Garba Dance Is Effective in Parkinson's Disease Patients: A Pilot Study

Background Dance as therapy is gaining attention as an adjuvant option for Parkinson's disease (PD). Assessing culturally popular dance forms is crucial for promoting the acceptance of dance therapy in a culturally sensitive context. Objectives The pilot study evaluated the efficacy of Garba dance for alleviating motor symptoms, nonmotor symptoms, cognitive functions, and mood. Furthermore, this pilot study also assessed the tolerability and safety of this dance form using fatigue severity scale and assessing falls, respectively. Methods Eligible participants with mild-to-moderate PD (H&Y stage 1 to 2.5) were sequentially randomized into the dance therapy, physical therapy, or control groups. Motor symptoms, nonmotor symptoms, cognitive functions, and mood were assessed using standard scales at baseline, week 6, and week 12. Tolerability was measured using the Fatigue Severity Scale, and safety was assessed by monitoring falls. Results In the Garba dance group, significant improvements in UPDRS scores were observed at week 6 (p=0.002) and week 12 (p < 0.001) compared to baseline. At week 12, UPDRS scores were better in the Garba dance group as compared to the control and physical therapy groups. Freezing of gait significantly improved at week 6 (p < 0.001) and week 12 (p < 0.001) in the Garba dance group. Garba dance also led to significant improvements in mood and sleep. Tolerability was favorable, with significantly better fatigue severity scores in the Garba dance group at week 12 compared to controls and physical therapy. About 6 patients in Garba dance group experienced near falls. Conclusion Underscoring a cautious optimism, results of the current study indicate that Garba dance may be an effective, safe, and well-tolerated intervention for Indian patients with mild-to-moderate PD (H&Y stage 1 to 2.5).


Introduction
Dopamine replacement therapy is the mainstay of treatment for Parkinson's disease [1].However, the efcacy of these pharmacological therapies in controlling motor symptoms wears of with disease progression.Furthermore, appearance of nonmotor symptoms and their refractoriness to currently available pharmacological treatments are known to adversely impact health-related quality of life [2].Overcoming these above limitations often necessitates a multidisciplinary approach comprising of surgical interventions, physical therapy, occupational therapy, cognitive therapy, and other rehabilitative interventions [3].However, several barriers are known to impede adherence to these surgical and rehabilitative interventions, especially in older adults with Parkinson's disease [3].Over the recent years, several complementary activities such as dance, music, theatre, art, and Tai Chi have been evaluated as therapeutic options for managing patients with Parkinson's disease [4][5][6][7][8][9][10].Although evidence for the efectiveness of these therapies is currently nascent, initial results are promising, especially with respect to management of nonmotor symptoms, psychological well-being, and overall quality of life.In a recent systematic review, Sotomayer et al. point out that music therapy may have benefcial efects on motor symptoms, nonmotor symptoms, and cognition and emotional wellbeing [11].Furthermore, studies by Mirabella et al. and Modugno et al. indicate that active theatre as a therapy may ofer an efective form of holistic rehabilitation, wherein individuals with Parkinson's disease might learn or relearn social and emotional strategies in a protected environment and transfer them to everyday life situations [8,9].Tese studies also indicate that active theatre may also be associated with reduced depression, apathy, and stigma.Another study by Li et al. indicates that Tai Chi may ofer benefcial efects on balance and frequency of falls [10].Overall, these studies indicate that art forms employed as therapy may efectively complement standard treatment paradigms for Parkinson's disease.
Over the years, dance as a therapy has been gaining increasing attention as an option for people with Parkinson's disease [4,5,[12][13][14][15][16]. When used as a therapy, dance is known to improve motor symptoms, nonmotor symptoms, cognitive functions, and increase striatal dopamine release [5].Furthermore, dance comes across as an enjoyable physical activity, which can subvert the sedentary consequences for people with Parkinson's disease [4].Tese features of dance as therapy may assist people with Parkinson's disease to shift their focus from impaired movements to the enjoyability of movements, which has important implications for compliance to treatments.Respectful inclusivity and sensitivities to diverse cultural backgrounds are important considerations when employing dance as therapy for people with Parkinson's disease.Several studies have reported that dance forms such as Irish set dancing, Argentine tango, Waltz/ Foxtrot are efective in improving balance, gait, and locomotion related aspects of PD [12][13][14].Data on the usefulness of these dance forms for people with Parkinson's disease are more applicable for European, American, and Latin American settings.Applying dance as therapy in Indian settings require evaluation of Indian dance forms, and a few initial reports indicate that dance forms such as Bharatnatyam and Kathak may complement conventional treatments for Parkinson's disease [10,11].While these data are encouraging, it is important to note that Bharatnatyam and Kathak involve complex movements and extensive training, which may not be feasible in all patients with Parkinson's disease [15].In Indian contexts, Garba dance, a popular dance form across India, which involves elegant footwork, hand gestures, and graceful movements of the body comes across as an easy-to-train and a relatively simple dance form.
On the above premise, the pilot study reported herein evaluated the efcacy of Garba dance for alleviating motor symptoms, nonmotor symptoms, cognitive functions, and mood.Furthermore, this pilot study also assessed tolerability of Garba dance using the fatigue severity scale, and safety of this dance form was assessed by monitoring falls.

Methods
Tis study was designed as an assessor-blind, randomized, three-arm, parallel group, single-center pilot study.As the nature of the study precluded double-blinding, patients and investigators were not blinded to treatment allocation.However, all assessments were made by raters who were blinded to treatment allocations at all time points in the study.Tis study was approved by the institutional ethics committee.People with idiopathic Parkinson's disease (stage 1 to stage 2.5 on Hoehn and Yahr staging system) aged between 30 and 80 years and willing to give an informed consent were included in the study.People with atypical Parkinson's disease; those with a known history of unstable cardiovascular status like arrhythmias/CCF, psychiatric conditions, osteoarthritis of knee, and respiratory Illness like asthma/COPD; those with a history of falls or head injuries in the last three months; and those with signifcant cognitive impairment (MOCA < 24) were excluded from the study.Following the procedures of informed consent, 55 eligible patients were sequentially allocated in a 1 : 1 : 1 manner to group A (Garba dance; n � 20), group B (physical therapy; n � 20), and group C (control; n � 15) using a computergenerated randomization sequence.Assessors were blinded to these allocations.
With respect to interventions, all patients were asked to continue their anti-Parkinsonian medications.Patients randomized to receive dance therapy (group A) were trained by a professional Garba dancer for a period of 1 week and subsequently underwent a few warmup sessions before study initiation.During these training sessions, patients were trained to perform Garba dance as part of group in a circular formation with rhythmic counterclockwise movements associated with sweeping actions of upper limbs.All these movements as part of Garba dance required patients to synchronize their movements to the tempo of associated music, which begins slowly with gradual increase in speed of movements.During the study period, patients performed Garba dance in 1-hour sessions for 5 days/week for a period of 12 weeks under supervision and assistance of trained professionals.All the dance sessions were conducted in a supervised environment at our center, and no dance sessions were done remotely or at home.To minimize the impact of falls, dance sessions during the warmup and experimental sessions were conducted on a specially prepared sponge-cushioned dance mat.Furthermore, dance assistants closely monitored the movements of all the patients in the dance group to avoid falls.Patients randomized to group B received 1-hour sessions of physical therapy for 5 days/week for a period of 12 weeks.Physical therapy was administered using 7 patterns of proprioceptive neuromuscular facilitation (PNF) technique to mimic Garba dance.Patients randomized to group C received standard pharmacotherapy.Efcacy and safety outcomes assessed in this pilot study included motor symptoms, nonmotor 2 Parkinson's Disease symptoms, balance, gait, activities of daily living (ADL), cognition, sleep, moods, fatigue, and falls.Tese assessments were performed at the baseline, week 6, and week 12.As this was a pilot study, no formal sample size calculation was performed.All assessments were performed by assessors blinded to the treatment groups.Data were summarized, and proportions were compared using chi-square test, and means were compared using t-test or ANOVA.A repeated measures ANOVA, incorporating a within-factor analysis for time (3 levels) and a betweenfactor analysis for group (Garba dance, physical therapy, and control), was conducted.Tukey's post hoc tests were used to assess multiple comparisons across the groups.Cohen's d statistic was used to compute efect sizes for estimation of strength of treatment efects using an online tool available at https://www.statskingdom.com.Te level of signifcance (α) was set at 0.05.All statistics were performed using IBM SPSS Statistics 22 software (IBM Corp 2013).

Results
Te study included data from 55 patients (22 females and 33 males) with PD aged between 37 and 76 years.Although the original plan was to include 20 patients in each group to achieve an overall sample size of 60 for the entire study, we could recruit only 15 patients for the control group.Te demographic and baseline characteristics of all patients are summarized in Table 1.Tere were no signifcant diferences between groups at baseline with respect to demographic data, disease characteristics (stage, duration, and levodopa equivalent daily dose), and presence of comorbid conditions.
Figure 5 depicts the incidence of near falls reported in the study.None of the falls were serious in nature and were not associated with any fracture or serious consequences.Te dropout rates were 15% (3 out of 20) each in the Garba dance group and in the physical therapy group.Te reasons for dropout included falls (1 out of 20 in the physical therapy group) and difculties in travelling (2 out of 20 in the physical therapy group and 3 out of 20 in the Garba dance group).

Discussion
Results of the current study underscore a well-evidenced observation that a multidisciplinary approach involving pharmacotherapy, deep brain stimulation, and rehabilitative therapies is often needed for achieving outcomes in people with Parkinson's disease [1].In this study, the mean change in UPDRS scores was better compared to baseline in the Garba dance group at week 6 and 12.However, mean change from in UPDRS scores in the physical therapy group and control groups was not signifcantly diferent at week 6 and week 12. Results of post hoc comparisons using the Tukey test noted that diferences between groups were signifcant at week 12, wherein the people in the Garba dance group had better UPDRS scores as compared to physical therapy (p � 0.031) and control group (p < 0.05).Furthermore, statistically signifcant improvements were noted for freezing of gait (Figure 2) and fatigue severity scores (Figure 3) at week 12. Te percentage improvement in freezing of gait was 50.31 and 20.86 in Garba dance and physical therapy groups, respectively.Furthermore, percentage improvement in fatigue severity scores was 41.33 and 9.77 in Garba dance and physical therapy groups, respectively.Tese improvements are generally in line with the fndings of another study by Hackney et al. which noted that Argentine tango and American ballroom dance both led to signifcant improvements in gait and balance and also observed an increase in dopamine release in the putamen following tango dancing [12].Te current study did not fnd any efect of employing Garba dance as therapy in improving nonmotor symptoms, activities of daily living (ADL), or cognition.However, results of the current study indicate that Garba dance may have a benefcial efect on mood (Figure 4) and sleep (Table 2).Tese fndings are in agreement with other studies that have shown improvements in mood and reduction of depressive symptoms with dance therapy in individuals with Parkinson's disease [7,14].Volpe et al. note that the efcacy of dance as therapy may be attributable to the fact that it engages diferent brain regions such as the sensorimotor and limbic and cortico-basal ganglionic systems and promotes neural plasticity [14].Furthermore, Hashimoto et al. in their article explain that dance as therapy may be more motivating and enjoyable than traditional exercise, leading to better adherence and long-term benefts [4].Our observations showed that patients randomized to the Garba dance group did have an enjoyable time during the study.Tus, it appears that the enjoyability of Garba dance may lead to increased adherence to dance as therapy in people with an afnity for dancing and must therefore be seen as another option and not as a replacement for physical therapy in the overall multidisciplinary approach to managing patients with mildto-moderate Parkinson's disease.
In this study, we used PNF techniques for administering physical therapy and intended it to mimic Garba dance movements, which involves limb movements in diagonal patterns.Furthermore, the PNF pattern of movements is diagonal movements that mimic functional activities of daily living as they involve movements characterized by crossing the midline of the body.Previous studies indicate that PNF techniques are efective in improving balance and gait [16].In the current study, physical therapy was associated with signifcant improvements with respect to freezing of gait at week 12.
While there were no falls in the control group, 6 patients in the Garba dance group (n � 20) and 4 patients in the physical therapy group (n � 20) experienced near falls (Figure 5; p � 0.072).Although the falls were completely avoided by having dance attendants closely monitor the patients during the dance and physical therapy sessions and none of the patients in this study experienced falls, it appears to be a concern and individuals with a susceptibility to falls must be excluded or must be monitored closely and sufcient precautions must be instituted.Cushioning the dance foor properly is a necessity for both clinical and research settings for dance therapies in PD.Nevertheless, in this study, the near falls were not associated with reasons for dropouts in the Garba dance group.

Parkinson's Disease
We specifcally chose to include Garba dance over other Indian dance forms due to its relatively higher popularity and uncomplicated range of movements.Garba dance is a lively dance in a circular formation with counterclockwise movements associated with sweeping actions.Te strong beats of the music for Garba stimulate engagement of body movement.Dancing begins slowly and increases in speed.Te tempo of the music creates an energy that inspires rhythmic movement.
In this study, a notable decrease in their UPDRS scores (35.4 to 19.95 over a 12-week period) was noted in people allocated to the Garba dance.A key limitation of the current study is that lack of a premise to explain the magnitude of this UPDRS change.Data available from studies evaluating active theatre have indicated that individuals with Parkinson's disease might learn or relearn social and emotional strategies in a protected environment and transfer them to everyday life situations.Although data from the current study cannot provide a premise for such inferences, they does provide a suggestive premise for future studies to explore if such supervised environment to real-life transferences infuences the change in UPDRS noted in the study [8,9].In this study, freezing of gait was seen in both the "of" and "on" states and more in the "of" state.However, this study did not capture the intergroup diferences between the two states, and this may be another key limitation of this pilot trial.Furthermore, the operational constraints of the current pilot study did not allow for a post-study followup to check for the persistence of efects.
Overall, the results of this pilot study provide for a cautious optimism for considering Garba dance as an additional option in the multidisciplinary approach for managing people with mild-to-moderate Parkinson's disease.While the small sample size and the inherent limitations of a pilot study usher in caution, the noticeable improvements in UPDRS, freezing of gait, and fatigue severity scores along with improvements in mood and sleep   Parkinson's Disease lend premise for continued optimism.We computed Cohen's d to ascertain the efect size (change in UPDRS from baseline to week 12), which was −1.688.In a planned future study, we aim to detect an efect size of 0.8 with a power of 80% and a level of signifcance at 0.05 with allowances for 20% dropout.Tus, we plan to recruit 105 participants for the planned trial.

Figure 4 :
Figure 4: Mood as assessed by geriatric depression score at baseline, week 6, and week 12.

Figure 5 :
Figure 5: Incidence of near falls in the study.

Table 1 :
Baseline characteristics of patients included in the study. *

Table 2 :
Mean change in outcome measures assessed in the study.
Te bold values indicate statistically signifcant values.