Effects of Amazonian Dance on Motor and Non-motor Symptoms of People With Parkinson's: Study Protocol

Cognition will be assessed in two ways using traditional pen-and-paper tests and incorporating innovative instruments and using digital technology. Executive function and attention will be measured using the Tablet-based Cognitive Assessment (Tab-CAT) application, developed for the efficient detection of mild neurocognitive disorders, which assesses cognitive abilities including memory, executive/speed, visuospatial and language (Possin et al., 2018). In this battery, the Dot-counting, Set-shifting, Flanker, and Animal Fluency tests will be used. The Montreal Cognitive Assessment (MoCA) Brazilian version (Hobson, 2015) will be used to screen for mild cognitive impairment, accessing different cognitive domains in the following areas: attention and concentration, executive functions, memory, language, visuoconstructive skills, conceptualization, calculation and guidance. The total MoCA score is 30 points, with a score of 26 or more considered normal.

This task assesses sustained attention and working memory. The participant is presented with various screens containing different sets of shapes and is instructed to count a specific type. In addition to counting, the participant must remember the totals across multiple trials, which requires continuous focus and short-term retention. This task is sensitive to impairments in attentional and memory systems, often affected in neurological conditions.

This task aims to assess executive shifting, one of the cognitive functions involved in mental flexibility. The stimuli consist of geometric shapes (rectangle or triangle) in different colors (red or blue). During the test, the participant sees a cue word displayed in the center of the screen-either "color" or "shape". Above this cue, a target stimulus (a colored shape) appears. In the lower left and right corners of the screen, two response options are shown, each representing a different combination of shape and color. The participant must select the correct option based on the instruction word shown-i.e., they must match the target either by color or by shape, alternating between these classification rules depending on the cue presented on each trial.

The Flanker Task is used to assess selective attention and inhibitory control. The participant sees a row of five arrows and must quickly indicate the direction of the central arrow (the target), while ignoring the surrounding arrows (flankers). These flankers may be congruent (pointing in the same direction) or incongruent (pointing in the opposite direction). The task measures the individual's ability to suppress irrelevant stimuli and respond accurately to the target, making it a valuable tool for detecting deficits in executive control.

In this task, the participant is asked to name as many animals as possible in one minute. It evaluates semantic verbal fluency and is highly sensitive to early dysfunction in brain regions associated with language, particularly in the frontotemporal areas.

The MoCA (Montreal Cognitive Assessment) was used to assess global cognition. In Brazil, the interpretation of MoCA scores varies according to educational level and group differences (Cesar et al., 2019). The MoCA cutoff score to differentiate cognitively unimpaired (CU) from people with dementia is 15. To distinguish cognitively unimpaired (CU) from people mild cognitive impairment (MCI), the cutoff score is 19. Furthermore, the MoCA cutoff score for identifying MCI varies according to individuals' educational levels, reflecting the importance of tailoring assessments to educational contexts. For individuals with no formal education, the cutoff score is 11.5. Those with 1 to 4 years of education have a cutoff score of 18. Individuals with 5 to 8 years of education have a cutoff score of 19.5, as do those with 9 to 11 years of schooling. Finally, for individuals with 12 or more years of education, the cutoff score is 22. These values underscore the need to consider educational context

The Toolkit to Examine Lifelike Language (TELL) will be used in this study to assess elements of language and speech. This application enables the recording, storage, and encryption of participants' oral productions. Speech samples will be recorded in Wave format (.wav) with an optimal sampling rate of 44.1 kHz and bit depth of 24 bits. Transcriptions will be performed automatically via Whisper, integrated within the TELL platform, and manually reviewed according to standard criteria established in previous studies (Steeb et al., 2018). Both audio files and transcriptions will undergo pre-processing using validated pipelines, allowing for the extraction of linguistic and acoustic features. These automated methods will be employed to identify distinct speech patterns, as described by Garcia et al. (2022). In addition, the tools used in the study offer potential to assess and monitor disease progression and treatment effectiveness in relation to verbal communication (Garcia et al, 2016)

Anxiety disorders will be assessed using the Parkinson Anxiety Scale (PAS), an instrument specifically developed to assess anxiety in PwPD (Leentjens et al., 2014). This scale consists of 12 questions, each of which can be scored from zero (0) to four (4), totalling a maximum score of 48 points. It is divided into the persistent anxiety subscale (AF; 1st to 5th questions), which measures generalized anxiety disorders; the episodic anxiety subscale (EA; 6th to 9th questions), which assesses panic disorder; and the avoidance behaviour subscale (AB; 10th to 12th questions), which assesses anxious symptoms of agoraphobia and social phobia.

For the evaluation of depressive symptoms, the Geriatric Depressive Symptoms (GDS-15) will be used, which is a scale widely used and validated as a diagnostic tool for depression in the elderly, classified into mild, moderate and severe levels. It is a scale for assessing depressive symptoms, self-assessed, consisting of 15 questions, in which the result of five or more points is indicative of a probable depressive episode. (Paradela et al., 2005).

Quality of life will be measured by applying the Parkinson's Disease Questionnaire - 39 (PDQ-39), proposed and validated by Peto et al. (1995). The PDQ-39 comprises eight domains: mobility, daily life activities, emotional well- being, stigma, social support, cognition, communication, and bodily discomfort. Each item can be answered according to five predetermined answers: never; rarely; sometimes; often; always. The score of each item ranges from 0 to 4 points, and the total score varies from 0 to 100 points, where the lowest scores reflect a higher quality of life (Marinus et al., 2002; Lana et al., 2007).

To assess the levels of hope, the Herth Hope Scale will be used, which has 12 affirmatively written items where the items are graded on a 4-point Likert-type scale, ranging from completely agree to completely disagree, where 1 indicates completely disagree and 4 indicates completely agree. The total score ranges from 12 to 48 and the higher the score, the higher the level of hope (Sartore & Grossi, 2008).

In the Timed up and Go (TUG) test, participants will start sitting in a chair with their arms crossed over their chest, knees, hips and feet at a 90º angle, with their feet placed parallel, and instructed to stand up, uncross their arms, walk a distance of 3 meters, pass in a cone (180º turn), go back and sit on the chair crossing your arms over your chest (Podsiadlo & Richardson, 1991). Participants will perform the TUG test three times, at two speeds (SSS and FS). The best result of the three repetitions at each speed will be considered.

The Falls Efficacy Scale - International (FES-I) works as an indicator of the possible occurrence of a fall event and is composed of 16 items that establish the risk of falling for each elderly person within their life context, during basic daily life activities and instrumental/social, on a four-point scale. The total score varies between 16 points (not worried) and 64 points (very worried). (Yardley et al., 2005).

The Freezing of Gait Questionnaire (FOGQ) consists of six questions about gait freezing episodes: duration, frequency of freezing, hesitation, walking in the worst state of walking, and whether these events affect functional independence and activities of daily living. It has a total score of 24, with the highest score representing severe gait impairment (Baggio et al., 2012).

Part III of the MDS-UPDRS (Movement Disorder Society - Unified Parkinson's Disease Rating Scale) will be used in this study to assess participants' motor impairment. This section includes 18 items that evaluate speech, facial expression, resting and postural tremors, rigidity, hand and leg agility, posture, gait, balance, and dyskinesias. Each item is scored from 0 to 4, with a total score ranging from 0 (normal function) to 56 (greater motor impairment) (Goetz et al., 2021; Mello & Botelho, 2010).

The Goldsmith's Dance Sophistication Index (Gold-DSI) is used to assess the participants' level of dance experience. Twenty items assess experience in dance participation along four subscales: body awareness (six items), social dancing (six items), urge to dance (five items), and dance training (three items). The general factor dance participation comprises all 20 items from the four subscales. The mean of range values (i.e., 1 to 7) reflects the result of each subscale or general factor, with higher scores (i.e., those near to 7) indicating higher dance sophistication. A further six items measure experience in watching dance. This questionnaire provides a brief, standardized, and continuous evaluation of doing, watching, and knowing about dance (Rose, Müllensiefen, Lovatt & Orgs, 2022).