Parkinson's Disease:- Prof Bas Bloem "What type of exercise is best for people with Parkinson's"

hello everyone my name is Michelle thank you very much for joining us today to Listen to Professor Buzz Bloom on the topic of which type of exercise is best for people like us people with Parkinson's today's session has attracted an unprecedented level of Interest and this is no surprise even that exercise is a critical tool for people with Parkinson's to manage their symptoms he's also no surprise given the privilege that you have today to Listen to Professor Bloom one of the world's leading experts on Parkinson's disease I would like to remind everyone that this session is for information and education purposes only so if you are seeking medical advice diagnosis or treatment or if you are simply unsure as to which type of exercise is suitable to your own medical condition you should then really consult a medical professional there will be time for questions at the end of this presentation please use the Q a function at the bottom of your screen please do not use the chat function for questions as we will not see them for those of you who don't know us yet no Silver Bullet is a Parkinson's support group managed by Mark Lambert and myself our aim is to help people with Parkinson's because become well-informed generalist in their conditions and help them manage their symptoms actively and to the time we've been hosting fascinating speakers like tonight every few weeks we post the recordings of our sessions on YouTube and recently now on Spotify if you exercise you can listen to Spotify and I invite you to subscribe to those channels so that you are informed when we post new content the details are available will be made available by Mark in a second in the chat section at the bottom of your screen but let's come back to today's topic and to Professor Bloom who will share with us the key findings from his research on the benefits of physical activity on General Health and motor functioning in people with Parkinson's Professor Bloom is consultant neurologist at the Department of Neurology at the read about University Medical Center in the Netherlands is without a doubt one of the world's top Parkinson Specialists and through his efforts with Parkinson Nets people with Parkinson's in the Netherlands and in a growing number of other countries are able to much more easily access Specialized Care Professor Bloom was also recently awarded a prestigious step in a premi award which is the highest scientific prize in the Netherlands so Professor groom congratulations we are extremely fortunate to have you with us tonight and the stage is now yours thank you so much for the uh very kind introduction let me start sharing the screen here with sound there you go so can you confirm that you can see let me see put it on presentation perfectly well okay that is excellent so as you can still see me somewhere in the background or can you just see you on the side we have the whole the whole monthly the whole month brilliant well thank you so much again for the kind introduction so yes I I received this extremely prestigious award in the Netherlands which in my country has been named The Dutch Nobel Prize for science it's incredible and it's it actually happens to be here on my this is the bronze statue that comes with it it's called The Stephen award and Stephen was a famous scientist in uh the 17th century who was a physician and a physicist and a mathematician and a genius so it's an incredible honor to have received this award So today we're talking about um um a lifestyle exercise and lifestyle interventions um my main disclosure is that according to a geneticist in my hospital I am um The Unofficial carrier of a mutation in the gene for optimism and I am very hopeful that during my lifetime and during my active career we will make substantial improvements in the way we help and support families with Parkinson's to create a better future for for all of you and my other main disclosure is that I'm a former athlete so one reason why I'm so excited to study exercise is that I was part of the Dutch national volleyball team under 18 and what always gives me great pride to show it that this is henkian Health who won Olympic gold in 1980 98 I believe it was in in Atlanta another gold medalist ronsver for another gold medalist and that's me uh at the age of 18. but I uh whereas they went on to win Olympic gold I went on to become a doctor and uh with a focus on Parkinson's disease but you can see that I'm still very why I'm still very passionate about exercise there's a lot to tell you and I have a lot to share with you today so please bear with me there are now over 2 000 papers on Parkinson's and exercise and the number keeps increasing by the day what is good news for all of you is that there are currently 137 trials ongoing to further develop an Evidence base for exercise I think all of us believe that exercise is good um I will show you a lot of new evidence that exercise is indeed actually good but more evidence is underway and why is this important well if not for anything else to persuade the payers and the hospitals to reimburse exercise as a medicine to persuade your medical team to prescribe exercise as a drug as a therapy and to motivate fellow patients to regularly engage in exercise so this is all good news I just wanted to mention this book called Sweat by Billy Hayes um and uh Billy Hayes is a an avid exerciser uh himself he's the spouse of the Late Oliver Sacks uh and it's a brilliant book that I really enjoyed reading and I will quote here and there from this book one thing from the book that I thought was really interesting is we talk about exercises as if it is something new but what Bill Hayes in his book describes is that in Olympia you see the images of the beautiful antique Olympia here in those days exercise was very common and exercise was derived from the Latin word excessio free from restraint to allow unbridled activity interestingly enough it also includes mental exercise including good manners it was initially deployed for animals to make them fitter but it was later used particularly of course by the Spartacus to better prepare for war and exercise is all about the intention it's the intention the explicit intention to stay healthy and to prevent disease so if you go from A to B that is called transportation if you compete it's sports that's different from exercise and for those of you who are in the gym looking in the mirror all the time it's not to improve your own beauty that is called vanity so we're talking today about exercise and he also describes how miraculously exercise disappeared from the uh from the scene until the 17th century when this gentleman called girolamo mercuriale brought exercise back to the fore which is really interesting he was a physician that wrote this book about exercise emphasizing why it is so incredibly important and he describes a definition of exercise as a physical movement that is vigorous and spontaneous it involves a changing breathing pattern and is undertaken with the aim of keeping healthy or building up a sound Constitution the breathing pattern is really interesting because patients with Parkinson's have and I should say persons with Parkinson's and I apologize every time I speak about patient that's a slip of the tongue I hate the word patient you are persons you are not patients um um but persons with Parkinson's have a difficulty cranking up their heart rate above 100. this is not something you should worry about it's because the autonomic nervous system that is sending a nerve signal to the Heart is also part of the disease process so it means that tailoring your exercise to your heart rate can be very frustrating and you should really tailor your exercise to your breathing pattern so I always tell my patients when you are panting but still able to maintain a conversation that is just about the right dose and mercuriale in the 17th century already acknowledged that and I increasingly feel I you know I'm a sports buff myself still I increasingly feel that exercise and sports are very similar to having Parkinson's this is an image from um the route the the the tour of Flanders a famous cycling event in Europe in Belgium where the guy on the left much over the pool a Dutch guy beats the guy on the right uh in yellow uh about art by by just by a fraction of an inch and the difference between winning or losing among Elite athletes is because everything needs to be right your bicycle your diet your sleep your stress levels and this is exactly what you guys and girls uh need to do Parkinson's is like being Elite athlete everything needs to be right your bowel movements your sleep your regular exercise your diet your stress levels I will only be talking about exercise today but all of this needs to be well um it includes your diet and includes stress levels and we can have separate conversations around diet and stress if you invite me for other silver bullets later on but we'll talk about exercise today and why is it important to increase your physical activities well for one if not for anything else there are generic health benefits exercise is good for your bone health it reduces the risk of dementia it's good for your heart it's good for your lungs it's good for your muscles this is all well established there is now good evidence and I will show you some findings that exercise physical activities help to suppress motor symptoms as well as a number of non-motor symptoms so like a drug they alleviate symptoms there is some very exciting New Evidence to suggest that maybe maybe regular exercise could slow down disease progression and if it can slow down disease progression in those who already have Partnerships who knows who knows it might prevent Parkinson's altogether or delay the manifestation in those at risk of developing Parkinson's that's an area of research and again I'll come to that later on there are some interesting new insights into the working mechanisms behind exercise and I'm giving to that to you first because it may motivate you even further to regularly engage in exercise so on the one hand exercise is still pretty much a black box and buy a black box I mean we know what goes in running on a treadmill for 45 minutes we know what comes out Better Health what mediates the effects of exercise is in many ways relatively poorly understood there are many papers that have discussed in good journals that have discussed how and why exercise should work and this is a difficult cartoon and I understand but it's just to show you that there are many ideas and thoughts and also scientific evidences to support the merits of exercise it may work through enhancing the blood flow flow through the brain just simply more blood in your brain it may work by driving adaptive plastic changes in functional connectivity in the brain it may stimulate the release of growth factors it may stimulate the release of dopamine so there's all sorts of working mechanisms but I just wanted to highlight one very recent study and I truly urge you to fasten your seat belts about what you're about to hear now this is a brand new study published in nature earlier this year and it was done not for Parkinson's but for Alzheimer's disease so keep that in mind while I come to Parkinson's in a minute this is the paper published in in nature which as you know is one of the elite journals on the planet and what they did in this study is take mice and half of the mice were forced to exercise on a daily basis by running in a treadmill the other mice were just left in their cage and did nothing they were just sedentary rodents and what they then did is do a blood transfusion of the sedentary mice and also the exercising mice into a third new group of mice who had been sedentary themselves lazy mice so lazy mice receiving the blood from active mice or receiving the blood from other lazy mice and lo and behold they were able to convey the benefits of exercise through a blood transfusion isn't that totally fascinating and they were able to identify from blood that the active ingredient was a compound called closterin and clostrin is an anti-inflammatory protein in your blood so maybe one of the reasons why exercise benefits the brain is that it may suppress inflammatory inflammatory processes in the brain and we now know that inflammation is probably part of the pathophysiology that's leading to Parkinson's disease so in an editorial that we published in the Journal of Parkinson's disease we speculate that the same compound clustering may affect and inhibit neuroinflammation in people with Parkinson's who regularly exercise I think that is really exciting what I do not want you to remember is that you should hope for a blood transfusion of somebody else who's done your workout please exercise yourself so this man is dreaming of a six-pack through blood transfusion but that's not going to work you'll have to do this yourself so one take-home message here is that we are beginning to build a reasonable understanding of why exercise might benefit persons with Parkinson's disease so what about the efficacy then I will show you one brief video which I always like to show this is by Nicolas kukulakis who friended me on Facebook he is a wonderful man who is a former European champion in weightlifting and he shared this beautiful video which is wonderful for a variety of reasons this is him at home with freezing of gate in which you know as many of you know will recognize is this is more difficult in a crowded environment but he can climb stairs as a compensatory strategy he can ride a bicycle um which is why cycling is such a good exercise for Parkinson patients but the moment he Dismounts he's stuck and Frozen again um and but he's still an avid exerciser uh as you can see here and what I find really encouraging is that look at this he can barely walk but after exercise he can walk normally and look at the end isn't that really encouraging and amazing now what is important is that he feels an improvement immediately after exercise and I have to admit I'm showing this video because it is so motivating most people who exercise feel fatigued after exercise and they may feel a worsening of their symptoms please please please don't take this as evidence that exercise is bad for you it's a medal for good behavior because it drives adaptive processes in your body that help to counter your Parkinson's so yes you may feel extra tired after exercise your Tremor may be worse your walking your gait may be more difficult but that's a sign that you've done a proper exercise and your workout will drive adaptive changes in your body if you feel excessively fatigued after exercise take extra medication prior to exercise just in the minutes in the lead up to my talk I saw the first question in the chat which I already answered is it's best to exercise in an on State rather than in an off State because it allows you to get a better workout and to also combat the fatigue that may happen after exercise and if you're on a regular regime of medication with the same dose at different times of the day nothing keeps you from taking extra medication prior to exercise to allow you to engage in that decent workout so I hope I don't repeat myself but this is so close to my heart if you're tired after exercise if symptoms worsen it's not damaging your brain it's not deleterious the opposite is true and please remember that so this is a review paper published by my group where we looked at the benefits of aerobic exercise for people with Parkinson's and what you see here is a complex slide but I'll walk you through it these are all different studies that looked at Fitness VO2 max on the left top is a measure of physical fitness and when you sum up all the different studies you have this little Diamond here at the bottom and if it is to the right of the zero line it means there's a benefit so exercise in all these studies taken together leads to Greater physical fitness so that's good this is an even busier slide but I'll walk you through it this is the unified Parkinson's disease rating scale in the on State and the onstate and the updrs is the scale used by physicians like myself to score the severity of your Parkinson's symptoms and again a number of Studies have looked at the benefits of exercise on the motor symptoms of Parkinson's according to the updrs and there is a tendency for improvement in this case a negative score means Improvement because there are fewer symptoms that's why it's a negative score but you see that the diamond is overlapping with the zero line meaning it is a tendency but it's not statistically significant but if you look at the updrs score measured in the off State when the medication is not working now there is a significant benefit of exercise so you should do your exercise when you are on but you will experience the greatest benefits when you are off does it make sense I hope so which is nice because it means that exercise suppresses your symptoms at a time when the medication isn't working well which is when you need it most other studies looked at um different lifestyle factors and and Parkinson's and they looked in this case at disease progression and even mortality and in this particular study which was a very nice study they found that several factors um helps to slow down progression and reduce mortality it was a regular coffee intake which is really fascinating not for today but coffee seems to protect against Parkinson's but it may also slow down disease progression moderate alcohol consumption engaging in competitive Sports and engaging in regular physical activity they did not look at dietary intake in further detail what is bad for you is smoking so as you may know a number of Studies have shown that people who smoke regularly during life have a lower risk of developing Parkinson's disease and some people have taken this as evidence that they should start to smoke don't ever ever ever do that smoking leads to heart disease cancer what not and this study shows that if you already have Parkinson's and you still smoke it worsens your Parkinson's and it increases your risk of death and so does heavy alcohol consumption so these are things that you can start to do tomorrow yourself another study which was even better designed was published this year in Jama open network by Michael Schwartz child my good friend from Harvard in Boston and basically and again this is a busy slide but look at the two red squares if you engage in regular physical activity the risk of dying from Parkinson's or dying with Parkinson's is significantly lower if you if you're regularly physically active and the upper square is for regular physical activity in the time prior to your diagnosis but the bottom red square is for regular physical activity after you acquired the diagnosis so engaging in physical activity is better for your future if you do that prior to Parkinson's but also after you've acquired Parkinson's they also looked at a Mediterranean diet and Mediterranean diet was also good in determining your prognosis so a good diet Mediterranean diet and exercise together are good for you and this is the summary a lower mortality associated with more physical activity and in Practical terms it's about 10 to 20 hours of walking per day or about five to nine hours of moderate intensity activities per week as well as a healthier diet and it applied to both pre and post-diagnostic interestingly there was no interaction effect suggesting that diet and exercise are independent separate effects that will both benefit you so I hope that encourages you to take your own responsibility and eat well and exercise well um so yeah this is basically summarizing what I've just said and this comes again from the book by um Billy Hayes um it's so interesting that we're now seeing this sort of dual effect of exercise and diet and Hippocrates the founding father of modern medicine already said this hundreds of years before Christ so makes us humble doesn't it but we forgot all about these good advices so which components of exercise this is something that um Michelle and Mark specifically asked me to talk about it really doesn't matter what you do as long as you do it that's that's the short message there is now evidence both from just daily life but also from trials that for example boxing is good ping pong I know that there are ping pong fans today I'm a great fan of ping pong I love to play ping pong myself there are ping pong tournaments there's even a world championship of ping pong so ping pong is really good um cycling is really good this is our annual cycling event in the Netherlands where the the other man I'm on the right and the man on the left is somebody with Parkinson's who was actually a way better cyclist than I was so uh cycling is good this is a marathon runner you can see that he has no arm swing so he's got Parkinson's disease but he runs marathons with Parkinson's even though regular walking is difficult uh running marathons is still Pro possible and what I find really wonderful is that together with two other Parkinson patients they now do a triathlon so one of the guys is swimming the other guy is cycling and the third guy is running and together they do a triathlon now that's Goosebumps and real teamwork and I really like that this is basketball this is somebody with Parkinson's from Italy my good friend Alfonso Fasano gave me that video you see that gate is Disturbed there's a markedly reduced arm swing um but look at him with a basketball Market Improvement in the quality of the movements he was a former professional basketball player and uh well I can't do that I can tell you that and this is dancing this is in the north of the Netherlands beautiful dancing group where this young girl touches all these people mimicking mimicking the stooped posture of Parkinson's actually all of them have partisans and they all open up like flowers these were the goosebumps every time I see it and people are dancing even when they're a wheelchair bound and there's now good scientific evidence to show the merits of dance as a therapy for participations so this is a recent editorial that we published in German neurology which is one of our lead journals again going back to ancient uh uh Rome and ancient Greece under the title citiz the motto of the Olympic Games and we opened a debate as to what component of exercise is best so it doesn't really matter whether it's volleyball or basketball or ping pong or you know swimming but what is what is the component and um haziot the famous Greek poet said the immortal gods have made it so to achieve Excellence we must first sweat and like I said the the Greeks got it right so yes the sweat component is important it's one of the drivers and this is a beautiful study by Margaret shankman and the senior author is Daniel corcos two wonderful scientists from the United States who are leading very important exercise studies in the United States they were the first to really study the dose of exercise and the benefits for people with Parkinson's and what they did is they had three groups one was not doing any exercise one group was motivated to crank up their heart rate while running on a treadmill to 60 to 65 percent of their maximum heart rate and another group was motivated to crank up their heart rate to 80 or 85 percent of their maximum and the dark dots is the high intensity group and as you can see they Faithfully complied and the the Open Circles is the low intensity group and also they Faithfully complied with what they were instructed to do and this is the clinical outcome which you see at the y-axis is the difference in the updrs motor score so a zero line means no difference positive scores uh mean um uh worsening and what you see on the right for usual care is that the square is above zero so the control people not exercising were worsening over time there was less worsening in the low intensity group and there was clinical stabilization in the high intensity group Isn't that cool so the higher the intensity the greater the benefit of exercise so low intensity is better than nothing but high intensity is better than a low intensity I hope that's clear so the dose of exercise matters and this is the sweat component sweating matters but Plato again going back to the ancient Greeks Plato said it's not the number of exercises but they're moderate nature that brings about a good human Constitution and Plato 400 BC was also right I mean isn't that amazing these these ancient Greeks City guys were wonderful so there are now two papers to show that in addition to the aerobic to the sweat component this simple the sheer volume of activities is also important this is one of two papers and what they looked here is again dying with Parkinson's as the outcome measure and they looked not at the intensity of exercise but the volume of exercise so taking 10 000 steps per day at a Leisure Pace versus 5000 steps at a Leisure Pace per day and what they showed as shown here is that people with a lot of exercise or a greater volume of activities had a lower risk of dying it with Parkinson's than those who were inactive so this study shows that in addition to the sweat component simply doing more even if it's at a Leisure pace is also helpful and I find that highly encouraging and that was confirmed by this study done in Japan where they also looked at the volume of physical activities what you can see here in the blue line is controls who maintained their level of physical activity the pace score on the y-axis is a scale for physical activity healthy people remain active at a stable level for about a six year period where people with Parkinson's became less and less active over time and we know that this is happening so that's one finding but what they also showed is that people who did more shown in the left cartoon in uh in red declined slower over time than people with low levels of physical activity so again this study showed that a greater volume of activities is helping you to slow down disease progression and on the right its activities of daily living and these decline faster in people with little physical activities compared to people with high physical activities shown in red so two independent studies from different parts of the world showing that in addition to sweat just doing simply more is helpful and Thomas Jefferson the famous American president said no less than two hours a day should be devoted to exercise and I like this quote and the weather shall be little regarded isn't that wonderful no excuses for you if the body is feeble the mind will not be strong so your take-home message here is that the drivers of exercise include the intensity but also the volume and these appear to be two Independent Drivers so bear that in mind now now we go to something really cool and exciting these are Dutch snacks and I tell you boy these are really really good the the round ones are my favorites they're called bitterballer for the Dutch bitter balls but these are really good they're and are not particularly healthy but they're good and these are obviously snacks and what is so really interesting is there is now novel work from California to show that exercise snacks are also helpful so what we always tell our patients is you should exercise three times a week for 30 minutes and many people say oh hecky darn when can I free up 30 consecutive minutes to do my exercise the latest research is now showing that if you do an exercise for one minute and an hour later you do another one minute it all adds up so 30 times a snack of one minute is as good as one block of 30 minutes and I call this exercise snacks so instead of taking the elevator you climb the stairs and you've got your snack and taken together you should reach 150 of those snacks per week which is just over 20 per day now that's certainly quite doable people think oh where do I find 30 consecutive minutes treat yourself with exercise snacks and there is now actually evidence this is published work on exercise snacks that it also helps for bone health cardiac health Etc so think about snacks these may be helpful and I find that a very powerful message so this is one of my uh interesting studies where I participated where we looked at um making the exercise a bit more complex and what we did in this study is put people on a treadmill the aerobic exercise and we tried to combine it with virtual reality and our thought was that a more complex intervention both working out on the treadmill and being engaged immersed in this complex 3D environment would be extra beneficial so we compared people on a treadmill with just a treadmill to people on the same treadmill but also with a virtual reality environment I hope that makes sense and what we show here is using falling as the primary outcome measure that the decline in Falls happens in both groups so both groups are better so treadmill training helps to prevent Falls but the prevention of Falls was greater in patients who combined treadmill training with virtual reality so the more complex the intervention the better it is so that was an important message and by the way um if you come to think of it running outside is combining treadmill running with virtual reality so maybe you should just run outside instead of indoors on the treadmill but anyway so multi-modal interventions both aerobic and a more cognitive demanding task are better than just aerobic exercise alone so that's another interesting one it was also an extremely frustrating study and it was frustrating because we needed this complex and expensive equipment to train people so they had to come to the hospital all the time to train and many people declined to participate so this brings us to barriers and motivators for exercise which I think is important to talk about today what can we do to promote compliance so that people actually do what is good for you and after all many of us are lazy we prefer a pill or debrange stimulation over an active lifestyle and I hope that after today you are motivated to the Bone to exercise more and to have a healthier diet um and yes exercise can be tough this is again the genius Mercury real in the 16th century we in no way dispute that exercise can sometimes be hard and when it is being performed unpleasant but good health is not incompatible with some discomfort isn't that beautiful no pain no gain is the other phrase that I think the Americans are using so we published a paper on barriers and motivators for exercise in persons with Parkinson's disease and this is a complex slide but again I'll walk you through it one key barrier by patients was I feel the same whether or not I'm physically active but I will show you in a number of studies that in fact your outcome six months down the line is better if you exercise so no matter whether you notice it today you will be better six months down the line if you exercise regularly I have little time think about your snacks no excuse and a fear of falling prevents me from exercising we've already seen that exercise actually prevents Falls and I will give you one other study in a minute to show that falling should not be one of your primary fears obviously when you have a lot of freezing of gait speak to your physiotherapist about an exercise that is safe for you for example cycling on a stationary bicycle but there are always exercises with a low risk of falling so this was an interesting study where we looked at motivation for exercise it's a paper published in the British medical journal and what we basically did is I'm not sure if there's only Europeans or maybe Americans in the audience but this is the famous Tom Brady uh the most famous quarterback in the United States and even the famous Tom Brady needs a personal coach and if you are a person with Parkinson's I think you will benefit from having a coach who designs a personalized exercise intervention that is tailored to your abilities your wishes and your needs so what we did in this trial is allocate coaches to persons with Parkinson's they were either instructed to move more safely or to move more vigorously so park safe versus Park fit but they both had a coach I'm showing this study for one main reason the eligible candidates if you look at the right were more often so people who wanted to participate were particularly men so women were less likely to enter our trial the people interested to join were slightly younger the people who were interested to join had a shorter disease duration and importantly the people who were already very active were interested to join an exercise study whereas people who were sedentary who needed the exercise most refused to be randomized isn't that interesting so the folks on the left the older ones the ones with longer disease and the least active did one did not want to go into my trial and they needed it most so think for yourself if this applies to you so we took this at heart in a in a study that we published in the Lancet neurology this study was proclaimed as one of the 10 best studies in the entire Parkinson field for the year 2019 and what we did here is we delivered a stationary bicycle into the patient's homes you've seen the one patient the Greek weight lifter unable to walk because of freezing but still able to ride a bicycle so we felt a bicycle was good because even people grounded by freezing can still ride a bicycle and you can't fall off the bicycle on unlike a treadmill so this was good for a home-based intervention and as you can see there's a big screen so it was a very fancy bicycle and I'll tell you why um because we we gamified the intervention do you recognize this famous lady from the United States this is Alice Waters a founding chef of Berkeley chapanese and she said good health shouldn't be the goal of exercise make pleasure the goal and it will lead to good health so make sure you enjoy your exercise and health will be the automatic and inevitable consequence of your exercise I really like that quote so we decided to gamify the intervention and even elderly people as you can see here are able to enjoy a game or two and what we did is we built a customized app on a tablet that motivated people to start exercising because they were given all sorts of anticipated Rewards we rewarded people during the exercise on the bicycle for example they were playing the Pac-Man game but the monsters were moving faster and faster so you had to cycle faster and faster to kill the monsters so in the end the participant said ah I killed 10 monsters but in effect you had cycled at 40 percent uh for 45 minutes at 80 cardiac output and then we rewarded people after the exercise for example because there was Applause by our fans and this is the study design and people were either doing this aerobic exercise combined with a personal coach and this gamified app and the control group had the exact same deal but they were only doing stretching exercises and this is a cool slide again it's it's maybe a bit complex but I'll walk you through it the instruction was to exercise for 26 weeks three times a week for 30 minutes in your designated heart rate zone hrz is heart rate zone now we talked about how difficult it is to regularly engage in exercise how people always have an excuse not to exercise how people see barriers but thanks to these gamification elements people did what they had to do and sometimes even more so that was brilliant the gamification worked and what we so we had excellent compliance with a home-based intervention with remote supervision by a coach and gamification elements called extra gaming but crucially this is again the updrs our scale for scoring Parkinson's symptoms on the y-axis and it's a different score so the zero line means no change the control group in Gray is above the zero line can you see that meaning that the controls got worse over time which is what you're going to expect from Parkinson's because it is a progressive disease and the people in green who were exercising stabilized and the difference between the two groups was 4.2 points on the updrs which is equivalent to the effect of a drug for Parkinson's so three times a week on your bicycle and you will stop your decline and have the effect that is equivalent to a drug so now we've have two studies the shankman study you know with the study you may remember with the with the dosing on the treadmill and our study to show that if you are not exercising you will decline over time but we now have two independent studies to show that you can stabilize your motor functioning through exercise isn't that really really encouraging and our latest findings now really fasten your seat belts again if you untie them faster your seat belts again what we did in my study and this is now published in the annals of Neurology we did brain scans before and after exercise in our cycling study and we also did brain scans before and after stretching in the control group and this was a structural MRI scan to look at how the brain looks like and also a functional MRI scan to see how the brain was working and the results were stunning we showed that the brain in this stretching group was shrinking a little bit the medical term is called atrophy the green box shows that it's below zero meaning that the brain was shrinking in controls and we stopped the shrinking from happening through exercise how cool is this and I did not bring a slide to show this but the exercising patients persons had new functional connectivity between the diseased Parkinson brain areas and the healthy motor cortex so if you are on your treadmill if you are playing ping pong if you are playing basketball and you're no longer motivated to exercise think about this study because while you're exercising your brain is making new connections which help you to stabilize your symptoms which I think is extremely encouraging and it reminds me of this study in rodents it's an old video but the mouse on the left is an exercising mouse that exercises every day it's a parkinsonian mouse and the poor Mouse at the other treadmill that's falling off all the time is a mouse that is allowed to stay sedentary and and stay in his cage all day this is rodent work from San Francisco sorry Los Angeles to show that not only do exercising mice with Parkinson's look a lot healthier when they sacrifice their mice and looked at the brain they found the exact same thing that we found with our scans in the patients so there is now converging evidence from animal studies and human studies to show that exercise repairs your brain I mean isn't that wonderful now you need to personalize your exercise so again it doesn't matter what you do but do something that you like and that you are likely to stick with or change you know do hiking on day one do swimming on day two do cycling on day three but do something that you like and that you will adhere to I think it is really important to always listen to the individual so extreme patient participation is important in designing your optimal personalized exercise intervention I'll skip this one for now and very importantly do it so that it is close to your home so you don't have to go to the gym all the time but there's a lot you can do in your own home environment and our studies show that The Closer To Home the exercise the more likely people are to stick to it so this is why I'll be brief about this we're now doing the stepwise study the step by study is a very cool study where we use a smartphone to deliver a gamified intervention to people with Parkinson's so we use the smartphone to deliver an intervention but also to measure the outcome of this study remotely um it's a it's like a Pokemon go for the elderly does any one of you play Pokemon go it uh it changed my uh my son's uh uh in uh in their puberty from in in from inertia into really active disciples trying to catch all these monsters so we we took the Pokemon go experience and we've built a customized app for people with Parkinson's which motivates them to exercise on a daily basis the reward is not a monster as in Pokemon go but the reward is knowledge about exercise and insights it's a dosing study so we we dose people with a little bit extra a lot extra or a lot and a lot extra so we are going to learn more about the dose of exercise which is really cool and we also measure the outcome with the same smartphone because you can hold the phone in your hands and measure Tremor you can tap on the screen and measure your slowness you can speak to the phone and it analyzes your voice it's a really cool remote study and this is my final slide because we are so convinced about the benefits of exercise we are now taking this to the next level in the slow speed study I just presented the design of the study last weekend in Boston where we are using the same gamified intervention to people at risk of developing future Parkinson's so these are people with a genetic risk for people with the first prodromal symptoms like a REM sleep behavior disorder and they will be randomized to either do nothing or to exercise regularly and we want to show that we can actually postpone Parkinson's by engaging in regular exercise so that's it folks I will stop the um the share oop and we'll open it up for debate no doubt thank you very much Professor this is an amazing presentation I think that it's far more uplifting than what I even imagined and I imagined already quite a lot um it wasn't so late in London I would probably go for a run right now but thank you very much for this um I know you're extremely familiar with zoom you want to go through the questions in the Q a section yourself I know you've started answering some that might be more efficient than me reading them over to you sure so uh Saget advice says what kind of food or food supplement do you recommend to support people and maintain muscle um so um food and muscle is is difficult um that's not been studied specifically for Parkinson's I um what I did not emphasize today yet is that in addition to aerobic exercise and to the volume of activities strength training is also important so Saget it's important that you raise this issue because people with Parkinson's are at risk of developing weakness in their muscles which may then jeopardize your balance for example when you try to get out of bed or when you try to get out of a chair so strength training is important uh there's very little evidence specifically from the Parkinson field um what dietary components are helpful um what is important is that many people with Parkinson's are cautioned against the use of proteins because these May in your food because these be May interfere with levodoba but at the same time you need to see the same proteins for your muscles so try to avoid simultaneous intake of levodopa with proteins make sure that you spread your proteins across today and probably an adequate dose of proteins is needed to build up a sufficient muscle mass in addition to strength training I hope that answers your question um Audrey Boyle says what level of exercise will result in release of bdnf and for the listeners that is brain derived neural growth factor in those that find exercising difficult or have injury um so this this this relates to the question you know what to do in general so so setting aside all these growth factors or other mediators of exercise what can I do when I find it difficult to exercise well hopefully if you've listened to my talk today brief bouts of exercise are already helpful that's one simply walking a little bit more is also helpful if you have difficulty walking consider a treadmill sorry or consider a a bicycle if that is even impossible there are hand bicycles or speak to your therapist about a seated bicycle where you sit in your own comfy chair where you can just pedal with your legs strength training can often be done even with light weights so if you find it difficult to exercise go see a physical therapist or a sports trainer and when you sit down and look at your abilities I realize it can be challenging for some but my experience is there's always something to be found and build it up so you don't have to run a marathon right away start small think big act fast so start small and reward yourself with a little bit extra the next day athletes don't run marathons right away if you've got Parkinson's Build It Up start small but think big um Sue Vandal says I have sinus tachycardia so my heart rate is normally higher than average does this affect the heart rate I should be seeking while exercising well so what I did not address in the end is the fact that people with Parkinson's have a slightly higher risk of cardiovascular complications um and I think anyone listening and the reason is that because of physical inactivity we have a slightly higher risk of atherosclerosis but levodoba which is interesting increases the risk also of atherosclerosis so a number of Studies have shown that people with Parkinson's have a slightly higher risk of Strokes in the brain and heart attacks um now that's a small risk and most people can just normally exercise if in slightest doubt I would recommend doing an exercise test prior to building up your aerobic workout just to be on the safe side we've done that in our trials nearly everyone will save but one or two had a cardiac issue that required attention before they could engage in exercise and for example I'm not a cardiologist but I can see how a sinus tachycardia might be a reason to see an exercise expert or maybe a cardiologist and ask about your right dose of exercise um Harley Stanton says can you provide a specific references for the published articles and yes Mark and Michelle and I will communicate and we will send PDFs of the relevant papers so you can read that um Audrey Boyle says should I take up moderate drinking to slow progression if I don't drink that is a very good question my sincere advice would be I think the benefits of alcohol are grossly overestimated I think we all want alcohol so desperately to be good that we are ignoring the bad studies and highlighting the good studies I personally think that if you think of brain atrophy liver toxicity muscle wasting alcohol is in general not good if you enjoy alcohol these studies show that you shouldn't be all that fearful if you do alcohol enjoy it drink it with pleasure but do it modestly one maximally two consumptions and not every day and if you don't drink I would never recommend picking up drinking now as a therapy um Ali says I've heard sport climbing is also good yes there was a recent study from Austria from actually one of my PhD students um Heidi Zach who's done wonderful work on sport climbing and yes they are showing some very favorable results Holland is flat as a pancake there's nothing to be climbed here other than the stairs but if you live in a country with stair with climbing definitely there is some research to show the benefits now um Francis was there a follow-up on the study five years later that's an excellent question Grant and one major limitation in these prospective studies that I mentioned is that the follow-up was only six months um and then then we ran out of money I mean imagine these are one million euro trials these are costly difficult expensive studies and yes we need long-term follow-up studies that needs to be done uh obviously the epidemiological work which is retrospective studies looking at existing data they span decades they show that engaging in exercise for longer periods of time is beneficial but the proof of the pudding ultimately comes from prospective studies and yes we need more long-term studies these are now underway I told you about the 137 ongoing studies but so far we are stuck with relatively short-term studies these are positive and and encouraging but yes we need long-term work um how does the lower heart rate of people with Parkinson's affect and maximum heart rate for proper exercises this is Thomas Brown so Thomas uh it's it's not a different uh resting heart rate but what people with but some people with Parkinson's have difficulty with is increasing their heart rate above 100 so your resting heart rate is probably identical but when you start to exercise normally your heart rate goes up and what people typically do is they will encourage you to bring your heart rate to 120 130 to maybe up to 160 and that may be difficult for people with Parkinson's because the nerve going to the heart is affected it's not dangerous it's nothing to worry about but it means that when your heart rate plateaus you are one of those folks where the nerve isn't working well and you should tailor your exercise to your breathing pattern other than to your heart rate even though many of the studies that I mentioned were actually using heart rate to monitor the exercise intervention but I think breathing is a lot easier and Anonymous attendee says since developing PD I don't sweat much at all will that negatively affect the impact of my high intensity activity well that's a brilliant question thank you for asking I'm actually hoping that Michelle and Mark are taking minutes so that I can address some of these in my future uh lectures yes sweating can be affected by Parkinson's and quite mysteriously it can go both ways there are people with Prof diffuse profuse excessive sweating and there are people who cannot sweat anymore we published a case report by somebody who was unable to sweat because this lady in fact had multiple system atrophy and developed a heat stroke accordingly and sweating is a mechanism to um get rid of body heat so yes probably this will affect your ability to engage in very vigorous exercise I don't think any Studies have been done it's the first time I've heard the question I think it's a really good question and I would recommend you to go see a therapist and just work with a therapist on a treadmill in controlled circumstances where there is cooling nearby Etc to find your individual ride dose Audrey Boyle again um most persons with Parkinson's can't run or do high intensity training what about them well Audrey I disagree that most people can't run many people have difficulty walking the strange thing is that many people can run even when they can't walk so running on a treadmill is surprisingly often possible cycling on a home trainer is impossible for the large majority of patients and as I indicated before it doesn't have to be high intensity training the volume of activities is also important so brief bouts of exercise are good um and prolonged exercise at a low intensity is also very good so if you have listened carefully to the whole recipe I think there's something to be gained for every person with Parkinson's so Sharon maplethorpe says why is an exercise program like PD Warrior so highly recommended as it has minimal cardio element and focuses on Power and amplitude and not speed well you know I think this is good advertising um PD Warrior is uh I'm not saying it's bad it's probably good but I agree that the focus should primarily be on the aerobic component and the exercise volume component yes as we said earlier uh strength training is also important PD Warrior does a great job in raising awareness for their program it's probably a good program but it's not the only program maybe that's the the main point that I'm making here and don't forget about the aerobic component and or the volume component Fiona McKenzie says I've had rheumatoid arthritis for 30 years fibromyalgia and having had both patella removed my knees need carefully as well I can imagine uh Parkinson the patella is the knee pads Parkinson's diagnosed this year I like exercise but pain from non-parkinson's sources makes it hard is anyone researching exercise for people who start out with difficulties in exercising already now yes Fiona this I can see how that might be an issue but for example I mentioned the head bicycle so if your legs are hurting during exercise a head bicycle can allow you to do a workout without any strain on your legs or your knees so there is always something that can be done and I would seriously consider doing a hand bicycle uh Sharon maplethorpe how is it possible to incorporate strength balanced cardio stretching exercises all elements that are recommended in only 30 minutes three times a week this is a good question Sharon and yes this is a challenge um there's a lot you need to do um at the same time you know um if you've got Parkinson's you've been dealt a bad card you know a bad head of cards and what I am saying here today is that instead of relying on your doctor to give you more pills you can take matters into your own hands and do yourself a tremendous favor by Faithfully exercising and the three times 30 minutes is something you that we often recommend but that you might as well forget at the same time I tell all my patients that they should exercise every day and the reason I'm saying every day is that if you exercise three times a week There's Always Tomorrow if you have to exercise every day there's no ifs ands or buts and if you do that with snacks or six times five minutes or simply climbing stairs leaving your car at home and taking the bicycle taking a regular walk every day 150 minutes per week is doable and if you've got Parkinson's if I would have had Parkinson's I would be extremely motivated to do it and yes you know I realize it's an intense regime strength exercise plus 250 minutes of you know other exercises but the people I see in my clinic the people sitting at the other end of the desk who are doing best are the people who exercise on a regular basis I know this disease inside and out I see patients every week and setting apart all the trials and the evidence that I mentioned just from my own experience in clinical practice the people who exercise are the ones who are doing best and it's it's a matter of incorporating this into your daily routine so not three times a week but every day and by simply thinking about exercise with everything you do I think 150 minutes per week should be doable plus a bit of strength training um and you know I'm a former athlete myself and I enjoy it so much that I can't wait to begin my next exercise again so the better the fitter you become the nicer it becomes to exercise and then it becomes more motivating okay Bill Buckley hi Bill nice to virtually meet you here when considering the two factors and exercise you spoke about duration or volume and intensity do we have any idea what the relative impact or the synergistic effects are uh the short answer is no I don't people have studied this separately and not really as an interaction effect I think the two effects are likely to be independent and additive maybe even synergistic but the honest answer is I don't know but I would recommend everyone listening to at least do the volume component if you find high intensity exercise difficult and if you can do high intensity or moderate intensity exercise the dose matters to combine the two and he says as a corollary is there a limit I'm referring to limits on brain health only why with this question as I'm aware that physically and otherwise there will be limitation or diminishing returns with the amount or volume of exercise so is there this is a difficult question Bill next time phrase it so an average Dutch person can read it so are there diminishing returns with the amount of volume of exercise I think he's asking whether is there a point where you're doing so much that actually in additional hour you do that week has no longer the same impact as the first hour yeah yeah I I haven't seen any studies where it plateaued um so the more the better the only thing that I do know but these are anecdotes of some people who started to rent marathons every day and who worsened and some of them never got back to normal now it might be that these people had a genetic form of Parkinson's that affected their mitochondria their respiratory organs of the brain cells and if you overdo your exercise you might deplete your body from ATP the body's energy mechanism and maybe even kill nerve cells so the dose matters I haven't seen Plateau studies but people who were excessively overdoing it again running a marathon every day there are anecdotes of people worsening so don't over overdo it um Scott Henley says I reversed all my symptoms to zero through cognitively intense exercise well that's beautiful sculpture that reminds me of the study we did with treadmill training combined with cognitive training and I've definitely had people you know I I run into meetings with people and they say I met you eight years ago Professor Bloom you told us to exercise I started to exercise I I'm now better than eight years ago I mean I I have many many of these anecdotes uh man says what do you think of vitamin B1 supplementation um that I'm not in in a favor in favor of what you should have checked on an annual basis according to the latest guidelines is vitamin B12 levodopa can lead to vitamin B12 deficiency and vitamin B12 deficiency in turn is the factor that may lead to atheros atherosclerosis which then in turn may lead to cardiac infarctions or Strokes so B12 should be checked and supplemented if reduced and so does vitamin D for dirk or David so those two need to be checked and supplemented if needed if you have a good regular diet you should be okay but because of levodopa you may run into B12 deficiency and for some reasons that we don't fully understand people with Parkinson's have a higher risk of the vitamin D for David deficiency so have those two ones checked and they can actually lead to sometimes good improvements if you supplement it um so I've answered that one is the app being developed it will easily be available to patients with Parkinson's this is a question by Vicky and uh Vicky the the app is still only available in our trial um because we want to do the study first and build up the evidence once the app has been definitively proven to be efficacious it will obviously be made available at no cost uh to anybody with Parkinson's so hold your horses for a little more until we've completed our trial um what do you advise PD people with joint issues or dystonia to get up their heart rate vigorously um that's that's again a good question that the best advice would be to go see your physiotherapist or sports trainer and find something because these people are really good you know and and find a an individually tailored exercise that matches your abilities again people with you know the the person with the uh bad knees a hand bicycle can be a solution um and um uh the dystonia is a whole separate issue because dystonia in Parkinson's is not as uncommon as people think but dystonia is treatable sometimes with levodoba sometimes with botulinum toxin sometimes with deep brain stimulation um so I would have the botula the the dystonia treated first if that interferes with your exercise um Kimberly Camp analysis I'm slightly frustrated as I'm exercising six to seven days per week all sorts of things but I'm getting uh still getting gait issues she's a young onset person at the age of 41 any advice um well Kimberly you know you're doing all the right stuff and I would encourage you to keep it up unfortunately I think what exercise is doing at this point is slowing down disease progression I don't think for all patients it's halting disease progression altogether and I I'm with you I understand I'm I you have my sympathy I I yeah Parkinson's is a progressive disease you are doing great stuff with your daily exercise and if you had an exercise so vigorously I will tell you Kimberly you would be way worse than you are now um keep exercising to slow down your disease progression as much as possible you're young we're working hard every day and finding improved treatments whether this be lifestyle interventions with diet or stress or other exercise regimes or perhaps pills that may slow down the progression and again I hope that during my lifetime you know I'm an optimist that we will find that treatment that will slow down your disease maybe even stop the symptoms from progressing or maybe reverse the symptoms but keep yourself as fit as possible until that day arrives and I wish we could stop Parkinson's altogether but we can't right now but you're still doing a great job and keep it up please uh Irene Tracy says excellent presentation thank you so much well you're welcome have you heard of smoothie vibration therapy um I I I've heard of vibration therapy we're actually engaging in a trial here at my center and there are other centers also doing vibration therapy um I'm not convinced yet I've seen spectacular results but that could well have been a placebo response Parkinson's is one of the most Placebo sensitive conditions on the planet because the placebo effect is mediated through dopamine so if if you tell in a very persuasive way that eating horseshit is good for Parkinson's some people will benefit no doubt particularly if I tell you um but that doesn't mean it works um I think there is no convincing evidence for vibration therapy I've seen encouraging case reports and I think we need more evidence so I wouldn't recommend people to purchase any vibration therapies unless they are eager to do so themselves and to wait for the evidence Paul Nichols hi Paul Paul says good evening boss fantastic presentation you're welcome I'm the founder of walking football in the UK brilliant we now have 14 centers delivering a walking football in the UK and have a Gloucester Hospital looking to start a research study and why it is so effective do you know if there's been any study into walking football or why moving a ball is so effective well I've seen videos Paul and I'm a great fan of walking football I love it I'm a fan of sports in general football in particular and of course I love English football although I hope that the Dutch will beat the out of the English at the Europe at the world championships and also the French for that matter in the world championships that are about to come the orange machine um I don't think that walking football is unique in that it combines but but it nicely combines like boxing is the movement which is good and it's externally driven because you need to follow the ball and internally generated movements are defective in Parkinson's the automatic pilot is damaged so any externally driven movement is easier for people with Parkinson's compared to internally driven movements so that's why I think football is such a good exercise like boxing because it's externally driven and it combines movement with following the ball I would love to see the evidence coming out I can already predict it's better than doing nothing um uh uh and who knows you you might persuade me to enjoy a good game of walking football one day um Steph Cockrell I feel so hopeful now thank you so much you're welcome Steph I take no medication I was only diagnosed in February I'm only 49. I sometimes struggle on Peloton Peloton is a fancy exercise bicycle has can't move the legs fast enough to raise the heart rate well there you go Steph maybe it's not your legs that are causing the problem maybe it's your heart and you don't need to worry about your heart but instead dose your exercise based on your breathing pattern any advice for improving leg strength um also can we get involved in your step trial so a couple of things don't dose your exercise based on your heart rate but tailor it to your breathing start panting but still be able to maintain a conversation that's one strength can be increased with strength training in the gym and any physio or sports trainer will be able to help you out to train your qualts and your hamstrings your calf muscles so weakness is part of the Parkinson issue probably your legs are strong enough I think your heart rate is not going up because of this Parkinson related issue so so maybe it's not your strength but maybe you have a sports trainer look at it or exercise trial the stepwise study is running in the Netherlands so we're only including Dutch patients at this point the slow speed study is in the prodromals so this is only for people who haven't had a diagnosis yet so but that will be starting anytime soon uh any views on the benefits of intermittent fasting combined with exercise is questioned by Eamon no evidence even um there's actually a bit of evidence but not much an intermittent fasting seen a few studies but it's not at the level yet where I would prescribe it as a physician I think there are some encouraging early evidence but not enough to prescribe it as a physician let alone about the interaction um the one study that I mentioned um uh that looked at both diet and exercise found these to be independent effects which I personally find encouraging that both diet and exercise are good and that if you do both the effects sum up so but whether this the the if you adhere to diet I think the evidence is best for a Mediterranean diet a few cups of coffee avoiding milk products or excessive milk products spreading your proteins across today and avoiding peaching proteins and eating organic as much as you can because for those of you who follow my work I'm very very worried about pesticides as your cause of Parkinson's pesticides according to recent work may even accelerate disease progression if you already have Parkinson's so try to avoid exposure to pesticides by eating organic or washing your fruit and veggies as carefully as possible so Jasmine Garcia says in addition to aerobic exercise and strength training what complementary therapies physio massage acupuncture do you recommend it's the most beneficial or is it most based on individuality and what is relief is found from um so Jasmine I don't like the term complementary therapies I'm a very holistic thinker as you may have gathered from my presentation I don't think it is regular versus complementary it's all treatment it's all on a Continuum and the Continuum is not so much determined whether it's complementary or regular but it's about the level of evidence and there's Simply Better evidence for levodoba than there is for yoga or mindfulness or um if I could I could probably or probably should do a whole separate lecture here on my vision about complementary therapies or holistic medicine or Integrative Medicine but the one element in addition to diet and exercise that I would like to pick out is anything that alleviates stress is crucial so I'm a strong believer in yoga and mindfulness and there is good evidence to support yoga and mindfulness stress worse and symptoms in Parkinson's uh in the in the short term and there is some careful evidence including new work by my own group that chronic stress May accelerate disease progression so conversely mindfulness may slow down disease progression that remains to be studied I am a believer so the package in my team is exercise diet and anything that reduces stress um and there's a whole range of other things but that's for a separate you know talk um Frank says what's your opinion on the ketogenic diet the ketogenic diet is not an easy diet to adhere to there are some reports that have mentioned a beneficial effect of the ketogenic diet but these were not particularly well designed and I think there is at best hints that it may be effective um but I'm not prescribing the ketogenic diet yet um because the there's not enough evidence for its efficacy um and it's not easy to adhere to so I'm not I'm not prescribing it yet um next question by Marietta Robin from the Netherlands hi Marietta nice to see you and she says duncaville which is Dutch for thank you which is your welcome very motivating talk now my question is about do the exercise you like after 10 years of Parkinson's and now running our own Parkinson Sports Club I think it would be a relief for many people to recognize that exercise is not always fun training for an Olympic medal is not always fun I guess the there simply is a part of exercise that is not fun the bit that is fun is your long-term goal and that is exactly right you know mercuriala said it um exercise comes with a bit of pain I'm not always enjoying myself on the treadmill or the exercise bicycle I do it because of the Happy Feelings the endorphins immediately after the exercise and what should really motivate people is my conviction and I'm 100 convinced that if you regularly exercise your future will be better so please adhere to your exercise even if the workout itself isn't always Pleasant think of the dot or the Horizon and you will be better with exercise down the road if you do it now John Palmieri thank you for the amazing talk I noticed that in the Thunder called 2009 study that was the gamified home-based exercise study with stationary bicycles there were a few participants that did not respond well to the bicycling intervention so do you have any insight in what determines whether someone is a responder or a non-responder well John that's a brilliant question it's a 10 billion dollar question if I could answer it now I would probably not be here but I would be in Stockholm collecting my Nobel Prize the honest answer is I don't know what I do know is that this is the next level of research we talk about personalized medicine with drugs we try to tailor the drugs to your personalized DNA profile but I think we should also begin to learn and understand why some people respond to exercise and others don't I predict it relates to polymorphisms changes in your DNA your genetic profile for neural growth factors so people who have a genetic profile that allows them to build growth factors more readily than others May respond better to exercise but that's just an educated guess it needs to be researched and it's on our list so to be to be determined Barry Burton who's a physiotherapist are you going to compare live running in nature with virtual reality now that's a really cool study Mary if I had the funding I would do the study tomorrow I would I would predict that running outside is at least as good as treadmill combined with virtual reality um we're not planning to do it I don't have the funding for it but I would love to see the result but my prediction is that running Outdoors is at least as good if not better then maybe also because of the oxygen levels Etc and much more versatile and Marieta Robin says we climb trees in the Netherlands um I'll take that for granted some of us do Marietta it's been a while since I last climbed the tree I have to say Irene says a neuroscientist Andrew humberman did an excellent podcast on alcohol and alcohol the outcome is that alcohol is really damaging the brain so Irene that is very much in line with what I said one study showing that moderate alcohol consumption was beneficial excessive should be avoided altogether and again I I think the literature is biased towards the more positive studies and I agree that alcohol overall is probably not good for your brain if you do take it do it modestly and enjoy it uh David Martin says our exercises that involve impact better than say swimming as they might help to maintain bone density God these questions are really good you know we have an educated audience here and I'm enjoying the questions uh not been studied specifically but I would absolutely concur that this is on the one hand better because yes people with Parkinson's are at risk for losing their bone density um because of their inactivity but also because of the vitamin D deficiency that we talked about earlier so again have your vitamin D controlled on an annual basis um and yes putting strain on your bones helps to maintain bone density so in that regard um it's better than swimming quick word about swimming we published a paper about near drowning people with Parkinson's have a increased risk of drowning and one reason is that swimming requires a complex synchronization of arm movements and leg movements that depends on the spinal pattern generator that spinal pattern generator is also defective in Parkinson's so people sink down to the bottom of the of the swimming pool and are at risk of of drowning so if you consider swimming tell your swimming instructor first that you've got Parkinson's and let them supervise you carefully and I think some form of supervision will always be helpful if you are a swimmer with Parkinson's uh Anonymous attendee does decaf coffee have the same positive effect as caffeinated coffee it does not it appears to be the caffeine we don't fully understand why and how caffeine works for people with Parkinson's but the caffeine definitely seems to be part of the trick so decaf no but if you enjoy decaf do it but three to four cups of real coffee appears to be beneficial I'm looking at Michelle and Mark I know we're there's still 230. I was going to say yes it is basically the questions are coming taken fast and actually we are we are we are fighting a losing battle here we stay stuck at the amount of like around 38 40 questions um I think that what I would suggest perhaps is that we just use maybe 15 minutes more if that is okay for you bus we'll we'll do 10 more otherwise my wife well that's exactly that that's exactly that I was going to suggest that we basically focus on a few questions that would be the most interesting for people uh let's just look at them together if you want um sure sure okay we'll be quick and and uh it will not be the last time I'm doing a silver bullet talk so I'll I'll come we spoke about vibration technology that is already a topic you have touched on uh exercise classes I think that is General the heart rate we spoke a lot about that um well yeah you can remove questions that we've already had and I'll just go from bottom to the um so and I'll focus on new people also Harry Bates um exercise definitely will help but eventually Parkinson's will progress that's what we talked about earlier the the young outset lady who progressed despite uh exercise when the next breakthrough occurs in this terms of disease modification you would expect those already exercising to do better so yes you know we're testing all sorts of drugs now to slow down Parkinson's I think out of all the interventions that we're testing exercises closest to delivering the promise of being a disease modifying therapy and if a drug arrives that slows down Parkinson's I predict it will interact with exercise so don't wait for the drug to arrive don't wait for the miracle therapy but take matters into your own hands and exercise the stepwise app is not available yet it's part of the trial but as soon as the results come out we will put the app freely out on the web shoot one focus on increasing VO2 max breath work before commencing exercise um that I'm not entirely sure if that's a question by David Martin um so Vue to Max was studied in our studies because it's a nice sort of intermediate objective quantitative outcome to prove that people were complying with the exercise um yes I would do it because when I went to the gym and I started doing aerobic exercises they did a VO2 max test to test my own personal you know abilities so if you want to have your customized personalized individualized regime a VO2 max test at the outset might be helpful David is also asking does a rowing machine help to maintain arm actions well some swing may be absent in normal walking I like the rowing because rowing combines arm and leg movement so it's much like a total body workout I don't think it will restore our movements in all fairness because that is the arms are not weak it's the ultimatism it's the um uh it's the it's the it's the the huge it's the the movement pattern that's defective in Parkinson's and you're not going to cure that with rowing but rowing is a brilliant exercise for many other reasons if you don't if you don't make you just read the question it could be quicker a question from Adrian who is asking are there any exercises specifically to help with freezing um not specifically to alleviate freezing um I think if you have a lot of freezing um then obviously regular walking might be difficult or frustrating but some people with freezing can still run on a treadmill partially because running is different motor program partially also because the treadmill acts as a tactile queue but many people with freezing can still ride a bicycle so for those folks cycling on a stationary bicycle is an excellent solution someone is asking about infrared and near infrared therapy which is entirely different from the topic of today but do you have a view on those new technologies I don't think there's any robust evidence for uh any of those therapies not that I'm aware of it doesn't mean it doesn't exist but it didn't catch my eye so it's not not a not a good evidence-based uh intervention I think thank you very much I think that I'm looking very quickly at the remaining questions I think that we basically what I would suggest actually about is maybe that we we do stop here because the questions are still coming in we have covered a lot of the topics that I think you uh come up regularly in those questions um what I do want to say is a is a huge thank you for your time today because I know that you're a very busy man and uh I can't believe how lucky we were today to have so much of your time I also would like to say a big thank you for dedicating your career to help to helping people like all of us on the line here manage our symptoms better and maybe find new therapies that will help us go through this condition better so thank you ever so much for this and to congratulate you again for your Steven Premier award which is an amazing reward and recognition of your your work in the Netherlands and globally so thank you ever so much Professor room for your time today I will send you the the transcript of the the questions so that you can basically have a look at dinner afterwards and if you don't mind sending Mark and I the copy of the pdf version of your slides I will share them with the audience absolutely and then they will also have the references which was one of the questions um and um yeah no that's totally fine and I hope that people enjoyed it and and are motivated to you know engage in regular exercise and um that would you know I've dedicated my life to helping people with Partnerships and um I'm convinced that exercise is one of my best ways to to help you folks so thank you for showing up in such large numbers it's a privilege and um stay healthy and uh see you at some later occasion see you soon thank you very much bye-bye okay bye bye okay

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Length: 97min 16sec (5836 seconds)

Published: Tue Oct 11 2022