METHODS published: 12 November 2020 doi: 10.3389/fneur.2020.567891 PasoDoble, a Proposed Dance/Music for People With Parkinson’s Disease and Their Caregivers Lydia Giménez-Llort 1,2* and Lidia Castillo-Mariqueo 1 1 Department of Psychiatry and Forensic Medicine, School of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain, 2 Institut de Neurociències, Universitat Autònoma de Barcelona, Barcelona, Spain Managing the heterogeneity of Parkinson’s disease symptoms and its progressive nature demands strategies targeting the hallmark disrupted neurotransmission but also the comorbid derangements and bolstering neuroprotection and regeneration. Strong efforts are done to find disease-modifying strategies, since slowing disease progression is not enough to hamper its burden and some motor symptoms are resistant to dopamine-replacement therapy. The inclusion of non-pharmacological Edited by: strategies can provide such a multitarget umbrella approach. The silent long-term Adolfo Ramirez-Zamora, University of Florida Health, biological process that precedes the clinical onset of disease is a challenge but also an United States opportunity to reinforce healthy lifestyle known to exert preventive/therapeutic effects. Reviewed by: These non-pharmacological strategies are foreseen as able to reduce the prevalence Silmar Teixeira, and the global impact of long-term diseases demanding strong management of Federal University of Piauí, Brazil Marta San Luciano, patient-caregiver quality of life. In this regard, European guidelines for Parkinson’s disease University of California, San Francisco, recommend physical-related activities such as aerobic exercise and dancing known to United States improve functional mobility and balance in patients. Here, we propose “PasoDoble,” *Correspondence: Lydia Giménez-Llort a novel dance/music patient-caregiver intervention with additional preventive value. lidia.gimenez@uab.cat The rationale is founded on evidence-based therapeutic benefits of dance/music therapy and the singular features of this widely extended Hispanic dance/music Specialty section: targeting motor symptoms, mood/cognition, and socialization: (i) As a dance, an This article was submitted to Movement Disorders, easy and simple double-step pattern (back-and-forward and lateral movements) that a section of the journal evolves from a spontaneous individual dance to a partnered dancing, performed in Frontiers in Neurology social groups and involving dancing-figures of increasing complexity; (ii) “PasoDoble,” Received: 30 May 2020 Accepted: 02 October 2020 as a music that can be sung, has musical rhythmicity with high groove and Published: 12 November 2020 familiarity that will help to synchronize the steps to the rhythm of music; (iii) Widely Citation: extended (Spain, Mexico, Puerto Rico, Colombia, and USA) and easy-to-learn for Giménez-Llort L and others. As a regular dancing “PasoDoble” can improve and preserve function, Castillo-Mariqueo L (2020) PasoDoble, a Proposed Dance/Music mood and socialization, as an intervention the method is structured to improve for People With Parkinson’s Disease gait and balance; facilitate movement, reaching and grasping; muscle power and and Their Caregivers. Front. Neurol. 11:567891. joint mobility; reduce of risk of falls, and increase of aerobic capacity. Finally, this doi: 10.3389/fneur.2020.567891 easy-to-implement into patient care and free-living environments (elderly social centers, Frontiers in Neurology | www.frontiersin.org 1 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers home care) rehabilitation programs can promote positive emotions and self-esteem, with added general improvement of social attachment and recognition, thus improving the quality of life of patient-caregiver. Keywords: Parkisnon’s disease, prevention, rehabilitation, quality of life, caregiver, dance and movement psychotherapy, family-centered care, home care INTRODUCTION preceding onset of motor symptoms of the disease (10). Excessive daytime sleepiness, fatigue, pain, apathy, and dysfunction Parkinson’s disease (PD), as most aging associated of other autonomic responses such as urinary dysfunction neurodegenerative pathologies, has a heterogeneous and orthostatic hypotension, excessive sweating, are also presentation. Besides the hallmark motor symptoms, sensorial, commonly reported in the early-stage PD. Neuroimaging cognitive, and psychiatric alterations can also be developed of NMS in PD showing early affectation of monoamine (1, 2). Managing such a diversity of symptoms and progressive and cortical systems beyond the nigrostriatal dopaminergic nature demands strategies targeting the hallmark disrupted pathway supports these broad spectrum of symptoms that neurotransmission but also the comorbid derangements and the during the progress of the disease will also involve cognitive bolstering of neuroprotection and regeneration (3). Currently, domains, with executive dysfunctions (11), deficits in procedural there are various treatment strategies to address the symptoms learning (12, 13), visual hallucinations and dementia, as well and progression of PD but pharmacotherapy is the treatment of as complex behavioral disorders (14). Executive functions choice (2–4). and attention seem to be associated with gait and balance, The dopaminergic therapy targets the prominent loss of a relationship that is conspicuous in normal aging and dopaminergic neurons in the substantia nigra that caused in neurodegenerative diseases that affect cognition and/or a deficiency of dopamine and results in the main clinical motor functions (15). However, other reports found no symptoms that characterize the disease: tremor, bradykinesia, correlation between NMS burden and motor severity, age, or rigidity, and postural instability (4–6). Besides, other typical gender (10). motor symptoms can be observed, such as an altered gait At the therapeutical level, strong efforts are done in pattern, freezing of walking steps and deficits in coordination, order to find disease-modifying strategies, since slowing directly impacting general motor control, and mobility of the disease progression is not enough to hamper the burden entire body of the individuals who suffer from it (7). Thus, of disease and some symptoms are resistant to dopamine- these motor disorders are dramatically evidenced in the gait replacement therapy (1–4, 16). The above mentioned prodromal of the individual as the disease progresses, recognizing an stages unveiled by NMS point at new scenarios for early “akinetic-rigid gait” when these alterations are accentuated intervention, but inability to make a conclusive diagnosis at (8). Gait disturbances include decreased steps speed with the earliest stages as well as difficulties in the management decreased length as well, a narrow support base, and a hunched of symptoms at advanced stages of the disease are still posture that affects the neck, shoulders, and trunk. Also, the important clinical challenges (1). In this sense, the inclusion oscillation of the arms and the rhythmic movement of the of non-pharmacological strategies and managing PD with a upper and lower cingulum are reduced, causing the arms multidisciplinary perspective can contribute to provide such to remain in an adducted position and flexed toward the a multitarget umbrella approach. Thus, the silent long-term trunk. In the lower extremities, the feet are raised less than biological process that precedes the clinical onset of disease normal, which can lead to walking intermittently causing greater is a challenge but also an opportunity to reinforce healthy variability in each step and therefore the gait time spent lifestyle known to exert preventive/therapeutic effects. For its increases (4, 7, 8). Freezing usually occurs at the start of the part, non-pharmacological treatment requires the intervention gait but can also appear when turning or approaching an of several disciplines, among which is therapeutic exercise, obstacle. It develops from early stages and usually decreases use of auditory, visual and somatosensorial stimuli, care with medication in less severe stages. While the adaptation strategies and complementary therapies, which reflects the mechanisms and postural adjustments along with the dynamic wide range of options and alternatives of choice. These non- balance are altered during the execution of the steps in the pharmacological strategies are foreseen as able to reduce gait (6). the prevalence and the global impact of long-term diseases With regards to non-motor symptoms (NMS) of PD, demanding strong management of patient-caregiver quality of growing number of literature (3, 9) consistently describes REM life. In this regard, European guidelines for Parkinson’s disease sleep behavior disorder and constipation; mood and affect recommend physical-related activities such as aerobic exercise disorders with anxiety and depression; sensory disfunction and dancing known to improve functional mobility and balance with hyposmia and taste loss, as early non-motor features in patients (17). Frontiers in Neurology | www.frontiersin.org 2 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers “PASODOBLE”, A PROPOSED Based on this traditional pasodoble dance/music, here, we DANCE/MUSIC INTERVENTION FOR propose “PasoDoble,” a novel dance/music patient-caregiver intervention with additional preventive value. We also want PEOPLE WITH PARKINSON’S DISEASE to highly its potential value for maintenance of physical well- AND THEIR CAREGIVERS being as a regular dancing in the lifestyle of the Hispanic elderly. We aim to provide a methodological scenario (see PD rehabilitation programs for people with PD include combined Figure 1) and the theoretical fundaments (see Box 1) for the multimodal exercises of strength, balance, coordination, and/or benefits of this dance and method (see Box 2) improving aerobic training for the improvement of physical and motor gait, balance, and functional disturbances in people with condition (18, 19). It is possible to create circuits with a great Parkinson’s disease but also patient-caregiver quality of life, variety of exercises, for example, those used in walking and as a family caregiving intervention. However, the investigation overcoming obstacles that can provide benefits in patients with of this approach as an intervention targeting PD is still a mild and moderate PD, reducing intrinsic fragility and providing work that is currently in progress (see Figure 2 for Measures greater possibilities for the control of dynamic balance in the and Tools). performance of the steps in each stride (20, 21). The rationale of our proposal “PasoDoble” as a PD intervention is In this context, pasodoble is a type of ballroom dance that is founded on evidence-based therapeutic benefits of dance/music characterized by its base step consisting of walking, so integrates many features of therapeutic exercise. In this traditional dance, therapy that will be discussed below. Also, it is based in the the couple is of great importance since figures of eight are made singular features of this widely extended Hispanic popular in eight steps in a coordinated and harmonious way to the dance/music targeting motor symptoms, mood/cognition and rhythm of the music (2 × 4). The important thing is to perform socialization (see Box 2). the dance steps with the upright posture, raising the chest and Rehabilitation programs for PD should be “goal-based” contracting the abdomen for proper control of the trunk. Some of (aimed at practicing and learning specific activities in core the basic figures that can be performed include walking back and areas), but it is necessary to identify a number of practical forth on the same site, making turns, and incorporating lateral variables (intensity, specificity, complexity), as well as movements. Then it progresses to separation and return of the adaptations related to the individual characteristics of the couple, walk of the woman and crossed steps at different times. patients according to the degree of involvement and severity Finally, fast turns are made with forward, backward, and lateral that the disease has caused with its clinical manifestations of movements in 8 times. motor disorder. FIGURE 1 | Key features of the ‘PasoDoble’ protocol. Frontiers in Neurology | www.frontiersin.org 3 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers BOX 1 | Scientific rationale of “PasoDoble.” BOX 2 | The 5 key fundaments of the “PasoDoble” Method The “Pasodoble” methods is based on the 5 key features, that can be The evidence-based therapeutical benefits of dance/movement summarized as follows: therapy and the singularity of PasoDoble features. The European physiotherapy guideline for Parkinson’s disease recommends dance as i) As a dance, an easy and simple double-step pattern (back-and- “a meaningful approach to improve functional mobility and balance” (17). forward and lateral movements) that evolves from a spontaneous According to the stage of progression of the disease, the proposed individual dance to a partnered dancing, performed in social groups time-line of intervention relays on four key areas: and involving dancing-figures of increasing complexity; Based in a simple 1) Cueing strategies to improve gait, walking pattern (2 beats, 8-to-8 steps, 2 × 4 rhythm), easy to translate 2) Cognitive movement strategies to improve transfer, into a training program. Its basic performance is spontaneous and flexible, 3) Exercises to improve balance and not predefined routine from start to end, but guided by the rhythm of the 4) Training of joint mobility and muscle power to improve physical music, with the directionality of movement including the facilitatory effect capacity (22). of the partner. In fact, since the early work by Westbrook and McKibben (23), ii) “PasoDoble,” as a music that can be sung, has musical rhythmicity dance/movement therapy has been reported been more effective with high groove and familiarity that compels the body to move, than exercise in the outpatient treatment of patients with Parkinson’s overcoming the difficulties and tiredness that the parkinson’s patient disease. Underlying neural mechanisms are a research area of growing encounters with each movement. It also helps to synchronize the interest (24) and it has been speculated that regular dancing practice may steps to the rhythm of music with the extra-guidance of the dance facilitate activation of sensory-motor areas impaired in the brain of people partner (caregiver); with PD (25). On parallel activation by means of music of brain areas such iii) Widely extended (Spain, Mexico, Puerto Rico, Colombia, and USA) and as amygdala, nucleus accumbens, hypothalamus, hippocampus, insula, easy-to-learn for others. cingulate cortex, and orbitofrontal cortex are pointed out as those providing iv) While as a regular dancing “PasoDoble” can improve and preserve emotional benefits (26). Besides, in partnered dancing, dance partner and function, mood and socialization, as an intervention the “PasoDoble” music may exert additive effects on achievement of rhythmicity since they method is structured to improve gait and balance; facilitate movement, both provide spatial external cues and timeframes that may facilitate reaching and grasping; muscle power and joint mobility; reduce of risk of movement initiation and execution in a PD-brain with impaired basal-ganglia falls, and increase of aerobic capacity. that leads not only to movement disturbances but also worse rhythm v) Finally, this easy-to-implement into patient care and free- perception as compared to controls (27). Motor control, expertise and living environments (elderly social centers, home care) action-perception links, sensory cues for physical contact, synchronization rehabilitation program can promote positive emotions of the steps to the rhythm of music, familiarity with the music, groove and self-esteem, with added general improvement of social that compels the body to move, and motor learning processes are also attachment and recognition, thus improving the quality of life considered among key factors in neurocognitive control of dance perception of patient-caregiver. and performance (24, 28). Furthermore, partnered dancing as a social dance practice in community settings has been described as an effective and attractive form of entertaining for patients with PD due to the level of physical interaction and amusement between partners and the social group. weeks considers 4 phases of intervention or stages of training. Initially, simple and less complex movements will be performed until reaching the dance performance in pairs (1. spontaneous The implementation and realization of the protocol movement rhythmicity and 2. sequence of dance steps), then 3. “PasoDoble” include the following methodological aspects: partnered dance and finally 4. dance-figures with partner. That is, firstly, where the dance takes place, it must provide the an intervention program would fit with a trimester proposal, and participants first security. It must have the physical requirements 1 session per week. In the context of Hispanic population, but that provide a spacious and illuminated space to develop not restricted to them, a widely extended habit of elder people is each of the sessions. The environment can be adapted for to enroll to social clubs, when once a week (usually Sundays) life video-recordings and train the professional team (neurologist, music is performed and elderly dance with their own partners nurse, occupational therapist, psychologist, kinesiologist, and or other elderly attending the social event. Family associations professional dancers). According to precedent data in other for PD also have their own spaces were rehabilitation programs dance/movement therapies, 1 h session, twice a week, 12 weeks, are performed. Here, the intervention time was designed to pre-test (Evaluation 0) and follow-up evaluation at 3, 6, 9, be perfectly adapted to this natural timings and habitudes, but and 12 months would be the proposed duration by which an under a structured protocol where decisions have been made individual must engage in the intervention to elicit a therapeutic by the therapist, not the participants. An important question benefit. Here, we have designed the intervention also considering in the inclusion criteria to be part in the program is to do a how dancing is scheduled in social clubs elderly people. The functional evaluation (pre-test) to determine the stage of PD (I, protocol lasts 12 consecutive weeks (a seasonal trimester) with II, and II of the Hoehn and Yahr scale) so that the person can be a frequency of therapy of once a week with a structure and allocated to the corresponding level. Age of participants should duration of each session as follows (see Figure 1): duration of not be a criteria. Control of drug therapy must be done. The 50 min (a total duration of 1 h if considering get started/get over) inclusion of a regular partner in this partnered dance provides with an opening with relaxation and breathing (5 min), general an internal control group, at least for most functional variables. mobilization (5 min), PasoDoble dancing (30 min), and a closing However, since the proposed method is also aimed to improve with relaxation and breathing. The dance progression during the quality of life of caregivers, enrolling as the partners in the dance, Frontiers in Neurology | www.frontiersin.org 4 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers FIGURE 2 | Measures and tools to evaluate the effects of ‘PasoDoble’ in normal aging, the PD patient and the caregivers. self-reliant older adults would be the best control group, for control standard physical activity, include: improvement of gait burden of disease in PD patient and caregiver’s burden as the and balance, facilitation of movement through external cues and partner. As in many other proposals, blind evaluators, and pilot specific movements, better coordination and stability with the studies in real settings, are also advised. partner, reaching and grasping, muscle power and joint mobility, Although non-pharmacological therapy has gained great reduction of risk of falls, increase of aerobic capacity (see importance, there is still little consensus on how to measure Figure 1). This rehabilitation program will be easy to implement the analysis of therapies, being a wide and interesting field of into patient care but also in already socially established free-living research to address (29–31). The current ongoing research using environments (community setting such as elders social centers, this PasoDoble protocol is focused on clinical measures of PD and home) improving patient-caregiver quality of life by means of caregiver’s health, such as motor symptoms, mood/cognition, promotion of positive emotions and self-esteem with additional and socialization (UPDRS, BBS, TUG, 6MWT, FOG, DGI, Sit- general improvement of social attachment and recognition. to-stand test, Beck, Zarit QoL). The instruments and specific Finally, limitations of the proposal, most of them in tests for each variable are as mentioned in illustration 2. The common with other non-pharmacological strategies, must also be expected result in a pre- post- analysis and as compared to mentioned here. Studies in older adults have shown that exercise Frontiers in Neurology | www.frontiersin.org 5 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers outcomes, such as improved self-efficacy, are more strongly the functional circuits involved in PD. Furthermore, exercise predicted by the social cognitive factors associated with exercise. is a fundamental element of motor learning, influencing, In fact, in spite of being a common shortcoming, PasoDoble has and modifying motor deficit parameters in neurodegenerative an advantage, as the naïve ballroom dance (pasodoble) is already diseases (29). The exercise is a fundamental element of motor popular in elderly social centers, and part of its strength to be learning, influencing and modifying motor deficit parameters in implemented as a preventive or rehabilitation program (with neurodegenerative diseases. In PD, the exercise increases synaptic a schedule or protocol) relies on this “familiarity” or “social” strength and influences neurotransmission, thus enhancing the aspect. So, social cognitive factors are part of the virtues of this functional circuits involved in PD (29, 33). dance and looked for, with purpose, as an intervention. The small Engagement of PD patients in different types of physical number of participants, lack of partner for the interventions or exercise, such as walking on a treadmill, is reported to reduce gait dancers unfamiliar with PD can be also foreseen as a critical disturbances, to improve executive functions and motor learning point. However, this kind of dance is so popular but also intimate, (15, 30). Still, gait improvements seem to be specific to the type of that it can be implemented to the minimum of one patient motor activity practiced during exercise, whereas improvements and his/her therapist. Regarding the time schedule, a 3-month in cognitive inhibition are not. This suggests indirect action duration of the intervention may be too short to see strong effects mechanisms such as enhancement of cardiovascular capacity to. upon participation, and commitment over a 10-week period may These results are also relevant for the development of targeted be difficult, in this and other programs. As mentioned before, aerobic exercise training interventions to improve functional the initial proposal is established in 12 weeks (3 months) as autonomy in PD patients (15). In this sense, regarding exercise it is a formula that fits trimestral (seasonal) activity proposals dosage, there are various exercise guidelines that generally have a and easier to be committed with. With regards to the severity training duration of 4 to 48 weeks and a total of 4 to 96 h, which of PD, it may vary within the sample. Thus, heterogeneity in vary according to the therapeutic objectives and the selected the level of impairment requires a prior accurate evaluation of training modality (21). The exercise is usually performed under the motor impairment, could affected participation but could be moderate to high intensity for a long term (34). Mak et al. (19) solved with the establishment of different groups or levels. The point out that a training period of at least 6 months is effective to last, but not least, randomized controlled trials are necessary to achieve a clinically significant improvement in UPDRS-III scores better understand the effects of programs of dance therapy for as well as improvements in gait and walking ability. Here, an older adults with and without PD, and this also applied to this intervention time of 12 consecutive weeks is proposed as it is proposed method that is currently under study. a schedule feasible to be implemented as seasonal “trimestral” (alone or repetitive in an annual schema) schedules in most elderly social center settings (i.e., Winter PasoDoble Program). “PASODOBLE” AS A FORM OF As specific resources, improving gait parameters, workouts THERAPEUTIC EXERCISE FOR PD AND with differentiation of surfaces, weight support, among others, PROTECTIVE STRATEGY FOR have also been described (21). These have been combined with CAREGIVERS signaling strategies, which provide external signals to facilitate the initiation and/or continuation of movement, so patients are In the following paragraphs we will provide further discussion instructed to pay attention to signals and to step on the line or on the benefits that can be derived as a form of therapeutic markers, or to go to the rhythm of an auditory or somatosensory exercise programs for rehabilitation in PD, thereafter those that signal (20, 35). Some examples include visual cues (lines or are in common with other dances, and finally we’ll present the markers on the floor and on the treadmill), rhythmic auditory scenario of PasoDoble in this 2020–2030 Decade of Healthy cues, metronome rhythms, or music at a preset frequency, Aging where family-centered care models are among the most somatosensory cues–tactile sensation given to a part of the body important needs pointed out by UN. as in Tai Chi (a repetitive bodyweight martial art that shifts from The main objective of therapeutic exercise and rehabilitation one foot to the other, taking a step and turning in different is to improve and maintain the quality of life of people directions) (33, 36, 37). with PD. This is done by helping to improve or increase In this context, Pasodoble is a type of ballroom dance and high mobility, balance, gait, coordination, and thus maintaining the groove music. Dance has been incorporated as a rehabilitation functional autonomy of the patient for a longer time. Educating strategy since it has sequenced movements performed with music their environment, family, caregivers, and community will also (31, 36). The treatment of neurological diseases is complex contribute to finally promote an active role in the rehabilitation due to emotional factors, so dance/movement therapy is of process (18, 32). The benefits of exercise and physical activity potential benefit in such circumstances. Dance therapy for the are widely known and have led researchers to become interested rehabilitation of PD (dance/movement) would be more effective in the possibilities it offers as a therapeutic resource of than exercise in the outpatient treatment of patients (25, 38) rehabilitation. It has its own characteristics and multiple (Hackney and Earhart, 2010). An example is Tango, which physiological benefits, according to the “dosage” used, which is improves aerobic capacity, coordination, and balance (26). The why it attracts even more to differentiate its effects in diseases benefits observed in dance as therapy can be explained through such as PD (18). At the brain level, exercise increases synaptic several mechanisms such as external signals, which can be strength and influences neurotransmission, thus enhancing derived from the music or the couple, as well as the specific Frontiers in Neurology | www.frontiersin.org 6 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers movements incorporated in the form of the dance (39, 40). with the progress of disease with the consequent burden of Music provides auditory cues to the premotor cortex through care (53). The disease severity and duration are determinant the cerebellum and to the supplemental motor area via the factors for caregiver burden, with sleep problems, autonomic thalamus, allowing the use of these auditory cues to impact dysfunction and psychiatric symptoms amplifying the burden of individual’s gait (35). Some studies indicate that speed, start care in PD (53, 54). Thus, family caregiver burnout in PD is of gait and cadence are favored with this type of therapy in been considered primarily dependent on patient’s NMS, requires PD (41, 42). The rhythm of the music and the dance partner considerable time investment and can trigger depression in the can facilitate the coordination of the steps, increase balance spouse /family member (53). For the good quality of caregiving and postural stability (43). In turn, signals such as a change in and also the quality of life of the physically, emotionally and weight and direction of movement given by the dance partner psychosocially exhausted informal caregiver, early and continued can help initiate the movement and increase or maintain the collaboration and support is essential (55). Caregiver unmet length and cadence of the steps (Hackney and Earhart, 2010). The needs trigger the requirement of professional care at home dance provides specific patterns of guided movement, as well as or the early institutionalization of the beloved person with proprioceptive and tactile signals in interaction with the auditory PD and the beginning of a new period for family members signals that the music gives off, facilitating the integration of key that may experience anticipatory grief (53). More importantly, elements for rehabilitation in this disease. The current evidence increasing number of studies aware of the need to recommend indicates dance, as a complementary therapy, can contribute to protective therapies for caregivers already in those caring early the improvement of various symptoms of the patient, both motor, stages of PD (56). Thus, there’s a clear need to provide family- cognitive, and emotional (26, 44, 45). centered care as it is done in oncology (57). As mentioned Dance is a pleasurable and captivating activity that involves before, guidelines for family caregiving intervention in PD point motor, cognitive, visuospatial, social, and emotional engagement at non-pharmacological strategies that include physical-related (39). It is contributing to the configuration of the body schema, activities known to improve functional mobility and balance the perceptual organization, favoring coordination. Increase in patients while at the neuronal level exert brain plasticity body awareness and movement awareness through musical and neuroprotective effects (17, 58). A comparison of dance rhythms and melodies (35). It requires spatial integration, interventions in people with PD and older adults points out rhythm, synchronization with external stimuli, balance, and substantial and wide-ranging benefits but also aware that, as coordination of the whole body, which makes it a highly compared to what is known in older adults, more efforts are useful therapeutic resource for the rehabilitation of PD needed to investigate the growing literature for dance in PD (59). (25, 35). Furthermore, the dance and movement has a Dance as part of lifestyle is important, for both patients psychotherapeutic, which aims to integrate the individual and caregivers. Prevalence of physical activity in some countries physically and emotionally, increase the level of personal (i.e., the United States) has become a behavioral risk factor and body perception, which allows for wide movements and (60). The studies aware that an important number of people encourages the individual to express himself authentically over age 65 do not meet physical activity recommendations through the integration of the unconscious (40). The dance and this situation is worsened in PD (61). In such a case, rhythmic stimulation may be used to improve gait automation promotion of social activities that involve physical activities and since it helps cognition in the emotional domain, requiring are part of culture and tradition, like dancing during weekends reinforcement in the connections of the frontal cortex and the in elderly social centers or in public areas during festivities, can amygdala (39, 46). In addition, the dance allows participants be more easily implemented. In this sense, dance is presented to establish positive emotional aspects and valence that they as a promising intervention because it requires the integration experience and store, facilitating knowledge about postures and of multiple sensorial information, namely auditory, vestibular, movements in the most optimal way (47, 48). visual, and somatosensory. Besides, any dance style can induce Previous studies of dance therapy (Tango, Ballroom, Valls) functional adaptations in older adults, especially related to have shown beneficial results on some gait parameters, as well balance as it involves the fine-grained motor control of the whole as an increase in the perception of time, modifying the altered body (62). Behavioral studies have already provided evidence elements for displacement. In turn, improvements in postural of better performance in balance and memory tasks in elderly balance and motor adjustments for general stability have also dancers (63–65). The psychotherapeutic use of movement, which been included (46). Dancing in PD promotes greater dynamic aims to integrate the individual physically and emotionally, balance, increased walking speed, longer step length, positive increase the level of personal and body perception, which effects that can be sustained over time (49–51). allows for wide movements and encourages the individual to Pasodoble is a ballroom where both the person with PD express himself authentically through the integration of the and his/her caregiver (spouse, most of the times) can be unconscious (40). Dance contributes to the configuration of the involved, although the partner can be another subject or the body schema, the perceptual organization, favoring coordination. therapist, too. In this aging population, the role of caregivers Increase body awareness and movement awareness through for the well-being of the elderly, especially of those affected by musical rhythms and melodies. It requires spatial integration, neurodegenerative disorders, is crucial (52). In most cases, the rhythm, synchronization with external stimuli, balance and spouse or a family member becomes the informal caregiver, coordination of the whole body, which makes it a highly holding a demanding full-time responsibility that will worse useful therapeutic resource for the rehabilitation of PD (25, Frontiers in Neurology | www.frontiersin.org 7 November 2020 | Volume 11 | Article 567891 Giménez-Llort and Castillo-Mariqueo PasoDoble for Parkinson’s Disease Patients and Caregivers 35). A recent compilation of research work on sound, music, “PasoDoble” can also contribute to improving physical capacity and movement in PD provided new scientific evidences and and all its components. Besides, “Pasodoble” is also a music per arguments highlighting the benefits of therapies using visually, se, with familiarity and groove that compels to move which can acoustically, and somatosensorially enriched environments (66) serve as an external reference to facilitate specific movements. but most importantly how the intact ability of PD’s patients to We consider that this easy-to-implement into patient care pick up and use external sensory information to initiate and time and free-living environments (elderly social centers, home) movement would encourage them to actively seek out programs rehabilitation program can promote positive emotions and self- that use sound, music, and movement so that they can lead more esteem, with added general improvement of social attachment active and fulfilling lives (46). and recognition, thus improving the quality of life of patient- caregiver as a patient and family caregiving intervention that CONCLUSIONS can be tailored to the individuals. The comparison with other ballroom dance and/or rehabilitation circuits and with regards In summary, founded on evidence-based therapeutic benefits to different stages of disease, will contribute to fully describe its of dance/music therapy we present “PasoDoble,” derived from benefits, but also limitations, in different rehabilitation programs the widely known Latin ballroom dance traditionally danced in and settings. family celebrations and festivities, as a dance/music intervention suitable for family-centered Parkinson’s Disease care. As a regular DATA AVAILABILITY STATEMENT dancing at home, satisfactory “PasoDoble” dance practice can improve and preserve function and mood in the elderly, while in The original contributions presented in the study are included community settings will also promote and improve socialization. in the article/supplementary material, further inquiries can be The same singular features can be beneficial through rhythmic directed to the corresponding author/s. auditory stimulation and signing for patients with PD since a gait training plan is performed with rhythmic and groove AUTHOR CONTRIBUTIONS sound stimulation that marks each of the steps in company with the guide of the dance partner, usually the spouse (and family LG-L: concept. LG-L and LC-M: development of the concept caregiver). The dance partner can help the mastery of balance and and review, protocol of intervention and graphical abstract, and displacement by contributing to the control of dynamic balance, review and approving final version of manuscript. controlling external disturbances. We provide “PasoDoble” the methodological proposal and the key features of our protocol, FUNDING an intervention the method which is structured to improve gait and balance; facilitate movement, reaching and grasping; muscle Financial support Envellir bé – Saber Envejecer power and joint mobility; reduce of risk of falls, and increase - Healthy Aging Charity Organization, Envellir of aerobic capacity. “PasoDoble” can address each of the four be/AntonioGimenezBlasco/290520. LC-M is recipient of a key areas in people with PD on which the benefits of physical CONICYT/BECAS CHILE/72180026. exercise in PD are based: to improve gait, cognitive strategies to improve transfers, exercises to improve balance, and exercises ACKNOWLEDGMENTS to increase joint range and muscle strength to improve physical capacity. Depending on the intensity of the requested exercise, We thank the people supporting Envellir be.org fundraising. REFERENCES 8. Benatru I, Vaugoyeau M, Azulay JP. Postural disorders in Parkinson’s disease. Neurophysiol Clin. (2008) 38:459–65. doi: 10.1016/j.neucli.2008.07.006 1. Kalia LV, Lang AE. Parkinson’s disease. Lancet. (2015) 386:896–12. 9. Poewe W. Non-motor symptoms in Parkinson’s disease. Eur J Neurol. (2008) doi: 10.1016/S0140-6736(14)61393-3 15(Suppl. 1):14–20. doi: 10.1111/j.1468-1331.2008.02056.x 2. Armstrong MJ, Okun MS. Diagnosis and treatment of parkinson disease: A 10. 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Dance training is superior to repetitive physical exercise in potential conflict of interest. inducing brain plasticity in the elderly. PLoS One. (2018) 13:e0196636. doi: 10.1371/journal.pone.0196636 Copyright © 2020 Giménez-Llort and Castillo-Mariqueo. This is an open-access 63. Kattenstroth JC, Kolankowska I, Kalisch T, Dinse HR. Superior article distributed under the terms of the Creative Commons Attribution License (CC sensory, motor, and cognitive performance in elderly individuals BY). The use, distribution or reproduction in other forums is permitted, provided with multiyear dancing activities. Front Aging Neurosci. (2010) 2:31. the original author(s) and the copyright owner(s) are credited and that the original doi: 10.3389/fnagi.2010.00031 publication in this journal is cited, in accordance with accepted academic practice. 64. Rehfeld K, Hökelmann A, Lehmann W, Blaser P. Auswirkungen No use, distribution or reproduction is permitted which does not comply with these einer Tanz- und Kraft-Ausdauer-Intervention auf kognitive terms. Frontiers in Neurology | www.frontiersin.org 10 November 2020 | Volume 11 | Article 567891