Complementary Therapies in Clinical Practice 43 (2021) 101348

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Complementary Therapies in Clinical Practice

journal homepage: http://www.elsevier.com/locate/ctcp

Binary dance rhythm or Quaternary dance rhythm which has the greatest
effect on non-motor symptoms of individuals with Parkinson’s disease?
Jéssica Moratelli a, f, *, Kettlyn Hames Alexandre b, f, Leonessa Boing a, Alessandra Swarowsky c, f,
Clynton Lourenço Corrêa d, f, Adriana Coutinho de Azevedo Guimarães e, f
a
PhD Student in Sciences of Human Movement of the Center of Sciences of the Health and of the Sport of the State University of Santa Catarina, Brazil
b
Master’s Degree Student in Sciences of Human Movement of the Center of Sciences of the Health and of the Sport of the State University of Santa Catarina, Brazil
c
Professor of the Department of Physiotherapy and Post-Graduation Program in Physiotherapy at the Health and Sports Sciences Center of the State University of Santa
Catarina, Brazil
d
Professor of the Department of Physiotherapy and Post-Graduation Program in Physical Education of the Federal University of Rio de Janeiro, Brazil
e
Professor of the Department of Physical Education and Post-Graduation Program in Human Movement Sciences at the Health and Sports Sciences Center of the State
University of Santa Catarina, Brazil
f
Brazilian Parkinson’s Disease Rehabilitation Initiative – BpaRkI, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: This study aimed to compare the effect of a binary and quaternary rhythm protocol on cognition, mental activity,
Parkinson’s disease daily life, and quality of life among individuals with Parkinson’s Disease. A two-arm randomized clinical trial
Dance with 31 individuals diagnosed with Parkinson’s disease, who were allocated to the binary group or quaternary
Binary rhythm
group. Both groups underwent a 12-week intervention. The following variables were analyzed: personal and
Quaternary rhythm
Quality of life
clinical information; MoCA; UPDRSI and II; PDQ-39. Both intervention groups improved cognition, mental ac­
Cognition tivity, activities of daily living, and quality of life. In addition, there were intergroup differences in total UPDRSII,
writing, and hygiene where the quaternary group was superior to the binary group. It concludes that the binary
and quaternary rhythm positively influenced and presented similar effects on the complementary treatment of
individuals with Parkinson’s disease on the studied variables. Thus, it is believed that both interventions are
possible and feasible for the health professionals involved in the area.

1. Introduction population with PD that presents positive results in rehabilitation. As

In the last few years, there has been an increase in the number of
physical activity and/or exercise protocols to be investigated as adju­
vant treatment in individuals with Parkinson’s disease (PD) [1] The
search for these protocols brings health professionals new possibilities,
and directions regarding the practice, in addition to favoring the
adherence and frequency during the classes. There are exercise protocols
in PD that benefit the motor symptoms of the disease, such as balance [1,
2], decreased number of falls [3], gait [4,5], mobility [6,7], and by
improving non-motor symptoms of the disease, such as quality of life
and cognition [8,9].
In addition, to assist in the complementary treatment of PD, recent
studies showed that dance may be a beneficial approach, capable of
reducing the symptoms of the disease and providing greater gains than
traditional exercise classes, as it is an activity that involves the body and
the mind [10–12]. There are dance protocols in the literature for the
shown by the study by Solla et al. (2019) [13], who proposed a Sardinian
Folk-Dance protocol, which had positive effects of dance on gait per­
formance, upper limb flexibility, lower limb strength and non-motor
disease symptoms such as quality of life and cognitive performance.
And other dance protocols found similar results [6,14].
However, there are still some types of dance modalities studied in
PD, with an emphasis on tango [15,16] and American ballroom dancing
[17,18] which, as a result, may not be sufficient to encourage partici­
pants’ continuity, participation, and motivation [6,19]. Thus, it is
necessary to explore other types of dance modalities that explore
different musical rhythms, so that they bring new possibilities in the
rehabilitation of PD, which can be an excellent tool in the adherence of
classes, as already demonstrated by studies with samba [20], dance
therapy [12] and Irish dance which promoted excellent results in the
symptoms of the disease.
Therefore, it is important to include in the classes different dance

* Corresponding author. R. Pascoal Simone, 358 - Coqueiros, Florianópolis, SC, 88080-350, Brazil.

https://doi.org/10.1016/j.ctcp.2021.101348
Received 11 August 2020; Received in revised form 12 February 2021; Accepted 27 February 2021
Available online 4 March 2021
1744-3881/© 2021 Elsevier Ltd. All rights reserved.
J. Moratelli et al.
modalities for the population with PD [21,22] and the classes can be
developed through musical beats (meter), such as, the binary rhythm
characterized by a two-beat meter that covers wide dance modalities
(forró; merengue; foxtrot; bolero …) [23], as well as the quaternary
rhythm, with four-beat meter dance modalities (samba; zouk; tango;
waltz; salsa …) [16,24]. Both rhythms provide great diversity in the
execution of movements, changes in speed, intensity, difficulty, and
possibility of varied steps, as well as in the progression of classes,
making them diverse and attractive for practitioners. However, to our
knowledge, no other study has investigated and compared these
rhythms with individuals with PD.
Thus, it can be seen in the literature that specific dance modalities of
binary rhythm have brought benefits to individuals with PD, with
improvement in the quality of life, anxiety, and cognition levels [25,26].
In addition, in the quaternary rhythm modalities, literature showed an
improvement in activities of daily living, quality of life, cognitive as­
pects, and depression [27,28], but these rhythms have never been
compared and it is not known which will give better results in in­
dividuals with PD. Therefore, this study aims to compare the effect of a
binary, and quaternary rhythm protocol on cognition, mental activity,
daily life, and quality of life of individuals with PD, in order to establish
a relationship between the rhythms (binary and quaternary) and not just
dance modalities, to elucidate which can bring greater benefits to the
population with PD.
2. Material and methods
A 12-week two-arm randomized clinical trial comparing two dance
rhythm protocols (binary and quaternary). The project was approved by
the UDESC Human Research Ethics Committee (CEPSH) - protocol
2.380.719 and registered with the international clinical trial registration
platform “Clinical Trials. gov” n. NCT03235453. Participants were
voluntarily recruited through the Santa Catarina Parkinson’s Associa­
tion (APASC) and interested parties included in the CEFID-UDESC Par­
kinson’s Disease Rhythm and Movement Program and Brazilian
Initiative for Parkinson’s Disease (BPaRkI), who subsequently signed the
Informed Consent to participate in the study.
The groups were randomized using a computer program, Microsoft
Excel (randomized entry mode), and those who agreed to participate in
the study were divided into blocks of 10 participants and subsequently
randomized to both groups (binary and quaternary). The distribution of
individuals was made by a second researcher not involved in the inter­
vention, a member of the Laboratory of Research in Leisure and Physical
Activity - LAPLAF.
For inclusion criteria, individuals with a clinical diagnosis of PD were
considered, as described by the UK brain bank [29], as well as stable
doses of the medication in the last two weeks (unchanged); individuals
of both sexes, aged 50 years or over and without dancing for at least
three months before the intervention.
Thus, the exclusion criteria are the non-compliance with cut-off
point (considering educational level) of the Mini-Mental State Exami­
nation (MMSE) [30]; individuals classified in stage 5 PD according to
Hoehn and Yahr; those who performed combined physical activity and
who obtained 25% of absences and or absences during the interventions.
The sample calculation used was performed using the G * Power 3.1.9.2
software, with the effect size of 0.33, the significance level of 5%, the
test power of 95%, and the sample loss of 20% [31]. Thus, 20 individuals
were expected for each group.
Thus 38 individuals diagnosed with PD were interested in partici­
pating in the study, and they were randomized into two intervention
groups, binary group (BG) (19 individuals) and quaternary group (QG)
(19 individuals). Of these, one individual was excluded for not
complying with the pre-defined cutoff points in the inclusion criteria by
the Mini-Mental State Examination (MMSE), five individuals were
excluded because they did not reach 75% of the prescribed activities and
unfortunately, one died. Thus, 31 individuals completed the study, 18
2
Complementary Therapies in Clinical Practice 43 (2021) 101348
from BG (68.3 ± 8.6 years) and 13 from QG (64.3 ± 14.8 years).
Individuals who did not attend 75% of the prescribed classes were
excluded from the final analyzes. Therefore, it was not possible to
analyze the intention to treat (IIT), as the individuals excluded from the
final analyzes did not return to the post-intervention assessment.
Fig. 1 presents the flowchart that demonstrates the process of
selecting participants and the steps of the study protocol.
2.1. Intervention
Participants allocated to BG received interventions using the binary
rhythm protocol for individuals with PD and participants randomized to
QG received the quaternary rhythm protocol intervention. The in­
terventions occurred separately by group (BG and QG) with the partic­
ipants who were in the “on” phase for an uninterrupted period of 12
weeks, with classes taking place twice a week, lasting 45 min each
session. The entire intervention was carried out by trained researchers,
members of LAPLAF and carried out at the Santa Catarina Rehabilitation
Center (CCR) in partnership with the Rhythm and Movement Extension
Program of the Santa Catarina State University (UDESC).
2.2. Binary protocol intervention
The class session was divided into a warm-up, the main part, and a
rest period. The warm-up (10 min) focused on dance styles that incor­
porate the binary rhythm, with walks in the marking the double beats,
muscle release techniques in the lower and upper limbs, and working on
the musicality. The main part (30 min) was performed by a teacher who
first demonstrated and taught the steps to be performed, then the par­
ticipants performed the steps alone and then with their partners. Every
five minutes the participants changed partners, so that everyone could
have other experiences when dancing with their colleagues, in addition
to stimulating the partner’s leadership. Finally, the rest period with the
stretching and slow walking, performed to provide muscle relaxation for
five minutes.
The dance movements were carried out at different intensities (light,
moderate and vigorous) in order to be able to progress through the 12
weeks of intervention. The light, moderate and vigorous intensities were
defined by the beats per minute (bpm) of the songs. Thus, in the first two
weeks, the classes were carried out at light intensity, that is, with songs
of up to 72bpms. In the third and fourth weeks, the songs were faster
achieving light to moderate intensity, with songs of up to 120 bpms. In
the fifth, sixth and seventh weeks, classes were only carried out at
moderate intensity, ranging from 72bpms to 120bpms. In the eighth and
ninth weeks, the intensity adopted was moderate to vigorous, with songs
from 72bpm to 208bpm. Finally, in the last week, only 120 bpms to 208
bpms songs were performed achieving the vigorous intensity. The de­
gree of difficulty of the stages increased at every week, along with the
intensities [20,32,33]. Blood pressure (BP) and heart rate (HR) were
monitored during classes for greater safety of participants during in­
terventions and for the progression of the intensity (supplementary file).
2.3. Quaternary protocol intervention
Like the binary group, the intervention of the quaternary group was
also classified according to the intensity (light, moderate and vigorous).
Each week, the degree of difficulty of the steps taught has evolved along
with the intensity. Blood pressure (BP) and heart rate (HR) were
monitored during classes for greater safety for participants during in­
terventions and increases in intensities. To establish the different in­
tensity rates, the songs were selected according to the Bpms: light from
40 to 72 Bpms; moderate from 72 to 120 Bpms and vigorous from 120 to
208 Bpms [20,32,33].
All classes lasted 45 min, organized in three parts: warm-up (10 min);
main part (30 min) and cool-down (5 min); The warm-up was focused on
dance styles that include the quaternary rhythm, with rhythm step
J. Moratelli et al.
Fig. 1. Flowchart of participant selection and the steps of binary and quaternary protocol.
markings, muscle release, breathing, movements for upper and lower
limbs, while constantly stimulating musicality. The main part was
divided into three moments, first the teacher/researcher demonstrated
the stage to be developed and then the students performed it. Soon after,
the students repeated the same movement in pairs. The partners were
constantly changed. During the cool-down period, they stretched and
walked slowly to provide muscle relaxation (supplementary file).
2.4. Evaluation measures
Data collection took place two weeks before the intervention period
and two weeks after the intervention period, through a questionnaire
applied individually in an interview simultaneously between the groups.
They were performed by trained researchers from LAPLAF and in the
same place of application of the protocol (CCR). Validated instruments
were used as evaluative measures: a) Personal and clinical information;
b) Mini-Mental State Examination - MMSE (exclusion criteria); c)
Disability stages - Hoehn and Yahr scale; d) Quality of life - PDQ-39; e)
Cognition - MoCA; f) Unified Parkinson’s Disease Rating Scale (UPDRS)
session 1 and 2.
a) Personal and clinical information: age, marital status, education
and initial characteristics of the disease.
b) Mental state mini examination (MMSE): used as an exclusion
criterion for those individuals who did not reach the cutoff points
according to the criteria of Bertolucci et al. (1994) [30]. It provides
information on different cognitive parameters, containing questions
grouped into categories, designed to assess specific cognitive func­
tions. Cut off point considering the level of education.
c) Hoehn and Yahr Disability Stage Scale: developed in 1967 and
validated, indicates the general condition of the patient with PD. It
comprises five stages of classification to assess the severity of PD and
encompasses global measures of signs and symptoms that allow the
individual to be classified according to level of disability. Patients
classified in stages I, II and III have mild to moderate disability, while
those in stages IV and V have more severe disability [34,35].
d) Quality of Life in Parkinson’s disease - PDQ-39: This is a validated
and specific scale for assessing quality of life in PD, comprising 39
items. The questionnaire is divided into eight dimensions: mobility,
daily living activities, emotional wellbeing, stigma, social support,
cognition, communication, and body discomfort. It has been vali­
dated in Brazil in 2007, Cronbach’s alpha coefficient was 0.923 of
the 39 questions included in PDQ-39, showing internal consistency
and high reliability (p < 0.001) [36].
e) Montreal Cognitive Assessment (MoCA): brief screening tool for
mild cognitive impairment. It broadly assesses eight different
cognitive aspects: executive function, visuospatial ability; memory;
3
Complementary Therapies in Clinical Practice 43 (2021) 101348
attention; concentration and working memory; language, temporal
and spatial orientation [37].
f) Unified Parkinson’s disease rating scale (UPDRS): This scale as­
sesses patients’ signs, symptoms, and certain activities through self-
report and observation. Consisting of 42 items, divided into four
parts: mental activity, behavior, and mood; activities of daily living;
motor exploration and complications of drug therapy [38]. In this
study, sessions 1 (mental activity) and 2 (activities of daily living)
were analyzed according to the purpose of the study.
Mental activity, behavior, and mood: section 1. The four questions
that make up this item address different aspects of mental activity in PD
namely intellectual behavior, thinking disorder (generated by medica­
tion use), depression and motivation.
Activities of Daily Living (ADL’s): section 2. Contains questions
(numbering 5 to 17) that address everyday tasks that are directly
influenced by PD symptoms, especially motor signs. These include
speaking, writing, handling utensils, hygiene, falls, and gait.
2.5. Statistical analysis
Statistical analysis was performed using the statistical package SPSS -
IBM, version 20.0, in which descriptive and inferential statistics were
performed. Fisher’s Exact Test and T-test for independent samples were
used to verify possible associations between BG and QG. To analyze the
BG and QG in the periods before and after intra and intergroup inter­
vention, we used the two-way ANOVA test with repeated measures and
Sydak comparison test. To investigate the association of cognition with
quality of life, mental activity and activities of daily living, the Multiple
Linear Regression test was used, applying the Enter method of variable
selection. The adopted significance level was 5%.
3. Results
When profiling the 31 individuals diagnosed with PD, it was noticed
that both groups (BG, n = 18 and QG, n = 13) presented homogeneous
characteristics, with no significance differences in the general charac­
teristics of the sample. Adherence to classes was verified by the per­
centage (%) of prescribed sessions completed, considering the absences
and non-compliance with certain established exercises, and the partic­
ipants in this study performed 84.3% of the activities [39].
Table 1 shows a predominance of males (72.2%) in BG, with a mean
age of 68.3 ± 8.6 years, in which 55.6% had moderate disease severity.
In the same way, the QG was also predominantly male (69.2%) with a
mean age of 69.7 ± 8.9 and moderate grade severity (53.8%) (according
to Hoehn and Yahr classification). In addition, BG presented average
values of 49.3 ± 30.5 for quality of life, 19.5 ± 5.3 for cognition, 2.61 ±
J. Moratelli et al. Complementary Therapies in Clinical Practice 43 (2021) 101348

Table 1 = 0.003) and discomfort (p = 0.006). As for QG, emotional improve­

General characterization of the binary and quaternary groups of individuals with ment (p = 0.001), communication (p = 0.007) and discomfort (p =
Parkinson’s disease. 0.002) can be evidenced. In both groups, differences in total quality of
BG QG P* life scores were found, with changes in scores from 11.5 for BG (p =
n (%) n (%)
0.008) and 15.7 for QG (p = 0.002).
Table 5 shows an association between cognition, quality of life,
Sex 0.856
mental activity and daily life in both groups. It was found in the simple
Male 13(72.2) 9(69.2)
Female 5(27.8) 4(30.8) analysis that for each additional value in cognition scores, mental ac­
Severity 0.435 tivity is expected to improve 1.84 points (p = 0.032) and daily life ac­
Light 8(44.4) 5(38.5) tivities 0.49 points (p = 0.041) in the study BG. In QG it is noted that
Moderate 10(55.6) 7(53.8) with each increase in cognition scores, quality of life tends to improve
Severe – 1(7.7)
0.13 points (p = 0.050), and daily living activities 0.47 points (p =
X (sd) X (sd) P# 0.005). When the analysis adjusted for the severity of the disease is
Age 68.3 ± 8.6 69.7 ± 8.9 0.396 verified, mental activity and daily life did not maintain association for
QoL 49.3 ± 30.5 59.3 ± 29.9 0.369 BG. However, for the QG, the severity of the disease was associated with
Cognition (MoCa) 19.5 ± 5.3 17.3 ± 6.3 0.306
activities of daily living (p = 0.024).
UPDRSI 2.61 ± 1.4 3.85 ± 2.6 0.106
UPDRSII 10.6 ± 7.1 16.8 ± 9.7 0.061
4. Discussion
BG = Binary Group; QG = Quaternary Group; X = mean; sd = standard devia­
tion; n = frequency; * Fisher Exact Test # t-test for independent samples.
The main objective of the study was to compare the effect of a binary
and quaternary rhythm protocol on cognition, mental activity, daily life,
1.4 for UPDRSI and 10.6 ± 7.1 for the UPDRSII. While QG presented and quality of life of individuals with PD. When comparing the in­
59.3 ± 29.9 for quality of life, 17.3 ± 6.3 for cognition, 3.85 ± 2.6 for terventions, both proved to be effective to individuals with PD, showing
UPDRSI and finally 16.8 ± 9.7 for UPDRSII. It is possible to understand improvement in the investigated symptoms. The main change was in
the average heart rate during interventions for the 93bpm BG and relation to cognition where BG and QG presented improvements after
91bpm QG, that is, two groups with small variations that were not the 12 weeks of intervention. Similar results were also found in other
significant. studies investigating different dance modalities, as free dance, tango,
In comparing cognitive dysfunction (MoCA) and mental activity after and ballroom dancing [10,40–42] that showed that dance improves the
the twelve weeks of intervention (Table 2), it was noted that both ability and cognitive skills of these individuals, as it acts on motor
intervention groups were effective in improving both aspects, and in­ control, tuning, and spatial memory.
dividuals who performed the binary rhythm classes obtained a change of In addition, overall mental activity showed positive changes after the
− 4.16 (p < 0.001) in cognition scores and a difference of 1.11 (p < intervention of both groups in this study. Corroborating these findings,
0.001) in mental activity (UPDRSI). Similar results were found in the Hashimoto et al. (2015) [40] found that dance was effective in the
quaternary rhythm where there was a difference of − 3.54 points (p < mental activity of individuals with PD in Japan, as its practice can
0.001) in cognition and 1.38 points (p < 0.001) in mental activity. It is promote the activation of brain regions with low activity. The results
also noteworthy that when investigating the UPDRSI items, the QG was also suggest that dance requires the ability to connect movement to each
highlighted in intellectual impairment (p = 0.005) and motivation (p = another and to change motor planes, thus influencing short-term
0.021). memory and the execution of movement actions; Other studies also
Table 3 shows that the daily life activities (UPDRSII) of both groups shown similar results [41–43].
presented lower scores after the twelve weeks of intervention, with a However, when we analyzed the items that constitute the aspects of
difference of 2.67 points for BG (p = 0.005) and 3.84 points for QG (p = mental activity, it was found that only the quaternary rhythm improved
0.001). By observing the variables that compose the activities of daily the scores of motivation and intellectual commitment. A similar result
living, most items had a change in the scores, but it is noteworthy to occurred in the study by Hashimoto et al. (2015) [40] and by
rotate in bed (p = 0.036), gait (p < 0.001) and sensory complaint (p = Giménez-Llor and Castillo-Mariqueo, (2020) [44] which also studied the
0.049) for BG and swallowing (p = 0.003), writing (p = 0.029) and effects of different dances on individuals with PD, and by using music,
dressing (p = 0.005) for QG. It is also noteworthy that intergroup dif­ dance induced pleasurable feelings, desire to continue, mutual under­
ferences were found in total UPDRSII (p = 0.025), written (p = 0.037) standing of the emotion shared among other participants, benefiting
and hygiene (p = 0.002), which showed different results in the post- humor, anxiety, socialization and especially motivation in class. We
intervention comparison of the two groups, thus highlighting the believe that the positive influence in our study that occurred only in the
improvement. to the QG. quaternary rhythm was because the songs used in the classes were more
The comparison of the quality of life in both groups is presented in attractive, lively, and already experienced by the participants at other
Table 4, where it can be observed that BG improved in almost all items, times in their lives, a fact that may have provided greater motivation and
especially mobility (p = 0.017), daily activity (p = 0.027), emotional (p

Table 2
Comparison of cognition and mental activity (UPDRSI) after 12 weeks intra and intergroups of individuals with Parkinson’s disease.
BG QG

Pre Post CE d p-value* Pre Post CE d p-value* p-value#

Cognition (MoCA) 19.50(5.33) 23.66(4.51) − 4.16 0.384 <0.001 17.30(6.35) 20.84(6.55) − 3.54 0.263 <0.001 0.166
UPDRSI total 2.61(1.47) 1.50(1.46) 1.11 0.354 <0.001 3.84(2.64) 2.46(1.56) 1.38 0.303 <0.001 0.090
Intel.commit 1.27(0.42) 1.18(0.40) 0.09 0.109 0.689 1.75(0.96) 1.08(0.28) 0.67 0.428 0.005 0.152
Disorder 1.66(0.48) 1.00(0.00) 0.66 0.697 0.084 1.80(0.83) 1.20(0.44) 0.6 0.411 0.053 0.482
Depression 1.00(0.00) 1.00(0.00) – – 1.000 1.00(0.00) 1.50(0.57) − 0.5 0.527 0.293 0.423
Motivation 1.50(0.48) 2.00(0.89) − 0.5 0.330 0.424 2.60(1.34) 1.40(0.54) 1.2 0.506 0.021 0.338

*p value for comparison between the pre- and post-periods of BG and QG; #p value for comparison between BG and QG in the post intervention period. CE: Change
scores. Intel.commit = Intellectual commitment; Anova Two Way Test with repeated measures and Sydak Comparison Test were used.

4
J. Moratelli et al. Complementary Therapies in Clinical Practice 43 (2021) 101348

Table 3
Intra and intergroup comparison (BG and QG) of daily living activities (UPDRSII) of individuals with Parkinson’s disease.
BG QG

Pre Post CE d p-value* Pre Post CE d p-value* p-value#

UPDRSII total 10.61(7.16) 7.94(5.26) 2.67 0.190 0.005 16.84(9.70) 13.00(6.68) 3.84 0.190 0.001 0.025
Speak 1.42(0.48) 1.28(0.44) 0.14 0.150 0.579 1.87(0.67) 1.75(0.52) 0.12 0.099 0.603 0.081
Salivation 1.28(0.48) 1.14(0.35) 0.14 0.164 0.545 1.66(0.48) 1.66(0.51) – – 1.000 0.120
Swallow 1.33(0.83) 1.00(0.00) 0.33 0.270 0.252 1.83(0.51) 1.00(0.37) 0.83 0.681 0.003 0.170
Writing 1.54(0.64) 1.54(0.77) – – 1.000 2.37(0.91) 1.87(0.60) 0.50 0.308 0.029 0.037
Cut food 1.50(0.79) 1.25(0.48) 0.25 0.025 0.334 2.11(0.92) 1.55(0.85) 0.56 0.301 0.071 0.122
Wear 1.36(0.63) 1.09(0.28) 0.27 0.266 0.084 2.00(0.83) 1.50(0.66) 0.50 0.316 0.005 0.065
Hygiene 1.27(0.43) 1.18(0.40) 0.09 0.107 0.630 2.25(0.81) 2.00(1.03) 0.25 0.133 0.265 0.002
Rotate in bed 2.33(0.68) 1.77(0.60) 0.56 0.400 0.036 1.66(1.03) 1.22(0.67) 0.44 0.245 0.085 0.096
Falls 1.50(0.78) 1.16(0.40) 0.34 0.264 0.330 1.71(0.72) 1.28(0.46) 0.43 0.335 0.184 0.637
Freezing 1.50(0.68) 1.16(0.40) 0.34 0.291 0.110 1.33(0.96) 1.16(0.37) 0.17 0.116 0.401 0.734
Gait 2.00(0.69) 1.16(0.37) 0.84 0.604 <0.001 1.42(0.67) 1.28(0.67) 0.14 0.103 0.356 0.182
Tremor 1.58(0.51) 1.25(0.45) 0.33 0.324 0.096 1.70(0.70) 1.40(0.90) 0.30 0.182 0.167 0.550
Sensitive complaint 1.66(0.51) 1.00(0.00) 0.66 0.675 0.049 1.50(0.67) 1.16(0.54) 0.34 0.269 0.170 0.516

*p value for comparison between the pre- and post-periods of BG and QG; #p value for comparison between BG and QG in the post intervention period. CE: Change
scores. We used the two-way ANOVA test with repeated measures and Sydak comparison test.

Table 4
Comparison of the quality of life of individuals with Parkinson’s disease after 12 weeks, intra and intergroups.
Quality of Life BG QG

Pre Post CE d p-value* Pre Post CE d p-value* p-value#

Total 49.33(30.5) 37.83(25.0) 11.5 0.201 0.008 59.38(29.9) 43.61(26.1) 15.7 0.190 0.002 0.539
Mobility 13.27(11.5) 9.72(10.5) 3.55 0.156 0.017 14.38(10.5) 11.53(9.75) 2.85 0.137 0.096 0.629
ADL 7.94(7.23) 5.22(5.18) 2.72 0.211 0.027 10.07(7.63) 7.84(7.12) 2.23 0.193 0.115 0.244
Emotional 6.44(5.60) 3.88(3.49) 2.56 0.244 0.003 8.00(5.59) 4.53(4.73) 3.47 0.323 0.001 0.701
Stigma 2.05(2.55) 2.11(2.72) − 0.06 0.002 0.939 4.07(5.13) 2.38(3.68) 1.69 0.189 0.054 0.841
Support 7.38(1.85) 7.72(1.17) − 0.34 0.109 0.412 7.84(1.72) 8.00(0.81) − 0.16 0.075 0.746 0.471
Cognition 4.83(4.57) 3.27(2.82) 1.56 0.201 0.082 6.16(3.82) 4.53(2.87) 1.63 0.233 0.123 0.233
Communication 2.50(3.05) 2.27(2.60) 0.23 0.040 0.668 3.69(2.92) 1.92(2.62) 1.77 0.294 0.007 0.284
Discomfort 5.44(4.04) 3.61(2.35) 1.83 0.266 0.006 5.38(2.36) 2.84(1.99) 2.54 0.509 0.002 0.350

*p value for comparison between the pre- and post-periods of BG and QG; #p value for comparison between BG and QG in the post intervention period. CE: Change
scores; Anova Two Way Test with repeated measures and Sydak Comparison Test were used. Quality of Life assessed by the Parkinson Disease Questionnaire (PDQ-39).

Table 5
Influence of cognition on quality of life, mental activity, and daily life of individuals with Parkinson’s disease.
Cognition

Binary Quaternary

Simple Adjusted Simple Adjusted

R(IC95%) p- value* R(IC95%) p-value** R(IC95%) p-value* R(IC95%) p-value**

Quality of Life − 0.02(-0.12/0.06) 0.513 – − 0.13(-0.26/0.0) 0.050 − 0.06(-0.18/0.06) 0.311

Mental activity − 1.84(-3.51/-0.18) 0.032 − 1.19(-3.47/1.08) 0.289 − 1.05(-3.66/1.55) 0.393 –
Activities of daily living − 0.49(-0.96/-0.2) 0.041 − 0.26(-0.90/0.36) 0.382 − 0.47(-0.77/-0.18) 0.005 − 0.40(-0.74/-0.06) 0.024

Multiple Linear Regression, Enter Method. *p values for simple linear regression; **p values for adjusted linear regression; Data adjusted by disease grade in the
adjusted analysis.

interest in the classes.
The findings of our study reveal a reduction in the total scores of
activities of daily living (UPDRSII) in both groups. These results showed
that dance rhythms can help to increase the individuals’ ability to move,
with their simultaneous, directional movements, turns in the same
place, and due to the double task of listening to music, leading a partner,
moving around the room, speak and perform movements [45,46], that is
provide unpredictable movement patterns. Dance classes tend to assist
in daily movements and in carrying out activities of daily living, pro­
moting greater independence outside the dance class setting and facili­
tating daily life, as avoiding falls, improving mobility in the workplace,
in the bed, when picking up objects, getting dressed and in routine ac­
tivities [11,47,48].
Thus, it can be observed that the items that obtained significant
differences in the activities of daily living were related to the sensory
complaint, bed turn, and gait in the BG. Studies in the field have shown
that the motor aspects of the disease improve after dance interventions
in which binary rhythm modalities are present [27], as in the study by
Granacher et al. (2012) [49] who showed positive results in motor
symptoms after ballroom dance classes. However, the results of the QG
differed from the BG, in which there was an improvement in swallowing,
writing, and dressing; These results indicate that the quaternary rhythm
can be an excellent way to improve the actions used in the daily life of
those living with the disease, helping to improve the diet, dressing, and
personal hygiene care [25,27]. These results showed the importance of
using both rhythms (binary and quaternary) together, since both bring
different benefits, but are complementary and necessary in the lives of
individuals with PD. Both can help to reduce the many symptoms caused
by the disease and, consequently, increase the quality of life.
In addition, difficulties with activities of daily living cause an
increasing feeling of despair and depression, causing a decline in the
quality of life of these individuals. Thus, dance in PD can promote

5
J. Moratelli et al.
feelings of pleasure, joy, improved self-esteem, in addition to reducing
social isolation, and allowing participants to forget the symptoms of the
disease during classes [11,24]. These aspects justify the findings of the
present study related to increased quality of life in both groups after
interventions, with an improvement of 11.5 points for BG and 15.7
points for QG. Other studies point to this same relationship of dance
effects by providing great improvement in the quality of life of the
population with PD, emphasizing the benefits of this activity [10,28].
Moreover, when analyzing the quality of life items, it was observed
that BG was effective in improving mobility, daily activity, emotional
and discomfort; similar results to the QG where we found statistical
difference in the emotional, communication, and discomfort. Our find­
ings confirm those found in previous studies showing the improved
health-related quality of life in individuals with PD after participating in
dance programs [11,24] with development of the social senses, by
increasing the sense of autonomy, and reduction the negative mood after
the dance classes [27,43,50].
Finally, the present study found an association between cognition
and activities of daily living in the QG. One hypothesis for this finding
would be that as individuals’ cognition increases, the activities of daily
living tend to improve. Thus, the dance modalities found in the QG
present a greater degree of difficulty in relation to the steps and figures
than the BG, demanding more cognition from the participants. The
development of cognition is very important to individuals with PD, as it
is commonly associated with tasks performed in the daily lives [10,51].
In addition, the study by Intzandt, Beck and Silveira (2018) [52]
observed that cognition can worsen mobility and gait by directly
interfering with activities of daily living.
This study has some limitations such as sample size, which made it
impossible to include a control group to obtain greater comparisons, and
we suggest that it should be presented in new studies. It was not possible
to perform the IIT analyzes because of the post-intervention assessment,
which would be of great importance. And the failure to follow up the
participants to verify the lasting effect of the interventions. In addition,
the study investigated the participants symptoms improvement while
the conventional pharmacological treatment was maintained. However,
it is important to highlight that our study provides important and rele­
vant information for future interventions about the improvements found
in dance rhythms and the well-being of this population.
5. Conclusion
Binary and quaternary rhythm positively influenced and had the
same effects on the variables studied over the 12 weeks, following the
duration, frequency, and intensity of the protocol proposed to in­
dividuals with PD. Thus, the importance of using both rhythms indi­
vidually or together in the rehabilitation or practice of physical activity
is highlighted, as both protocols prove to be an excellent tool in reducing
symptoms, as well as in the great adherence of the participants to clas­
ses. Therefore, dance rhythms classes should be considered as a possible
adjunctive treatment for individuals with PD and should be available to
this population as a form of rehabilitation of the disease. In view of this,
both interventions are possible and feasible to be used by health
professionals.
Contributors
JM conceived of the study, initiated the study design, developed the
methodology, and commented on initial drafts of the manuscript. KHA
initiated the study design and developed the methodology. LB, AS and
CLC initiated the study design and commented on initial drafts of the
manuscript. ACAG initiated the study design and commented on initial
drafts of the manuscript. All authors read and approved the final
manuscript.
6
Complementary Therapies in Clinical Practice 43 (2021) 101348
Funding
The main investigator of this study was supported in part by the
Coordination for the Improvement of Higher Level -or Education-
Personnel (CAPES) [Finance Code 001].
Declaration of competing interest
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at https://doi.
org/10.1016/j.ctcp.2021.101348.
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