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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, [email protected]
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 [email protected] [email protected]
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
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
PWR! Hands
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PWR! Moves EssentialsBuilding Blocks for FUNction!
DRIVERS of CHANGE!
PWR!Moves Basic4
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PWR!
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Ho
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Wal
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Building Blocks for FUNction!
Rec
rea-
tio
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Functional Movement Sequences - Movements
Participation
PWR! MOVES™
Sta
nd
&
Rea
ch
Flo
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Sta
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Wo
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En
rich
-m
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Bu
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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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0 9 18Monotherapy
Par
kin
son
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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
gn
osi
s
Refe
rral
to
thera
pyNeuroprotectio
n
Adaptation
Time (years)
Moto
r S
ymp
tom
s 1
st
Ap
pear
Neurorepair
% D
op
am
i ne n
eu
ron
s
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
0
5
10
15
20
25
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IRT (n = 25) CONTROL (n = 25)
Un
ifie
d P
D R
atin
g S
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
n A
uto
ma
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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