https://orcid.org/0000-0003-0675-0147
Figures
Abstract
Objective(s)
To determine (1) the quality of systematic reviews about dance-based intervention in individuals with Parkinson’s disease (PD) and (2) standard evidence for dance-based intervention efficacy based on the categories of The International Classification of Functioning, Disability, and Health (ICF) from the World Health Organization’s (WHO).
Methods
The data source included MEDLINE, PUBMED, Embase, Scopus, CENTRAL (Cochrane Library), CINAHL, PEDro, SPORTDiscus, APA PsycNet (APA PsycINFO), LILACS, SciELO, and AMED. Pairs of independent reviewers screened titles, abstracts, and full texts of eligible studies by using the software Covidence. Criteria included: systematic review designs; individuals with PD; dance-based interventions aimed to change critical PD symptoms matched to IFC domains (body functions, activities, and participation). Independent reviewers extracted information regarding the characteristics of all systematic reviews included and appraised quality using A MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2). Randomized controlled trials and their risk of bias were identified within each review and were used to perform an updated pairwise meta-analysis.
Results
Of the 571 manuscripts screened, 55 reviews met the inclusion criteria. The overall confidence in the results of 38 reviews (69%) was rated as ’critically low,’ nine (9%) as ’low,’ one (2%) as ’moderate,’ while seven of 55 reviews (13%) were rated as ’high’. Dance associated with pharmacological usual care is better than pharmacological usual care alone for essential components of ICF, such as motor symptoms severity (body function), depressive symptoms (body function), balance (body function and activity), and functional mobility (activity), but not for gait distance (activity) and quality of life (participation). Dance is also superior to multimodal exercise to improve balance.
Conclusions
Clinicians and people with PD can refer to this paper for a summary of high-quality reviews and the overall evidence supporting dance as an adjunct rehabilitation. This umbrella review not only underscores the therapeutic potential of dance but also reinforces the use of arts-based approaches into healthcare practices for people with neurological conditions.
Citation: Pinto C, Simon Myra R, Severo do Pinho A, Pereira F, Orgs G, Pagnussat AS (2024) Quality assessment and umbrella review of systematic reviews about dance for people with Parkinson’s disease. PLoS ONE 19(12): e0311003. https://doi.org/10.1371/journal.pone.0311003
Editor: Mansueto Gomes Neto, Universidade Federal da Bahia, BRAZIL
Received: January 2, 2024; Accepted: September 10, 2024; Published: December 31, 2024
Copyright: © 2024 Pinto et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The author(s) received no specific funding for this work.
Competing interests: The authors have declared that no competing interests exist.
Abbreviations: PD, Parkinson’s Disease; ICF, The International Classification of Functioning, Disability and Health; WHO, World Health Organization; AMSTAR, A MeaSurement Tool to Assess Systematic Reviews; PROSPERO, International Prospective Register of Systematic Reviews; PRIOR, Preferred Reporting Items for Overviews of Reviews; RCT, Randomized Clinical Trial; GRADE, Grading of Recommendations Assessment, Development and Evaluation; UPDRS III, Unified Parkinson’s Disease Rating Scale, Motor Section; BDI, Beck’s Depression Inventory; BBS, Berg Balance Scale; TUG, Timed Up and Go; 6MWT, Six Minute Walking Test; PDQ-39, Parkinson’s Disease Questionnaire
Introduction
According to the World Health Organization (WHO), Parkinson’s disease (PD) is the second most common neurodegenerative movement disorder in the world (8.5 million in 2019), and prevalence has doubled in the past 25 years. The International Classification of Functioning, Disability and Health (ICF) by the World Health Organization (WHO) [1] is a classification of health categories to assess health well-being by looking at the individual patient in a more integrative way. The ICF expands on the biopsychosocial perspective of PD disability in terms of body function (e.g. balance), activities (e.g. functional mobility such as turning, walking, and sitting to standing), and participation (e.g. quality of life) by including personal and environmental factors [2–4] into the assessment. The negative influences of PD motor and non-motor symptoms on daily living tend to progress over time, so optimizing ICF domains is the overall goal of PD management [2, 3]. The most known treatment with pharmacological usual care (e.g. levodopa) does not cover all PD symptoms, and side effects, such as dyskinesias and anxiety, can become more severe with chronic administration [5, 6]. For this reason, evidence-based practices reinforce the use of nonpharmacological approaches, in particular, rehabilitation with active physical exercises [7, 8]. Exercise would have a potential to alleviate anxiety associated with levodopa treatment in individuals with PD. When people diagnosed with PD do not receive proper nonpharmacological treatment, the disease progresses more rapidly, the need for institutionalization increases and the costs can become very high for the patient and the family [9, 10].
Dance has emerged as both a popular and effective intervention to enhance the quality of life in PD. Dance provides health benefits similar to other forms of exercise or multimodal training [2, 11], yet as an art-based form of body and emotional expression it has additional social and cognitive benefits associated with the learning and remembering of movement sequences, improvisations, storytelling and collective movement guided by music. Dance serves multiple purposes including physical exercise, recreational programs, and rehabilitation. European [2] and American [12, 13] Guidelines for physiotherapy include dance as a therapeutic, multimodal, and community-based intervention recommended for people with PD. Multimodal training interventions encompass three or more combined modalities or components of physical exercises, such as balance, aerobic resistance, motor coordination, and flexibility, among others. The European Physiotherapy Guideline for PD (2014) [2] recommends dance for improving functional mobility, but not as an intervention to support quality of life or motor symptoms severity [2]. More recently, the American Guideline (2022) [12] provides strong recommendations for community-based exercise to improve functional mobility and quality of life, and reduce motor symptoms severity. It includes activities such as dance, yoga, Pilates, but does not provide any specific evidence that dance can improve PD symptoms or quality of life. Future research should focus on a target modality due to the range of variability between dance and other community-based modalities [12].
The primary source of guidelines for clinical practice are systematic reviews and meta-analyses [14]. Over the past ten years, several systematic reviews [15–20] and meta-analyses [11, 21–35] have shown the efficacy of concomitant in-person dance-based interventions for individuals with PD and compared these to pharmacological usual care alone or other types of physical exercise. A meta-analysis published in 2020 showed a significant improvement in quality of life after dance-based intervention in individuals diagnosed with PD (SMD = −0.30; 5 RCTs) compared to pharmacological usual care [36]. Another meta-analysis published in 2021 showed benefits on motor severity (MD -6.91; 5 RCTs) and balance (MD 4.47; 3 RCTs) when comparing dance-based intervention to pharmacological usual care, but no difference in quality of life [25]. Overall, while there appears to be some consensus that dance is beneficial, it is unclear if dance is primarily beneficial to quality of life, or also improves specific PD symptoms, i.e. balance.
It is therefore important to help clinicians and patients to identify the best reviews, i.e. those that base their recommendations on a meta-analysis and are transparent with respect to their limitations, such as heterogeneity, low-quality clinical trials and risk of bias [37]. As a solution, AMSTAR (A MeaSurement Tool to Assess Systematic Reviews) was developed in 2007 [38] to evaluate the quality of systematic reviews with or without meta-analysis. This tool was upgraded in 2017 as AMSTAR 2 [39] and presents crucial domains that can critically affect the validity and conclusions of a review if the domains are not followed.
The contradictions of guidelines and reviews evaluating the efficacy of dance-based interventions in people with PD justify assessing the methodological quality of systematic reviews with the help of the AMSTAR 2 tool. As mentioned above, there are inconsistent findings between guidelines and systematic reviews regarding the efficacy of dance-based intervention. Thus, based on ICF domains, a question remains about how the variability of movement strategies used in dance would effectively improve body functions, activities, and participation in people with PD. Thus, it is timely and important to systematize low-bias randomized clinical trials included in these reviews and update these findings through a pairwise meta-analysis.
Objectives
Firstly, we aim to appraise the overall confidence of systematic reviews with and without meta-analysis about dance-based intervention for people with PD by using AMSTAR 2 tool. Secondly, we aim to provide standard evidence of high-quality RCTs included in meta-analyses of systematic reviews selected. Thus, this study brings two questions:
- To what extent can we rely on systematic reviews and meta-analysis recommendations to assess the efficacy of dance-based interventions’ for people with PD?
- Does dance-based intervention improve ICF domains (body function, activity, and participation) in people with PD when compared to pharmacological usual care alone or other active exercises?
Methods
Our paper provides an umbrella review of existing reviews on the efficacy of dance-based interventions for PD). The protocol for this study has been registered in the International Prospective Register of Systematic Reviews (PROSPERO) under the registration CRD42023413814. This review was reported based on the Preferred Reporting Items for Overviews of Reviews (PRIOR) [40] and Cochrane Collaboration’s recommendations for conducting an overview of reviews (Chapter V) [41]. The PRIOR statement was developed in 2022 [40] based on aspects of Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2020 [42] but focused on particular challenges in reporting overviews.
Eligibility criteria
According to the eligibility criteria (PICOT), any study designed as a systematic review (if the review authors had identified it as such) with or without meta-analysis aimed to include (P) individuals with PD at any stage of the disease severity or duration; (I) dance-based intervention associated or not with pharmacological usual care; (C) compared with pharmacological usual care alone, other active intervention, or minimal intervention (e.g. education); (O) critical outcomes for PD management that are related to IFC domains (body functions, activities, and participation), such as motor symptoms severity, depressive symptoms, balance, functional mobility, walk distance, and quality of life; (T) post-treatment follow-up at least for four weeks of intervention. Studies that were not fully published in peer-review journals or designed as an overview of systematic reviews were excluded. This review has no publication time restriction and no language restriction.
Search methods.
We performed a comprehensive search strategy with support from a health sciences librarian. We started the search on March 2023 and consulted the databases MEDLINE, PUBMED, Embase, Scopus, CENTRAL (Cochrane Library), CINAHL, PEDro, SPORTDiscus, APA PsycNet (APA PsycINFO), LILACS, SciELO, and AMED. We finished the selection in May 2023 and updated the search in June 2024. We also checked reference lists of included articles, prospero registries, grey literature and performed a hand search of general and specific journals. Health professionals with backgrounds in dance and PD were consulted as experts to ensure we did not miss any additional reviews. We contacted authors by email if the full paper was not available online. The search terms comprised "parkinson", "dance", and "review", as well as their synonyms and MESH terms adapted for distinct databases. Although the search was based on PICOT, we did not include search terms of outcomes and time to guarantee high sensitivity. S1 Table details the complete search strategy.
Data collection and selection.
Two independent reviewers (CP and RSM) performed the search and screened titles and abstracts according to the eligibility criteria. To facilitate this systematic approach, we used the Covidence Software. Then, two reviewers (CP and RSM) independently read full articles eligible, any disagreements were resolved through discussion with a third (ASP) reviewer when necessary.
Data extraction and management.
Two authors performed the data extraction independently (CP and RSM or FP) and then cross-checked each other’s work. We extracted data for all included reviews into a built data extraction form to allow a qualitative overview of all the available evidence. We only included reviews on dance interventions in the context of PD. If reviews covered forms of exercise beyond dance, then data on these interventions was not extracted.
We extracted information from all RCTs included in all reviews that performed pairwise or network meta-analyses. Title, author’s names, and doi of RCTs were extracted and filled out into a worksheet. Two authors (CP and FP) extracted all the data outcomes from the original RCT individually (not from meta-analyses conducted in the reviews). We did not extract data from NRCT because RCTs in this field provide the necessary outcome data and a complete picture of the efficacy associated with dance intervention [39]. After completing data extraction, we managed to evaluate the RCTs that implemented random methods of treatment allocation and were in line with PICO eligibility criteria of this review. We extracted the methodological quality of RCTs based on PEDro scale classified by the Physiotherapy Evidence Database Team (www.pedro.org.au). Then, the authors filled all outcomes into a report sheet based on ICF patient assessment components [2].
Assessment of quality of included reviews
Two reviewers (CP and RSM) evaluated methodological quality independently with disagreements resolved by the third author (ASP). The quality of systematic reviews with or without meta-analysis was assessed using the AMSTAR 2 (A MeaSurement Tool to Assess Systematic Reviews) [39]. The tool contains a checklist of sixteen items (16 AMSTAR-2 items) that are rated as yes (positive result), partial yes, or no (negative result), with other response options for cases if the review did not conduct a meta-analysis. Importantly, for those reviews that included exercises other than dance, we considered only review results of dance-based interventions for items 8, 9, 11, 12, 13, 14, and 15 of AMSTAR 2. There are critical and non-critical domains in AMSTAR 2. If critical domains are not fully followed, the rate of overall confidence will drop. The study’s overall confidence is categorized into four rates that range from high, moderate, low or critically low, calculated according to https://amstar.ca/Amstar_Checklist.php. With high overall confidence, for example, the review presents no or just one non-critical domain or weakness, providing an accurate and comprehensive summary of the results of the studies that address the question of interest. Reviewers learned how to use AMSTAR-2 by referred literature and carried out a training trial before starting the evaluation of articles included in this paper. We used a previous quality assessment paper already published to learn and train our evaluation and discuss disagreements with an expert in the field. This training trial took around one month. Finally, each reviewer (CP and RSM) independently assessed the included articles and compared the results. Discrepancies were handled in a consensus dialogue in a group and remaining disagreements were resolved by a third author (ASP).
Data synthesis and criteria for meta-analyses
The summary characteristics of systematic reviews included were synthesized qualitatively. Moreover, we provided a quantitative synthesis by re-analyzing the efficacy of dance for people with PD. For this purpose, we compared a dance-based intervention in addition to pharmacological usual care with pharmacological usual care alone or in combination with other active exercises. Outcomes related to the International Classification of Functioning, such as motor symptom severity (body function), depressive symptoms (body function), balance (body function and activity), functional mobility (activity), gait distance (body function and activity), and quality of life (participation), were assessed. Motor symptom severity was evaluated using the Unified Parkinson’s Disease Rating Scale, Motor Section (UPDRS III). Depressive symptoms were assessed using Beck’s Depression Inventory (BDI). Balance was measured using the Berg Balance Scale (BBS). Functional mobility was evaluated with the Timed Up and Go (TUG) test. Gait distance was assessed using the Six Minute Walking Test (6MWT). Quality of life was evaluated using the Parkinson’s Disease Questionnaire (PDQ-39). We performed a meta-analysis based on at least two similar studies with respect to interventions, comparators, and outcomes [41]. There are several randomized and non-randomized studies about our field of study; however, most of them confuse the results because of their high risk of bias. Thus, we excluded quasi or only partially randomized clinical trials, and we only included RCTs with scores of six or higher rated as ’good’ or ’excellent’ on the PEDro scale, ensuring a low risk of bias and thereby providing better evidence for guidelines in meta-analyses. The data extracted from RCTs included pre- and post-intervention assessments. All RCTs included in meta-analyses used the same test to assess outcomes of interest, thereby substantially reducing the heterogeneity of our results. For quantitative synthesis, data were pooled using a random effect model. Regarding the continuous outcomes, if the unit of measurement was consistent across trials, the results were presented as the weighted mean difference with 95% confidence intervals (CIs). Statistical heterogeneity was assessed using I2 statistics and classified as follows: low heterogeneity (I2 below 25%); moderate heterogeneity (I2 between 25% and 50%); high heterogeneity (I2 above 50%). A P value ≤.05 was considered statistically significant. All analyses were conducted using the R statistical software (version 3.3.3, package metaphor version 2.0–0).
Certainty of evidence
The overall certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). This tool aims to score the certainty of the body of evidence for each outcome as "high" (++ ++), "moderate" (+++), "low" (++), or "very low (+). The assessment included judgments about risk of bias, imprecision, inconsistency, indirectness, and publication bias [43, 44]. An evidence profile and summary of findings tables for each population was created using GRADE’s electronic tool GRADEpro GDT (www.gradepro.org).
Results
PRISMA flow diagram is detailed in Fig 1. From 571 records identified from databases, registries, and other methods, 135 reports were assessed for full consideration according to eligibility criteria and 55 reviews were included in the review (40 with meta-analysis and 15 systematic reviews without meta-analysis).
Reference: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71.
Tables 1, 2 presents the overall characteristics and results of 55 systematic reviews with and without meta-analysis included. In terms of patients, 53 systematic reviews investigated only the PD population, except for two reviews that included other types of neurodegenerative diseases [45] or physical illnesses [46]. Regarding intervention, 25 reviews investigated only dance as the experimental group, and 30 reviews covered other types of exercises [23, 26, 30, 35, 36, 47–71].
Quality assessment of included reviews
Table 3 shows the rating overall confidence and each of the 16 items of AMSTAR 2 used to access 55 systematic reviews included. 38 reviews (69%) were rated as ’critically low’ on quality (with more than one critical flaw with or without non-critical weaknesses), nine reviews (16%) were rated as ’low’ (with only one critical flaw with or without non-critical weaknesses), one review (2%) was rated as ‘moderate’ (more than one non-critical weaknesses), and seven reviews (13%) were rated as ’high’ (none or only one non-critical weakness).
From seven systematic reviews rated as ’high’, only one was directly aimed at investigating dance-based intervention [25]. The others had a broader focus on physical exercise [36, 50, 70], therapeutic exercise [56], rehabilitation interventions [55], and mind-body exercises [53]. The systematic review rated as ’moderate’ aimed to investigate the benefits of physical exercise [51]. The AMSTAR 2 critical domains and the percentage of total studies that did not fulfill the domain are summarized below:
- Item 2: not establishing a protocol before conducting the review (58%)
- Item 4: not appraising all relevant aspects of the literature search (94%)
- Item 7: not providing adequate justification for excluding individual studies (38%)
- Item 9: not reporting risk of bias from individual studies being included in the review (30%)
- *Item 11: Appropriateness of meta-analytical methods (25%)
- Item 13: not discussing the impact of risk of bias in the interpretation of the results (38%)
- *Item 15: not explaining in detail the presence and likely impact of publication bias (52%)
*Items with an asterisk represent the percentage of those 40 reviews with meta-analysis.
Umbrella review
We identified 186 RCTs from included systematic reviews and meta-analyses. The exclusion of RCTs comprised:164 duplicate RCTs; four RCTs that compared different styles [72, 73] or sets [72] of dance; one RCT that associated dance with physiotherapy sessions [74]; one that evaluated the same participants as another RCT already included; and seven RCTs were rated lower than six on the PEDro scale [75–81]. The RCT of Shanahan et al. (2017) [82] with Irish dance was not included in the analysis due to unavailable data and no response after contacting authors by email. Thus, seven RCTs with ’good’ or ’excellent’ scores on the PEDro scale were considered for our meta-analysis. These scores can be found at Physiotherapy Evidence Database Team (www.pedro.org.au). These studies were from Italy, United Kingdom, Ireland, the US, Japan and the Republic of Korea. Five studies compared dance (Argentine tango dance [83], Irish dance [82], Qi dance [84], Tango dance [85], Sardinian folk dance [86], and mixed repertoire dance [87]) relative to pharmacological usual care. An exception is that the study of Rios Romenets et al. (2015) [85] differed from the other RCTs because its control group associates pharmacological usual care with a self-administered learning intervention (i.e. participants received a pamphlet about exercises for people with PD from Parkinson Society of Canada and were instructed to practice the exercises at home [85]). Another study included three groups and compared mixed repertoire dance in one program to pharmacological usual care or an active multimodal exercise program [88]. Another study compared dance (Irish dance) to an active multimodal exercise program [89]. Participants included in experimental groups with dance maintained their pharmacological usual care (i.e. antiparkinsonian drugs) during the programs. All RCTs included in meta-analyses used the same test to assess outcomes of interest, thereby substantially reducing the heterogeneity of our results. Thus, we included seven RCTs for the meta-analyses.
For the six studies that included [83–88] dance-based intervention plus pharmacological usual care compared to pharmacological usual care alone, the intervention duration ranged from 8 to 12 weeks, twice a week for 60 to 90 minutes per session, except for one study [88] that participants danced only once a week. Individuals were between 64 and 70 years old, with mild to moderate PD symptom severity (based on the Hoehn & Yahr Scale). Two studies compared dance to multimodal exercise intervention, both in addition to pharmacological usual care [88, 89]. The intervention duration for these two studies ranged from 12 to 24 weeks, once a week, for 60 to 90 minutes each session. Individuals were 61 to 67 years old at mild to moderate stages of PD symptom severity (based on the Hoehn & Yahr Scale).
Body function. Motor symptoms severity (UPDRS III).
Dance-based intervention reduced motor symptoms severity in comparison to pharmacological usual care alone (MD -2.26, 95% CI -3.29 to -1.22, p < 0.001; I2 0%; 4 RCTs) (Fig 2A). A sensitivity analysis showed that these values did not change significantly even when excluding the study by Rios Romenets et al. (2015) [85]. Finally, a linear regression test of funnel plot asymmetry (t = -0.44, df = 2, p-value = 0.70) confirmed that there is no bias publication for this outcome. The GRADE analysis showed that there is moderate-certainty evidence that dance plus pharmacological usual care is superior to pharmacological usual care alone for diminishing motor symptoms severity in people with PD (Table 5).
(A) Dance compared to usual care regarding UPDRS III (Unified Parkinson’s Disease Rating Scale, Motor Section); (B) Dance compared to usual care regarding BDI (Beck’s Depression Inventory).
Body function. Depressive symptoms (BDI).
Dance-based intervention plus pharmacological usual care diminished depressive symptoms in comparison to pharmacological usual care alone (MD -4.88, 95% CI -8.86 to -0.91, p = 0.01; I2 50%; 2 RCTs) (Fig 2B). The number of studies is too small to test for small study effects (publication bias). The GRADE analysis showed that there is low-certainty evidence that a dance-based intervention is superior to pharmacological usual care alone for diminishing depressive symptoms in people with PD (Table 5).
Body function and activity. Balance (BBS).
Dance-based intervention plus pharmacological usual care improved balance capacity in comparison to pharmacological usual care alone (MD 3.24, 95% CI 0.64 to 5.83, p = 0.01; I2 68%; 4 RCTs) (Fig 3A). Linear regression test of funnel plot asymmetry (t = 0.75, df = 2, p-value = 0.5305) confirmed that there was no bias publication for this outcome. The GRADE analysis showed that there is low certainty of evidence that dance-based interventions are superior to pharmacological usual care alone in improving balance in people with PD (Table 5).
(A) Dance compared to usual care regarding BBS (Berg Balance Scale); (B) Dance compared to multimodal exercise regarding BBS (Berg Balance Scale).
Dance-based intervention improved balance capacity in comparison to multimodal exercise intervention plus pharmacological usual care (MD 3.98, 95% CI 1.44 to 6.52, p = 0.002; I2 0%; 2 RCTs) (Fig 3B). The number of studies is too small to test for small study effects (publication bias). The GRADE analysis showed that there is moderate certainty of evidence that dance plus pharmacological usual care is superior to multimodal exercise intervention plus pharmacological usual care to improve balance capacity in people with PD (Table 5).
Activity. Functional mobility (TUG).
Dance-based intervention plus pharmacological usual care improved functional mobility in comparison to pharmacological usual care alone (MD -1.14, 95% CI -1.84 to -0.43, p = 0.001; I2 22%; 4 RCTs) (Fig 4). When conducting a sensitivity analysis, values do not change significantly even when excluding the study by Rios Romenets et al. (2015) [85]. Moreover, a linear regression test of funnel plot asymmetry (t = 2.62, df = 2, p-value = 0.12) confirmed that there is no bias publication for this outcome. The GRADE analysis showed that there is low certainty of evidence that dance plus pharmacological usual care is superior to pharmacological usual care alone to improve functional mobility in people with PD (Table 5).
Dance compared to usual care regarding TUG (Timed Up and Go).
Body function and activity. Gait distance (6MWT).
Dance-based intervention plus pharmacological usual care does not provide benefits over and above pharmacological usual care alone (MD 22.91, 95% CI -12.61 to 58.43, p = 0.20; I2 0%; 2 RCTs) (Fig 5A). When conducting a sensitivity analysis, we excluded the study of Solla [86] from the meta-analysis because the delta difference was much higher (MD = 239) than other studies, with a higher heterogeneity (I2 89%). Overall, the number of studies is too small to test for small study effects (publication bias). The GRADE analysis showed that there is moderate-certainty evidence that dance plus pharmacological usual care is similar to pharmacological usual care alone to improve functional mobility in people with PD (Table 5).
(A) Dance compared to usual care regarding 6MWT (Six Minute Walking Test); (B) Dance compared to usual care regarding PDQ-39 (Parkinson’s Disease Questionnaire).
Participation. Quality of life (PDQ39).
Dance-based intervention plus pharmacological usual care provide similar benefits compared to pharmacological usual care alone for quality of life (MD 0.69, 95% CI -5.32 to 6.70, p = 0.82; I2 0%; 2 RCTs) (Fig 5B). We did not include Lee (2018) [84] in this meta-analysis because the authors used another outcome measurement for quality of life (PDQL) [90]. When conducting a sensitivity analysis, values do not change significantly, even when excluding the study by Rios Romenets et al. (2015) [85]. The number of studies is too small to test for small study effects (publication bias). The GRADE analysis showed that there is moderate-certainty evidence that dance plus pharmacological usual care is similar to pharmacological usual care alone for quality of life in people with PD (Table 5).
Overall results of outcome measurements based on ICF
Table 4 presents outcome measures matched with ICF guidelines and core sets for PD [2–4]. The three components of ICF with their respective constructs/categories were shown accordingly. Overall results based on GRADE Recommendations were also detailed (details of GRADE recommendations are available in Table 5).
Discussion
As far as we know, this is the first quality assessment study and umbrella review of systematic reviews and about dance-based intervention effectiveness for individuals with PD. From 48 reviews included, only six were considered high quality based on the AMSTAR 2 tool. We also updated and extended the understanding of dance as an adjunct rehabilitation to pharmacological usual care on ICF outcomes effectiveness in people with mild to moderate PD. We found moderate-certainty evidence to recommend dance-based intervention for people with PD to ameliorate ICF body functions and activity domains, such as motor symptoms severity and balance, compared to pharmacological usual care alone or multimodal exercises, respectively.
Overall, the quality of the included systematic reviews on the effectiveness of dance for people with PD was rated critically low to low (i.e. 85%). Previous methodological survey studies on the effectiveness of exercise also reported critically low confidence in the results of the majority of systematic reviews (i.e. 74%), for example in the context of lower back pain [91]. Another systematic review [45] also assessed the quality of studies included on dance interventions for people with neurodegenerative conditions such as mild cognitive impairment, Alzheimer’s disease, and PD. According to AMSTAR and PEDro criteria, reviews and RCTs were moderate to low quality [45]. However, the authors applied the first version of AMSTAR tool 1 (11 questions) for only 16 reviews. In our study, we used the newest version of AMSTAR tool 2 (16 questions) and included 55 reviews in the field. Surprisingly, we found several reviews and a low number of low risks of biased randomized clinical trials. Most of the different results are due to the inclusion of clinical trials with a high risk of bias [50, 53], non-RCT [56] and combining music therapy, aquatic therapy [50] or other exercises [36] into the dance-based meta-analyses. We found that the only dance-specific review with high quality and overall confidence is Ismail (2021) [25].
The overall confidence for the majority of included reviews was mostly downgraded due to study limitations on AMSTAR critical domains. More than the overall score, reviews might be interpreted considering the impact of each individual item of AMSTAR [92]. In our results, more than two-thirds of reviews did not report a protocol registration (e.g., PROSPERO or COCHRANE) and did not appraise all relevant aspects of the literature search. The low quality found was also a consequence of not considering the impact of risk of bias on discussing the results. The AMSTAR 2 tool does not look at the quality of clinical studies included in reviews but how well the review provided a transparent discussion about the potential risk of bias and heterogeneity, which is not covered if the review simply assessed the risk of bias. Also, it is not recommended to cluster RCTs and non-RCTs in the same meta-analyses [39, 93]. Among the reviews with meta-analyses, many did not assess potential publication bias by performing a sensitivity analysis (e.g., funnel plot asymmetry perhaps due to the lack of a sufficient number of studies to include.
Some systematic reviews with meta-analysis included RCTs that were, in fact, non-randomized or had very small sample size in meta-analysis. As an attempt to update and compile low-risk-of-bias RCTs regarding the effects of dance-based interventions on the PD population, we conducted pairwise meta-analyses of low-risk-of-bias RCTs focusing on outcomes that match the ICF domains. We found moderate certainty of evidence for dance plus pharmacological usual care improving body functions, such as motor symptoms severity (UPDRS-III; MD = 2.26), compared to pharmacological usual care alone. However, the mean difference of 2.26 points may not reach the minimal clinically important difference for UPDRS-III in people’s daily lives [94]. Our results support existing American guidelines from 2022 [12] but not the European guidelines [2] from 2014, possibly because the latter do not consider more recent evidence. We also showed moderate-certainty evidence that dance plus pharmacological usual care is superior to multimodal exercise plus pharmacological usual care to improve body function and activity, such as balance (BBS; MD = 3.98). Dance typically requires a certain level of balance, for example to step in multiple directions and these balance requirements can be designed to be more challenging if performed in choreographies or dance improvisation [2, 51]. This helps to explain why we found that dance is better at improving balance capacity than multimodal exercise programs, including balance training. In conclusion, our results showed that dance associated with pharmacological usual care reduced depressive symptoms (BDI; MD = 4.89), and improved balance (BBS; MD = 3.24) and functional mobility (TUG; MD = -1.44 sec) when compared to pharmacological usual care alone.
The BBS tool evaluates balance by looking at activities, such as reaching, turning, and unipedal stance. The ICF checklist from WHO evaluates the outcome balance as a body function, although European and American PD recommendations1,2,86 considered it an activity domain. However, this conceptual conflict over balance classification can lead to confusion, and recommendations should start from the same assumption to minimize these differences. Finally, our meta-analyses found that dance plus pharmacological usual care is similar to pharmacological usual care alone for improving gait distance (6MWT; MD = 22.91) and quality of life (PDQ39; MD = 0.69). Although dance can increase cardiovascular resistance over practice, this might not be sufficient to improve gait distance during six minutes. In terms of quality of life, the PDQ-39 tool includes the frequency of difficulties the person reports for mobility, daily basic activities, emotional well-being, stigma, social support, cognition, verbal communication, and body discomfort. The extent to which dance could underpin several aspects of quality of life is complex to measure and it might require more than twelve weeks of intervention to achieve a clinical effect plausible.
Limitations
Overall quality scores for each systematic review included in our umbrella study must be interpreted cautiously, especially when comparing reviews with and without meta-analysis. Most of our meta-analysis results presented 0% heterogeneity, except for depressive symptoms and balance compared to pharmacological usual care that showed substantial heterogeneity (50%-70%) and so low certainty of evidence. Moreover, variations in healthcare systems, medications, and cultural differences in dance practice and traditions across regions of the globe might influence the results and overall well-being in individuals diagnosed with PD. Each country seems to use a traditional form of dance style, in keeping with local tradition and culture. Our study does not recommend a specific dance style for the general PD population; on the contrary, we recommend using the most popular and familiar dance style within a specific population.
Recommendations
In our meta-analysis results, most of the participants were older adults (over 60 years) at mild to moderate stages of PD symptom severity [95]. We recommend a dance intervention dose twice weekly, 60 minutes each session, for at least 12 weeks. However, RCTs included did not describe the intervention protocol in detail, as suggested by Template for Intervention Description and Replication (TIDieR) [96]. Trials rarely reported how the program advanced, such as frequency, intensity, time, type, volume, and progression (FITT-VP) [97]. In some studies, it is unclear whether the intervention involved solo or group dancing, although typically dance is practiced and performed in groups. Finally, it was unclear for many studies if the dance protocol included in clinical trials was or could be adapted to sitting on a chair, standing with support or both. We encourage future clinical trials to provide more detail on the specifics of the dance intervention protocol.
We recommend conducting more RCTs that compare dance with other modalities of therapeutic exercise in people with PD to establish consistent quality guidelines. Future RCTs should adopt standardized templates, such as TIDieR [96], to enhance comparability of studies and interventions, thereby facilitating translation into clinical practice. We strongly recommend systematic reviews to differentiate between non-randomized controlled trials (NRCT) and RCTs in meta-analyses for different outcomes and to select unbiased studies. Additionally, future reviews should adhere to PRISMA, Cochrane, and AMSTAR guidelines and should pre-register protocols. The quality and confidence of reviews concerning other active forms of therapeutic or physical exercise, apart from dance, for people with PD remain uncertain. We also encourage future studies to align outcome measurements with the International Classification of Functioning (ICF) components relevant to the PD population.
Conclusions
We captured the most relevant literature and provided directions for recommendations of seven reviews with high overall confidence. This understanding is critical to generate unbiased estimates of treatment effects for decision-making and alerting clinicians to base their practical conduct only on high-quality reviews. Additionally, we integrated ICF components by updating meta-analyses on the effectiveness of dance-based interventions for the PD population. Dance-based interventions combined with pharmacological usual care are recommended to improve body functions and activities as categorized by the WHO International Classification of Functioning, Disability and Health, by reducing motor symptom severity and depression, and by improving balance and functional mobility. Elucidate these findings to strengthen the use of dance for people with PD and its potential implications on patient-reported outcomes.
Supporting information
S1 Data. Research results and data extracted from the primary research sources.
https://doi.org/10.1371/journal.pone.0311003.s004
(XLSX)
References
- 1.
International Classification of Functioning, Disability and Health. Available at: http://www.who.int/classifications/icf/en. Accessed May, 2024.
- 2. Keus S.H.J., Munneke M., Graziano M., al. e (2014) European Physiotherapy Guideline for Parkinson’s disease. KNGF/ParkinsonNet, the Netherlands.
- 3. Keus SH, Oude Nijhuis LB, Nijkrake MJ, Bloem BR, Munneke M (2012) Improving community healthcare for patients with Parkinson’s disease: the dutch model. Parkinsons Dis 2012: 543426. pmid:22496990
- 4. (2014) Parkinson Evidence Database to Guide Effectiveness (PDEDGE) task force—Recommendations for patients with Parkinson disease. Academy of Neurologic Physical Therapy—American Physical Therapy Association.
- 5. Poewe W, Antonini A, Zijlmans JC, Burkhard PR, Vingerhoets F (2010) Levodopa in the treatment of Parkinson’s disease: an old drug still going strong. Clin Interv Aging 5: 229–238. pmid:20852670
- 6. Wilson J, Alcock L, Yarnall AJ, Lord S, Lawson RA, et al. (2020) Gait Progression Over 6 Years in Parkinson’s Disease: Effects of Age, Medication, and Pathology. Front Aging Neurosci 12: 577435. pmid:33192470
- 7. Speelman AD, van de Warrenburg BP, van Nimwegen M, Petzinger GM, Munneke M, et al. (2011) How might physical activity benefit patients with Parkinson disease? Nat Rev Neurol 7: 528–534. pmid:21750523
- 8. Petzinger GM, Fisher BE, McEwen S, Beeler JA, Walsh JP, et al. (2013) Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease. Lancet Neurol 12: 716–726. pmid:23769598
- 9. Oliveira de Carvalho A, Filho ASS, Murillo-Rodriguez E, Rocha NB, Carta MG, et al. (2018) Physical Exercise For Parkinson’s Disease: Clinical And Experimental Evidence. Clin Pract Epidemiol Ment Health 14: 89–98.
- 10. Ellis T, Rochester L (2018) Mobilizing Parkinson’s Disease: The Future of Exercise. J Parkinsons Dis 8: S95–S100. pmid:30584167
- 11. Zhang Q, Hu J, Wei L, Jia Y, Jin Y (2019) Effects of dance therapy on cognitive and mood symptoms in people with Parkinson’s disease: A systematic review and meta-analysis. Complement Ther Clin Pract 36: 12–17. pmid:31383428
- 12. Osborne JA, Botkin R, Colon-Semenza C, DeAngelis TR, Gallardo OG, et al. (2022) Correction to: Osborne JA, Botkin R, Colon-Semenza C, et al. Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline From the American Physical Therapy Association. Phys Ther. 2022;102:pzab302. Phys Ther 102. pmid:34963139
- 13. Osborne JA, Botkin R, Colon-Semenza C, DeAngelis TR, Gallardo OG, et al. (2021) Physical Therapist Management of Parkinson Disease: A Clinical Practice Guideline from the American Physical Therapy Association. Phys Ther.
- 14. Shekelle PG, Woolf SH, Eccles M, Grimshaw J (1999) Clinical guidelines: developing guidelines. Bmj 318: 593–596. pmid:10037645
- 15. Emmanouilidis S, Hackney ME, Slade SC, Heng H, Jazayeri D, et al. (2021) Dance Is an Accessible Physical Activity for People with Parkinson’s Disease. Parkinsons Dis 2021: 7516504. pmid:34721836
- 16. Berti A, Pini M, Ferrarello F (2020) Argentine tango in the care of Parkinson’s disease: A systematic review and analysis of the intervention. Complement Ther Med 52: 102474. pmid:32951724
- 17. Casaca-Carreira J, Raheem AR(2018) Effects of ballroom dancing in patients with Parkinson`s disease: A systematic review. EC Neurology: 108–116.
- 18. Aguiar LPC, da Rocha PA, Morris M (2016) Therapeutic Dancing for Parkinson’s Disease. International Journal of Gerontology 10: 64–70.
- 19. Mandelbaum R, Lo AC (2014) Examining Dance as an Intervention in Parkinson’s Disease: A Systematic Review. American Journal of Dance Therapy 36: 160–175.
- 20. Valverde Guijarro E, Flórez García MT (2012) Efecto de la danza en los enfermos de Parkinson. Fisioterapia 34: 216–224.
- 21. Simpkins C, Yang F (2023) Do dance style and intervention duration matter in improving balance among people with Parkinson’s disease? A systematic review with meta-analysis. Parkinsonism Relat Disord 106: 105231. pmid:36470708
- 22. Hasan SM, Alshafie S, Hasabo EA, Saleh M, Elnaiem W, et al. (2022) Efficacy of dance for Parkinson’s disease: a pooled analysis of 372 patients. J Neurol 269: 1195–1208. pmid:33966112
- 23. Karpodini CC, Dinas PC, Angelopoulou E, Wyon MA, Haas AN, et al. (2022) Rhythmic cueing, dance, resistance training, and Parkinson’s disease: A systematic review and meta-analysis. Front Neurol 13: 875178. pmid:36034281
- 24. Wang LL, Sun CJ, Wang Y, Zhan TT, Yuan J, et al. (2022) Effects of dance therapy on non-motor symptoms in patients with Parkinson’s disease: a systematic review and meta-analysis. Aging Clin Exp Res 34: 1201–1208. pmid:35091970
- 25. Ismail SR, Lee SWH, Merom D, Megat Kamaruddin PSN, Chong MS, et al. (2021) Evidence of disease severity, cognitive and physical outcomes of dance interventions for persons with Parkinson’s Disease: a systematic review and meta-analysis. BMC Geriatr 21: 503. pmid:34551722
- 26. Barnish MS, Barran SM (2020) A systematic review of active group-based dance, singing, music therapy and theatrical interventions for quality of life, functional communication, speech, motor function and cognitive status in people with Parkinson’s disease. BMC Neurol 20: 371. pmid:33038925
- 27. Carapellotti AM, Stevenson R, Doumas M (2020) The efficacy of dance for improving motor impairments, non-motor symptoms, and quality of life in Parkinson’s disease: A systematic review and meta-analysis. PLoS One 15: e0236820. pmid:32756578
- 28. de Almeida HS, Porto F, Porretti M, Lopes G, Fiorot D, et al. (2021) Effect of Dance on Postural Control in People with Parkinson’s Disease: A Meta-Analysis Review. J Aging Phys Act 29: 130–141. pmid:32736345
- 29. Kalyani HHN, Sullivan K, Moyle G, Brauer S, Jeffrey ER, et al. (2019) Effects of Dance on Gait, Cognition, and Dual-Tasking in Parkinson’s Disease: A Systematic Review and Meta-Analysis. J Parkinsons Dis 9: 335–349. pmid:30958312
- 30. Monteiro Mazzarin C, Valderramas SR, de Paula Ferreira M, Tiepolo E, Guerios L, et al. (2017) Effects of dance and of Tai Chi on functional mobility, balance, and agility in Parkinson disease: a systematic review and meta-analysis. Topics in Geriatric Rehabilitation 2017 Oct-Dec;33(4):262–272.
- 31. Dos Santos Delabary M, Komeroski IG, Monteiro EP, Costa RR, Haas AN (2018) Effects of dance practice on functional mobility, motor symptoms and quality of life in people with Parkinson’s disease: a systematic review with meta-analysis. Aging Clin Exp Res 30: 727–735. pmid:28980176
- 32. Sharp K, Hewitt J (2014) Dance as an intervention for people with Parkinson’s disease: a systematic review and meta-analysis. Neurosci Biobehav Rev 47: 445–456. pmid:25268548
- 33. Lotzke D, Ostermann T, Bussing A (2015) Argentine tango in Parkinson disease—a systematic review and meta-analysis. BMC Neurol 15: 226. pmid:26542475
- 34. Shanahan J, Morris ME, Bhriain ON, Saunders J, Clifford AM (2015) Dance for people with Parkinson disease: what is the evidence telling us? Arch Phys Med Rehabil 96: 141–153. pmid:25223491
- 35. Alves Da Rocha P, McClelland J, Morris ME (2015) Complementary physical therapies for movement disorders in Parkinson’s disease: a systematic review. Eur J Phys Rehabil Med 51: 693–704. pmid:26138090
- 36. Chen K, Tan Y, Lu Y, Wu J, Liu X, et al. (2020) Effect of Exercise on Quality of Life in Parkinson’s Disease: A Systematic Review and Meta-Analysis. Parkinsons Dis 2020: 3257623. pmid:32695306
- 37. Bastian H, Glasziou P, Chalmers I (2010) Seventy-five trials and eleven systematic reviews a day: how will we ever keep up? PLoS Med 7: e1000326. pmid:20877712
- 38. Shea BJ, Grimshaw JM, Wells GA, Boers M, Andersson N, et al. (2007) Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 7: 10. pmid:17302989
- 39. Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, et al. (2017) AMSTAR 2: a critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. Bmj 358: j4008. pmid:28935701
- 40. Gates M, Gates A, Pieper D, Fernandes RM, Tricco AC, et al. (2022) Reporting guideline for overviews of reviews of healthcare interventions: development of the PRIOR statement. http://europepmc.org/abstract/MED/35944924. BMJ (Clinical research ed). pmid:35944924
- 41. Pollock M, Fernandes RM, Becker LA, Pieper D, L. H ((updated February 2022).) Chapter V: Overviews of Reviews. Cochrane Handbook for Systematic Reviews of Interventions version 6.3. Cochrane
- 42. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, et al. (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. Bmj 350: g7647. pmid:25555855
- 43. Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, et al. (2011) GRADE guidelines 6. Rating the quality of evidence—imprecision. J Clin Epidemiol 64: 1283–1293. pmid:21839614
- 44. Hultcrantz M, Rind D, Akl EA, Treweek S, Mustafa RA, et al. (2017) The GRADE Working Group clarifies the construct of certainty of evidence. J Clin Epidemiol 87: 4–13. pmid:28529184
- 45. Wu CC, Xiong HY, Zheng JJ, Wang XQ (2022) Dance movement therapy for neurodegenerative diseases: A systematic review. Front Aging Neurosci 14: 975711. pmid:36004000
- 46. Kiepe M-S, Stöckigt B, Keil T (2012) Effects of dance therapy and ballroom dances on physical and mental illnesses: A systematic review. The Arts in Psychotherapy 39: 404–411.
- 47. Santos L, Campos C, Bento T, Lattari E, Nardi AE, et al. (2016) Effects of dual-task interventions on gait performance of patients with Parkinson’s Disease: A systematic review. MedicalExpress (São Paulo, Online) v. 3, n. 4.
- 48. Šumec R, Filip P, Sheardová K, Bareš M (2015) Psychological Benefits of Nonpharmacological Methods Aimed for Improving Balance in Parkinson’s Disease: A Systematic Review. Behav Neurol 2015: 620674.
- 49. Murray DK, Sacheli MA, Eng JJ, Stoessl AJ (2014) The effects of exercise on cognition in Parkinson’s disease: a systematic review. Transl Neurodegener 3: 5. pmid:24559472
- 50. Ernst M, Folkerts AK, Gollan R, Lieker E, Caro-Valenzuela J, et al. (2023) Physical exercise for people with Parkinson’s disease: a systematic review and network meta-analysis. Cochrane Database Syst Rev 1: CD013856. pmid:36602886
- 51. Zhang M, Li F, Wang D, Ba X, Liu Z (2023) Exercise sustains motor function in Parkinson’s disease: Evidence from 109 randomized controlled trials on over 4,600 patients. Front Aging Neurosci 15: 1071803. pmid:36865410
- 52. Yang C-L, Huang J-P, Wang T-T, Tan Y-C, Chen Y, et al. (2022) Effects and parameters of community-based exercise on motor symptoms in Parkinson’s disease: a meta-analysis. BMC Neurology 22: 505. pmid:36581847
- 53. Mustafaoglu R, Ahmed I, Pang MYC (2022) Which type of mind-body exercise is most effective in improving functional performance and quality of life in patients with Parkinson’s disease? A systematic review with network meta-analysis. Acta Neurol Belg 122: 1433–1446. pmid:36056269
- 54. Lorenzo-García P, Núñez de Arenas-Arroyo S, Cavero-Redondo I, Guzmán-Pavón MJ, Priego-Jiménez S, et al. (2023) Physical Exercise Interventions on Quality of Life in Parkinson Disease: A Network Meta-analysis. J Neurol Phys Ther 47: 64–74. pmid:36730998
- 55. Goh L, Canning CG, Song J, Clemson L, Allen NE (2022) The effect of rehabilitation interventions on freezing of gait in people with Parkinson’s disease is unclear: a systematic review and meta-analyses. Disabil Rehabil: 1–20. pmid:36106644
- 56. Yang Y, Wang G, Zhang S, Wang H, Zhou W, et al. (2022) Efficacy and evaluation of therapeutic exercises on adults with Parkinson’s disease: a systematic review and network meta-analysis. BMC Geriatr 22: 813. pmid:36271367
- 57. Wang Y, Sun X, Li F, Li Q, Jin Y (2022) Efficacy of non-pharmacological interventions for depression in individuals with Parkinson’s disease: A systematic review and network meta-analysis. Front Aging Neurosci 14: 1050715. pmid:36438007
- 58. Hao Z, Zhang X, Chen P (2022) Effects of Ten Different Exercise Interventions on Motor Function in Parkinson’s Disease Patients-A Network Meta-Analysis of Randomized Controlled Trials. Brain Sci 12. pmid:35741584
- 59. Álvarez-Bueno C, Deeks JJ, Cavero-Redondo I, Jolly K, Torres-Costoso AI, et al. (2023) Effect of Exercise on Motor Symptoms in Patients With Parkinson’s Disease: A Network Meta-analysis. J Geriatr Phys Ther 46: E87–E105. pmid:34392264
- 60. Radder DLM, Lígia Silva de Lima A, Domingos J, Keus SHJ, van Nimwegen M, et al. (2020) Physiotherapy in Parkinson’s Disease: A Meta-Analysis of Present Treatment Modalities. Neurorehabil Neural Repair 34: 871–880. pmid:32917125
- 61. Hidalgo-Agudo RD, Lucena-Anton D, Luque-Moreno C, Heredia-Rizo AM, Moral-Munoz JA (2020) Additional Physical Interventions to Conventional Physical Therapy in Parkinson’s Disease: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. J Clin Med 9. pmid:32272665
- 62. Tang L, Fang Y, Yin J (2019) The effects of exercise interventions on Parkinson’s disease: A Bayesian network meta-analysis. J Clin Neurosci 70: 47–54. pmid:31526677
- 63. Kwok JY, Choi KC, Chan HY (2016) Effects of mind-body exercises on the physiological and psychosocial well-being of individuals with Parkinson’s disease: A systematic review and meta-analysis. Complement Ther Med 29: 121–131. pmid:27912936
- 64. de Dreu MJ, van der Wilk AS, Poppe E, Kwakkel G, van Wegen EE (2012) Rehabilitation, exercise therapy and music in patients with Parkinson’s disease: a meta-analysis of the effects of music-based movement therapy on walking ability, balance and quality of life. Parkinsonism Relat Disord 18 Suppl 1: S114–119. pmid:22166406
- 65. Tomlinson CL, Patel S, Meek C, Clarke CE, Stowe R, et al. (2012) Physiotherapy versus placebo or no intervention in Parkinson’s disease. Cochrane Database Syst Rev: CD002817.
- 66. Tomlinson CL, Patel S, Meek C, Herd CP, Clarke CE, et al. (2012) Physiotherapy intervention in Parkinson’s disease: systematic review and meta-analysis. BMJ 345: e5004. pmid:22867913
- 67. Hao Z, Zhang X, Chen P (2023) Correction: Hao et al. Effects of Ten Different Exercise Interventions on Motor Function in Parkinson’s Disease Patients—A Network Meta-Analysis of Randomized Controlled Trials. Brain Sci. 2022, 12, 698. Brain Sciences 13: 885.
- 68. Wang D, Cui WJ, Hou ZH, Gao Y (2023) Effectiveness of different exercises in improving postural balance among Parkinson’s disease patients: a systematic review and network meta-analysis. Front Aging Neurosci 15: 1215495. pmid:37529009
- 69. He S, Fang W, Wu J, Lv H, Zhang J, et al. (2023) Whether mindfulness-guided therapy can be a new direction for the rehabilitation of patients with Parkinson’s disease: a network meta-analysis of non-pharmacological alternative motor-/sensory-based interventions. Front Psychol 14: 1162574. pmid:37780170
- 70. Lorenzo-García P, Cavero-Redondo I, Núñez de Arenas-Arroyo S, Guzmán-Pavón MJ, Priego-Jiménez S, et al. (2024) Effects of physical exercise interventions on balance, postural stability and general mobility in Parkinson’s disease: a network meta-analysis. J Rehabil Med 56: jrm10329. pmid:38298133
- 71. Costa V, Suassuna AOB, Brito TSS, da Rocha TF, Gianlorenco AC (2023) Physical exercise for treating non-motor symptoms assessed by general Parkinson’s disease scales: systematic review and meta-analysis of clinical trials. BMJ Neurol Open 5: e000469. pmid:37808516
- 72. Hackney ME, Earhart GM (2009) Effects of dance on movement control in Parkinson’s disease: a comparison of Argentine tango and American ballroom. J Rehabil Med 41: 475–481. pmid:19479161
- 73. Rocha PA, Slade SC, McClelland J, Morris ME (2017) Dance is more than therapy: Qualitative analysis on therapeutic dancing classes for Parkinson’s. Complement Ther Med 34: 1–9. pmid:28917359
- 74. Frisaldi E, Bottino P, Fabbri M, Trucco M, De Ceglia A, et al. (2021) Effectiveness of a dance-physiotherapy combined intervention in Parkinson’s disease: a randomized controlled pilot trial. Neurological Sciences 42: 5045–5053. pmid:33743108
- 75. Poier D, Rodrigues Recchia D, Ostermann T, Bussing A (2019) A Randomized Controlled Trial to Investigate the Impact of Tango Argentino versus Tai Chi on Quality of Life in Patients with Parkinson Disease: A Short Report. Complement Med Res 26: 398–403.
- 76. Hackney ME, Earhart GM (2009) Health-related quality of life and alternative forms of exercise in Parkinson disease. Parkinsonism Relat Disord 15: 644–648. pmid:19329350
- 77. Lee NY, Lee DK, Song HS (2015) Effect of virtual reality dance exercise on the balance, activities of daily living, and depressive disorder status of Parkinson’s disease patients. J Phys Ther Sci 27: 145–147. pmid:25642060
- 78. Hackney ME, Kantorovich S, Earhart GM (2007) A study on the effects of Argentine Tango as a form of partnered dance for those with Parkinson disease and the healthy elderly. American Journal of Dance Therapy 2007 Dec;29(2):109–127.
- 79. Duncan RP, Earhart GM (2014) Are the effects of community-based dance on Parkinson disease severity, balance, and functional mobility reduced with time? A 2-year prospective pilot study. Journal of Alternative & Complementary Medicine 2014 Oct;20(10):757–763.
- 80. Hackney ME, Kantorovich S, Levin R, Earhart GM (2007) Effects of tango on functional mobility in Parkinson’s disease: a preliminary study. J Neurol Phys Ther 31: 173–179. pmid:18172414
- 81. Michels K, Dubaz O, Hornthal E, Bega D (2018) "Dance Therapy" as a psychotherapeutic movement intervention in Parkinson’s disease. Complement Ther Med 40: 248–252. pmid:30219460
- 82. Shanahan J, Morris ME, Bhriain ON, Volpe D, Lynch T, et al. (2017) Dancing for Parkinson Disease: A Randomized Trial of Irish Set Dancing Compared With Usual Care. Arch Phys Med Rehabil 98: 1744–1751. pmid:28336345
- 83. Duncan RP, Earhart GM (2012) Randomized controlled trial of community-based dancing to modify disease progression in Parkinson disease. Neurorehabilitation and Neural Repair 2012 Feb;26(2):132–143. pmid:21959675
- 84. Lee HJ, Kim SY, Chae Y, Kim MY, Yin C, et al. (2018) Turo (Qi Dance) Program for Parkinson’s Disease Patients: Randomized, Assessor Blind, Waiting-List Control, Partial Crossover Study. Explore (NY) 14: 216–223.
- 85. Rios Romenets S, Anang J, Fereshtehnejad SM, Pelletier A, Postuma R (2015) Tango for treatment of motor and non-motor manifestations in Parkinson’s disease: a randomized control study. Complement Ther Med 23: 175–184. pmid:25847555
- 86. Solla P, Cugusi L, Bertoli M, Cereatti A, Della Croce U, et al. (2019) Sardinian Folk Dance for Individuals with Parkinson’s Disease: A Randomized Controlled Pilot Trial. J Altern Complement Med 25: 305–316. pmid:30624952
- 87. Kunkel D, Fitton C, Roberts L, Pickering RM, Roberts HC, et al. (2017) A randomized controlled feasibility trial exploring partnered ballroom dancing for people with Parkinson’s disease. Clin Rehabil 31: 1340–1350. pmid:28933613
- 88. Hashimoto H, Takabatake S, Miyaguchi H, Nakanishi H, Naitou Y (2015) Effects of dance on motor functions, cognitive functions, and mental symptoms of Parkinson’s disease: a quasi-randomized pilot trial. Complement Ther Med 23: 210–219. pmid:25847558
- 89. Volpe D, Signorini M, Marchetto A, Lynch T, Morris ME (2013) A comparison of Irish set dancing and exercises for people with Parkinson’s disease: a phase II feasibility study. BMC Geriatr 13: 54. pmid:23731986
- 90. Martinez-Martin P, Serrano-Dueñas M, Forjaz MJ, Serrano MS (2007) Two questionnaires for Parkinson’s disease: are the PDQ-39 and PDQL equivalent? Qual Life Res 16: 1221–1230. pmid:17534735
- 91. Almeida MO, Yamato TP, Parreira P, Costa LOP, Kamper S, et al. (2020) Overall confidence in the results of systematic reviews on exercise therapy for chronic low back pain: a cross-sectional analysis using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR) 2 tool. Braz J Phys Ther 24: 103–117. pmid:31113734
- 92. Pieper D, Koensgen N, Breuing J, Ge L, Wegewitz U (2018) How is AMSTAR applied by authors–a call for better reporting. BMC Medical Research Methodology 18: 56. pmid:29914386
- 93. Higgins JP, Thomas J, Chandler J, Cumpston M, Li T, et al. (2021) Cochrane Handbook for Systematic Reviews of Interventions Version 6.2. Cochrane.
- 94. Sánchez-Ferro Á, Matarazzo M, Martínez-Martín P, Martínez-Ávila JC, Gómez de la Cámara A, et al. (2018) Minimal Clinically Important Difference for UPDRS-III in Daily Practice. Mov Disord Clin Pract 5: 448–450. pmid:30838303
- 95. Hoehn MM, Yahr MD (1998) Parkinsonism: onset, progression, and mortality. 1967. Neurology 50: 318 and 316 pages following. pmid:9484345
- 96. Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, et al. (2014) Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide. BMJ 348: g1687. pmid:24609605
- 97. Bushman BA (2018) Developing the P (for Progression) in a FITT-VP Exercise Prescription. ACSM’s Health & Fitness Journal 22: 6–9.