PWR! Retreat 2013

1. Parkinson Wellness Recovery PWR! Retreat 2013 Empowerment, Education, Exercise, Enrichment Becky Farley, PhD, MS, PT Founder/Executive Officer becky@pwr4life.org Sally Michaels, PT, CCM Chief Operations Officer sally@pwr4life.org

2. EXERCISE REVOLUTIONISTS Sally Michaels, PT, CCM Chief Operations Officer Becky G. Farley, PhD, MS, PT Founder/CEO

3. 501(c)(3) nonprofit organization Vision A community where individuals with Parkinson disease have access to “Exercise as Medicine.” We believe people with PD can get BETTER and STAY BETTER with exercise! Becky Farley, PhD, MS, PT Sally Michaels, PT, CCMFounder/Executive Officer Chief Operations Officerbecky@pwr4life.org sally@pwr4life.org Parkinson Wellness Recovery

4. The PWR! Model: Cutting-edge research in exercise & neuroplasticity Exercise4BrainChange® teaching principles PWR! Clinicians & Fitness Professionals Specialty Exercise Events PWR! Gym Real world implementation Via the PWR! Project Model Community Neurofitness Center of Excellence

5. Components of the PWR! Project Developing the networks and infrastructure for implementing exercise as medicine PWR! Academy PD-Exercise Experts Individuals with PD Care Partners & Community Educate, Empower, Exercise, Enrich PWR! Clinician Training PWR! Fitness Training Introductory PWR! Events PWR! Retreat May 19-25 PWR! Train May 27-31 PWR! Gym Community Model NeuroFitness Center of Exercise Excellence Tucson, AZ PWR! MOVES PWR! Circuit

6. Model Community NeuroFitness Center of Excellence for Parkinson Exercise Tucson, AZ Implementing “Exercise as Medicine” www.pwr4life.org

7. PWR! RETREAT EXERCISE TEAM Amanda Borneman – Wisconsin Val Carter – Arizona Amy Chan – Ohio John Dean – Colorado JosefaDomingos – Portugal Stephanie Dunn – Colorado Shana Gatschet – Kansas Eleanor Hagan – NewJersey Nancy Hillmer – Colorado Amy Marriott – NorthCarolina Claire McLean – California Nancy Nelson – Oregon Sarah Stahr – Ohio

8. PWR! RETREAT FACULTY Margaret Anne Coles, OTR/L, MQI Don Fiore Catherine Genzler, E-RYT Naomi Salins, MD Holly Shill, MD Tom Viviano

9. Exercise as Medicine for Parkinson disease Exercise is a tool to optimize brain health, repair, and FUNction Becky G. Farley, PhD, MS, PT becky@pwr4life.org WWW.PWR4LIFE.ORG

10. What does it mean? • What is the evidence supporting new paradigms for individuals with Parkinson disease? • What does it look like in action for individuals with Parkinson disease? • What can you do today? • Exercise4BrainChange techniques LIVE DEMO Exercise as Medicine Objectives

11. Exercise promotes • Brain health/protection • Brain repair • Brain adaptation • Behavioral recovery…….. from the INSIDE! Exercise as Medicine?What does it mean?

12. Synapses Blood Vessels How does exercise change the brain?At a structural level by making more & better… Neurotransmitters Neuron

13. Improves glucose utilization • Improves immune system • Suppresses oxidative stress • Stabilizes calcium homeostasis • Reduces inflammation • Improves mitochondrial function/ATP production • Increases growth/survival factors, neurotransmitters Molecular, Metabolic and Physiological brain changes also occur! Cotman& Berchtold 2002; KleimJA, Jones TA, & SchallertT. 2003

14. Exercise promotes redundant, healthy, efficient brains: • protect vulnerable neurons from stress & toxins • enhance recovery of damaged circuits • help brains adapt to do more with less!! Exercise targets multiple systems!!! Motor/Cognitive/Emotional/Autonomic Bottom LINE:

15. Prevention of cardiovascular complications • Arrest of osteoporosis • Improved cognitive function • Prevention of depression • Improved sleep • Decreased constipation • Decreased fatigue • Improved functional motor performance • Improved drug efficacy • Optimization of the dopaminergic system Speelman, AD et al. Nature Reviews Clinical Neurology 7, 528-534 (September 2011) Potential motor/nonmotor targets of exercise!

16. Parkinson disease is the only chronic neurodegenerative disease for which there are highly effective symptomatic therapies. Medication Deep Brain Stimulation Exercise What about exercise in a neurodegenerative disease?

18. Exercise IS Medicine for People with PD -----forced “rate” pedaling on a tandem---- Subcortical fMRI activation during UE force tracking task Acute 3-h post exercise N=9 averaged 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 2

19. WHAT you do and HOW you do it MATTERS! Essential Components for Optimal Brain Change “ready” to move & learn • 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

20. Exercise4BrainChange in ACTION Progressive Aerobic Training

22. Is vigorous exercise neuroprotective in people with PD? Ahlskog1Je. 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.

23. High Physical Effort – Forced Use • Push beyond self selected effort! • ACTIVATE for FUNCTION High Attentional Focus • Train awareness of movement/actions High Cognitive Engagement • Progressively challenge difficulty High Emotional Engagement • Novel/reward-based/meaningful practice Skill Acquisition Essentials Applied to PD

24. 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 PWR! MOVES Use it or lose it! Use it and Improve it! Target PD-Specific deficits – Integrate exercise programs or techniques that are research-based and neuroplasticity-principled

25. Exercise4BrainChange in ACTION ACTIVATION for FUNction.

26. Social Support/Stress Reduction/Optimism/Empowerment

27. 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 Unmet needsForced Use Training That Targets Multifactorial Deficits

28. How you practice matters! Forced Turning Use it and Improve it Anti-Freezing

29. Postural Control Progressive Difficulty with success and no fear.

30. Recent advances in basic neuroscience: Animal models with PD show response to exercise varies with phase of disease • Preclinical phase — Neuroprotection • Early/Moderate phase — Neurorepair • Late phase — Adaptation

31. Brain Change in Parkinson disease – animal models Preclinical Early/Moderate Advanced 100 Motor Symptoms 1st Appear Diagnosis Referral to therapy Neuroprotection DA level threshold % Dopamine neurons Neurorepair Adaptation Window of disease reversibility 0 Time (years)

32. 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

33. Direct Evidence for Neurorepair in Human PD • 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! • Fisher et al. 2004; 2008; Petzinger et al. 2007; • Vuckovic et al. 2010; Fisher et al., submitted!!!

34. Evidence that high-intensity exercise normalizes corticomotor excitability in early PD Cortex “noise” measured with Transcranial Magnetic Stimulation (TMS) High Low Intensity of Exercise 3 x per week for 8 weeks Zero Low High Silent period duration Silent period duration increases | | | | | | Pre Post Pre Post Pre Post Fisher et al., 2008 overactive “noisy” motor cortex was silenced

35. Evidence for Neurorepair in People with Early PD 2. PD Phase: Early/Moderate • Mechanisms of Repair cont… • more D2 receptors!!!! Aerobic PLUS Skill acquisition Fisher et al., Submitted!!!

36. Evidence that annual intensive bouts of exercise augment the effects of medication in human PD Differences statistically different (p < 0.0001) dashed lines = not significant 30* mg/d more 50* mg/d less * Time X Group P = 0.004 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

37. High Intensity Treadmill Training in ADV PD

38. 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 Response to exercise, dosage, specificity of training may be different across disease severity.

39. Time for new Paradigms!!! Exercise4BrainChange™ Intermittent intensive bouts for LIFE! PWR! Project Neuroplasticity-principled Early Intervention Forced use Optimal Meds Continuous Access PARKINSON EXERCISE REVOLUTION !!!

40. 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! What you can do Today!

41. PWR! MOVES™ NOT JUST EXERCISE. PD-specific skill training for FUNction. • PWR! Step • PWR! Twist • PWR! Rock • PWR! Hands • PWR! Reach • PWR! Voice • PWR! UP

42. Build Complexity Retrain Automaticity

43. 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 PWR! MOVES Skill Acquisition Essentials Applied to PWR! MOVES

44. 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 What are PWR! MOVES

45. Exercise4BrainChange! • 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, function • FUNction - Motivate/Reward-based/Empower/Educate

46. 8 sets of 1 rep each direction • Right Forward x1 • Right Sideward • Right Backward • Left Forward • Left Sideward • Left Backward 1 set of 8 reps each direction • Right Forward x8 • Right Sideward • Right Backward • Left Forward • Left Sideward • Left Backward Progressive Multidirectional Stepping – PD-specific Skill acquisition training Model; Mental Imagery; Add Auditory Cues; Add/change secondary tasks; Increase complexity of motor sequence

47. 8 sets of 1 rep each direction • Right Forward x1 • Left Forward • Right Sideward • Left Backward • Right Backward • Left Backward 8 sets of 1 rep each direction • Right Forward x1 • Left Sideward • Left Backward • Right Sideward • Left Forward • Right Backward Progressive Multidirectional Stepping – Skill acquisition training Model; Mental Imagery; Add Auditory Cues; Add/change secondary tasks; Increase complexity of motor sequence.

48. www.pwr4life.org