Parkinsonism and Related Disorders 18S1 (2012) S114–S119

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Parkinsonism and Related Disorders

journal homepage: www.elsevier.com/locate/parkreldis

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

M.J. de Dreua , A.S.D. van der Wilka , E. Poppea , G. Kwakkelb , E.E.H. van Wegenb, *
a Research Institute MOVE, Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands
b Department of Rehabilitation Medicine, Research Institute MOVE, VU University Medical Center, Amsterdam, The Netherlands

article info summary

Keywords: Recent evidence suggests that music-based movement (MbM) therapy may be a promising
Parkinson’s disease intervention to improve gait and gait-related activities in Parkinson’s disease (PD) patients, because
Exercise therapy it naturally combines cognitive movement strategies, cueing techniques, balance exercises and
Cueing physical activity while focussing on the enjoyment of moving on music instead of the current
Music mobility limitations of the patient.
Dance A meta-analysis of RCTs on the efficacy of MbM-therapy, including individual rhythmic music
Rhythm training and partnered dance classes, was performed. Identified studies (K = 6) were evaluated on
methodological quality, and summary effect sizes (SES) were calculated.
Studies were generally small (total N = 168). Significant homogeneous SESs were found for the Berg
Balance Scale, Timed Up and Go test and stride length (SESs: 4.1, 2.2, 0.11; P-values <0.01; I2 0, 0, 7%,
respectively). A sensitivity analysis on type of MbM-therapy (dance- or gait-related interventions)
revealed a significant improvement in walking velocity for gait-related MbM-therapy, but not for
dance-related MbM-therapy. No significant effects were found for UPDRS-motor score, Freezing of
Gait and Quality of Life. Overall, MbM-therapy appears promising for the improvement of gait and
gait-related activities in PD. Future studies should incorporate larger groups and focus on long-term
compliance and follow-up.
© 2011 Elsevier Ltd. All rights reserved.

1. Introduction
Parkinson’s disease (PD) is a common progressive neurological
disorder in the aged population of Europe [1]. A range of motor and
non-motor symptoms have severe consequences for the functioning
of the patient, affecting the everyday activities and Quality of
Life [2].
Despite optimal medical and surgical treatment, consequences
of the motor symptoms cannot be eliminated and disabilities
due to mobility problems remain. Many of the balance deficits
in PD as well as gait deficits and freezing are resistant to
most pharmacological and surgical treatments [2]. Rehabilitation
programs are an important adjunct to medical treatment by
learning to compensate for, and coping with, the remaining motor
disabilities, using task- and context-oriented practice aimed at
assisting with life-long application of strategies and changes in
exercise patterns [3,4].
With regard to physical exercise, which is an important
therapeutic tool in rehabilitation programs [4,5], two recent
* Corresponding author. E.E.H van Wegen, VU University Medical
Centre, de Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
E-mail address: e.vanwegenl@vumc.nl (E.E.H. van Wegen).
reviews of evidence from animal and human studies suggest that:
(1) regular physical activity and exercise engagement reduces the
risk of developing PD and (2) there may be a neuroprotective effect
of exercise through upregulation of brain-derived nerve growth
factors [6,7]. Definitive evidence regarding neuroprotection of
exercise therapy in patients with PD however is still lacking.
A common and effective strategy to improve gait performance
and mobility is to apply external (auditory) cueing techniques [8,9].
Auditory cues can also be provided through rhythmic music.
Additionally, music may elicit physiological pleasure sensations
related to reward and emotions [10], which may in turn distract
from sensations such as fatigue [11] and increase therapy
compliance for long-term interventions. These positive effects of
music might explain the recent interest in incorporating music
and/or dance in movement therapy in PD, in this review termed
Music-based Movement-therapy (MbM-therapy) [12,13].
MbM-therapy can be applied in the form of individual gait
training or in a group, as ‘partnered dance’. Such approaches
using rhythmic music may be effective because they are highly
task specific for improving gait skills, incorporate stepping, turning,
and weight shifting, and the embedded rhythm serves as an
auditory cue. At the same time effects of music on mood and

1353-8020/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
 M.J. de Dreu et al. / Parkinsonism and Related Disorders 18S1 (2012) S114–S119
emotion may distract from sensations of fatigue [10]. Rhythmic
dance classes may be a promising therapeutic intervention [13],
because they naturally combine cueing techniques, cognitive
movements strategies, balance exercises and physical exercise with
group dynamics (which include social interaction, partnership in
misfortune and peer support) while focussing on the enjoyment of
moving on music instead of the current mobility limitations of the
patient.
However, studies performed to date have included small sample
sizes with heterogeneous outcomes. To date no review has assessed
the methodological quality of intervention studies involving
MbM-therapy or bundled the effect sizes of individual studies.
Therefore a research synthesis on the efficacy of MbM-therapy
in people with PD was performed. It was hypothesized that
people with PD benefit from MbM-therapy when compared to
conventional therapy or no therapy in terms of standing balance,
transfers, gait performance, severity of freezing and Quality of Life.
2. Methods
2.1. Literature search
Two reviewers (MdD, AvdW) independently searched PubMed,
Embase, Cochrane, Cinahl and SPORTDiscus for articles published
until 1th August, 2011, with keywords: Parkinson’s disease,
dance therapy, music therapy, acoustic stimulation, and rhythmic
movement, and MeSH terms: Parkinson Disease, Parkins*, Parkin-
sonian Disorders, Dancing, Dance Therapy, Music, Music Therapy,
Acoustics, Acoustic Stimulation and Recreation Therapy (search
string available from the corresponding author). The following
selection criteria were applied: (1) people with PD were targeted,
(2) the study was a randomized controlled trial (RCT) of high
quality (PEDro score of >4), (3) the intervention contained MbM
and (4) the rhythmic cues were embedded in music. Disagreements
in study inclusion were resolved by consensus.
2.2. Methodological quality
Two reviewers (MdD, EP) independently rated the studies’
methodological quality, using the PEDro-scale [14]. Cohen’s
kappa was calculated for inter-rater reliability [15]. In case
of disagreement, a third reviewer (EvW) determined the final
PEDro score.
2.3. Meta-analysis
Standard methodology for meta-analysis for continuous outcomes
was employed [16]. Each reviewer extracted relevant data
from the included studies. The post-intervention scores of the
experimental and control groups were used to calculate the mean
differences (MD) using Comprehensive Meta-analysis software.
With one outcome measure (HR-QoL) different measurement scales
were used, therefore the Standardized Mean Difference (SMD)
was calculated instead of the Mean Difference. The statistical
homogeneity was obtained by the Q statistic and the I2 -test was
used to measure the degree of variation. With I2 >0.50, implying
significant heterogeneity between studies, the random effects
model was used instead of the fixed effects model. Sensitivity
analysis was performed for the different subtypes of MbM-
therapy (gait-related and dance-related interventions). When a
study consisted of two intervention groups and one control group
or vice versa, the number of participants in the relevant group was
divided by two, to prevent doubling of numbers and allow pooling.
Subsequently, the results were visualized by forest plots.
S115
3. Results
3.1. Search
A total of 402 citations were identified (results available from
the corresponding author). After application of the inclusion
and exclusion criteria, 6 articles remained for further analysis,
comprising a total of 168 patients [12,13,17–20], see Table 1.
3.2. Methodological quality
Table 2 shows the Pedro scores of the studies included. The inter-
rater agreement Cohen’s ú was 0.80.
3.3. Quantitative analyses (see Fig. 1 for forest plots)
Berg Balance Scale (BBS)
Two studies, containing three partnered-dance interventions, used
the BBS [13,18]. A significant homogeneous SES of 4.1 was found in
favor of MbM-therapy [SES (fixed): 4.1, 95% CI 2.12–6.14; Z = 4.02;
P < 0.01; I2 = 0%].
Timed Up and Go (TUG)
Two studies, comprising three partnered-dance interventions,
measured TUG [13,18]. A significant homogeneous SES was found in
favor of MbM-therapy [SES (fixed): 2.22, 95% CI 1.16–3.29; Z = 4.08;
P < 0.01; I2 = 0%].
Stride Length (SL)
Three studies, comprising five intervention groups, measured SL, of
which one study investigated partnered dance [19] and two studies
investigated music-based gait training [12,20]. A significant homo-
geneous SES was found in favor of MbM-therapy [SES (fixed): 0.11,
95% CI 0.034–0.19; Z = 2.83; P < 0.01; I2 = 7%]. A sensitivity analysis
for gait- and dance-related therapy showed these to be equally
effective.
Walking Velocity (WV)
Four studies, containing five intervention groups, measured WV,
of which two studies investigated partnered dance [13,18] and
two studies investigated music-based gait training [12,20]. The
homogeneous SES for WV was not significant [SES (fixed): 0.03,
95% CI −0.027–0.088; Z = 1.04; P = 0.30; I2 = 46%]. Sensitivity analysis
resulted in a significant homogeneous SES for gait-related
interventions [SES (fixed): 0.13, 95% CI 0.020–0.24; Z = 2.31; P = 0.02;
I2 = 39%] but not for dance-related interventions [SES (fixed): −0.007,
95% CI −0.074–0.061; Z = −0.19; P = 0.85; I2 = 0%, not shown].
UPDRS-Motor Score (UPDRS-III)
Four studies, comprising five intervention groups, measured the
UPDRS-III, of which one study investigated rhythmic music ther-
apy [17], two investigated partnered dance [18,19], and one study
investigated music-based gait training [20]. The heterogeneous SES
was nonsignificant [SES (random): 5.21, 95% CI −3.19–13.61; Z = 1.22;
P = 0.22; I2 = 92%]. Sensitivity analysis performed based on type of
MbM-therapy did not yield significant findings.
Freezing of Gait Questionnaire (FOG)
Two studies, comprising three partnered-dance intervention
groups, used the FOG questionnaire [13,18]. The homogeneous SES
for FOG was not significant [SES (fixed): −1.02, 95% CI −2.42–0.374;
Z = −1.44; P = 0.15; I2 = 0%).
Quality of Life (QoL)
Two studies, comprising three intervention groups, measured QoL.
One study investigated music therapy [17] and the other partnered
dance [19]. Pacchetti et al. [17] measured HR-QoL using two
Table 1
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Characteristics of the studies included in the present meta-analysis

Study (year) Number of subjects Age, Hoehn & Intervention/Control Intensity Measurement outcomes used Methodological
(N) Mean (SD) Yahr scale (hours/per week/weeks) difference quality,
(1–5) (hours) PEDro (0–10)

de Bruin (2010) [20] I = 11 I = 64.1 (4.2) I = 2.3 (0.4) Walking while listening to 19.5 UPDRS-III 5
C = 11 C = 67 (8.1) C = 2.1 (0.4) personalized music (30/3/13) 10 meter walkway self-selected pace in six conditions:
Control (0/0/0) 1–2) music/no music
3–4) single/dual task
5–6) obstacle/no obstacle
Forward velocity/stride time/stride length/cadence
Error rate double tasks
Hackney (2007) [18] I=9 I = 72.6 (6.6) I = 2.2 (2.1) Tango dance lessons (1/2/10–13) 0 UPDRS-III 5
C = 10 C = 69.6 (6.6) C = 2.2 (1.9) Control (1/2/10–13) BBS
TUG-test
FOG
Walking velocity
Hackney I = 14 (Tango) I = 68.2 (5.2) I = 2.1 (0.4) 1. Tango (1/2/10–13) 20 UPDRS-III 6
(2009a) a [19] I = 17 (Waltz/Foxtrot) I = 66.8 (9.9) I = 2.0 (0.8) 2. Waltz/Foxtrot (1/2/10–13) BBS
C = 17 C = 66.5 (11.5) C = 2.2 (0.8) TUG-test
6MWT
FOG questionnaire
Forward velocity/stride length/single support time
Backward velocity/stride length/single support time
Hackney I = 14 (Tango) I = 68.2 (5.2) I = 2.1 (0.4) 1. Tango (1/2/10–13) 20 UDPRS-III 4
(2009b) a [13] I = 17 (Waltz/Foxtrot) I = 66.8 (9.9) I = 2.0 (0.8) 2. Waltz/Foxtrot (1/2/10–13) PDQ-39: mobility/ADL/emotional wellbeing/stigma/
I = 13 (Tai Chi) I = 64.9 (8.3) I = 2.0 (0.4) 3. Tai Chi (1/2/10–13) social support/cognitive impairment/communication/
C = 17 C = 66.5 (11.5) C = 2.2 (0.8) Control (0/0/0) bodily discomfort
PDQ-39 SI
Pacchetti (2000) [17] I = 16 I = 62.5 (5) Total range Music therapy (2/1/13) 6.5 UPDRS-III 5
C = 16 C = 63.2 (5) I&C = 2–3 Control (1.5/1/13) UPDRS-ADL
HM part 1/combi
PDQL
Thaut (1996) b [12] I = 15 I = 69 (8) I = 2.4 Walking program on music with I-NT = 10.5 Flat velocity 5
C = 11 (NT) C = 71 (8) C = 2.6 RAS (0.5/7/3) I-SPT = 0 Incline velocity
C = 11 (SPT) C = 74 (3) C = 2.5 Control (NT) (0/0/0) Cadence
M.J. de Dreu et al. / Parkinsonism and Related Disorders 18S1 (2012) S114–S119

Control (SPT) (0.5/7/3) Stride length

EMG variability/symmetry/timing/onset and termination

N, Number of subjects; SD, Standard Deviation; I, Intervention group; C, control group; UPDRS-III, Unified Parkinson’s Disease Rating Scale – Motor Subscale; HM, Happiness Measure; PDQL, Parkinson’s Disease Quality of Life
Questionnaire; BBS, Berg Balance Scale; TUG-test, Timed Up and Go test; 6MWT, Six Minute Walk Test; FOG questionnaire, Freezing of Gait Questionnaire; PDQ-39, Parkinson’s Disease Questionnaire; NT, No-Training; SPT, Self-Paced
Training; RAS, Rhythmic Auditory Stimulation
a These studies were performed on the same participants with different outcome measures.
b In this trial 2 control groups were used. One group followed the same training program without music and RAS (SPT). The other one did not follow any training (NT).
 M.J. de Dreu et al. / Parkinsonism and Related Disorders 18S1 (2012) S114–S119 S117

Table 2
Methodological quality of the RCTs based on the PEDro score

Article (year) Criteria a Sum

1 2 3 4 5 6 7 8 9 10 11

de Bruin (2010) [20] Yes 1 1 1 0 0 1 0 0 0 1 5

Hackney (2007) [18] Yes 1 0 1 0 0 1 0 0 1 1 5

Hackney (2009a) [19] Yes 1 1 0 0 0 0 0 0 1 1 4

Hackney (2009b) [13] Yes 1 1 1 0 0 1 0 0 1 1 6

Pacchetti (2000) [17] No 1 0 1 0 0 1 0 0 1 1 5

Thaut (1996) [12] Yes 1 0 1 0 0 0 1 0 1 1 5

Score per item 5/6 6/6 3/6 5/6 0/6 0/6 4/6 1/6 0/6 5/6 6/6
a Criteria: 1 = Eligibility criteria specified (Yes/No); 2 = Random allocation; 3 = Concealed allocation; 4 = Comparable at baseline;
5 = Blinded subjects; 6 = Blinded therapists; 7 = Blinded assessors; 8 = Adequate follow-up; 9 = Intention-to-treat analysis; 10 = between-
group comparisons; 11 = Point estimates and variability
For items 2–11, 0 indicates the criterion was not satisfied, 1, the criterion was satisfied.

Study name Outcome Statistics for each study Difference in means and 95% CI
Difference Standard Lower Upper
in means error Variance limit limit Z-Value p-Value
Hackney (1) 2009a BBS 5.000 2.148 4.615 0.790 9.210 2.328 0.020
Hackney (2) 2009a BBS 5.100 2.430 5.906 0.337 9.863 2.099 0.036
Hackney et al. 2007 BBS 3.500 1.331 1.770 0.892 6.108 2.630 0.009
4.127 1.026 1.052 2.117 6.137 4.024 0.000

Hackney (1) 2009a TUG 4.400 2.217 4.914 0.055 8.745 1.985 0.047
Hackney (2) 2009a TUG 3.600 2.483 6.166 -1.267 8.467 1.450 0.147
Hackney et al. 2007 TUG 2.000 0.576 0.332 0.871 3.129 3.471 0.001
2.221 0.544 0.296 1.155 3.288 4.083 0.000

-10.00 -5.00 0.00 5.00 10.00

Hackney (1) 2009a SL (m) 0.180 0.091 0.008 0.002 0.358 1.982 0.047
Hackney (2) 2009a SL (m) 0.080 0.091 0.008 -0.098 0.258 0.880 0.379
de Bruin et al. 2010 SL (m) 0.100 0.067 0.005 -0.032 0.232 1.483 0.138
Thaut et al. (1) 1996 SL (m) 0.300 0.129 0.017 0.047 0.553 2.325 0.020
Thaut et al. (2) 1996 SL (m) 0.000 0.093 0.009 -0.182 0.182 0.000 1.000
0.112 0.040 0.002 0.034 0.190 2.831 0.005

Hackney (1) 2009a WV (m/s) 0.100 0.100 0.010 -0.096 0.296 1.000 0.317
Hackney (2) 2009a WV (m/s) 0.040 0.100 0.010 -0.157 0.237 0.398 0.691
Hackney et al. 2007 WV (m/s) -0.030 0.039 0.002 -0.107 0.047 -0.767 0.443
de Bruin et al. 2010 WV (m/s) 0.060 0.084 0.007 -0.104 0.224 0.716 0.474
Thaut et al. (1) 1996 WV (m/s) 0.320 0.120 0.015 0.084 0.556 2.656 0.008
Thaut et al. (2) 1996 WV (m/s) 0.100 0.098 0.010 -0.091 0.291 1.025 0.305
0.030 0.029 0.001 -0.027 0.088 1.037 0.300

-1.00 -0.50 0.00 0.50 1.00

Pacchetti et al. 2000 UPDRS-III 15.000 1.874 3.513 11.327 18.673 8.004 0.000
Hackney (1) 2009a UPDRS-III 6.400 3.879 15.046 -1.203 14.003 1.650 0.099
Hackney (2) 2009a UPDRS-III 8.100 5.065 25.651 -1.827 18.027 1.599 0.110
Hackney et al. 2007 UPDRS-III -2.000 1.768 3.125 -5.465 1.465 -1.131 0.258
de Bruin et al. 2010 UPDRS-III -1.300 3.536 12.506 -8.231 5.631 -0.368 0.713
5.210 4.286 18.366 -3.189 13.609 1.216 0.224

-20.00 -10.00 0.00 10.00 20.00

Hackney (1) 2009a FOG -1.600 2.556 6.531 -6.609 3.409 -0.626 0.531
Hackney (2) 2009a FOG -1.700 2.430 5.906 -6.463 3.063 -0.700 0.484
Hackney et al. 2007 FOG -0.900 0.780 0.608 -2.428 0.628 -1.154 0.248
-1.023 0.713 0.508 -2.421 0.374 -1.435 0.151

-10.00 -5.00 0.00 5.00 10.00

Favours A Favours B

Fig. 1. Meta-analysis of music-based therapy for outcomes Berg Balance Scale (BBS), Timed Up and Go (TUG), stride length (SL), walking velocity (WV), Freezing of Gait
Questionnaire (FOG), and Unified Parkinson’s Disease Rating Scale – motor subscale (UPDRS-III). CI, Confidence Interval; A, control; B, intervention. See text for details on
statistics.
S118 M.J. de Dreu et al. / Parkinsonism and Related Disorders 18S1 (2012) S114–S119
distinct questionnaires: the Happiness Measure (HM) and PD
Quality of Life (PDQL) [17], while Hackney and Earhart measured
HR-QoL using the PD Questionnaire (PDQ-39) [19]. In a sensitivity
analysis, the heterogeneous SESs of the HR-QoL scores displayed
a trend in favor of MbM-therapy for the Happiness Measure
[SES (random): 1.69, 95% CI −0.43–3.8; Z = 1.56; P = 0.12; I2 = 93%,
not shown] and the PDQL [SES (random): 1.47, 95% CI −0.36–3.31;
Z = 1.58; P = 0.12; I2 = 91%, not shown].
4. Discussion
To our knowledge this is the first meta-analysis investigating the
effects of MbM-therapy. Small but significant SESs in favor of
MbM-therapy were found for BBS, TUG and SL. A sensitivity analysis
on type of MbM-therapy (dance- or gait-related MbM-therapy)
revealed a significant improvement in WV for gait-related
MbM-therapy, but not for dance-related MbM-therapy. The SESs
of the UPDRS-III, FOG and Quality of Life (PDQ-39, HM & PDQL)
did not reach significance.
Falls are a major problem in people with PD, and novel
interventions to improve balance performance are needed. The
current results for the BBS suggest a relevant improvement in
standing balance control due to ‘partnered dance’ MbM-therapy
as the SES of 4.1 points is close to the smallest detectable
difference (SDD) of 5 points [21]. The effect may be related to the
dynamic pattern of stops, starts, turns, side-steps and backward
walking in dance-therapy sessions, which may act as functional
standing balance exercises.
The TUG test combines walking, chair transfers and turning,
thereby mimicking everyday activities, and is an important
functional outcome since it predicts overall health, new difficulties
in ADL and falls [22]. The significant SES of 2.22 seconds in the
TUG-test is larger than the SDD of 1.63 seconds [23] confirming an
important effect of MbM-therapy on performance of ADL.
The significant positive SES for SL of 0.11 m suggests an
important normalization and stabilization of walking pattern in
light of the defective scaling of SL as a cause of gait disturbance
in PD [24]. Additionally, a significant and clinically meaningful
improvement [25] in WV with a SES of 0.13 m/s was found for gait-
related MbM therapy. Walking ability is very important for ADL
and is related to independent living and QoL [26]. Moreover gait
speed is an important predictor for a decline in overall health and
survival [27].
The current meta-analysis did not reveal effects of MbM-therapy
on the UPDRS-III, which fits with the contention that typically
rehabilitative therapies do not affect basic symptomatology [2,4].
Freezing severity appears not to be affected by MbM-therapy. This
is unexpected as cueing training has been found to be effective
at least in freezers [9]. However only two studies included the FOG
questionnaire as outcome measure, therefore statistical power was
limited.
For PD, rehabilitative therapy should be directed at gait-related
activities while using cues, transfers, balance activities and physical
exercise [3,4]. Partnered-dance classes appear to address all these
recommendations for improving mobility related aspects. The
multiple stops, starts and turns that are naturally present in dance
can be seen as a form of functional balance and mobility training for
people with PD, combined with group dynamics that are considered
motivating, engaging and enjoyable. Moreover, the intensity of
dance can be sufficient to increase fitness, at least in patients with
heart disease [28].
Music may contribute to therapy efficacy as the temporal
musical structure may act as rhythmic cues [9], which is
consistent with general functional perspectives of rhythmic music
enabling and facilitating entrainment and precise synchronization
of movements [29]. Moreover music elicits emotional responses,
as moving to music activates endorphin-related brain’s pleasure
circuits, and the rhythm of dancing to music may promote that
satisfactory patterning [10] which in turn may distract from
sensations such as fatigue [11].
The present review has some limitations. First, the total number
of subjects included is relatively small, resulting in limited power.
Therefore the results may change when future RCT’s are published.
Moreover there is considerable heterogeneity between the studies.
Even though all studies investigated a form of rhythmic movement
accompanied by music, differences in interventions should be noted
(see Table 2). In most studies therapy intensity, expressed in hours,
differed between intervention and control group, which also might
explain the additional effect of MbM-therapy when compared to
conventional therapy in some studies [17].
Future studies are needed to determine whether MbM-therapy
impacts hypothesized neuroprotective related changes due to
physical exercise [6,7] and follow-up studies should be performed
to investigate long-term compliance to MbM-therapy.
Acknowledgements
The authors would like to thank Janne M. Veerbeek for her support
with data analysis.
Conflict of interests
The authors have no conflicts of interest to declare.
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