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Exercise as Medicine for Parkinson disease

Exercise is a tool to optimize brain health, repair, and FUNction

Becky G. Farley, PhD, MS, PTbecky@pwr4life.org

WWW.PWR4LIFE.ORG

It’s a Parkinson Exercise Revolution

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www.pwr4life.org

Community NeuroFitness Center of Excellence

for Parkinson ExerciseTucson, AZ

Implementing “Exercise as Medicine”

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Becky Farley, PhD, MS, PT Sally Michaels, PT, CCMFounder/Executive Officer Chief Operations Officerbecky@pwr4life.org sally@pwr4life.org

Parkinson Wellness Recovery

We believe people with PD can get BETTER and STAY BETTER with exercise!

501(c)(3) nonprofit organization

Vision 

A community where individuals with Parkinson disease have access to “Exercise as Medicine.”

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Real worldimplementation

Via thePWR! Project

Cutting-edgeresearch in exercise &

neuroplasticityExercise4BrainChange®

teaching principles

PWR! Gym

PWR! Clinicians & Fitness Professionals

The PWR! Model:

Model Community Neurofitness Center of Excellence

Specialty Exercise Events

Translating Research into Exercise4BrainChange®

Approaches for Individuals with Parkinson Disease:Real World Rehabilitation and Community Implications

September 21-22, 2013Tucker, Georgia

14 contact hours

PWR! Faculty Becky G. Farley, PT, MS, PhD

becky@pwr4life.org

PWR! CLINICIAN TRAINING

The Exercise4BrainChange® modelA toolbox to optimize learning and neuroplasticity.

PD-Specific Training – Targeted to address symptoms

Bradykinesia – slow/small everyday movement Practice high effort for whole body movements and

action sequences Rigidity – reduced spinal flexibility and posture

High effort for sustained active stretch and awareness Incoordination/Balance - Agility

Link movement/action sequences Cognition

Building complexity and attentional focus (environmental/dual task)

Emotion Reward-based feedback/FUNction

PWR! MOVES

Singular focus on FUNction as

exercise

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PWR! Moves EssentialsBuilding Blocks for FUNction!

DRIVERS of CHANGE!

PWR!Moves Basic4

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Functional Movement Sequences - Movements

Participation

PWR! MOVES™

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Exercise as Medicine Objectives

1. What does it mean?2. What is the evidence supporting it benefits

individuals with Parkinson disease?3. What does it look like in action for

individuals with Parkinson disease?4. What can you do today?5. Exercise4BrainChange techniques LIVE

DEMO

Exercise as Medicine?What does it mean?

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Exercise promotes• Brain health/protection• Brain repair• Brain adaptation• Behavioral recovery……..

from

the

INSID

E!

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How does exercise change the brain?

At a structural level by making more & better…

Neuron

Synapses

Neurotransmitters

Blood Vessels

Exercise effect on neuron growth and survival.

Venture out and make new connections! Try something challenging!

Your dendrites will love you for it!

Isolation, depression, stress and inactivity are pro-degenerative!

dendrites

Couch potato FIT & FUN

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Molecular, Metabolic and Physiological changes also occur across systems!

Improves glucose utilization Suppresses oxidative stress Stabilizes calcium homeostasis Reduces inflammation Improves mitochondrial function/ATP

production Increases growth/survival factors,

neurotransmitters

Cotman & Berchtold 2002; Kleim JA, Jones TA, & Schallert T. 2003

Bottom LINE:Exercise optimizes

brain health and function.

protect vulnerable neurons from stress & toxinsenhance recovery of damaged circuitshelp brains adapt to do more with less!!

What about exercise in PD?

Parkinson disease is the only chronic neurodegenerative disease for which there are

highly effective symptomatic therapies.

Medication Deep Brain Stimulation

Exercise

SpecificVs.

non specific

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It Is Not About the Bike, It Is About the Pedaling: Forced Exercise and Parkinson's Disease. Alberts, Jay; Linder, Susan; Penko, Amanda; Lowe, Mark; Phillips, Micheal. Exer

Sport Sci Rev 2011

Exercise helps your brain do more with less -----forced “rate” pedaling on a tandem----

Acute 3-h post exercise

N=9 averaged

SubcorticalfMRI

activation during

UE force tracking task

Exercise IS Medicine in PD!

Prevention of cardiovascular complicationsArrest of osteoporosisImproved cognitive functionPrevention of depressionImproved sleepDecreased constipationDecreased fatigueImproved functional motor performanceImproves immune system

Speelman, AD et al. Nature Reviews Clinical Neurology 7, 528-534 (September 2011)

Exercise targets multiple systems!!! Motor/Cognitive/Emotional/Autonomic

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Progressive Aerobic Training - Neural Priming Promotes

Brain/Muscle interactions

Turns on attentional/working memory systems

Increases motor output

Skill Acquisition Essentials - Learning

Promotes structural restoration, reorganization

Underlies long term behavioral changes

Automaticity

WHAT you do and HOW you do it MATTERS!Essential Components for Optimal Brain Change

“ready” to move & learn

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Exercise4BrainChange in ACTIONProgressive Aerobic Training

Pole Walking Benefits

• Whole body activation• Forced-use arm swing• Cues posture• Retrains stride length, gait

symmetry and walking speed• Provides for stretching• Reduces fear and pain of PD• Increases endurance

Aerobic plus PD-specific skill learning

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Aerobic plus PD-specific skill learning

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Is vigorous exercise neuroprotective in people with PD?

Ahlskog1 Je. Neurology 2011;77:288-294

CONCLUSIONS - Progressive Aerobic Exercise Ongoing vigorous exercise and physical fitness should be highly encouraged. PD physical therapy programs should include

structured, graduated fitness instruction and guidance for deconditioned patients with PD. Levodopa and other forms of dopamine therapy

should be used to achieve maximum capability and motivation for patients to maintain fitness.

Are YOU optimally medicated for optimal participation and QoL?

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Grosset D et al. J Neurol Neurosurg Psychiatry. 2007;78:465-469.Adapted by permission from BMJ Publishing Group Limited. J Neurol Neurosurg

Psychiatry. Grosset D, Taurah L, Burn DJ, et al. Vol. 78, pp. 465-469, Copyright 2007.

(n=53)(n=61)

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Skill Acquisition Essentials Applied to PD

High Physical Effort – Forced Use◦ Push beyond self selected effort!High Specificity – PD-Specific◦ ACTIVATE for FUNCTION – PWR! MOVESHigh Attentional Focus ◦ Train awareness of movement/actionsHigh Cognitive Engagement◦ Progressively challenge difficultyHigh Emotional Engagement◦ Novel/reward-based/meaningful practice

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Exercise4BrainChange in ACTIONACTIVATION for FUNction.

How you practice matters!

Forced TurningUse it and Improve it

Anti-Freezing

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Social Support/Stress Reduction/Optimism/Empowerment

Is it disease modifying?

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Does it spare or rescue or rejuvenate vulnerable DA neurons?

NEUROPROTECTIVE

Does it normalize (reorganize) abnormal neural

circuitry?NEUROREPAIR

What about exercise in a neurodegenerative disease?

Recent advances in basic neuroscience:

Animal models with PD show response to exercise varies with phase of disease

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1. Preclinical phase — Neuroprotection

2. Early/Moderate phase — Neurorepair

3. Late phase — Adaptation

Brain Change in Parkinson disease – animal models

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0

Dia

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osi

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Refe

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to

thera

pyNeuroprotectio

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Adaptation

Time (years)

Moto

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Ap

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Neurorepair

% D

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Preclinical Early/Moderate Advanced

DA level threshold

Window of disease reversibility

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Indirect Evidence for Neuroprotection in People With Parkinson’s Disease.

Epidemiological, Anecdotal & Experimental

Direct evidence in healthy seniors for improved brain health with aerobic exercise

Regular, moderate to vigorous exercise in midlife–lowers risk for developing PD.

Exercise may increase survival rate. Higher cognitive scores associated with greater

physical fitness Regular exercise reduces the severity of

motor/nonmotor symptoms and improves function with 3-6 month retention.

Chen et al. 2005; Hale et al. 2008; Gray et al. 2009; Bilowit 1956; Sasco et al.1992; Palmer et al. 1986; Archer et al. 2011;

Reuter et al. 2011

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The Dopamine system is more efficient with exercise in human PD too!!!

• Noisy circuits are silenced• MORE DA receptors• Medications are more effective.

Direct Evidence forNeurorepair in Human PD

Fisher et al. 2004; 2008; Petzinger et al. 2007; Vuckovic et al. 2010; Fisher et al., submitted!!!

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Evidence that high-intensity exercise normalizes corticomotor excitability in early PD

Motor cortex “noise” was

silenced.

Pre Post Pre Post Pre Post

Intensity of Exercise Zero Low High

High

Low

Sile

nt p

erio

d d

ura

tion

| | | | | |

Silent perioddurationincreases

Fisher et al., 2008overactive “noisy” motor cortex was silenced

Transcranial Magnetic

Stimulation(TMS)

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Evidence for Neurorepair in People with Early PD

Mechanisms of Repair cont…

more D2 receptors!!!!

Fisher et al., Neuroreport 2013

Aerobic PLUS Skill acquisition

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Effectiveness of Intensive Inpatient Rehabilitation Treatment on Disease Progression in Parkinsonian Patients: A Randomized Controlled Trial With 1-Year Follow-up.

Giuseppe Frazzitta, MD et al. Neurorehabi Neural Repair, Aug 15, 2011

Evidence that intensive bouts of exercise reduce the need for medication over 1 year.

start After 4 weeks IRT

end of year

After 4 weeks IRT

start end of year

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5

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IRT (n = 25) CONTROL (n = 25)

Un

ifie

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D R

atin

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cale

III

Differences statistically different (p < 0.0001)dashed lines = not significant

50*mg/d less

30*mg/d more

* Time X Group P = 0.004

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High IntensityTreadmill Training in ADV PD

Timing matters: early is better than later Intensity matters – dosage

(frequency/duration/work) Forced Use – Beyond self selected effort Intermittent bouts Vigorous aerobic training

Specificity matters – Make it PD-specific “use it or lose it” or “use it and improve it”

Continuous (threshold) of exercise to sustain Inactivity/Stress is pro-degenerative Exercise may optimize response to meds

Implications to Human

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1 2 3 4 5

Loss ofpostural stability

Advanced Stage

DXExercise

Current recommended approaches target improvement and maintenance of mobility/function for people with moderate PD when balance becomes

impaired.

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Real World Practice Today

Early Stage

Moderate Stage

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Slow motor deteriorationOptimize brain health/brain function

1 2 3 4

Loss of postural stability

Pre-motor symptomatic

period

ExerciseDX

1 2 3 4 5

Loss of postural stability

End Stage

DXExercise

Improve function

TIME FOR NEW PARADIGMSExercise is a Medicine – take it

everyday!

Disease severity – H&Y

Disease severity – H&Y

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Mission impossible…

PWR!

Time for new Paradigms!!!

Exercise4BrainChange™

PWR! Project

Early

Intervention

Continuous

Access

PARKINSON EXERCISE REVOLUTION !!!

Forced use

Intermitten

t intensive

bouts for

LIFE!

Optimal M

eds

Neuroplastic

ity-principled

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Sally Michaels, PT, CCMChief Operations Officer

EXERCISE REVOLUTIONISTS

Becky G. Farle

y, PhD, M

S, PT

Founder/CEO

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www.pwr4life.org

PWR! Hands

PW

R! vo

ice

PW

R!

UP

PW

R!

Ro

ck

PW

R!

Twis

t

PW

R!

Ste

p

PWR! Voice

PWR! Moves EssentialsBuilding Blocks for FUNction!

DRIVERS of CHANGE!

PWR!Moves Basic4

PW

R!

Ro

ck

PW

R!

Twis

t

PW

R!

UP

PWR!

VoicePW

R! vOICE

PW

R!

Han

ds

PW

R!

Ste

pW

alk

to

Sit

Co

me

to

Sit

Sit

to

S

tan

d

Ro

llin

g

Rea

ch

&G

rasp

Ho

bb

ies

Wal

k &

Tu

rn

AD

L

Sp

ort

s

Building Blocks for FUNction!

Rec

rea-

tio

n

Functional Movement Sequences - Movements

Participation

PWR! MOVES™

Sta

nd

&

Rea

ch

Flo

or

to

Sta

nd

Wo

rk

En

rich

-m

ent

Bu

ild C

ompl

exi

ty

Re

trai

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uto

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ticity

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Postural Control Progressive Difficulty with success and no fear.

Assisted Whole Body Activation

BIG movementsNO fear/anxiety

Bungee jumping—

● To empower with potential and success

● To retrain activation for voluntary whole body movements.

● To make exercising and movement FUN!!

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ACTIVATION FOR BIGGER FASTER MOVEMENTS

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ROCK/STEP with ACTIVATION

PROGRESSIVE ADVANCED

PWR! MOVES

ACTIVATION for FUNction

Multidirectional stepping,antigravity postural control,

sensory awareness and posture

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FUNctional ACTIVATIONSport or Fitness Based

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Amplitude and timing of movement = agility and balance

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Turning and obstacle

avoidance

Feedbackcueing

EMPOWER/CONNECT/SUPPORTBuild FUNction through social interactions,

complexity/novelty

PWR! hands

PWR! reach

Skills for Real LIFE FUNction!

Arm Swing Stride Amplitude

Posture Wide BOS

From this To this

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Laurie and Bill Van Heukelem

Aug 2011

Foot Clearance

IT IS about understanding limitations while pursuing possibilities through empowerment

Buddies withadvanced PDhiking the Black Hillsof South Dakota

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