Renewable Fitness & ABLE Bodies

Research: A unique way to share your story

Tough Love vs Spanking

Renewable Fitness & ABLE Bodies

Sue Scott, MS

Renewable Fitness

Parkinson’s-SpecificAgility Training

Continuous feedback loops

Automaticity of balanceSelect, initiate & maintain movementSequencing and pace Sensory IntegrationMulti-tasking

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Role of Basal Ganglia

Today’s presentationis the work of many

• Fay B Horak, PT, PhD• Laurie A King, PT, PhD

• Researchers• Physical Therapists• Three PD-focused PhD• Six Certified Trainers

With permission: ABLE Bodies Balance Training,

2008; Human Kinetics

Renewable Fitness, LLC

Achieving Better Living with Exercise

Postural instability 5X age-matched

38% fall each year18% falls are fractures

Exercise helps avoid falls and fractures Medications don’t help reduce falls

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Falls are Leading Cause of Death

Immobility impairs heart, muscles, social relations, independence

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Cardiovascular Events 2nd -leading Cause of Death

Aerobic Exercise• CV System & Endurance• Strength & Balance • Flexibility • Social Ties • Attitude

Regular

3

HOW does exercise help PD?

Prevention

Compensation

Neuroprotection

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Prevention

Falls Cardiovascular events Poor coordination Back pain, stiffness Fatigue, inactivity Apathy, depression

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Compensation

Improved motor function

“Useful tricks” External cues Visual, sound, somatic

Cognitive strategies Break down task into parts Mental rehearsalThink BIG

Use alternative parts of the brain

Neuroprotection

Increase brain transmitters Reduce cell death Improve cell function Increase brain plasticity

Start exercise early in PD to PROTECT &

PRESERVE neurons and function Renewable Fitness &

ABLE Bodies

Aerobic: Treadmill running vs: Dopamine More neural transmitter Better motor function

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Exercise & Neuroprotection in PD Rats

Balance & Agility training vs: Strength or Aerobic Larger improvements in

motor function More new synapses

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Task Specific AgilityTraining for Rats

Sensori-motor Tasks Largely controlled by

basal ganglia

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Human PD StudiesRandomized Controlled Trials

• Increased kinematics of gait• Walking speed • Stride Length

• Improved • Flexibility• Strength & Mobility• Functional abilities• Quality of life

•Reduced • Medications • Falls

What type of exercise is best for PD?

Lance Armstrong (Endurance)?Muhammad Ali (Agility, quickness/power)?

Arnold Schwarzenegger (Strength)? Guru? (Tai Chi, Yoga, Pilates)

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Renewable Fitness & ABLE Bodies

EXERCISE IS MEDICINE

Active Ingredient: ModeStrength: IntensityHow often: FrequencyHow long: Duration

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Exercise can target . . .

Physical Activities/Challenges Improve specific problems

with mobility

Mobility Constraints of PD

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HELP PD Targets Constraints of Mobility

Rigidity - Stiffness; flexed posture

Brady- & hypo-kinesia - Slow, small movements

Freezing -Initiating movement

Coordination - Turning, rolling, quick switching

Sensory Integration - Coordinate sensory input

Executive function – Tasks & attention

Characteristics – increased muscle tone, stiffness◦High tonic background activity (flexors)◦Co contraction (axial muscles)

Results/Symptoms◦Joint pain, stiffness◦Flexed Posture◦Lack of trunk rotation

Vertebral flexibility, ROM Difficulty turning while walking, rolling over in bed Enbloc movement

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RIGIDITY

Tai chi Pilates/yoga

Think BIG Reciprocal, Whole-Body

Movement LungesRenewable Fitness &

ABLE Bodies

Strategies to HELP RigidityLarge, flowing moves

Spinal suppleness Lengthen flexors

Strengthen extensorsSomatic self-awareness

Practice difficult transitions

Slow, small, weak movements/responses Inefficient muscle recruitment patterns Reduced postural stability Gait

◦Weak push-off ◦Delayed, reduced lift-height of swing limb◦Small stride length, slowed turning ◦Multi-joint reaching, absent arm swings

Not improved by medications

BRADYKINESIA

Cognitive or central strategies Self initiated & paced

Get their imaginations to help Go BIG, rehearse

Require postural control & adjustments Voluntary, reactive, anticipatory, quick Practice large protective steps Lunges, boxing

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Strategies for Bradykinesia

Movement hesitation Not well understood Major contributor to falls Executive (central) disorder

• Preplanning movement • Quickly selecting motor program

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FREEZING

Difficulty/symptoms: • Shifting attention• Crowded rooms, doorways

Safe practice for difficult scenarios Environments where freezing typical Obstacle Courses

Quick turns, negotiating narrow or tight spaces – corners or near walls

Ducking , stepping over obstacles Picking up objects while walking Quick changes in directions and foot

placement

With permission: ABLE Bodies Balance Training,

2008; Human Kinetics

Strategies to HELP Freezing

CharacteristicsSelection & sequencing Inflexible program selectionDifficulties/symptomsComplex motor actionsPostural transitions New and challenging environmentsNot improved by dopamine

replacement

SEQUENTIAL COORDINATION

Complex, sequential patterns Whole Body Multi-segmental

Quick selection

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HELP for Sequential Coordination

Characteristics Abnormal kinesthesia Associated w/Bradykinesia

–o/estimation of motionPoor use of proprioceptionDecreased perception of movementOverdependence on vision

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SENSORY INTEGRATION

Reduce visual input Wear dark sun glasses No-body glasses Dim room, slightlyUse variety of surfacesReduce external feedback & cues

Strategies for Better SI

With permission: ABLE Bodies Balance Training, 2008; Human Kinetics

With permission: ABLE Bodies Balance Training, 2008; Human

Kinetics

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External Cues

Use initially, then limitAs disease progresses, use again

Characteristics & SymptomsMulti-tasking difficult High stress Increased fall risk

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COGNITIVE CONSTRAINTS

No math

Math

40

30

0

10

20

% o

f Tria

ls w

ith F

alls

CONTROLS PARKS ON PARKS OFF

No

Fal

ls

Doing Math Increases Falls During Balance Disturbances

PD Affects Automaticity of Balance Control

Used with permission; Presented at the Movement Disorders Conference in Paris June 7-11, 2009:  We-215. Effect of cognitive dual-task on balance in

Parkinson’s disease, R.M. Allen, P. Carlson-Kuhta, J.V. Jacobs, J.G. Nutt, F.B. Horak.

Addition of a second task

Dual tasks improve Attention skills Automatic Balance

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Cognitive Strategy:Dual Tasks

With permission: ABLE Bodies Balance Training,

2008; Human Kinetics

Verbal Tasks◦ Engage in conversation◦ Easy recitation

Motor Tasks◦ Balance something on a tray◦ Toss/catch a ball◦ Pick up object from the floor in passing

Cognitive Tasks◦ Word Winks/Tongue Twisters◦ Math◦ Alphabetize words, order numbers

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Order of Difficulty

Constraints

Rigidity

Bradykinesia

Freezing

Sequential Coordination

Sensory Integration

Executive/Cognitive Processing

Constraints & Strategies

StrategiesBIG, Flowing, Reciprocal, Sequential

Multiple directions, quick

Dual Task

Upright posture, supple spine; strengthen extensors, trunk rotation,

Reduce external cues, vision

Require plan, quick changes

Negotiate obstacles & difficult tasks

Develop somatic awareness

Click icon to add picture

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HELP PD

Strategies

Exercises

Constraints

Basal gangliaNeural plasticity

protection

Physical Activities Large, flexible,

reciprocal, upright Whole-body CoM movements in all

directions

Task Specific Functional, require planning, change, sensory

integration Dual tasks

Self

initiated

Self paced

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Assembly Required

Tai ChiKayakingBoxingLungesObstacle CoursesPilates & misc.

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HELP PD Rx for Agility

Research Big, flowing, sequential Coordinated, multi-

segmental (upper/lower) Weight shifts in multiple

directions Sensory integration Mindful of movement,

breath, body Upright posture

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TAI CHIPrayer WheelCat WalkingCloud Hands

Repulsing the Monkey

KAYAKING

Pictures with permission: ABLE Bodies Balance

Training, 2008; Human Kinetics

BIG, flowing, reciprocal, multi-segmental, whole body Axial mobility, rigidity

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Obstacle CourseQuick, fast,

flexible Quick weight changes Quick task changes Plan ahead, manage

obstacles, decisions Multiple directions,

environments Practice difficult

situations

As comfortable . .

.

High KneesTire Course

Lateral shuffleGrapevine

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BOXING

Quick, light, powerful, flexible, sequential, BIG, endurance, backward walking, mental agility,

Float like a butterfly . . .Sting like a bee!

Jab, Cross Hook Ducking Footwork KicksShouting!

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Lunges

With permission: ABLE Bodies Balance

Training, 2008; Human Kinetics

In-PlaceWalking

Corrective

With permission: ABLE Bodies Balance

Training, 2008; Human Kinetics

BIG, flowing, multi-

directional Reciprocal arms, legs

Vary direction, size, speed,

environment, Trunk rotation

BIG Lunges Multiple directions

Coordinate legs/arms

Pictures with permission: ABLE Bodies Balance Training; 2008;

Human Kinetics

Arm SwingsReciprocal limb motion around spine

Develop: Extensor Strength Spinal Suppleness Somatic awareness, breathing, relaxation Transitional skills (ADLs)

From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007

Pilates, misc.

◦Bridges◦Bird Dog◦Heel Slides ◦Paddle arms

ABLE Bodies Balance Training

Extensor (Axial)Strength & Length

Pilates Plus; Alan Herdman

From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007

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Spinal SupplenessKnee rolling & Cossack armsTelescoping ArmsCat & Camel & Shell poseThread the Needle

Undulate, Undulate!

Chair StandsHalf kneeling to standGet up from floorRolling on floor

Practice difficult ADLs

Tai chiKayakingObstacle CourseBoxingLungesPilates, etc.

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The BIG Six

• Develop form, skill• Increase complexity

My pizza is cold 4 31 19 7 T__ L__ S__ B__ __ F__V __G __R

Attention Training

Renewable Fitness . . .imagine the

possibilities

TTTT

Word Winks:Mental Agility

Think

Renewable Fitness . . .imagine the

possibilities

fry fry

Word Winks

Renewable Fitness . . .imagine the

possibilities

What noise annoys an oyster most? Noisy noise annoys an oyster most

(Google has bazillions of ideas)

Renewable Fitness . . .imagine the

possibilities

Tongue Twisters

Require concentration

Help diminishing verbal skills -

BIG enunciations, loud voice

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Other ways to assemble HELP PD strategies

Focus on ExtensorsStretch FlexorsUpper/Lower bodyThink BIGFunctional

Strength Training

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possibilities

Safely make it more PD-Specific? Involve more balance

◦Elliptical, treadmill vs: recumbent bike◦Changes in direction, environment, surface, tasks

Go BIG! – try trekking poles Mix it up, variety

Endurance Training

Renewable Fitness . . .imagine the

possibilities

Pilates Tai Chi Yoga Aerobics Dance Martial Arts Others (Zumba Gold is

Big, quick, imaginative & fun)

Community Programs

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possibilities

As PD Progresses . . .make changes

All stages: Flexibility, postural alignment, BIG movements, deep breathing, kinesthesia,

mind body connectionsEarly: Sports—physical & mental agility,

stamina, strength (neuroprotective)

Later: Walking, transitions, useful tricks, external cues, fall prevention

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Fall Risks ◦ Backwards◦ Obstacles, hazards◦ Low vision◦ Dual tasks

Light Headedness: Quick postural changes Musculoskeletal Injuries: Rigidity, difficulty

initiating movementRenewable Fitness & ABLE

Bodies

Safety Considerations for Exercise with PD

BIG, Flexible, Reciprocal, Sequential Self initiated, Self paced Upright & Supple Posture Mind-Body Connections Sensory Integration Arm and leg coordination Quickness Endurance

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Strategies for basal ganglia and neuroplasticity

Preserve/protect/enhance function & behavior Adapt, behave, function Increase neuro –transmitters Neuro-plasticity Increase number of synapses Cell proliferation?

Prevent falls Reduce cardiovascular events Improve, motor function Maintain quality of life, social ties, independence,

connections to community, Renewable Fitness & ABLE Bodies

Sensori-motor Activities:Benefits & Mechanisms

. . . Imagine the Possibilities

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What’s the Best Exercise?

The one they’ll do!

Thank You!

Sue Scottemail

RenewableFitness@comcast.net

Ph: 503-720-9161

I think my work here is done

Physical Therapy April 2009; v89:4

Active Aging Today January 2010

UprightControl

Parkinson'sDisease

Upright posture requires good kinesthesiaStooped posture reduces stability

Hip Flexor(Abs)

Knee Flexor(Hamstring) Ankle

Flexor(Tib)

Knee Extensor(Quad)

Hip Extensors(back/hip)

AnkleExtensors(Calf)

StrengthenExtensors

LengthenFlexors

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Strength & Endurance w/ Dual Task

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Exercise preserves neural function

No Exercise

Improved function!

Neuroprotective . . . Can exercise slow

progression?Function/Neurons

Years after Diagnosis

More

Less

Gentle, lithe rotation along long axis of spine

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Spinal Rotation

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Exercise is especially importantbecause it works!

Prevents anticipated problems

Reduces depression and apathy

May slow disease progression . . . ?

Kinesthesia Breath tied to movementSelf awarenessDual TasksUseful tricks

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Mind/Body Connections

Unknowns about Exercise for PD

What is the best kind? How intense and often? How long does it last when you stop? Does it reduce the rate of decline? Who would benefit the most?

Both young and older benefit Start: The earlier the better

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Renewable Fitness & ABLE Bodies