This is a 2 Part Interview with Dr. Becky Farley, Physical Therapist and Researcher

Parkinson Wellness Recovery® is an Arizona based non-for profit designed to translate cutting edge research on exercise and brain change into real world health care paradigms TODAY for individuals living with Parkinson disease. Recently I had the opportunity to interview its Founder, Dr. Becky Farley, DPT, and she explained:  “the PWR!4LifeExercise4BrainChange^® model begins at diagnosis and continues throughout the life of the individual, with an overarching goal to coordinate and integrate medical/rehabilitation goals with community-based exercise programs and wellness resources.

This model of care allows individuals with PD to receive a continuum of care for life that begins at diagnosis with a personalize exercise prescription from a PD-specialized physical therapist – cycles to PD-specific community exercise and wellness programs – and then cycles back to rehabilitation to update your plan of care. 

Education, goal setting, ongoing monitoring, intermittent bouts of therapy with PD-specific group exercise programming, and referrals to other healthcare and community professionals are essential components of this approach. Our goal is to empower individuals to use their full potential to get better and stay better. This model is being implemented at the PWR!Gym^® in Tucson, AZ.”

I wanted to ask Dr. Farley more about the evolution of her approach starting with LSVT^® BIG and she was kind enough to answer a few interview questions which I will be sharing in a special 2 part blog post. Part 1 of the interview begins below:

Mary: It’s hard to believe, but for many years, exercise was not a recommended rehabilitation strategy for persons with a diagnosis of idiopathic Parkinson’s disease (PD). Since it was believed that exercise had no measurable effect on PD, or might worsen the underlying pathology, it was to be avoided. In the last decade or more, however, a rich vein of bench and translational research now suggest non-pharmacological approaches, such as exercise or physiotherapy, have a far greater effect on the cardinal features of PD than previously believed. How did you become interested in developing an exercise approach specific to the motor symptoms associated with Parkinson’s disease?

Dr. Farley: During my post-doc at the University of Arizona I had an opportunity to attend clinic regularly with a local Movement Disorders Specialized Neurologist. As I learned about the symptoms of PD, I began to do research to characterize the muscle activation deficits underlying the primary symptom of bradykinesia (small and slow whole body movements). I then became interested in developing an exercise intervention that required PwP to use their full muscle activation potential for whole body movements to override the bradykinesia. This lead to a partnership to apply the LSVT^® LOUD principles of practice for amplitude training in the speech motor system to the limb motor system using the whole body exercise program I created. After receiving funding from NIH, I completed a randomized clinical trial and the LSVT^® BIG program was born! That was the first time that a whole body exercise approach, designed to target the high physical effort required to overcome bradykinesia had been done for the limb motor system. As you mentioned, the rehabilitation dogma at that time was keep things simple and don’t challenge people cognitively or physically! Turns out….that is what PwP (Persons with Parkinson’s) need the most!

Mary: The LSVT BIG^® approach which you developed increased amplitude of movement. Help readers understand why the singular focus may be helpful to people with bradykinesia from Parkinson’s move more efficiently and safely.

Dr. Farley: Bradykinesia is defined as the inability to generate adequate forces to meet the demands of a specific task or activity (i.e., getting out of a low chair). The severity of bradykinesia is directly correlated with the loss of dopamine and thereby, disease severity. To receive a diagnosis of PD, the symptom of bradykinesia must be visible to your neurologist during the clinical exam. It is most visible during everyday complex “habitual” movements b/c those motor circuits are impacted early in the disease by the loss of dopamine. But your doctor can’t watch you at home, so that is why they watch you move and talk as you enter the clinic or exam room; or ask you or your partner questions about ‘how long does it take you to get ready in the morning,” or “have people noticed differences in how you walk or move around the house” or “do you have trouble buttoning or writing your name.” 

Interestingly, under certain conditions, PwP have the potential to override bradykinesia by tapping into attentional resources (e.g., mental rehearsal, action observation, imagery) or learning to use external environmental cues (e.g., visual targets, auditory pacing). Unfortunately, without adequate training or in complex or stressful environments, it becomes more and more difficult to access those everyday movements spontaneously. As a result, PwP become less physically active and weak, and perceptually they begin to think that their movements are normal speed and size, even when they are not.

This perceptual mismatch is exaggerated by poor proprioceptive processing and problems in executive functioning interfering with problem solving and adaptation. That is why PwP do not “self-correct” their small and slow movements or soft speech even after they have just practiced with normal movement (and speech loudness). I initially developed the exercise for LSVT BIG because I wanted to find a way to challenge PWP to retrain their mind to accept that the high effort for whole body increased amplitude of movement is “normal” and then learn to use the cue “Think BIG” to generalize that high effort into everything activities.

Mary: We read and hear a lot about exercise and neuroplasticity. I know that you are very interested in the role of exercise and brain health and brain changes. Could you elaborate a little on the basic science rationale for exercise as medicine. 

Dr. Farley: First I would like to make the point that exercise is one subcategory of physical activity which includes any activities related to related to work, recreation, activities of daily living, health, or enjoyment. PwP are particularly vulnerable to adopting a less physically active lifestyle after diagnosis and may experience more stress, injury, sleep disorders, and illnesses than the healthy population that have been shown to negate the benefits of exercise. So although exercise is important, if you don’t participate more in life, and deal proactively with nonmotor symptoms, injuries or illnesses, you may not benefit from all your hard work!

There is no need to wait for a research study to prove exercise may slow, halt, or reverse disease progression to get started!  Physical therapy and exercise are ALREADY considered an essential component in the management of PD, complementary to pharmaceutical and surgical approaches. This is supported by multiple reviews and meta-analyses, physical therapy guidelines, and consensus statements by the scientific community.

Bottom line:  PwP get better at what they practice but if you stop the benefit will disappear in 3-6 months. Research also shows that long-term changes (1-year or more) are possible if community exercise resources are integrated into the rehabilitation plan of care for a lifetime of rehab-community care. In addition, group classes offer complementary benefits, not always possible in 1:1 settings, which include improved social and emotional well-being, self-efficacy, motivation, and non motor symptoms.  You need both!  For LIFE! 

But all exercise may not be the same. As the founder of PWR!, our vision requires that we advocate for the use of exercise as a physiologic tool to promote the body’s own endogenous brain repair mechanisms. It is a virtually an untapped resource for people with PD. Basic science research in the area of exercise neurobiology has shown that exercise may interfere with multiple mechanisms involved in cell death. For example, 3-months of vigorous exercise in mice with a defective alpha-synuclein gene was able to reduce the amount of toxic alpha-synuclein in brain and muscle tissues AND improve cognitive and motor symptoms! This study offers hope that exercise may be neuroprotective and able to slow, halt, or reverse disease progression. But even if exercise does not stop disease progression, it has been shown in animal and human studies to restore aberrant pathways making them more efficient – despite there being less dopamine. These studies offer hope TODAY that exercise can restore function to dopamine depleted pathways, so they do more with less!  And that means exercise may put off the motor deterioration and motor symptom for longer!  Despite living with PD!

So, how do you optimize your exercise prescription for getting the most body and brain benefit?  What is the right dosage? That story is evolving, but it won’t be easy and you will need a coach and lifelong updates to your exercise prescription. We already know that people with PD that exercise ≥ 2.5 hours/week have better quality of life after 2 years; and that at diagnosis, habitual exercisers start off with a more robust dopamine systems and less severe symptoms compared to their sedentary peers. But, to overcome a neurodegenerative disease that directly impacts an individuals’ capacity for, and willingness to, fully engage in vigorous exercise will take a lifelong plan and a coach!

What is the right type of exercise? There are two types of practice that are essential: progressive aerobics exercise and skill training. Progressive aerobics training requires that you challenge yourself to do more than your own self-perceived effort. Even if you are an habitual exercisers, you need a coach to determine your baseline, help you set goals, and give you feedback and instruction so you work at the appropriate physical effort without compromising quality of practice or safety. It can be a combination of many types of activities (biking, treadmill, pole walking, swimming, over ground walking, or whole body functional intervals). Start with an intensity where you can achieve 10’ bouts and build up to doing something daily, with at least 3-5 days of longer duration (30-60’). For a personalize plan see your PD-specialized therapist!

If you have read this far, I think you would agree, that Dr. Farley is definitely doing some amazing work developing programs that are helping people with Parkinson’s live fully while at the same time delaying the impact or progression of motor symptoms.

Next blog post Dr. Farley will discuss PWR!Moves, or what she describes as the  building block of function, and you will also learn more about  the Parkinson Wellness Recovery (PWR!) Retreat an annual event that has been held in Tuscon, Arizona for the last 8years

How are YOU Staying the Course after Speech Therapy?

Staying the course after speech therapy for PwP was the impetus behind the creation of Voice Aerobics®, a whole body voice exercise class. Following formal speech therapy for hypophonia (low voice volume), patients often asked me for exercise/s that they could perform at home, on their own. The 60 minute class focuses on: Posture * Breathing * Voice. Voice practice coupled with movement is unique to Voice Aerobics, and it provides you an opportunity to feel how movement can power your voice, and voice can power your movements.

In 2009, the Voice Aerobics® DVD was recorded, and now, no matter where you live or where you go, you can take the exercise with you. Buy the DVD for only $20 or rent for as little as $4.99.

My MissionTo enlist individuals in their treatment, and help them express their personality & spirit through voice. To educate and empower. Mary Spremulli, MA, CCC-SLP

Voice Aerobics the heART and Science of Voice Practice