test.30,31,36 Salient improvements were noted in comfortable, backward, and fast walking.30,31,36

Conclusion

In impaired older adults, 60% to 85% adherence to physical activity is considered high.39 With an 85% compliance rate, partnered dance’s feasibility has been demonstrated, along with benefits related to functional mobility and QOL in persons with PD, with initial evidence of efficacy within the general older population, as well. Maintenance of gains was also demonstrated, and participants reported favorable impressions and interest in continuing.31,32

Possibly, learning both leader and follower roles, and switching these roles several times during a dance session, may enhance mobility and the ability to accomplish daily activities. Motor skills needed to complete activities of daily living often require adaptability to ever-changing and unpredictable environments. While the practice and rehearsal of known or comfortable steps may reinforce “healthy” movement patterns, it may not encourage adaptability. By continually exercising mental and motor capacities through an ever-expanding motor repertoire and by switching roles repeatedly, older adults with PD may be better prepared to shift quickly to an appropriate motor skill in response to sudden changes in their environment.

In adapted tango classes, instructors have encouraged the honing of partnership skills by maintaining connection through the embrace while changing weight fully, walking backward, maintaining posture, and alignment. Participants are given ample time to practice steps and develop some confidence in their ability to perform these steps; however, some individuals with PD have expressed a preference for learning fewer steps but repeatedly practicing them. Switching the leading and following roles is also viewed as challenging. Learning new movements can be difficult and frustrating, and aging and disease increase the challenges. However, the acts of learning, practicing, and exploring new movement in a partnership should be emphasized over the perfection of any one step.

Balance and mobility disorders resulting in falls among older adults with and without PD pose a serious public health problem in the US. There are unprecedented numbers of people aged 85 years and older in the US who want to maintain independence throughout their lifetimes. Therefore, there is an immediate need for activity programs specifically designed to reduce physical frailty and the rising incidence of falls among the older adult population, as well as those with PD. For these programs to be most effective, continued research to determine mechanisms of improvement and to optimize training programs must be conducted.

Currently, there is insufficient information about how humans communicate the complex, sophisticated motor intentions of partnered dance by tactile means. How do partnered dancers interpret subtle changes in pressure at points of contact in order to determine (or influence) direction, magnitude, and timing? Knowledge about neural changes that may occur after repeated and targeted training with leading and following tasks will allow the development of better rehabilitation training strategies for those with PD.

Argentine tango is a partnered dance with worldwide presence. People dance tango all over the world, and many have become fanatical about it. Research on adapted tango has also appealed to individuals the world over, and studies about its effectiveness are taking place in a number of locations, including Australia, the UK, Argentina, the US, and Canada. Given the involvement of international researchers in the debilitating illness of PD, the melding of neurological rehabilitation with further study of dance and its powerful mechanisms will lead to the development of cross-cutting, novel ideas that transcend international and specialty-specific boundaries.

This work has underscored the power of dance to heal and to form connections between individuals of diverse backgrounds and needs. Dance has always had a multifaceted role in society. The research described here demonstrates dance’s ability to penetrate one of the most challenging human conditions: the gradual degeneration of the ability to move. Through dance, all of us—even those who are the most challenged—may be able to learn to move again.

Madeleine E. Hackney, PhD, formerly a professional dancer, is a research health scientist at the Atlanta VA Center for Visual and Neurocognitive Rehabilitation and an assistant professor of medicine at Emory University School of Medicine in Atlanta.

REFERENCES
  1. Bloem BR, van Vugt JP, Beckley DJ. Postural instability and falls in Parkinson’s disease. Adv Neurol 2001;87:209-223.
  2. Bloem BR, Hausdorff JM, Visser JE, Giladi N. Falls and freezing of gait in Parkinson’s disease: a review of two interconnected, episodic phenomena. Mov Disord 2004;19(8):871-884.
  3. Melton LJ, 3rd, Leibson CL, Achenbach SJ, et al. Fracture risk after the diagnosis of Parkinson’s disease: Influence of concomitant dementia. Mov Disord 2006;21(9):1361-1367.
  4. Gage H, Storey L. Rehabilitation for Parkinson’s disease: a systematic review of available evidence. Clin Rehabil 2004;18(5):463-482.
  5. Macera CA, Ham SA, Yore MM, et al. Prevalence of physical activity in the United States: Behavioral Risk Factor Surveillance System, 2001. Prev Chronic Dis 2005;2(2):A17.
  6. Toth MJ, Fishman PS, Poehlman ET. Free-living daily energy expenditure in patients with Parkinson’s disease. Neurology 1997;48(1):88-91.
  7. Hirsch MA, Toole T, Maitland CG, Rider RA. The effects of balance training and high-intensity resistance training on persons with idiopathic Parkinson’s disease. Arch Phys Med Rehabil 2003;84(8):1109-1117.
  8. Kudlacek S, Pietschmann F, Bernecker P, et al. The impact of a senior dancing program on spinal and peripheral bone mass. Am J Phys Med Rehabil 1997;76(6):477-481.
  9. Palo-Bengtsson L, Winblad B, Ekman SL. Social dancing: a way to support intellectual, emotional and motor functions in persons with dementia. J Psychiatr Ment Health Nurs 1998;5(6):545-554.
  10. Eyigor S, Karapolat H, Durmaz B, et al. A randomized controlled trial of Turkish folklore dance on the physical performance, balance, depression and quality of life in older women. Arch Gerontol Geriatr 2009;48(1):84-88.
  11. Federici A, Bellagamba S, Rocchi MB. Does dance-based training improve balance in adult and young old subjects? A pilot randomized controlled trial. Aging Clin Exp Res 2005;17(5):385-389.
  12. McKinley P, Jacobson A, Leroux A, et al. Effect of a community-based Argentine tango dance program on functional balance and confidence in older adults. J Aging Phys Act 2008;16(4):435-453.
  13. Hackney ME, Earhart GM. Health-related quality of life and alternative forms of exercise in Parkinson disease. Parkinsonism Relat Disord 2009;15(9):644-648.
  14. Hackney ME, Bennett C. Dance therapy for individuals with Parkinson’s disease: improving quality of life. J Parkinsonism RLS 2014;4:17-25.
  15. Howe TE, Lovgreen B, Cody FW, et al. Auditory cues can modify the gait of persons with early-stage Parkinson’s disease: a method for enhancing parkinsonian walking performance? Clin Rehabil 2003;17(4):363-367.
  16. van Wegen E, de Goede C, Lim I, et al. The effect of rhythmic somatosensory cueing on gait in patients with Parkinson’s disease. J Neurol Sci 2006;248(1-2):210-214.
  17. Horak FB, Dimitrova D, Nutt JG. Direction-specific postural instability in subjects with Parkinson’s disease. Exp Neurol 2005;193(2):504-521.
  18. Morris ME, Huxham F, McGinley J, et al. The biomechanics and motor control of gait in Parkinson disease. Clin Biomech 2001;16(6):459-470.
  19. Yogev G, Giladi N, Peretz C, et al. Dual tasking, gait rhythmicity, and Parkinson’s disease: which aspects of gait are attention demanding? Eur J Neurosci 2005;22(5):1248-1256.
  20. Jiang Y, Norman KE. Effects of visual and auditory cues on gait initiation in people with Parkinson’s disease. Clin Rehabil 2006;20(1):36-45.
  21. Morris ME, Iansek R, Kirkwood B. A randomized controlled trial of movement strategies compared with exercise for people with Parkinson’s disease. Mov Disord 2009;24(1):64-71.
  22. Jeka JJ. Light touch contact as a balance aid. Phys Ther 1997;77(5):476-487.
  23. Kliegel M, Phillips LH, Lemke U, Kopp UA. Planning and realisation of complex intentions in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 2005;76(11):1501-1505.
  24. Nieuwboer A, Rochester L, Muncks L, Swinnen SP. Motor learning in Parkinson’s disease: limitations and potential for rehabilitation. Parkinsonism Relat Disord 2009;15(Suppl 3):S53-S58.
  25. Kadivar Z, Corcos DM, Foto J, Hondzinski JM. Effect of step training and rhythmic auditory stimulation on functional performance in Parkinson patients. Neurorehabil Neural Repair 2011;25(7):626-635.
  26. Dibble LE, Nicholson DE, Shultz B, et al. Sensory cueing effects on maximal speed gait initiation in persons with Parkinson’s disease and healthy elders. Gait Posture 2004;19(3):215-225.
  27. Ballanger B, Thobois S, Baraduc P, et al. “Paradoxical kinesis” is not a hallmark of Parkinson’s disease but a general property of the motor system. Mov Disord 2006;21(9):1490-1495.
  28. Freedland RL, Festa C, Sealy M, et al. The effects of pulsed auditory stimulation on various gait measurements in persons with Parkinson’s Disease. NeuroRehabilitation 2002;17(1):81-87.
  29. Hackney ME, Kantorovich S, Levin R, Earhart GM. Effects of tango on functional mobility in Parkinson’s disease: a preliminary study. J Neurol Phys Ther 2007;31(4):173-179.
  30. Hackney ME, Earhart GM. Effects of dance on movement control in Parkinson’s disease: a comparison of Argentine tango and American ballroom. J Rehabil Med 2009;41(6):475-481.
  31. Hackney ME, Earhart GM. Effects of dance on gait and balance in Parkinson’s disease: a comparison of partnered and nonpartnered dance movement. Neurorehabil Neural Repair 2010;24(4):384-392.
  32. McKee KE, Hackney ME. The effects of adapted tango on spatial cognition and disease severity in Parkinson’s disease. J Mot Behav 2013;45(6):519-529.
  33. Hackney ME, Earhart GM. Short duration, intensive tango dancing for Parkinson disease: an uncontrolled pilot study. Complement Ther Med 2009;17(4):203-207.
  34. Hackney ME, Hall CD, Echt KV, Wolf SL. Multimodal exercise benefits mobility in older adults with visual impairment: a preliminary study. J Aging Phys Act 2015 Jan 6. [Epub ahead of print]
  35. Hackney M, McKee K. Community-based adapted tango dancing for individuals with Parkinson’s disease and older adults. J Vis Exp 2014;(94).
  36. Hackney ME, Earhart GM. Health-related quality of life and alternative forms of exercise in Parkinson disease. Parkinsonism Relat Disord 2009;15(9):644-648.
  37. Perera S, Mody SH, Woodman RC, Studenski SA. Meaningful change and responsiveness in common physical performance measures in older adults. J Am Geriatr Soc 2006;54(5):743-749.
  38. Lim LI, van Wegen EE, de Goede CJ, et al. Measuring gait and gait-related activities in Parkinson’s patients own home environment: a reliability, responsiveness and feasibility study. Parkinsonism Relat Disord 2005;11(1):19-24.
  39. Fielding RA, Katula J, Miller ME, et al. Activity adherence and physical function in older adults with functional limitations. Med Sci Sports Exerc 2007;39(11):1997-2004.
(Visited 135 times, 1 visits today)

Leave a Reply

Your email address will not be published. Required fields are marked *

Spam Blocker * Time limit is exhausted. Please reload CAPTCHA.

This site uses Akismet to reduce spam. Learn how your comment data is processed.