It takes two to…Rehabilitate

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Muhammad Ali

The legendary Muhammad Ali was so fast in the boxing ring, you couldn’t see his punches coming. In the last few years of his professional career however, his movements started slowing down, and his speech began slurring. After taking several thousand hits to his head, he retired at age 38, and was officially diagnosed with Parkinson’s disease three years later. The tough boxer’s hand was seen shaking involuntarily as he lifted the Olympic torch to start the 1996 summer games. His resilience remained consistent throughout and he redirected his energy towards philanthropy. At age 74, Ali succumbed to respiratory issues leading to septic shock, a frequent cause of fatality in Parkinson’s patients.

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Michael J Fox

Michael J. Fox of Back to the Future fame, was 29 years old when his pinky finger started twitching uncontrollably. This lead to his diagnosis of Parkinson’s disease. He kept the news private for the next 7 years, battling heavy drinking, depression and denial. He then emerged strong, becoming a beacon of hope for the community by raising over 750 million dollars for Parkinson’s Research. He has appeared in several interviews, highlighting how Parkinson’s patients struggle with their changing image as their bodies deteriorate over time with increasing rigidity and loss of balance.

As of 2016, an estimated 7-10 million people have been diagnosed with Parkinson’s disease worldwide. The average age at which symptoms develop is 60 years, but an estimated 4% of patients show symptoms before 50 –  Ali and Fox are the most prominent examples. Parkinson’s disease affects the “substantia nigra”, a region of the brain rich in nerve cells or neurons that produce a chemical messenger called dopamine. Brain pathways related to movement control and behavior motivated by reward are controlled by dopamine. Parkinson’s patients show a loss of these dopamine producing neurons thus causing a deficiency of dopamine. This leads to abnormal electrical activity in the brain translating to a loss in control of movements, pain, speech impairment, fatigue, depression, loss of smell, dementia and sometimes a decline in mental abilities. Although research suggests the involvement of genetic and environmental factors in Parkinson’s, what kills these specific neurons is still unknown.

There is no cure yet for this devastating disease. Disease management is complex, as not every patient shows the same variety and severity of symptoms. The most common drug prescribed to Parkinson’s patients, Levodopa, acts by increasing dopamine in the body. However, increased levels of dopamine in body parts apart from the brain cause unwanted side effects like nausea, fatigue and dizziness. In order to counter some of these side effects, another drug called Carbidopa is used in combination which specifically increases dopamine in the brain. These medications provide much needed relief from movement related symptoms, but don’t work consistently well over time as the brain loses more and more neurons. Patients also show long term side effects like unpredictable involuntary movements. Some other medications act by increasing the lifetime of available dopamine in the brain, but also cause short-term side effects like nausea, dizziness and stomach pain that affect patients’ quality of life. Effective doses of medications have to be tailored specifically for each patient and tweaked over time. In some cases, placing an equivalent of a pacemaker in patients’ brains using a technique called deep brain stimulation can provide relief from symptoms like tremor by countering the abnormal electrical activity. Rehabilitation using physical, occupational and speech therapies are also proven to increase the quality of patients’ life. Exercise benefits Parkinson’s patients, but many have a tough time sticking to schedules due to low hopes of positive outcomes, lack of self-confidence and fear of falling.

What if patients had a warm embrace to fall back on? A supportive community to get together with? What if they were taught techniques to specifically increase balance and focus with music? In an attempt to rethink rehabilitation, physicians, scientists and dance artists have come together to explore the dance form of Argentine tango for patients with Parkinson’s disease.

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Argentinian Tango

Argentine tango, was developed in Argentina and Uruguay in the late 19th century, with distinct African and European influences in rhythm and sound. Initially serving as a form of expression among the not-so-rich, the tango has evolved over time to include dancers of all classes, races and physical abilities.

So what makes tango a good rehabilitative strategy to explore in Parkinson’s patients? In essence, tango is an improvisational social dance. Many introductory Argentine tango classes define it as an embrace with a partner while walking to music. Dancers don’t have to remember complex step sequences, making it less overwhelming for beginners and Parkinson’s patients alike. The emphasis is on remembering simple spatial concepts and spontaneously reacting to the music and the partners’ movements. Opportunities to improvise are many, leaving room for creativity that is very rewarding, especially when shared intimately with another person.

Body dynamics in tango require the lower half of the body to be relaxed and heavy, thus grounding the frame. The upper body is held in good posture with the spine stabilized by the core muscles. At any given time, the individual’s body weight is balanced on one foot or another, which encourages the development of balance on both sides of the body. In addition, the Tango also inherently emphasizes constant feedback and support between partners. This may be critical for patients that suffer from a lack of balance.

The Tango is a collaboration between a pair – a ‘leader’ and a ‘follower’. Leaders initiate the dance movements and have to communicate effectively to the followers. They plan their next moves based on the follower’s responses. Thus, the tango is an intimate non-verbal feedback loop between two partners. Along with keeping track of this collaboration, the leaders also have to navigate the dance floor with acute spatial awareness. After all, no one wants to bump into anything or anyone else on the dance floor! In fact, brain imaging studies show that leaders have higher activity in brain regions related to planning, navigation, action monitoring and error correction. Followers, on the other hand, must quickly respond to cues from the leaders and  constantly adapt their movements and timing to maintain the embrace. Studies have shown that followers have higher activity in brain regions related to processing of sensory information, pattern recognition, motion tracking, and social behaviors.

Training in all of these areas could benefit Parkinson’s patients by not just improving movement capabilities, but also by allowing them to develop greater self-confidence. In a world of increasing social isolation for Parkinson’s patients and others alike, non-verbal communication with an embrace is a refreshing experience, an avenue less explored in day-to-day interactions. Talk to tango dancers and you’ll see that everyone comes to it for a different reason. Some to interact with the opposite or same sex in a safe space, some to explore and rediscover themselves through their interactions with others.

Studies testing the efficacy of tango in a small number of Parkinson’s patients have shown a positive effect on balance and movement capabilities. Expanding these studies to include more and diverse patients will help understand how widespread these effects are. Furthermore, future studies could more vigorously investigate the effects of positive social interactions, personal satisfaction and increased motivation that are anecdotally reported by patients doing the tango.

We’ve come a long way with Parkinson’s research, but it remains a complex problem to solve. Many more scientific studies are needed to understand the  root cause(s) of the disease along with carefully designed clinical trials for potential therapies and rehabilitative practices. The fact that more research is needed to effectively combat Parkinson’s disease, does not inspire hope for a quick solution. But, while scientists and doctors strive to untangle the complexities of Parkinson’s disease, it is our responsibility as a community to support these patients and their caregivers, to help improve their quality of life. The use of Argentine tango as a rehabilitative therapy for Parkinson’s disease could prove to be a much needed step in this direction, a way Back to the Future.  

 


Swati Khare recently graduated with a PhD from the University of Florida. Her final dissertation concentrated on the creation and evaluation of biological models for a rare neurological disorder called spinocerebellar ataxia 13 (SCA13). She enjoys scientific communication through podcasts and blogs.

 

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