All right, let's go ahead and get started. Welcome to AAP Virtual Didactics. My name is Sterling Herring. I'm a PGY3 at Vanderbilt. We're happy to have everybody today and we're excited about our guests. Just as a general announcement, we have two guests today. We have one now and then one starting in an hour. So right now, we're excited to have Dr. Hirsch, who's the Director of Movement Disorders at Carolinas Rehab. And then an hour from now, we have Dr. Hurwitz, who's the Chair of PM&R at the University of Michigan. So please stick around for the next lecture as well. As always, we want to first recognize and appreciate the people who have been most affected by this pandemic. We understand that for some of us, it's more personal than others and it has affected us personally and professionally. So we want to recognize and appreciate those of you who are on the front lines of this. So the purposes of these sessions is to augment didactic curricula that are already going on in your institutions, to offload overstretched faculty due to some of the logistical difficulties that this pandemic has brought about, to provide additional learning opportunities for off-schedule residents again due to some of the scheduling shifts that have occurred due to the COVID-19, and then to develop further digital learning resources and to support physiatrists in general during the COVID-19 pandemic. So again, housekeeping, we're going to keep everybody video and audio muted. So if we mute you, don't be offended. It's just trying to keep everything clean and bandwidth up. We're trying to funnel questions so that questions can be answered, but in an appropriate manner. So please, if you have a question, please click on your participants list. You'll see my name up there at the top against Sterling Herring, somewhere near the top anyway. Shoot me a message and I will ask it at appropriate times. Again, if you have any general questions, concerns, suggestions, anything like that, please shoot us an email or find us on Twitter. So today we're excited to have Dr. Mark Hirsch. He's a senior scientist and PM&R at the Carolinas Medical Center, as well as the director of the Parkinson's Disease and Movements Disorders Lab there. Dr. Hirsch, welcome. Sorry, I was I was muted. I think now I'm unmuted Yes, thank you for having me. I'm going to Share my screen. Let's see whether I can handle this Okay. So, good afternoon, everyone. It's nice to be here. I'm delighted to give this talk. The title of the today's talk is Rehabilitation of Parkinson's Disease During the COVID-19 Pandemic, PM&R Opportunities and Challenges. I'm hoping that there's something here of interest for everyone. I geared the talk primarily as a talk for resident physicians, but I'm hoping this will also be interesting to attendings, physical therapists, and other healthcare professionals who are in attendance. I'd like to start, because I've got your full attention, with a few questions that I think might be relevant. Question number one, the earliest non-motor features of idiopathic Parkinson's disease include which of the following? A, loss of arm swing, B, masked face, C, hyposmia, or D, mild cognitive impairment? The answer, of course, is C, hyposmia. Loss of smell is one of the earliest features of Parkinson's disease, and we will be talking more about the non-motor features of Parkinson's disease and how they relate to physical activity and exercise. Question number two, a patient who is ambulatory without assistive devices with tremor on both the right arm and left leg is most likely Hone and Yar Stage A, Stage 1, B, Stage 2, C, Stage 3, D, Stage 4, E, Stage 5? The answer is B, Stage 2. In Stage 1, Hone and Yar, Parkinson's disease, symptoms are on one side of the body. Stage 2, symptoms cross the midline, as in the question above. In Stage 3, patients generally have balance and equilibrium problems. Stage 4, patients are generally wheelchair mobile, and in Stage 5, they are generally bedridden. Now, most patients should never reach Stage 5 with optimal physical therapy and medication management. In fact, it's very unlikely for you to see patients who reach Stage 5. So, I'm going to give you my learning objectives for today. I'd like you to develop an appreciation for the value of promoting exercise and a physically active lifestyle in patients living with idiopathic Parkinson's disease. And I'd also like to focus on some of the challenges in providing exercise during our COVID worldwide pandemic and how our patients can benefit from your physiatric expertise. And throughout the presentation, you'll see a little red basket appearing on some of these slides. When you see that basket, I'd like you to take that information that's on the slide, put it in your shopping basket, and take it with you throughout the rest of your day. So, those are particularly important slides then. I'm also going to give my take-home points early. Number one is to make sure that patients avoid a sedentary lifestyle. These are inpatients and outpatients that might see you in clinic or be admitted in hospital. Promote physical activity. And what I mean by that is generally a program of muscle strengthening, aerobic exercise, and weight-bearing activities. Take-home point number two is that high-intensity exercise induces brain-derived neurotrophic factor in people with Parkinson's disease. And we think that BDNF is neuroprotective. Take-home point number three is that, as with most areas in PMNR, more research is needed, more randomized controlled trials are needed before firm conclusions can be made on the relationship between exercise and BDNF blood levels in Parkinson's disease. This is a picture of Carolina's Medical Center, and our rehab hospital is over to the lower left corner. And we're in Charlotte, North Carolina. Charlotte is, the downtown area is depicted on the top of the slide, and you can see the many skyscrapers that we have. It's a beautiful city, and I'd encourage you to come visit us. It's a wonderful community, very diverse, and a lovely place to live that I've called home for the past 15 years since coming here from my hometown of Düsseldorf, Germany. Charlotte is known as to be the second largest banking city in the United States. All of those buildings that you see, those skyscrapers are banks. I believe the one in the middle there, that's Bank of America. And that shows you that there's a great deal of wealth in the city, a great deal of hustle and bustle. So, Charlotte is really a banking, known as a banking metropolis. Charlotte is also known for RENEW. RENEW, and this relates to our talk today on Parkinson's disease. The acronym RENEW stands for Research and Education in Neuro Wellness. RENEW is a regional professional network in Mecklenburg County. Which you can see in the center of the square. RENEW provides physical activity and physical therapy for people at all stages of Parkinson's disease in one of 11 outpatient physical therapy clinics run by Carolinas Rehabilitation and six YMCA's. We have provided training to 93 healthcare professionals in evidence-based methods in Parkinson's disease since 2011. That includes five nurses, 35 PTs, 51 personal trainers, and three physicians. RENEW is novel for the United States. The concept was developed in socialized medicine in Holland and tested in, for efficacy in randomized controlled trials. Perhaps you've heard of the ParkinsonNet. We were the first to bring this concept from socialized medicine into the American healthcare system. Why am I telling you this? Why is it, is any of this really important? Why should we be thinking about these things? The answer is team science. More and more, multidisciplinary care involves teams of experts working collaboratively, patients, providers, and scientists. And recently, patients have been included as team members of the multidisciplinary team. And I'm going to talk just a little bit about this because I think it's important and relevant to our COVID discussion. Traditionally, patients are, in research at least, are seen as objects or subjects, and rarely as collaborators within that interaction, as collaborators or colleagues. Our concept is that patients and rehab physicians work hand-in-hand in providing a healthy lifestyle. In fact, we did a study a few years ago in which we asked patients with Parkinson's disease and their care partners how they would like to participate in healthcare reform in the United States. The overwhelming majority of patients said yes, they would like to participate as health coaches. Since that time, we have trained several patients as health coaches and are exploring this concept effect on health outcomes. For further reading on this, I'd like to refer you to the article in Parkinsonism and Related Disorders published in 2014, supplement one, if you are interested. Today's topic is Parkinson's disease. PD is one of the fastest-growing neurological, neurodegenerative conditions in the world. About 6.2 million people worldwide live with idiopathic Parkinson's disease, approximately 1 million Americans. Worldwide, the number of people with PD has doubled since 1990, and we expect nearly 13 million by 2040. The majority of those 13 million patients with Parkinson's disease are in what country? China. China has the largest number of people with Parkinson's disease. Those rates could accelerate even more quickly due to three reasons. Number one, population aging. The United States will have the oldest country in the world in 2023 due to the increase in baby boomers, that is individuals born between 1946 and 1964 who are coming of age in 2006, and that will last until roughly 2050 when we will again have more younger cohorts. The second reason we have more Parkinson's disease is because smoking rates have decreased, and there is evidence to suggest that smoking is neuroprotective. Third, earlier diagnosis. Patients are coming to us earlier, they're being diagnosed more often by primary care physicians and then referred to neurology and PMNR for further treatment. However, most patients are inactive at diagnosis, and this is, of course, also an issue with the healthy older adult population. In Parkinson's disease, the motor features and the non-motor features combine to induce a sedentary lifestyle and physical activity. The motor features, gait, postural instability, and fault tolerance. The motor features, gait, postural instability, and faults, and certainly the non-motor features such as depression, apathy, cognitive decline, constipation, problems with sleep, and fatigue combine to promote a sedentary lifestyle and physical inactivity. The result of this can be cardiovascular disease and increases in osteoporosis, and that can, of course, lead to increases in mortality. What you can also see from this slide is there's a dotted line from sedentary lifestyle and physical inactivity to Parkinson's disease. There is epidemiologic evidence to suggest that low levels of physical activity in young adulthood lead to a higher incidence of Parkinson's disease in later adulthood. So that is another reason why we ought to promote a physically active lifestyle in all of our patients who might be susceptible to Parkinson's disease who do not yet have the diagnosis. In terms of our talk today, there are two things that concern me regarding the C19 epidemic. One is anxiety. Many patients with Parkinson's disease, I would imagine, are experiencing a great deal of anxiety because they're unable to go to physical therapy, physical therapy clinics, or exercise as much as they would like to in gyms and public facilities. We know that anxiety is pro-degenerative in Parkinson's disease. So that is definitely something that greatly concerns me and that needs to be addressed. And I think that physiatrists are the perfect professionals to be dealing with cognitive, mental anxiety, mental health issues. The other is, of course, lack of physical activity. As patients spend more and more time indoors and are socially isolated, they become less physically active. And that is a worldwide issue, particularly in other countries where there's less space to exercise in your own home and in your backyard. Many other countries have much more, have much less space in individual dwellings. So this is a major issue. And of course, also in the United States. So just as a quick summary, and I'm not going to go through all of this, but the Parkinson's disease, their current thinking is that there's a 20-year prodromal period before the onset of motor features. The motor features, gait balance, slowness of movement and tremor and rigidity are actually late signs of the condition. And current hypothesis put forward by Brock and Associates is that the disease likely starts in the gut and makes its way to the brain. Although it's very difficult to know whether it starts in the brain and then goes to the gut or whether it starts in the gut and then goes to the brain. But what I'd like you to take away from this slide is that the earliest signs are hyposomia, constipation and bladder dysfunction, 20 years out, 10 years out, sleep disorders, obesity and depression. And then at diagnosis, usually tremor, rigidity and akinesia, poor balance, falls and cognitive decline follow. So it's difficult to put these pieces together if a person presents with constipation only, you probably wouldn't be thinking that they have Parkinson's disease. But from a patient perspective and taking that into consideration, many patients tell us that the earliest sign, symptom that they, excuse me, the earliest they notice is a loss of smell. The bottom line is that many patients are not getting the care that they need. In wealthy countries, 40% of people age 65 plus diagnosed with PD do not see a neurologist. And I would say in this country, that number is much lower. Among people with neurological disorders, we also need to acknowledge that African Americans and Hispanics are significantly less likely to see a neurologist in an office. And African Americans are four times less likely to receive any Parkinson's treatment and less likely to undergo deep brain stimulation surgery for Parkinson's disease. And of particular relevance to PMNR, only 7 to 56% of patients are ever referred into physical therapy, although there's a wide variety, a wide variation internationally. But that leaves a large, up to 93% of patients who are never referred into physical therapy. And that's astonishing to me. So what can help? How can we address the situation? And currently, our situation is that our patients are not coming to see us in clinic face-to-face, so how can we reach out to them? There are no definite answers, but one suggestion that has been put forward, again, by a Dutch team is to remove barriers to care. They have done that by developing the largest trial, a randomized controlled trial of high-intensity remotely supervised aerobic exercise using a home trainer bicycle that has been conducted to date. This paper is published in Lancet Neurology, and I would encourage you to read it. It is extremely novel because the Parkinson's patients received the training at home, and they were remotely supervised by research assistants to maintain a high intensity of training. The gold standard for evaluating whether or not their motor symptoms improved is the movement disorders UPDRS scale, the Unified Parkinson's Disease Rating Scale. You can see in square A, patients were tested before and after the training in the off state. That means they were not taking any dopamine and were tested in the off state, which gives a truer evaluation of the effect of the training on their Parkinson's disease. The training consisted of an aerobic intervention group, 65 patients, and an active control group who performed stretching at home, 65 patients. Both groups improved in their UPDRS score, however, there was less decline among the aerobic intervention group. The decline in UPDRS scores was 1.3 as opposed in the active control group that did the stretching. The decline was 5.6 points on the UPDRS, and a clinically important difference is around about three points. This was statistically significant, the difference in, so both groups did decline, but the group that received the high intensity remotely supervised exercise training on a home trainer declined less, significantly less. On the right, the study's proud sponsor, Dr. Bas Blum of Nijmegen University, he's an avid exerciser and cyclist himself. In my opinion, we ought to tell all of our patients with Parkinson's disease to cycle. And I can make that blanket statement, even though I'm not showing you all the evidence on the benefits of cycling, but there are many, many to be listed. Let's quickly go through some of the benefits of exercise in Parkinson's disease that you may not be thinking about. One is reducing osteoporosis. This is not typically a non-motor feature that's discussed, 63% of females and 20% of males with Parkinson's disease have osteoporosis, experience osteoporosis compared to 29% of females and 12% of males who are healthy, who do not have Parkinson's disease. So it's a much larger percentage of patients with PD who experience osteoporosis. The reasons for osteoporosis are many, physical inactivity, vitamin deficiency, D deficiency, muscle weakness, low body weight, hyperhomocystinemia are all reasons for osteoporosis that have been identified in Parkinson's disease. Of interest for vitamin D deficiency, we know that spending time indoors and lack of sunlight make it more difficult to receive vitamin D. Vitamin D is an important vitamin for basal ganglia function. Physical activity programs in general increase bone health and so might slow or arrest osteoporosis in Parkinson's disease. In specific, high impact activities such as jogging, jumping rope, and other anaerobic activities such as weight training have shown to improve osteoporosis in older adults. That has not been shown yet in Parkinson's disease. But if people with Parkinson's disease react similarly to high intensity, high impact activities as do other older adults, we can expect to see similar results. Of course, the most dangerous aspect of osteoporosis are increased falls and fall-related fractures. And with Parkinson's being also called a falling sickness, that is something that we need to be very mindful of. Second, preventing cardiovascular events. People with PD do have increased cerebrovascular complications. We know that exercise training positively influences cardiovascular risk factors. And the American College of Sports Medicine recommends that adults 18 to 65 ought to regularly participate in physical activity. Adherence to physical activity programs, especially aerobic exercise programs, results in a reduction of 20 to 30% in risk of cardiovascular disease. Of note is that men with Parkinson's disease might reach physiologic reserve earlier than healthy controls, perhaps due to rigidity. And so it might make it a little bit more difficult for them to achieve a higher intensity. Third, preventing depression. 15.6% of patients at HON-ER stage 1 and 2, that's at diagnosis and up to stage 2, present with clinical depression. That number rises to 47.9% in HON-ER stage 4 to 5. There has not been a whole lot of research on the effect of aerobic training on mood, particularly depression, in Parkinson's disease. Large clinical trials are needed in this area. However, it makes sense that aerobic activity might be helpful in preventing depression in people with Parkinson's disease. Third is improved sleep. Sleep dysfunction occurs in two-thirds of patients with Parkinson's disease. Most common are frequent night awakenings. All RCTs have been conducted on aerobic exercise and muscle strengthening and have shown small improvements in patients at all stages of Parkinson's disease who suffer from sleep dysfunction. Next is decreased constipation. 50 to 80% of patients with PD present with constipation at diagnosis. There have been no studies to look at the effect of physical medicine and rehabilitation interventions on constipation. But we might reasonably expect to see improvements as we have seen improvements in constipation with exercise in healthy older adults. The mechanisms for improvements with exercise after constipation are still being worked out, but might be increased colonic motility, decreased blood flow to the gut, or biomechanical stimulation such as running in place through a compression of the colon by the abdominal muscles or by increased fiber intake. Next is decreased fatigue. 30 to 50% of patients with PD experience decreased fatigue compared to about 18% of age and gender matched healthy controls. There have been very few studies on exercise and fatigue levels in Parkinson's disease. In healthy controls, cognitive behavioral training and aerobic exercise has shown to decrease fatigue. There have been no RCTs in Parkinson's disease to show exercise reduces or avoids PD. And paradoxically, exercise may increase fatigue, so future trials are needed to tailor the levels of exercise to each patient's ability. Other areas that I won't go into where exercise might benefit are improved motor performance, improved levodopa drug efficiency, and optimized dopaminergic signaling. Now we've talked a little bit about the benefits of exercise. We also need to address the risks of exercise in Parkinson's disease, the number one concern being falls. In my opinion, it is dangerous to exercise. However, it is more dangerous to not exercise. We need to weigh the risks and the benefits. I think it's important to think about this. There have been two studies that have looked at falls and exercise frequency in Parkinson's disease. One is the well-known ParkFit study conducted by Van Nymwegen in 2010. They compared two treatments. One treatment consisted of encouraging patients with PD to become more physically active and to exercise in the community as well as in health clubs. The other intervention consisted, was termed ParkSAFE, and it encouraged patients to exercise safely or to move safely, but it did not encourage them to become more physically active. The results of the study were that both groups continued to fall throughout the randomized controlled trial. There were no differences in the number of falls between the patients who were encouraged to be physically active and the patients who were encouraged to move safely. The take-home point there is that, oh, and I need to add that many, most of the falls or very few of the falls resulted in injuries such as fractures. The take-home point is that falls will occur throughout the disease, and we need to take precautions to minimize those falls, but a fall, again, in my opinion, is not a reason not to exercise. The other study that I wanted to mention is the RESQ trial, RESQ, the acronym stands for research and cueing, cues such as visual cues, walking while walking across lines that are presented perpendicular to the movement trajectory, and proprioceptive cues such as vibrating cues to take a certain number of steps were used in this study and improved mobility in patients and did not increase the number of falls, and these studies were conducted in the patient's home. So I hope those two studies give you a little bit of thought about this topic. The other thing to think about, of course, are cardiovascular complications such as sudden cardiac arrest or MIs. The risk is low, according to ACSM, in the healthy sedentary population, healthy sedentary adult population, but it could increase with vigorous activity. So that is something to consider, and I would encourage you to screen your patients for cardiovascular risk factors before clearing them for an exercise program. We also know that regular moderate intensity exercise is a protective factor for cardiovascular complications. So again, we need to balance the risks and the benefits. I'd like to, again, briefly go back to COVID. This is a COVID-like situation that I'm describing, a patient in 2007 when we had the economic downturn. This patient lost his job due to the economic downturn. He had Parkinson's disease, and he decided to wean himself off of his medication because he could no longer afford it. He was also an avid exerciser, ultramarathon runner, working out seven days per week, and he noticed that on the days that he didn't exercise, his Parkinson's disease symptoms got worse. This is only a case study, but it does give some clues that, again, if we think back to the van der Kolk study in Lancet Neurology with cycling where there was an improvement or less severe drop in motor symptoms with the aerobic training, we can see a very somewhat similar pattern in this case study. Again, I think it is important to encourage our patients to become more physically active. Last, I'd like to talk a little bit very quickly about brain-derived neurotrophic factor. Why is this important? BDNF is a circulating protein endogenously produced in the brain and elsewhere in the body. And it is thought to promote neurogenesis, synaptogenesis, and development of the central nervous system in young adulthood. It is also now one of the main players of neuroprotection in Parkinson's disease. Serum BDNF levels are low in early Parkinson's disease and BDNF levels have now also been implicated in maintaining cognitive functions in PD. Stanley Cohen, an American biochemist and Rita Levi-Montalcini were awarded the Nobel Prize in Physiology or Medicine in 1986 for isolating nerve growth factor and the discovery of epidermal growth factor. They worked in the area of cancer, of course, but the discovery of nerve growth factor led to work in brain-derived neurotrophic factor. And I wanted to acknowledge Dr. Rita Levi-Montalcini, who is from Italy, but came to the United States and did the bulk of her research there for this groundbreaking discovery. I'm gonna present quickly two studies, protocols that I think might be helpful as you're thinking about high-intensity cycling and brain-derived neurotrophic factor in Parkinson's disease. The first is the RCT by Sijatovic, 2017, 28 patients. They were Honorini R stage one through three, 6.8 years since diagnosis. The intervention consisted of interval high-cadence cycling three times per week for 12 weeks at 60 to 80% of a maximal heart rate. They also performed high-intensity resistance training. And the program was a peer and self-guided exercise program in which the patients with Parkinson's disease collaborated with the research assistants to provide exercise sessions. The results increased 300% increase in BDNF, a 28% reduction in the Madras depression scale, a 7.5% increase in the MoCA cognition and a 14% increase in the Scopa sleep scale. Most of the improvements were seen in the quality of night's sleep with patients waking less and staying asleep longer. The second trial is the trial by Frazita, Italy, 2014, 24 patients, 14 exercise, 10 control. This was an inpatient design. Sijatovic was outpatient, Honorini R one to 1.5, eight years since diagnosis. They received PT three sessions per day, five days per week for 60 minutes each session. And they exercised on a treadmill less than or equal to 60% of heart rate reserve at 3.5 kilometers per hour for 30 minutes a day for four weeks. They saw an increase of 12% in serum BDNF, the UPDRS reduced, which is an improvement by 46.3%, lower UPDRS scores signify a considerable motor improvement. The Berg balance improved by 9% and they were able to achieve a greater six minute walk time distance. For those of you who would like more information on these trials, we recently published a paper which is open access in translational neurodegeneration. It's a meta analysis on the effect of exercise on BDNF and human Parkinson's disease. And to my surprise, it's been accessed over 6,000 times. It's open access so I would encourage you to take a look at it. I think it's a hot topic in our field that's applicable to many different neurodegenerative conditions. The mechanisms of BDNF induced increases due to exercise are still being worked out. As I mentioned earlier, BDNF is involved in angiogenesis neuroplasticity and it has anti-oxidation properties. BDNF increases the affinity for the TRKB receptor which triggers changes in CREB, which has been linked to gene activation and improvements in cognition in healthy adults and also in people with Parkinson's disease. Excuse me. Other effects, molecular effects that have been shown with exercise, the two big ones are that dopamine stays in the synapse longer after physical exercise, after aerobic exercise specifically. And there is a higher amount of the dopamine transporter molecule in the synapse which means that a greater amount of dopamine crosses the synapse with after exercise. Oh, and the third mechanism I forgot to mention is that there's an increase in D2 synapses. D2 synapses are inhibitory and are obliterated in Parkinson's disease. So an increase in D2 or inhibitory synapses might also lead to an improvement in motor symptoms. Conclusions, excuse me, there's robust evidence. To suggest compelling evidence to support avoidance of a sedentary lifestyle and promotion of physical activity including muscle strengthening, aerobic exercise and weight-bearing activities for people at all stages of PD or at risk of developing PD. Currently, however, we lack adequate knowledge to prescribe exercise using a cookbook approach. So it's important to individualize our exercise prescription. And I think that's something that we do very well in our profession to begin with. The results that I presented on BDNF and exercise in Parkinson's disease are preliminary but I think that they are very intriguing and raise a number of important questions including whether there is a relationship between BDNF and changes in the symptoms of Parkinson's disease as shown in several of the studies, the RCTs that I briefly discussed. And of course, this is a tremendous opportunity for all of us to participate, to generate research and to contribute to improving the quality of care in Parkinson's disease through research studies which are urgently needed in our field. And I would encourage all of you to give this some deep thought because there's a great deal that of course you can contribute. I'd like to acknowledge Carolina's Atrium Health Foundation, the Pounding the Pavement for Parkinson's Disease Fund at Atrium Health, the Park Foundation, the Duke Foundation or the Duke Endowment for supporting our Renew program. The names that you see here, the names in black lettering are individuals who supported our program from internally to Atrium Health and the red names are, many of them are engaged patient participants and external consultants who helped make our Renew project, who helped put our Renew project on the map. And I'm very proud and humbled of course to be working with such a large team. And it really does take a team, it's a team effort. And coming back to the beginning, it is team science, which is driving the field forward. I'd also like to acknowledge the Leon Levine Foundation for providing a seed grant to bring the Renew program to the JCC in Charlotte. And last but not least, I'd like to acknowledge the Amsterdam University Holland Movement Science Innovation Planning Grant, which has brought together, has brought me together with others internationally in Italy, Switzerland, Holland and the United States to develop BDNF high intensity interval training studies in Parkinson's disease. Thank you very much for your attention. I hope this has been somewhat informative and it's 1249 and I'd like to open it up for questions. All right. Thank you very much, we appreciate it. I'm checking our chat here to see if we have any questions. We haven't had any questions yet. I appreciated your comments, particularly, it looks like there's a, I guess I shouldn't be surprised. We're seeing more and more evidence for exercise and about everything we do in PM&R. So I guess I shouldn't be too shocked that we're seeing increasing amount of evidence for exercise in Parkinson's disease. I would agree with that, absolutely. I think it's one of the hot topics. You know, in the, I started my research in 1992 and at that time there were almost no RCTs on exercise or physical therapy in Parkinson's disease and generally it was believed that exercise would make the condition worse and the physical therapists and many neurologists that I talked to thought, well, the neurologist thought it was a waste of time to be honest with you. The physical therapists, many of them believed that it would, especially high intensity exercise would be harmful because it might increase the underlying amount of tone. We've come a long way since 1993 in a very short period of time. But really the RCTs on efficacy for exercise and PT and PD really only started to come in, I would say 2000, 2005. So it's a relatively young field. There's still a lot left to discover and it's an exciting opportunity for those in our profession to contribute significantly. Excellent, thank you. One question that came in. So how do you maintain your patients on exercise regimens? Or do you have an exercise prescription that you give out or motivational interviewing? I know you specifically said that you didn't, that it's hard to be overly prescriptive. We don't have the evidence to be overly prescriptive in terms of exercise, but can you, what do you do? Do you give a physical prescription? So just telling patients to exercise is not enough. We know that patients do look up to their physicians as role models. So I think exercising yourself would be important as odd as that sounds. Behavioral interventions are efficacious. One thing is that each patient needs a coach, just like each athlete needs a coach, each patient needs a coach. And since we don't have enough professional coaches to go around because we have an excess of patients and we have a supply and demand problem, too few physicians, et cetera, physical therapists, we've developed a peer mentoring program and found that to be highly effective. That is to say that patients coach patients and the patients are actually helping the physicians understand Parkinson's disease better than they could by themselves. So that's one answer. Each patient needs a coach. Of course, these behavioral interventions, it requires trainings for the physical therapists, for the trainers who are working at the YMCAs and the fitness studios, et cetera. But I don't think there's an easy answer to that. It's amazing what patients are capable of. And I think patients as coaches, improving self-efficacy through cognitive behavioral interventions, health contracts is effective. Thanks, you mentioned coaching and I've seen an increase in uptake of coaching, health coaching type of interventions and even training programs. I know one of our residents chose to become certified in health coaching or health behavior coaching, something along those lines during residency. And she said she got a lot out of it and felt like she was better able to connect with her patients and saw progress there. Another question, one of the big issues in Parkinson's disease and inpatient or outpatient rehab is orthostasis. Do you have any specific recommendations kind of outside the box or something that isn't kind of off the top of our head, things like medication side effects, TED hose, abdominal blinders, maneuvering, Sinemet dosing, anything like that that you have advice on? As far as promoting exercise goes, I have worked with patients that had Shydrager syndrome or extreme orthostatic hypotension in a fitness environment. It was a YMCA slash nautilus type gym. And they were able to exercise under supervision. I think that patients such as that do need a personal trainer. However, I don't see any problems with exercising on a recumbent bicycle, a stationary bicycle, especially a recumbent cycle, but also an upright bicycle is a good option, I feel because it's stationary. It's awfully difficult to fall off of a recumbent cycle while you're exercising. But I do think that that would be a viable option. That's an excellent point, the recumbent cycle. Okay, I think we will go ahead and take a few minute break before our next lecture. Again, Dr. Hirsch, thank you so much for joining us. Thank you. Thank you. And so everyone else, again, if you have to go, feel free to look us up on Twitter. You can contact Dr. Hirsch. His Twitter handle is there as well. Otherwise, we encourage you to stick around. Dr. Ed Hurwitz, the chair of PM&R at the University of Michigan is gonna be joining us here in a few minutes. Thank you again, Dr. Hirsch. Thank you. Thank you and good luck with your series.

Parkinson's Disease rehabilitation

COVID-19 pandemic

exercise benefits

brain-derived neurotrophic factor

high-intensity cycling

individualized exercise prescriptions

falls and cardiovascular complications

physical activity promotion

Q&A session