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PWR! Retreat2013

Becky Farley, PhD, MS, PTFounder/Executive Officerbecky@pwr4life.org

Sally Michaels, PT, CCMChief Operations Officer

sally@pwr4life.org

Parkinson

Wellness

Recovery

Empowerment, Education, Exercise, Enrichment

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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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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

PWR! AcademyPD-Exercise Experts

PWR!FitnessTraining

PWR!ClinicianTraining

PWR! MOVESPWR! Circuit

Introductory PWR! Events

PWR! RetreatMay 19-25

PWR! TrainMay 27-31

PWR! GymCommunity

Model NeuroFitnes

s Center of Exercise

Excellence Tucson, AZ

Individuals with PDCare Partners & CommunityEducate, Empower, Exercise,

Enrich

Components of the PWR! Project

Developing the networks and infrastructure for implementing exercise as medicine

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www.pwr4life.org

Model Community NeuroFitness Center of Excellence

for Parkinson ExerciseTucson, AZ

Implementing “Exercise as Medicine”

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PWR! RETREAT EXERCISE TEAM

Amanda Borneman – Wisconsin

Val Carter – Arizona

Amy Chan – Ohio

John Dean – Colorado

Josefa Domingos – Portugal

Stephanie Dunn – Colorado

Shana Gatschet – Kansas

Eleanor Hagan – New Jersey

Nancy Hillmer – Colorado

Amy Marriott – North Carolina

Claire McLean – California

Nancy Nelson – Oregon

Sarah Stahr – Ohio

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PWR! RETREAT FACULTY

Margaret Anne Coles, OTR/L, MQI

Don Fiore

Catherine Genzler, E-RYT

Naomi Salins, MD

Holly Shill, MD

Tom Viviano

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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

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Exercise as Medicine Objectives

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

paradigms for 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

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Molecular, Metabolic and Physiological brain changes also occur!

Improves glucose utilization Improves immune system 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 promotes redundant, healthy, efficient brains:protect vulnerable neurons from stress & toxinsenhance recovery of damaged circuitshelp brains adapt to do more with less!!

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

Potential motor/nonmotor targets of exercise!

Prevention of cardiovascular complicationsArrest of osteoporosisImproved cognitive functionPrevention of depressionImproved sleepDecreased constipationDecreased fatigueImproved functional motor performanceImproved drug efficacyOptimization of the dopaminergic system

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

What about exercise in a neurodegenerative disease?

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

highly effective symptomatic therapies.

MedicationDeep Brain Stimulation

Exercise

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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 IS Medicine for People with PD -----forced “rate” pedaling on a tandem----

Acute 3-h post exercise

N=9 averaged

SubcorticalfMRI

activation during

UE force tracking task

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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

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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.

Skill Acquisition Essentials Applied to PD

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

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Target PD-Specific deficits – Integrate exercise programs or techniques that are

research-based and neuroplasticity-principled

Practice high effort whole body BIG movements and action sequences

Foundation for function, all practice Spinal flexibility Agility (coordination/balance training) Augment proprioceptive feedback Kinesthetic awareness training High effort rate or strength training Dual Task Training Dance, Tai Chi, Boxing, Qigong, Yoga

Use it or lo

se it!

Use it and Im

prove it!

PWR!

MOVES

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Exercise4BrainChange in ACTIONACTIVATION for FUNction.

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Social Support/Stress Reduction/Optimism/Empowerment

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Unmet needsForced Use Training That Targets Multifactorial Deficits

Bradykinesia, rigidity, sensory, environmental, attentional, cognitive, emotional, and medication

Postural Instability Inadequate anticipatory and reactive postural responses

◦ Delayed stepping responses/abnormal righting

Freezing “glued to floor” feeling Early indicators: hesitation, anxiety, dual task interference,

incoordination, hastening, marked shuffling, fear of falling

How you practice matters!

Forced TurningUse it and Improve it

Anti-Freezing

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Postural Control Progressive Difficulty with success and no fear.

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• DA receptors are upregulated• Medications are more effective

or optimized!

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

Cortex “noise” measured with Transcranial Magnetic Stimulation (TMS)

Pre Post Pre Post Pre Post

Intensity of Exercise3 x per week for 8 weeks

Zero Low High

High

Low

Sile

nt p

erio

d d

ura

tion

| | | | | |

Silent perioddurationincreases

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

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Evidence for Neurorepair in People with Early PD

Mechanisms of Repair cont…

more D2 receptors!!!!

Fisher et al., Submitted!!!

2. PD Phase: Early/Moderate

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 annual intensive bouts of exercise augment the effects of medication in human PD

start After 4 weeks IRT

end of year

After 4 weeks IRT

start end of year

0

5

10

15

20

25

30

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 (freq/dur/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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Response to exercise, dosage, specificity of training may be different across disease

severity.

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

What you can do Today!• Find a PWR! PD-exercise expert.

• Start exercise at diagnosis and go regularly. Just like medicine, get your dosages checked.

• Get annual INTENSIVE bouts of 1:1 PD-specific rehabilitation training every year at a minimum.

• Ask for a reassessment/tune-up every 3-6 months before you start to have problems. Don’t wait!

• Participate in community exercise and enrichment programs all the time!• Advocate for change!

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PWR! MOVES™

NOT JUST EXERCISE. PD-specific skill training for FUNction.

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Bui

ld C

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Ret

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Aut

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icity

Skill Acquisition Essentials Applied to PWR! MOVES

◦High Physical Effort – Forced Use Push beyond self selected effort! Train bigger/faster whole body movements and action sequences

◦High Attentional Focus Train awareness of movement/actions

◦High Cognitive Engagement Progressively challenge difficulty

◦High Emotional Engagement Novel/reward-based/meaningful practice

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PWR!

MOVES

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What are PWR! MOVES

Level 1 – Get ready to move; slow, guided movement and imagery; sustained active stretch; increase confidence; focus attention

Level 2 – increase effort across the entire motor system/ACTIVATE; 7+ effort

Level 3 – Challenge complexity, postural control, challenge attention

Level 4 – decrease predictability, increase cognitive load, reduce reliance of vision

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PD-specific exercise that targets the motor/sensory/cognitive/emotional symptoms. ◦ Relearning! Use it or lose it. Use it and improve it.

Foundation skills in PD target the primary DA dependent symptoms of bradykinesia and rigidity.◦ Rhythmical, whole body, high effort large amplitude

movements for maximal activation and re-calibration of normal movement awareness.

Add Difficulty/Complexity to address other symptoms related to the cognitive aspects of movement (agility/anticipatory & reactive postural responses; environmental adaptation; divided attention for multi-tasking).◦ Integrate into everyday living - recreation, sports, chores,

work, functionFUNction - Motivate/Reward-based/Empower/Educate

Exercise4BrainChange!

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Progressive Multidirectional Stepping – PD-specific Skill acquisition training

8 sets of 1 rep each direction

Right Forward x1Right SidewardRight Backward

Left ForwardLeft SidewardLeft Backward

Model; Mental Imagery; Add Auditory Cues; Add/change secondary tasks; Increase complexity of motor sequence

1 set of 8 reps each direction

Right Forward x8Right SidewardRight Backward

Left ForwardLeft SidewardLeft Backward

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Progressive Multidirectional Stepping – Skill acquisition training

8 sets of 1 rep each direction

Right Forward x1Left ForwardRight SidewardLeft BackwardRight BackwardLeft Backward

Model; Mental Imagery; Add Auditory Cues; Add/change secondary tasks; Increase complexity of motor sequence.

8 sets of 1 rep each direction

Right Forward x1Left SidewardLeft BackwardRight SidewardLeft ForwardRight Backward

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www.pwr4life.org