Neuroesthetic techniques for the treatment of Parkinson's disease
PERFORMING ARTS AS A COMPLEMENTARY THERAPY IN THE REHABILITATION OF PARKINSONIAN PATIENTS
Traditional medical treatments for Parkinson's disease (PD), both pharmacological and physiotherapeutic, are effective on motor disorders due to the disease, but can have a minimal impact on non-motor symptoms, especially psychiatric ones: even when the motor symptoms improve, patients may experience a deterioration in the quality of their life. Complementary therapies were then sought to obtain progress also on an emotional and relational level, aspects that greatly influence the daily lives of patients: it has in fact been proven that the performing arts can be a valid additional therapeutic intervention in their psychophysical rehabilitation. Therefore, below we will analyze two clinical studies  and two holistic laboratories on the development of the performing arts as a parallel way of recovery for those suffering from this disease. But first, it's worth spending a few words on what Parkinson's is.
3.1 The "agitating paralysis"
Parkinson's disease, which takes its name from its discoverer James Parkinson, a pharmacist and a surgeon of the nineteenth century, is a chronic degenerative disease that affects some specific brain functions, including programming and controlling the movements of daily life , with the result of making them slower and cumbersome. Parkinson's symptoms have been known for thousands of years: a first description would have been found in an Indian medical paper that referred to a period around 5,000 BC and another in a 2,500-year-old Chinese document. This disease is present all over the world and in all ethnic groups; it is found in both sexes, with a slight prevalence, perhaps, in the male one; the average age of onset is around 58-60 years, but about 5% of patients can have a youth onset between 21 and 40 years, while before the age of 20 it is extremely rare; over 60 years it affects 1-2% of the population, while the percentage rises to 3-5% when the age is over 85. The causes of the disease are not yet known: however, there seems to be multiple elements to compete in its development. For example, there are known genetic mutations associated with Parkinson's: among the identified genes the most important ones are alpha-synuclein (PARK 1 / PARK 4), parkin (PARK-2), PINK1 (PARK-6), DJ -1 (PARK-7), LRRK2 (PARK-8) and glucocerebrosidase GBA; about 20% of patients have a positive family history for the disease and it is estimated that the family members of people affected by the disease have a slightly higher risk of developing the disease than the general population. The risk of disease increases with exposure to toxins such as some pesticides, for example Paraquat, or hydrocarbon-solvents, such as trichlorethylene, and in some professions that subject workers to contact with heavy metals. Exposure to cigarette smoke, however, probably reduces the appearance of the disease: smoking seems to be a protective factor. The structures involved are located in very deep areas of the brain, known as the basal ganglia, which participate in the correct execution of movements. PD occurs when the production of dopamine in the brain, a neurotransmitter essential for the transmission of electrical impulses involved in the performance of human motor and social tasks, decreases consistently: this is due to the degeneration of neurons in an area called "black matter" , whose cell loss exceeds 60% at the onset of symptoms; accumulations of a protein called alpha-synuclein appear from the brain cord, which spreads the disease throughout the brain. The pre-clinical phase, or period of time that elapses between the beginning of neuronal degeneration and the onset of motor symptoms, is not yet known, but can be dated to around 5 years.
At the onset of the disease, the symptoms  of PD are often not recognized immediately, since they manifest themselves in a subtle, inconstant way and the progression of the disease is typically very slow. Most, but not all, patients experience tremor which is noticeable when the person is at rest. Another type of tremor frequently reported even in the early stages of the disease is "internal tremor": this sensation is felt by the patient but is not visible. Another physical change involves body stiffness. Bradykinesia is a slowdown in the execution of motions and gestures, akinesia, on the other hand, is a difficulty in starting spontaneous movements; most patients are aware of bradykinesia, which is referred to as an annoying symptom, as it makes even the simplest movements very slow: symptoms related to bradykinesia are the modification of the handwriting, which becomes smaller (micrograph), the sialorrhea, i.e. increase in the amount of saliva in the mouth due to a lack of swallowing, and reduced facial expression (hypomimia). The balance disorder occurs later in the course of the disease and is a symptom involving the body axis: the balance problems do not respond to dopaminergic therapy, therefore, physiokinesitherapy becomes an important intervention for its management. The voice may present hypophony or a loss of pitch and modulation, which leads the patient to speak in a rather monotonous way; sometimes a palilalia appears and there is a tendency to accelerate the emission of sounds; in some cases a sort of stutter is observed which can make it difficult to understand what is being said. In PD, non-motor phenomena can also occur , which may begin many years before the onset of motor symptoms, which are most often seen in the initial stages of the disease and with maximum frequency in the more advanced ones. The most frequently observed non-motor symptoms are vegetative disturbances (which include constipation, urinary and sexual dysfunctions, changes in blood pressure, excessive sweating, rashes, changes in the sense of smell), sleep (insomnia, daytime sleepiness, phase behavioral disorder REM or RBD, restless legs syndrome or RLS), mood and cognition (depression, apathy, anxiety, obsessive compulsive disorders, hallucinations or LBD and psychosis), fatigue and pain.
3.1.2 Traditional treatments
Although there is currently no cure for PD, there are several treatment options , both pharmacological and surgical. Among them are the dopaminergic drugs, including Levodopa, decarboxylase inhibitors, dopamine agonists, anticholinergics, MAO-B blockers, COMT inhibitors. Although PD drugs can be used to improve motor function, over time they lose their effectiveness, causing side effects; moreover, with the progression of the disease the doses of drugs necessary for the control of motor function can lead to intolerable or unwanted consequences. Among the surgical methods, however, we find pallidotomy, that is the destruction of a region of the brain involved in the control of movements, but among the adverse effects include bleeding, weakness, vision or language deficit and chronic confusional state. Finally, deep brain stimulation or DBS offers adjustable, if necessary reversible, treatment for PD, as it uses a medical device, similar to a pacemaker, which sends electrical stimulation to certain areas of the brain, allowing better functioning of the circuits. brain responsible for controlling movements.
So far we have talked about people affected by PD using the term "patients": it is precisely this condition of the patient that isolates those who are affected, since both in the health sector and within families, it is often only perceived this side of their person, overshadowing their intrinsic essence of human beings above all. This leads parkinsonians to experience embarrassment and a loss of confidence in their abilities, consequently aggravating their clinical picture and mental health in the same way . This is where neuroesthetic supportive therapies come into play.
3.2 Theatre: an existential recovery
An entirely Italian experimental research group, born from the collaboration of the Mediterranean Neurological Institute Neuromed of Pozzilli, the Department of Anatomy, Histology, Forensic Medicine and Orthopedics of the La Sapienza University of Rome and PARKIN-ZONE onlus of Rome, from 2004 to date deals with studying the effects of active theatre as a valid complementary intervention for the treatment of PD, supporting the significant improvement in the well-being of theatre patients compared to those undergoing conventional physiotherapy . Given that PD has a worldwide prevalence of around 10 million people and that this estimate is expected to double by 2050 due to the increase in longevity , the management and treatment of this disease will be a very important public health problem. and, consequently, the demand for the development of adequate complementary strategies, aimed at making improvements in the personal and social life of patients and caregivers, is rapidly increasing. Activities such as martial arts  have been shown to produce positive effects mainly on the balance and frequency of falls, but progress in cognitive and affective symptoms is absent or very limited. A fifteen-month pilot study  was conducted on twentyfour subjects with moderate idiopathic PD: half was assigned to a theatrical program in which physical-emotional training was carried out, the remaining part participated in group physiotherapy; during the entire process all patients continued to take dopaminergics and, where necessary, antidepressants and hypnotic agents; all subjects were evaluated at the beginning and end of their treatments, using a battery of eight different clinical scales and five neuropsychological scales, and it was found that theatrical training improved the emotional health of the patients, with a consequent drop in doses pharmacological and a positive increase in sleep quality, while there has been no measurable progress with physiotherapy. However, it is interesting to note that none of the groups showed improvements in motor symptoms or cognitive skills. Specifically, the theatrical workshop consisted of three-hour daily sessions on a weekly basis, for a total of about 12 hours a month for fifteen months; each lesson was always led by two teachers, an actor and, in turn, a dancer or singer, and ended with a short themed stage performance. The entire program was divided into three phases: 1) welcome, self-confidence, and group foundation; 2) processing of emotional stress focused on six moods: anger, fear, happiness, sadness, surprise, sensuality; 3) free organization, interpretation and representation of emotional states by each patient by means of improvisation, motion and literature. Physiotherapy, however, was organized in group sessions of 1.5h twice a week, for a total of approximately 12 hours per month for the months of treatment; physical therapy was based on the development of strength, power, endurance and aerobic capacity to improve motor functions, muscle control, balance and gait, according to the European Physiotherapy Guideline for PD. While motor symptoms and cognitive functions, as mentioned, were not influenced by either of the two treatments, four clinical scales that deal with emotional dominance, i.e. the meters of depression, apathy, stigma and well-being, showed significant improvements in the theatre group and not in physiotherapy, together with a re-acquisition of relational and communication skills, as well as an acceleration of reading times due to social integration. Although motor disorders are mandatory for making a diagnosis, there is a consensus  around the idea that non-motor symptoms play a more important role in reducing the health-related quality of life perceived by patients. Recent discoveries  have begun to shed light on the link between the exhaustion of dopaminergic neurons that occur in PD and the genesis of neuropsychiatric symptoms: the interruption of the dopaminergic system seems to influence decision-making processes at the beginning of motor acts, due to a incorrect assessment of the costs of movements and the latter decreases the motivation to act, inducing bradykinesis or akinesia. Other evidence  indicates that in healthy subjects L-dopa plays not only a role during the decision-making process under risky choices, but also in generating a feeling of subjective happiness consequent on receiving the reward: therefore, the loss of dopamine influences both action planning and pleasant sensations normally associated with rewarding events, which could lead to anhedonia. Overall, it is not surprising that objectively good control of motor symptoms may not be accompanied by a positive feeling of well-being experienced by patients and this evidence has led to the need to develop auxiliary approaches to medical therapy. Art therapies based on drawing, painting, sculpture or martial arts allow patients to express themselves spontaneously, but tend not to have the intersubjective interactions that normally occur in real life and their impact on motor control is rather limited. The opposite is true for occupational therapies such as theatre: theatrical training allows a more holistic approach because, to play a character, an actor must be able to control his own body, reproduce the emotions and thoughts of the character and identify himself with his social role. This is potentially a successful exercise through which Parkinsonian patients could develop new strategies to carefully control their bodily and mental impulses within a protected environment, in which they do not feel judged; moreover, both during the tests and in the middle of the performance, they are forced to interact continuously and, consequently, to socialize. Even if the physical discomforts did not improve, the experiment subjects stated that their feelings about their illness and its evolution were so positive that they could no longer stop their theatrical training. It should be emphasized that performing this theatrical practice is not a pleasant activity by definition: patients also experienced some form of anguish when they retraced emotionally negative events and, consequently, the results of this experiment cannot be explained simply by the that this social activity was pleasant for them. Theatre, therefore, is an ideal game in deeply motivating patients, as it allows them to regain control and pleasure of their existence and everyday life.
3.2.1 PARKIN-ZONE onlus
PARKIN-ZONE is a non-profit association of social utility founded in Rome in 2004 and chaired by dr. Nicola Modugno, neurologist and director of the Parkinson center and movement disorders at the I.R.C.C.S. Neuromed of Pozzilli: the non-profit organization aims to use the performing arts to develop care and rehabilitation strategies for Parkinson's disease and thus offers practical and psychological support to patients and their families through the conduct of complementary activities, including listening groups and information courses. Also through the aforementioned study, Modugno has shown that with a constant theatrical practice all his patients significantly improve their emotional sphere: therefore, his organization makes use of the advice of actors, directors, dancers, choreographers, musicians, singers and psychologists. Among the activities organized by PARKIN-ZONE onlus are Drum Circle (the creation of an impromptu and improvised orchestra of drums and percussion), the Body Voice course and the music-physio therapy laboratory. I cannot fail to mention the convention "Parkinson: body and soul" held in December 2018 in Rome, the first Italian forum that aimed to bring together people affected by PD, their families and assistants in a single context with health professionals, neurologists and theatre performers.
3.3 Active music therapy
The history of aesthetics has always caught an intimate and essential link between music and affectivity, between acoustic movement and soul movement: many of the expressions that characterize the empathetic and sympathetic experience draw on musical metaphor.
‹‹ The Pythagorean school, as Giamblico testifies in the Pythagorean life (XX, 112-113), had already theorized and practiced the psychosomatic efficacy of music, a powerful force capable of communicating immediately and sympathetically, through its rhythms and its melodies, with the most intimate fibers of man, and therefore capable of healing souls and bodies. ›› 
The treatment of PD, as we have seen, is regulated by both pharmacological and non-pharmacological treatments: currently, drug therapy is essentially symptomatic and does not have a satisfactory impact on symptoms related to the progression of neurodegenerative disease and a systematic review  of randomized studies controlled reached the conclusion that physiotherapy has only short-term benefits in PD. As a consequence, several health institutions have recommended the development of complementary non-pharmacological interventions as first-line treatment : in fact, in recent years more attention has been paid to the effectiveness of active music therapy and stimulation based on music such as motor training and cognitive in Parkinsonian patients . The power of music and its non-verbal nature make it an effective means of communication when language decreases or is entirely interrupted: music easily stimulates movement, stimulating interactions between perception and systems of action , and therefore music therapy was developed with the aim of improving motor recovery in patients with PD. The definition of music-based movement therapy is not just listening to music, but also singing and playing rhythmic instruments and percussion. An American study  performed a meta-analysis of all available clinical studies on dyskinesias and therapies of cognitive dysfunctions in patients with PD: this review was performed using a pre-specified protocol and was conducted based on the articles of the Preferred Reporting Items for Systematic Reviews and Meta-analyzes (PRISMA) . Eligible clinical trials were in any language and included patients with PD undergoing motor dysfunction and three electronic databases were examined systematically, namely PubMed, EMbase and the Cochrane library: the search strategy included keywords and MeSH terms related to movement therapy based on music. Researchers Shuai Zhang and Dong Liu examined the eligibility of the studies: both independently extracted and compiled data from the studies, using a standardized form for data extraction, and disagreements were resolved through consent or referral to a third reviewer, Kai Liu, while discrepancies and undetectable data were resolved by group discussion between at least three investigators. Basic information was extracted from the individual studies, including publication, year, country, study design, participants, disease type, disease duration, delivery, etc; the design of each individual study was included in these analyzes, as well as the method of intervention, the frequency and duration and time of evaluation of the result; in addition, the scale scores of the results measurements were extracted at baseline and the quality of the studies included with the Physiotherapy Evidence Database (PEDro) scale score was assessed . Eight studies  were identified for systematic review and meta-analysis and included 241 subjects assigned to music-based movement therapy or control. Most of the evidence has suggested that music therapy is associated with improvements in motor and cognitive functions and has positive outcomes on quality of life: a study  argues that music relaxation therapy could achieve similar efficacy to neuromuscular therapy on motor and non-motor symptoms; another research  has shown that specific music can improve the precision of the movements of the arm and fingers; in addition, training accompanied by "walking songs" was assessed using objective measures of the gait score and a latest study  has tested the effectiveness of using music during home exercise. The beneficial effects of music-based movement therapy therefore meet expectations: several possible and potential mechanisms could help explain the effects of music training on neurodegenerative symptoms; however, the mechanisms underlying the improvement of neurodegenerative dysfunctions thanks to successful musical therapies are not well understood and are still equivocal. The discovery of the clinical efficacy of rhythmic motor entertainment has also highlighted for the first time that the structural elements of music have enormous potential in clinical applications for the requalification of the injured brain .
PoppingForParkinson is a project born in London in July 2015 from the idea of Simone Sistarelli, a young Genoese dancer graduated in Contemporary Dance at the Trinity Laban Conservatoire of Music and Dance in London and currently a student in Dance Psychology at the University of Hertfordshire, of use popping, a Califonian hip hop current based on muscle contraction and relaxation to the rhythm of music, to exploit this same involuntary movement typical of PD patients, to transform the negative experience of tremors into a positive artistic expression. During his free lessons, the Parkinsonians are no longer patient, but smiling students and artists, capable for a moment of forgetting their condition and finding a new condition of humanity within themselves. The value of this laboratory is unlimited and can be transferred anywhere in the world: recently, PoppingForParkinson has started to raise funds to bring this project on tour around the world (to date, Germany, Italy, the United Kingdom and the United States of America are included) and he is currently flanked by numerous supporters, including Sadiq Khan, mayor of London, and the Dance For Parkinson's Mark Morris Dance Group in New York. PoppingForParkinson has also won the Universal Hip Hop Museum Award and has been included in the UHHM Hall of Fame this year.
‹‹ Making art is like making pasta: you are the pasta, your essence; the artistic act is the sauce. ›› 
The discovery of mirror neurons was undoubtedly a fortuitous event with an incredibly remarkable scope, since, thanks to the technological advances that led to the avant-garde of neuroimaging, it was possible to build an approximate brain map, which in turn demonstrated the existence of a prelinguistic and pre-reflexive reflex mechanism that, through the embodied simulation process, creates that contact between us and the other that has allowed us to evolve in society and culture. We have seen how the human mirror system is activated exclusively at the sight of actions moved by an internal intention, real or fictitious, as the brain reassembles in an image the voluntary motion previously broken down into smaller acts and assigns it a meaning: this allows any type of interaction, which therefore has an intrinsically intentional value. In fact, it is the purpose recited by the actor that allows the spectator to identify himself: by means of the reflections generated by the embodied simulation, that shared space of action is created in which the spectator resonates with the actor's will. Mirror neurons are also an indispensable requirement for our imitative abilities: without the recognition of the intentionality of an action belonging to our act vocabulary, our brain would not be able to send the necessary motor messages to imitate motion and consequently an evolutionary process of the species would not have been possible. Furthermore, the insula creates a connection between the motor system and the limbic system, simultaneously discharging the two brain areas with mirror properties and thus making us recognize and rework the emotions underlying the actions of others: in fact, we talked about the '"Emotion of mirror neurons". This allows us to enter into consonance with the other from us, including the actors on stage: it is because we recognize the purpose of an action, we internalize it by means of sympathetic imitation and we resonate with the same feelings that we are able to experience the Aristotelian catharsis. In light of this, it is possible to transfer the mechanisms of intention, imitation and empathy into the daily rehabilitation of Parkinson's patients and use theatre as an alternative means of filling the gaps of traditional drug therapies. It has been demonstrated by Theatre is a valid add-on therapeutic intervention for emotional rehabilitation for Parkinson's Disease patients that a performance-based treatment is able to slow the frequency of non-motor symptoms of PD, such as depression, apathy and isolation, and to decrease the doses of drug treatments, making improvements in the personal and social life of patients and their caregivers; such progress has been proven to be even greater than that recorded by both normal physiotherapy and other recreational forms, such as martial arts or art therapy. Has the thesis also been supported by the research Can music based movement therapy improve motor dysfunction in patients with Parkinson's Disease? Systematic review and meta-analysis, which has proven the existence of physical-emotional developments following continuous sessions of active music therapy, certainly considered a form of performing art. It appears, however, that, in any form of therapy, traditional or artistic, it is not yet possible to obtain visible results on motor symptoms: we hope, therefore, that research will soon progress in this direction. Could it be that theatre is the answer again?
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 From an interview to Simone Sistarelli, 13th November 2018.