Edited by: Jeremy M. Jacobs, Geriatric Rehabilitation, Hadassah Medical Center, Israel
Reviewed by: Lisa Robinson, Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom; Marios Kyriazis, ELPIs Foundation for Indefinite Lifespans, United Kingdom
Specialty section: This article was submitted to Geriatric Medicine, a section of the journal Frontiers in Medicine
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
The present pilot study investigated the effect of karate (according to the rules of the German Karate Federation) and dance training compared to an inactive control group in patients with Parkinson’s disease (PD). 65 patients were recruited. At the end, 37 patients completed the post-test. From those 37 patients, 16 had chosen the karate training, 9 the dance training and 12 the waiting control group. Before and after the whole training phase cognitive performance, emotional well-being and balance were measured. The results showed that both, karate and dance training groups, improved balance. Furthermore, the mood dropped only in the waiting control group receiving no training at all, whereas it remained stable in patients who attended the karate and dance group. The training adherence was higher in the karate than the dance group indicating a high acceptability in PD patients for karate. In sum, karate can have the same positive effects as dance for PD patients. Further studies with larger samples and more rigorous methodologies are required to investigate the reported effects in more detail.
Parkinson’s disease (PD) is determined by the cardinal symptoms bradykinesia, rigidity, tremor, difficulties in balance, and resulting difficulties in gait. This impaired motor performance sometimes has a detrimental effect on the quality of life, because it may be accompanied by emotional disorders like depression or anxiety (
Several studies showed the positive influence of sport training on motor symptoms of PD patients. Shulman et al., for example, proved that endurance as well as strength and flexibility improved by a treadmill, strength and flexibility training (
Dance seems to be an appropriate movement form to be applied in PD patients because it strengthens the muscle of the lower extremities (
Most studies which showed an improving effect of martial arts on PD are related to TaiChi, an old Chinese martial art. TaiChi includes a series of slow, meditative movements for self-defense, and for the accomplishment of inner peace and calm. Several studies showed a positive effect on motor systems such as balance (
Until now, there is no study which investigates the effect of a karate training on PD patients. Karate is a martial art, which entails moving forward and backward while performing arm movements. Up to this point, there are only three studies investigating the effect of karate on cognitive, motor, and emotional symptoms in older people. Muiños and Ballesteros showed an increased dynamic visual acuity in older people who trained karate compared to sedentary controls (
It is the first goal of this study to investigate if it is feasible to perform a karate training with PD patients. This provided, we further want to explore if karate as well as dance can improve emotional, cognitive as well as motor performance in patients with PD compared to an inactive control group. Third, by conducting an applied study and by giving the patients the opportunity to choose the kind of movement they like we want to mirror a real-life situation. We expect males to prefer a karate training and females to prefer a dance training.
In total, 65 patients diagnosed with idiopathic PD (Hoehn and Yahr stages 1–3) were recruited for participation through a newspaper announcement and with the help of a neurologist. According to our former studies (
Demographic data were assessed concerning the age, sex, and the physical activity (yes/no). The highest school/university degree was also measured (1 = 10 years of education; 2 = 10 years of education and a further higher education; 3 = university degree). Additionally, the participants were asked to mention any other illnesses and medication in an open text field (see Table
Demographic data dependent on the training group.
Karate ( |
Dance ( |
Control ( |
χ2 ( |
||
---|---|---|---|---|---|
Sex (male, female) | 13, 3 | 6, 3 | 8, 4 | 8.39 | 0.015 |
Age (M, SD) | 68.87 (7.24) | 72.33 (6.69) | 70.42 (10.07) | 0.523 |
0.597 |
Physical activity (yes/no) | 7/9 | 4/5 | 6/6 | 0.119 | 0.942 |
School education (low/middle/high) | 5/4/7 | 2/6/1 | 8/4/0 | 12.52 | 0.014 |
Session of training (M, SD) | 25.15 (5.48) | 20.67 (5.31) | 3.89 |
0.061 |
Subjective well-being was measured with the Multidimensional Mood Questionnaire (
Anxiety and depression were measured with the Hospital Anxiety and Depression Scale [HADS; (
Subjective health was analyzed with the 12-item Short-Form Health Survey (
General self-efficacy was investigated with the Short Scale of General Self-Efficacy (
Cognitive processing speed as well as executive function were measured with the Number Connection Test. In this test, participants have to connect numbers (1–90) printed randomly on a sheet of paper. The test consists of six sheets of paper, two practice sheets and four test sheets. The numbers have to be connected as fast and as accurately as possible in the right order. The mean time of the four test trials is calculated. The test–retest reliability is 0.95 (
General cognitive ability was measured with the Parkinson Neuropsychometric Dementia Assessment (PANDA). This scale includes a task of pair association, word fluency, visual–spatial cognition, working memory, delayed retrieval, and assesses mood (
Balance was measured with the one-leg stand. Here, patients were required to stand on one leg as long as possible, but at least for 60 s. Patients should cross their arms in front of their chests and fix some point in the room. The experimenter took the time the patients were able to stand on one leg. The best of three trials was taken for the analysis (
Each training took place once a week for 1 h and in a separate room. The whole trainings phase lasted for 30 weeks. The trainers registered the training attendance of each patient and the attending partner. The mean attendance of the dance training was 20.67 h and the one of karate training 25.15, see Table
The karate group received a Shotokan karate training according to the German Karate Federation. This kind of training involves the elements of Kihon, Kumite, and Kata. The training began with a short warm-up followed by the learning and exercising of some specific arm and leg movements (Kihon), sessions with a partner (Kumite), and the learning of sequences of movements (Kata). Kata are the most elaborated exercises because different movements have to be remembered in a prescribed order. The training further involved breathing exercises, strong and soft, and slow and fast movements. It ended with a short relaxation phase. There were three experienced trainers (two males, one female) with more than 20 years of practice and more than 10 years of teaching experience. They rotated in their teaching activities.
The dance sessions included simple dance movements which were compounded to a choreography and danced together in a line, i.e., elements of line dance were integrated. Later, standard dance forms such as rumba and waltz, were applied. Three different dance trainers (two males and one female) with several years of experience taught the dance lessons. They rotated in their teaching activities.
The rotation of trainers was welcomed by all patients in both groups. The tests were applied 1 week before the specific training started and again 1 week after the last training session. Each test session lasted around on hour. The tests were conducted by psychological research assistants.
The categorical data were analyzed with chi-square tests, see Table
In the karate group, there were 25 patients at the beginning and 16 completed the posttest. Nine patients did not complete the study due to private reason (1), health complaints (4), time constraints (2), death (1), or relocation (1). In the dance training group, 12 patients started with the training and 3 of them left it before the posttest due to health complaints (1), time constraints (1), and no interest (1). From the waiting control group, 18 patients completed the pretest but only 12 appeared again to complete the posttest. The remaining six patients did not give any reason for not showing up.
The correlational analysis showed a significant positive relation between the performance in the one-leg stand and the self-efficacy (
The repeated-measure analysis yielded a significant main effect of “time,”
Points in the mood measurement in the MDBF (in the pretest and posttest) for the karate, dance and waiting control group.
The MDBF subscales fatigue and agitation did not receive any significant result.
Concerning the analysis of the
For the physical score, there was no significant main effect at all. The analysis of the mental score yielded only a significant effect of the factor “group,”
The results showed simply a significant group effect,
Regarding cognitive processing speed and executive functions, there was just one significant main effect of the factor “time,”
Concerning the analysis of the PANDA, there was just one significant main effect of the factor “time,”
The analysis in the performance of the one-leg stand revealed a significant main effect of the factor “time,”
Performance in the one-leg stand (measured in seconds) in the (in the pretest and posttest) for the karate, dance, and waiting control group.
The one-leg stand test was performed for mostly 60s, and thereafter terminated. In the KG, already 37.5% participants achieved this score in the pretest. No participant of the DG and 16.7% of the WCG achieved this score. Because of this “ceiling effect,” no additional improvement could be measured for these persons in the posttest.
Regarding our first goal, it was shown that it is possible to conduct karate with PD patients. Furthermore, karate seemed to be more attractive for male patients compared to females: more males chose to attend a karate session compared to a dance session. Furthermore, the self-selection of the type of sport resulted in the fact that more patients with a higher school degree chose karate, an effect which might be mediated by the higher attendance of males in this group. Moreover, the karate group showed higher scores in some of the pretests than the other groups. Especially in the one-leg stand test more than one third of the karate participants started with the highest score possible. Therefore, it is impossible to demonstrate their improvement (ceiling effect). Concerning the results of this feasibility study, no difference between the effect of karate or dance on emotional, cognitive, or motor performance was found. Both interventions showed an improvement in balance as well as a prevention of mood drops. Another interesting result was that emotional, cognitive, and motor parameters relate to each other, suggesting a holistic approach when dealing with treatment of PD.
In addition, the study clearly proves a high treatment adherence, especially in the karate training, which might be an indicator for the high acceptability in PD patients. Because other kinds of therapies, such as long-term medication, suffer from a lower adherence (
The specific dance training applied in this study, a combination of line dance and standard dance, showed an improvement in balance as well as a stable state of emotional well-being compared to the inactive waiting control group. This is in accordance with Earhart’s claiming that dance can be a clinically meaningful therapy for individuals with PD (
In contrast to some other studies, for example the dance study of Natale et al., we did not find any significant improvements for cognitive functions (
The present investigation serves as a pilot and feasibility study exploring the potential benefits of karate as another promising exercise tool in the treatment of PD. The study is limited by the fact, that a randomization is missing, because the patients were free to choose the form of exercise they liked to do. This experimental setting was selected to enhance the validity of the study. It is quite unlikely that patients might be motivated to take part committedly in a motor training they do not like. One might suspect that this would result in a high number of drop-outs and/or and unreliable results. On the other hand, we could not exclude that the obtained effects are biased by a preference effect. We gained interesting information, that is males like to choose karate while females chose dance. Also, the patients who choose karate seem to have a better physical and mental health as the patients of the other two groups. The statistical analysis was impeded by these facts. It is also uncommon to invite the partners to take part in the intervention group. This limited internal validity but raised ecological validity. In this manner, a reasonable compromise between a high internal and external validity was implemented in this study. Another limitation is the fairly small number of participating patients.
This is the first study showing that karate might be a positive treatment method for the emotional, cognitive, and motor symptoms of PD patients. The advantage of this study lies in the investigation of the impact of karate and dance on body, emotion, and cognition. However, more studies with a bigger sample size and clear randomization have to be conducted. It may also be useful to investigate the effect of different karate postures as well as the role of the patients’ partners in the dance group in more detail.
Concerning the clinical practice, we can assume that it is useful for the PD patients to choose the physical training they like the most. If they get the general allowance of their neurologist, they are able either to attend an adapted karate or a dance training. Both adapted training forms should be considered as non-medicinal additional therapy beside medicinal treatment.
The study was approved by the Ethical committee of the German Association of Psychology, spring 2016.
KD-Z: conception of the work; acquisition and interpretation of the data: surveillance of the interventions; drafting the work, revising it critically; final approval of the version to be published; agreement to be accountable for all aspects of the work. PJ: conception of the work; analyzing and interpretation of the data; drafting the work, revising it critically; final approval of the version to be published; agreement to be accountable for all aspects of the work.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The authors want to thank all participating patients. Furthermore, they want to thank Agnes Halski, Hannah Körber, and Viktoria Weiss for their help during data acquisition.