CREATION OF .AN ADAPTED DANCE-THERAPY WORKSHOP IN COLLABORATION WITH PATIENTS7

The objective of this workshop was to give patients the benefit of both the regulating and stimulating role of rhythm in order to compensate for the dopamine deficiency that is at the origin of PD disorders.

Following this first session, we created and used an observation table (Table 13.1) in order to more clearly evaluate the impact of Primitive Expression on motor symptoms. However, this tool could only be used for a short period (four months). Indeed, it is very difficult for us today to be able to put in place tools to observe and evaluate our practice on PD in the institution where we work because the hospital lacks the resources, both financial and human, to support us in our sessions and in our research. However, it is important to note that the positive effects of the workshops felt by patients improved doctors’ interest and confidence in our work. To be able to propose a therapeutic strategy to treat the different aspects of the disease, we base our work on our observations as dance-therapists and also on listening to the complaints, i.e., the needs of the patients. These needs made us broaden our objectives since, on the one hand, the symptoms that manifested themselves at the physical level were not only motor but also fatigue and pain as well as the disease’s impact on the patients at the social and psychological levels.

At the Body Level

A DRT session begins by reconnecting the patients to their body through breathing and awakening their senses. Starting with a sitting circle we listen to the African drum (djembe) and then make slow movements of the arms (up-down, open-close) in connection with breathing and gentle stretches. This gradual entry establishes the first contact between the body, sound, external rhythm, and other participants. Work on motor and non-motor symptoms can begin.

Non-Motor Symptoms

There is much pain in PD: muscle, joint, tendons, visceral, and so on. (Moisan et al., 2018). Few studies were made on the effectiveness of dance to decrease the pain.

Note, however, the study of Berrol, Ooi, and Katz (1997) on the impact of dance/ movement therapy in the elderly who have had neurological trauma. Berrol observed that participants had less physical pain after five months of participation in the workshops.

(*) Score levels: 1: very infrequent 2: infrequent 3: frequent 4: very frequent 5: always

Score levels: 1: very difficult 2: difficult 3: fairly easy 4: easy 5: very easy

Additional comments:

Table 13.1 Observation Table—Impact of Primitive Expression on Motor Symptoms

Much research in music demonstrates the superiority of dance in physical therapy when the dance is, as in a tango, associated with the music. The music reduces the pain significantly after five minutes of exposure (Mitchell & MacDonald, 2006). Dance, which is usually pleasant, is a painkiller. Moving to music in a synchronized way, with a partner or group, makes it possible to better resist pain because the brain secretes endorphins (Tarr, Launay, Cohen, & Dunbar, 2015). These hormones have an analgesic role, and have an impact on the pain threshold of the participants. However, this happens on one condition: moving actively in rhythm with several people!

This is what we do in Primitive Expression to the beat of the drum. Indeed, bass and repetitive sounds, such as the sounds produced by the drum, promote muscle relaxation (Cungi & Limousin, 2003) and particularly affect the production of endorphins (Cardinale & Durieux, 2004). The state of well-being, strength, and effortless movement following the physical effort, is due to endorphins. Of course we do not ask for a performance from our disabled patients, but they may very well participate in the dance for 30 to 45 minutes at a pace of comfortable endurance.

Endorphins are also stimulated by laughter. It therefore seems essential to introduce an atmosphere of gaiety in the sessions, which is strongly supported by the humor of the patients and represented by an intelligent and effective defense system. For example, one day they sang, “We are Parkinsonians and we are not afraid of anything,” to accompany a collective choreographic creation.

Non-motor symptoms are also defined by fatigue. Music has several relaxing effects (De Dreu et al., 2012), and rhythm is an important therapeutic factor. So from the beginning of the sessions, we are accompanied by the drum which supports the rhythmic warm-up and body percussion (i.e., produce a rhythm using our body as a musical instrument). We observed from the very first session (and what has recurred each time) how the rhythm stimulates patients, “taking them” quickly in it is repetitive flow, “as if we put us on a treadmill” they would say, and their tiredness is forgotten. The rhythm is a regulator that manages gestures, so it lessens fatigue. The percussionist takes on the role of a co-therapist who, in interaction with the dancers, slows down or speeds up the pace according to their shortness of breath. The session must remain constantly doable and enjoyable while also being active. One of our patients, Sophie, talks about feeling “good tired” at the end of a session.

The repetition of gesture was immediately popular with the first therapy group. It allowed for better control and increased endurance and strength. Both muscular rehabilitation and energy boost, the gesture renews itself like the beating of the heart. It recreates automatisms that facilitate movement, thus reducing both physical and mental fatigue.

Motor Symptoms

We can observe patients’ PD motor symptoms in their walking and movements. We are not dealing with dancers; therefore the approach should be simple and promote awareness of their body by first separating the different parts of the body in a warm-up and then associating them again in dance movements accompanied by voice. Having a better awareness of one’s body helps to fight against body stiffness. This increases both muscle and joint flexibility and leads to deeper breathing, which helps patients to relax. One patient, Laurent, said:

This is an activity that I could never give up. In terms of pulsations, it allows me to better coordinate my movements and release any tensions.

In people with PD, deficiency of dopamine can cause an arrhythmia in walking. The walk of a Parkinson’s patient is stiff, unstable, sometimes in small steps under the effect of bra-dykinesia, with a total and painful inability to move. Explaining or showing the gesture by breaking it down is ineffective. However, different studies have shown that the use of rhythm facilitated walking by synchronizing movement to a regular pulse (Nombela et al., 2013) helped patients to overcome slow movement, freezing, and imbalance and improved their muscle control (McIntosh et al., 1997; Pacchetti et al., 2000; Sacks, 2007).

In Primitive Expression, the rhythm of the drum brings on the beat, the sound is short and repeated; it is the pulse that pounds, which pushes and exerts a thrust on the body. The patient responds that it is as if he heard the drum tell him “go on” or “1-2—3 walk.” The rhythm energizes the motor system.

“When I’m blocked, I put on some music and I walk. It releases me.” We have seen repeatedly a blocked patient, both elongated and rigid, unlock himself on hearing the drum, his feet beginning to beat, then landing on the ground, he stood up and begin to walk. The rhythm, repeating the beat on a regular basis, allows one to rely on it and synchronize the different parts of the body, head to toe.

During the research done in the field of music, the comments and remarks from patients have encouraged us to use rhythm walks and stops in space to help restart patients’ walking and decrease their apprehension of freezing, because they know how to identify it.

The feet take the beat proposed by the percussionist’s various rhythms (slow, medium, fast), which are sometimes associated with hand clapping to enhance synchronization of different parts of the body. This also relies on the symmetric arm swings and laterality. The exercise to stop walking when the percussionist stops the music (which he does voluntarily by surprise) focuses the patients’ attention on balance and body awareness. Then the music resumes and participants walk by taking large or small steps. During these sessions, we encourage walking by twos or threes, always in a playful spirit.

The work done on walking helps prevent falls, worry about which is part of the daily life of Parkinson’s patients. With the rhythm and repetitive movements becoming more precise, detailed, and safe, patients learn to prevent falls by managing imbalances, by accelerating the speed of movement, and by anticipating their movements and potential obstacles. Thus, when we work the repetition of actions stand/sit, we are working on the transfer of weight which ensures better balance in a sustainable manner, as demonstrated by Louis: “Now I can get up and go to the toilet easier.”

PD not only hinders the walking of our patients, but it also hinders their daily life movements. Therefore, we propose, through various dance exercises, to work on different aspects of movement such as amplitude, fluidity, coordination, tremor, voice, and facial expressions.

Amplitude is one aim of rehabilitation as the Parkinson movements are narrowed to a small kinesphere. Our way of expanding it, which has the advantage of being at the same time a source of pleasure, is the repetition of the gesture made on varying lengths of time (slow/medium/fast pace, or the execution of time in an 8, 4, 2, 1 time division). Repetition produces a resonance which results in an amplification and security, leading to gradual steps and movements, as if to loosen brakes because the apprehension of losing balance disappears, the movements “loosen up ”, expand, breathe.

The repetitive gesture leads to interaction between the protagonist/antagonist muscles: when one moves, the other, at the same time, relaxes. The repetition is automatic, the movement “walking alone”, allowing for letting go, releases itself from tension and surrenders to the stream that spreads throughout the body, freeing the movement and steps which become gradually more flexible, more fluid. The result is fast: “It frees the body, these dance sessions,” said Alice. It develops confidence in your own body, as Sophie pointed out:

I practice the dance-therapy and over time I realize all the benefits I get from this activity. Indeed, it helps to improve Parkinson’s symptoms by more flexibility, less pain and with a more secure walk.... This workshop gave me more confidence.

Having more confidence in her walk gives her more confidence in life. The body and the mind are linked. This is why, the Primitive Expression seeks to strengthen the supports of the body rather than relying on a partner as in couple dance. Symmetrical movement allows one to become aware of the body’s axis and to focus its support on the spine, which offers structure both physically and psychologically.

Improving the coordination of movements is an essential to combat against disease. With repetition, movements become more precise, movements are better directed in body space and surrounding space where the dancer gradually feels at home. Synchronization by rhythm makes it possible to involve several parts of the body in the movement (e.g., feet, pelvis, and arms).

Stimulating, the rhythm is also an authorizing factor of movement: it organizes, structures, and makes it more solid—the dancer can lean on it like a railing. Coordination is also essential for another common disorder in PD, dyskinesia, abnormal and involuntary movements, which are uncontrollable and dangerous. “My dyskinesia tends to decrease or even disappear,” said Laurent.

Before the workshop, some patients had hand tremors. These tremors were more or less strong and/or more or less wide. The movement attenuated tremors, and we were able to see that the use of rhythm accentuated this advantage: tremors decreased or even disappeared during the sessions. The presence of regular pulsations in auditor}' stimuli could increase the activity of basal lymph nodes affected by PD, thus compensating for the lack of dopamine stimulation that causes the tremors (Nombela et al., 2013). Here is an example with Paul:

Paul has tremors in his right hand which are very frequent. These tremors constantly decrease in frequency at the end of the sessions. They will even disappear in the middle of a session during a workshop.

Another particularly disabling symptom of bradykinesia in the face is weakening of the voice and making the voice monotonous. The production of vocal sounds makes it possible to work out the phonation muscles, which are often affected by PD. In Primitive Expression, the chanted voice (ha-ha-ha-ha) or the voice linked in melody is part of the musical accompaniment. The dance-rhythm-therapist and patients sing while dancing. Also, voice and movement train each other: the volume of the sounds emitted influences the posture and movements performed by patients. On soft/low sounds, the associated movements are small, while on a loud sound, the postures rise and the movements gain in amplitude.

It is also emotionally liberating. The chanted or melodic voice awakens the emotion and gives it a sonorous expression. Moreover, through the vibrations of the vocal chords, patients participate in resonance which involves all parts of the body, extends to the brain and spreads to the cortical areas. The tuning of movement to the voice through sounds, vocals, and songs reinforces the physical action by giving it sense. It fights speech disorders and participates in the letting go process, which allows the patients to feel confident.

In PD, facial expressions disappear in part; the face becomes inexpressive. Parkinson’s patients appear cold and scarcely smile. However, if in the playful atmosphere of Primitive

Expression, we “work” the faces through different choreographies, we notice that the muscles react. Moreover, this work on emotional facial expressions brings joy and laughter to the participants who forget all inhibition and have fun with each other.