Parkinson’s disease (PD) is the most common neurodegenerative movement disorder. It encompasses physical, psychological, social and functional effects.
The main symptoms include, but are not limited to, bradykinesia, rigidity, postural instability, freezing of gait, reduced bodily mobility and tremors. These motor symptoms frequently lead to loss of independence and inactivity which can cause social isolation and psychological and emotional difficulties. Symptom severity leads to consequences such as falls, immobility, decreased quality of life (QOL) and reduced participation in overall general activity and daily activities.
To address Parkinson’s symptoms, lifestyle changes are essential. A major component of this is physical exercise, which can improve physical function and reduce Parkinson’s related symptoms. However, as occupational therapists, how can we make exercise engaging and meaningful for these individuals?
Three ways to do this are by incorporating techniques such as therapeutic dance, music or boxing into their sessions. Not only do these activities involve exercise, but they also can improve motor, non-motor and psychosocial components of PD.
The benefits of therapeutic dance for those with Parkinson’s exceed many other exercise programs and interventions and can be more meaningful, inspiring and client-centered than other intervention types. Dance promotes positive responses in motor symptoms and can even help with non-motor symptoms such as depression.
Therapeutic dance interventions improve motivation, socialization and confidence in movement, which increases the likelihood of adherence to the program. The benefits of this multicomponent exercise include improvements in:
- Overall functional capacity
These components then contribute to improved functional ADL and iADL performance and enhanced satisfaction and QOL for those with PD.
Dance favors the exploration of the body and movement, optimizing neural, sensory, motor, cognitive and social functions. This can improve memory, cognitive functioning, physical capabilities and fluid movement while also providing a meaningful activity.
Dance can help those with Parkinson’s:
- Maintain and enhance functional skills and coordination
- Facilitate amplitude of movement
- Improve joint mobility
- Increase muscle flexibility, speed and agility
- Improve protection and balance reactions to reduce fall risks
As an intervention for Parkinson’s, dance allows individuals to participate in something fun and enjoyable that is unrelated to repercussions and stressors that accompany the condition.
Visual cues and musical rhythms during dance can also assist people with PD, who can no longer rely on their unconscious sense of balance and ability to initiate and control automatic movements, such as walking.
Auditory, visual and tactile input can also play an essential role in dance. Participants hear the rhythm of the music and respond to the beat.
Even better, dance can be individualized and adapted to fit the ability of the person.
Certifications that occupational therapists can pursue in dance movement therapy and implement into their practice include board certified dance/movement therapist (BC- DMT), somatic movement therapy certification (SMT) and registered dance/ movement therapist (R-DMT).
People with PD, their caregivers and friends can participate in dance classes individually, at his or her own level, while at the same time being part of a group. Dance classes can also be completed in one-on-one sessions or in online sessions; however, dance in a group setting and in person facilitates increased socialization.
Examples of popular dance programs for people with Parkinson’s include:
- Parkinson’s Movement Initiative (PMI): primarily based in North Carolina; however, also has a virtual participation option
- Power for Parkinson’s: variety of free dance classes offered for free on YouTube
- Dance for PD: offers variety of dance classes in person in communities around the world as well as at home virtual options
Therapeutic Music/ Rhythmic Auditory Stimulation (RAS)
Music helps individuals with PD synchronize their movement to a rhythm. Music therapy makes use of both music and imagery in an alternative medicine model of care to improve emotions, cognition and motor control.
Often times, music is used to improve motivation and performance in exercise and sports. Music can serve a similar role with people with Parkinson’s.
A study of the use of active music therapy in patients with PD revealed auditory or rhythmical cueing improved the following:
- Gait (including speed and stride length)
- Motor abilities
- Emotional status
- Functional performance with ADLs and iADLs
Therapeutic music in conjunction with exercise facilitates the organization and initiation of movement due to the extensive connections between auditory and motor areas in the brain. This can benefit gait disorders, balance difficulties and freezing during functional movement or mobility.
Brain imaging studies show that music and rhythm perception produce changes in the auditory-motor network that facilitate movement and can be taken advantage of in skilled occupational therapy treatments to maximize ADL and iADL performance, as well as enhance satisfaction and QOL of those with PD.
Additionally, external rhythm can help to control variability in musculoskeletal activation patterns, resulting in more efficient and effective joint movement and grading of movements.
The auditory cues can take many forms, such as music, the beat of a metronome, vocalization or any other type of rhythmic stimulation. The goal of RAS is to achieve synchronization of movements (ex: walking) to an external sound, in which the tempo is increased or decreased for optimal pace. This helps to make internal rhythm steady and possibly replaces the dysfunction in internal timing regulation in individuals with PD.
RAS presented in different forms in conjunction with exercise can improve gait parameters and facilitate safety and improved independence with overall mobility and overall daily performance tasks.
The type of music or RAS implemented can be based on the individual’s or group’s preference and can be graded depending on the movement level of the individual or group. Additional items such as props, scarves, weighted equipment or ribbon wands can also be implemented during classes to further grade functional movement and to increase variability, fun and enjoyment during treatments.
Boxing is a therapeutic exercise due to its complex nature and incorporation of whole-body movements. Therapeutic boxing treatments allow people with PD to work on:
- Muscular endurance
- Static and dynamic balance
- Hand-eye coordination
- Amplitude of functional movements
- Multidirectional footwork
- Overall functional strength
It also offers an outlet for frustration, anxiety and depression often associated with a progressive disease such as Parkinson’s. Boxing can also potentially result in improved vocalization due to the grunting and increased vocalizations that typically coincide with punching and exerting oneself during exercise.
Additionally, it combines both exercise and psychotherapy into one activity. It can be an empowering exercise and meaningful activity that allows the individual to express themselves with a combination of physical exercise and therapeutic benefits for their mental health.
In a recent study, participants identified six major themes related to the benefits of community-based therapeutic boxing on speech, social occupation and mental health of individuals with PD. They are:
- Role function in relationships
- Well-being, self-perceived health, and social connectedness
- Community-based group exercise environment
- Comfort in engaging in social occupations
Occupational therapists should look to expand available individualized, as well as community-based, boxing programs for individuals with PD to facilitate optimal cognitive, physical and functional performance benefits.
Therapeutic boxing treatments can be implemented in a one-on-one individual basis or in a group setting, with the group setting facilitating increased social confidence and interactions. The main equipment needed for treatment includes a punching bag and boxing gloves.
Incorporating therapeutic boxing into treatment sessions allows the individual to be more engaged and pursue individualized and meaningful exercise rather than completing general less meaningful exercise, such as repetitions with free weights.
Boxing can also be graded depending upon the individual’s physical and cognitive capabilities.
Rock Steady Boxing (RSB) is a popular exercise option for individuals with PD. RSB is a nonprofit organization that offers a non-contact boxing-based fitness program to patients with PD. The exercises are used by boxers and simultaneously incorporate elements of spinal flexibility, multidirectional footwork and functional movements performed faster than preferred speeds.
Participants of a study involving RSB reported decreased body stiffness and fatigue as well as improvements with balance, gait and overall functional mobility following participation in the RSB program.
Therapeutic Dance, Music and Boxing with Instrumental Activities of Daily Living (IADLs)
Implementation of therapeutic dance, music and boxing can facilitate significant physical, cognitive, and emotional improvements in individuals with PD as evidenced by research noted above. This will contribute to enhanced safety and functional improvements for optimal ADL and iADL participation with reduced fall risk.
Benefits of these interventions can facilitate enhanced independence with higher level tasks such as:
- Meal preparation
- Pet care
- Grocery shopping
- Clothing care
- Yard Work
- Home management tasks
These overall functional activities have task components that require efficient balance, increased amplitude of movement, weight shifting, functional reaching and proper sequencing skills for successful completion which can all be enhanced through therapeutic dance, music, and boxing interventions.
Patient Education and Home Exercise
OTs provide skilled and client-centered education regarding the importance of participating in meaningful exercise to slow down the progression of PD, as there is currently no cure.
Home exercise programs (HEPs) can be established and implemented regarding therapeutic dance, music, and boxing specifically related to the individual’s enjoyment level as well as their cognitive and physical capabilities and what deficits need to be addressed.
For example, a therapeutic dance or boxing HEP would consider the individual’s specific movement patterns, strength, coordination, flexibility, balance and cardiovascular endurance, as well as most enjoyed dance movements and accompanied pace of music.
The individual may be assigned an upbeat dance with increased tempo of music to facilitate larger amplitude of movements, speed of movements, and motivation for continued enjoyment.
It is also important for family and caregivers to be educated on the HEP for further facilitated carryover during the daily routine.
Using creative and client-centered treatments such as these, occupational therapists have the opportunity to challenge individuals with PD through specialized and meaningful interventions. Therapeutic dance, music and boxing have been shown as successful skilled interventions to facilitate and achieve functional ADL, iADL and mobility improvements as well as overall quality of life.
Encompass Health occupational therapists Sarah Thomas, Ashley Dorr, Courtney Strickland, Ashley Crabbs and Erin Nalle contributed to this post.
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