Category Archives: Physical activity

9 Things to Know About Exercise-induced Neuroplasticity in Human Parkinson’s

“A willing mind makes a hard journey easy.” Philip Massinger

“Lack of activity destroys the good condition of every human being.” Plato

Introduction: Much of my life has been spent exercising. Most of this exercise has been done with sheer delight.  Since receiving my Parkinson’s diagnosis, my opinion of exercise has changed.  With Parkinson’s, I’m now exercising as if my life depends on it.  Why?  Animal models (mouse and rat) of Parkinson’s have convincing shown the effect of exercise-induced neuroplasticity.  These animal studies demonstrated neuroprotection and even neurorestoration of Parkinson’s.  But we’re neither mice/rats nor are we an animal model of Parkinson’s disease; thus, this post is an update on exercise-induced neuroplasticity in human Parkinson’s.

“If you don’t do what’s best for your body, you’re the one who comes up on the short end.” Julius Erving

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9 Things to Know About Exercise-induced Neuroplasticity in Human Parkinson’s: Neuroplasticity,  neuroprotection and neurorestoration are catchy words that populate a lot of publications, blogs from many of us with Parkinson’s and from professionals who study/work in the field of Parkinson’s.  It is important for you to develop your own opinion about exercise-induced neuroplasticity. My goal in this post is to provide the basic elements, concepts and key reference material to help you with this opinion. Here is a 1-page summary of “9 Things to Know About Exercise-induced Neuroplasticity in Human Parkinson’s” (click here to download page).

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(1) Parkinson’s Disease (PD): Parkinson’s is a neurodegenerative disorder. Parkinson’s usually presents as a movement disorder, which is a slow progressive loss of motor coordination, gait disturbance, slowness of movement, rigidity, and tremor.  Parkinson’s can also include cognitive/psychological impairments. ~170 people/day are diagnosed with Parkinson’s in the USA; the average age of onset is ~60 years-old.

(2) Safety First: The benefit of an exercise routine/program will only work if you have (i) talked about it with your Neurologist and have his/her consent; (ii) you have received advice from a physical therapist/certified personal trainer about which exercises are ‘best’ for you; and (iii) you recognize that PD usually comes with gait and balance issues, and you are ready to begin. Safety first, always stay safe!

(3) Exercise: Exercise is activity requiring physical effort, carried out especially to sustain or improve health and fitness. Exercise is viewed by movement disorders clinicians, physical therapists, and certified personal trainers as a key medicinal ingredient in both treating and enabling patients at all stages of Parkinson’s.

(4) Brain Health: With or without Parkinson’s disease, taking care of your brain is all-important to your overall well-being, life-attitude, and health. For a balanced-healthy brain, strive for: proper nutrition and be cognitively fit; exercise; reduce stress; work and be mentally alert; practice mindfulness/meditation; sleep; and stay positive.

(5) Neuroplasticity: Neuroplasticity describes how neurons in the brain compensate for injury/disease and adjust their actions in response to environmental changes. “Forced-use exercise” of the more affected limb/side can be effective in driving neural network adaptation.  Ultimately, this can lead to improved function of the limb/side.

(6) Synapses are junctions between two nerve cells whereby neurotransmitters diffuse across small gaps to transmit and receive signals.

(7) Circuitry: A key result of neuroplasticity is the re-routing of neuronal pathways of the brain along which electrical and chemical signals travel in the central nervous system (CNS).

(8) Parkinson’s-specific Exercise Programs:
PWR!Moves (click here to learn more)
Rock Steady Boxing (click here to learn more)
LSVT BIG (click here to learn more)
Dance for PD (click here to learn more)
LIM Yoga (click here to learn more)
Tai Chi for PD (click here to learn more)

What types of exercise are best for people with Parkinson’s disease? Here is a nice overview of the benefits of exercise for those of us with Parkinson’s  (click here). Regarding the PD-specific exercise programs,  I am most familiar with PWR!Moves, Rock Steady Boxing and LSVT BIG (I’m certified to teach PWR!Moves, I’m a graduate of LSVT BIG, and I’ve participated in Rock Steady Boxing). A goal for you is to re-read ‘Safety First’ above and begin to decide which type of exercise you’d benefit from and would enjoy the most.

(9) Brain/Behavior Changes: The collective results found increase in corticomotor excitability, increase in brain grey matter volume, increase in serum BDNF levels, and decrease in serum tumor necrosis factor-alpha (TNFα) levels. These results imply that neuroplasticity from exercise may potentially either slow or halt progression of Parkinson’s.

What the terms mean: Corticomotor describes motor functions controlled by the cerebral cortex (people with Parkinson’s show reduced corticomotor excitability). Brain grey matter is a major component of the central nervous system consisting of neuronal cells, myelinated and unmyelinated axons, microglial cells, synapses, and capillaries. BDNF is brain-derived neurotrophic factor, which is a protein involved in brain plasticity and it is important for survival of dopaminergic neurons. Tumor necrosis factor-alpha (TNFα) is an inflammatory cytokine (protein) that is involved in systemic inflammation.  Some studies of exercise-induced neuroplasticity in human Parkinson’s found the above-mentioned changes, which would imply a positive impact of exercise to promote neuroplastic changes.

What can you do with all of the cited articles listed at the end? Compiled below are some comprehensive and outstanding reviews about exercise-induced neuroplasticity in Parkinson’s.  Looking through these papers, you’ll see years of work, but this work has all of the details to everything I’ve described.

“All life is an experiment. The more experiments you make the better.” Ralph Waldo Emerson

What I believe about neuroplasticity and exercise in Parkinson’s: [Please remember I am not a physician; definitely talk with your neurologist before beginning any exercise program.]  I think about exercising each day; I try to do it on a daily basis.  As a scientist, I’m impressed by the rodent Parkinson’s data and how exercise promotes neuroplasticity. The human studies are also believable; sustained aerobic exercise induces neuroplasticity to improve overall brain health. “Forced-use exercise” is an important concept; I try to work my right-side (arm and leg), which are slightly weaker and stiffer from Parkinson’s. Initially, I used my left arm more, now I ‘force’ myself on both sides with the hope my neural network is stabilized or even improving. If you enjoy exercising as I do, I view it as both an event and a reward; ultimately, I believe it can work and improve my response to Parkinson’s. If you don’t enjoy exercising, this may be more of a task and duty; however, the benefits over time can be better health. Exercise is good for you (heart and brain).  Begin slow, make progress, and see if you are living better with your disorder.  Remain hopeful and be both persistent and positive; try to enjoy your exercise.

“I am not afraid of storms for I am learning how to sail my ship.” Louisa May Alcott

Past blog posts: Both exercise itself and the benefit of exercise-induced neuroplasticity have been common themes for this blog, including (click on title to view blog posting):
Believe in Life in the Presence of Parkinson’s;
Déjà Vu and Neuroplasticity in Parkinson’s;
Golf And Parkinson’s: A Game For Life;
The Evolving Portrait of Parkinson’s;
Believe In Big Movements Of LSVT BIG Physical Therapy For Parkinson’s;
Meditation, Yoga, and Exercise in Parkinson’s;
Exercise and Parkinson’s.

“Do not let what you cannot do interfere with what you can do.” John Wooden

References on neuroplasticity and exercise in Parkinson’s:
Farley, B. G. and G. F. Koshland (2005). “Training BIG to move faster: the application of the speed-amplitude relation as a rehabilitation strategy for people with Parkinson’s disease.” Exp Brain Res 167(3): 462-467 (click here to view paper).

Fisher, B. E., et al. (2008). “The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson’s disease.” Arch Phys Med Rehabil 89(7): 1221-1229 (click here to view paper).

Hirsch, M. A. and B. G. Farley (2009). “Exercise and neuroplasticity in persons living with Parkinson’s disease.” Eur J Phys Rehabil Med 45(2): 215-229 (click here to view paper).

Petzinger, G. M., et al. (2010). “Enhancing neuroplasticity in the basal ganglia: the role of exercise in Parkinson’s disease.” Mov Disord 25 Suppl 1: S141-145 (click here to view paper).

Bassuk, S. S., et al. (2013). “Why Exercise Works Magic.” Scientific American 309(2): 74-79.

Lima, L. O., et al. (2013). “Progressive resistance exercise improves strength and physical performance in people with mild to moderate Parkinson’s disease: a systematic review.” Journal of Physiotherapy 59(1): 7-13 (click here to view paper).

Petzinger, G. M., et al. (2013). “Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease.” Lancet Neurol 12(7): 716-726 (click here to view paper)..

Ebersbach, G., et al. (2015). “Amplitude-oriented exercise in Parkinson’s disease: a randomized study comparing LSVT-BIG and a short training protocol.” J Neural Transm (Vienna) 122(2): 253-256 (click here to view paper).

Petzinger, G. M., et al. (2015). “The Effects of Exercise on Dopamine Neurotransmission in Parkinson’s Disease: Targeting Neuroplasticity to Modulate Basal Ganglia Circuitry.” Brain Plast 1(1): 29-39 (click here to view paper).

Abbruzzese, G., et al. (2016). “Rehabilitation for Parkinson’s disease: Current outlook and future challenges.” Parkinsonism Relat Disord 22 Suppl 1: S60-64 (click here to view paper).

Hirsch, M. A., et al. (2016). “Exercise-induced neuroplasticity in human Parkinson’s disease: What is the evidence telling us?” Parkinsonism & Related Disorders 22, Supplement 1: S78-S81 (click here to view paper)

Tessitore, A., et al. (2016). “Structural connectivity in Parkinson’s disease.” Parkinsonism Relat Disord 22 Suppl 1: S56-59 (click here to view paper).

“If we could give every individual the right amount of nourishment and exercise, not too little and not too much, we would have found the safest way to health.” Hippocrates

“Life is complex. Each one of us must make his own path through life. There are no self-help manuals, no formulas, no easy answers. The right road for one is the wrong road for another…The journey of life is not paved in blacktop; it is not brightly lit, and it has no road signs. It is a rocky path through the wilderness.” M. Scott Peck

Cover photo credit: http://paper4pc.com/free-seascape.html#gal_post_55564_free-seascape-wallpaper-1.jpg

Brain exercising cartoon: http://tactustherapy.com/neuroplasticity-stroke-survivors/

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Believe in Life in the Presence of Parkinson’s

“Life is not only merriment, it is desire and determination.” Kahlil Gibran

“Nothing will work unless you do.” Maya Angelou

Dedication: I recently participated in a Parkinson Wellness Recovery (PWR!) Instructor Workshop in Greenville, SC (July 30-31, 2016); now I am certified in PWR!Moves.  This post is dedicated to the workshop instructor Jennifer Bazan-Wigle; and to my classmates, all of the personal trainers interested in working with Parkinson’s disease patients.  Jennifer was simply a great instructor, with a real understanding of Parkinson’s and a true ability to ‘teach’.  The personal trainers who participated were very dedicated in their effort to master PWR!Moves and their willingness to instruct me during the weekend workshop made for a memorable experience.  And not to forget Steve Miller, a PWR!Moves instructor, who also helped teach; you were the inspiration that led me to apply for this workshop. To everyone certified in PWR!Moves and to those involved in my PWR!Moves workshop, thank you, thank you so very much.

PWR! Logo

“There are no shortcuts to any place worth going.” Beverly Sills

Introduction: Coach Lou Holtz said “Ability is what you’re capable of doing. Motivation determines what you do. Attitude determines how well you do it.”  This got me thinking about ability, motivation and attitude but especially how vital both motivation and attitude are for living successfully with Parkinson’s.

Believe in Life in the Presence of Parkinson’s:
I’m a healthy person that happens to have Parkinson’s; this is what I believe:
I believe daily exercise enhances my life in the presence of Parkinson’s.
I believe people-with-Parkinson’s can become healthier with exercise.
I believe sustained exercise can promote neuroplasticity to re-wire my neural network.
I believe I have the ability to do the repetitions to re-train my brain.
I believe staying positive will help control the course of my Parkinson’s.
I believe having courage will provide mettle in the battle against my disorder.
I believe being persistent allows me to restrain my Parkinson’s.
I believe motivation begins from within, and there can be no backing down to this disease.
I believe if I don’t give up I can slow the progression of my disorder.
I believe if you pity me it feeds the hunger of my Parkinson’s.
I believe if you join my team, you can help me stall this slowly evolving disorder.
I believe attitude is the fuel to sustain the effort to combat Parkinson’s.
I believe in science that new therapies/strategies against Parkinson’s are on the horizon.
I believe exercise with ability, motivation and attitude will work to my advantage each day.
I believe that each new day renews my chance of slowing the beast named Parkinson’s.
My daily mantra is to never give up; I refuse to surrender to Parkinson’s.

“Keep your thoughts positive because your thoughts become your words. Keep your words positive because your words become your behavior. Keep your behavior positive because your behavior becomes your habits. Keep your habits positive because your habits become your values. Keep your values positive because your values become your destiny.” Mahatma Gandhi

Cover photo credit: https://c7.staticflickr.com/9/8615/16157237102_f15e505c19_b.jpg

 

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The Evolving Portrait of Parkinson’s

“Aging is not lost youth but a new stage of opportunity and strength.” Betty Friedane

 “If we own the story then we can write the ending.” Brené Brown

Précis:  To showcase the amazing art/photography/videography of Anders M. Leines who lives in Norway, which gives me the opportunity to voice an opinion about the emerging picture/image of Parkinson’s today.

World Parkinson Congress (WPC) Promo Video: Please watch this video, it’s powerful; “This is Parkinson’s” a WPC Promo from Anders M. Leines (either view it below or click here).  Anders is a videographer and cameraman who works in Oslo, Norway; he’s been diagnosed with young onset Parkinson’s. One of his goals is to change the view about how Parkinson’s is perceived by the world.  One look at his video reinforces this notion.  A very nice article about Mr. Leines was recently posted in “Parkinson’s Life” (click here to read this story).  Anders also shares his story with his own blog “This is Parkinson`s” – The Exhibition.  The pictures, the script, and the music accompanying the WPC 2016 Promo by Mr. Leines says more in 1 min 42 sec about Parkinson’s than someone could likely summarize by writing a blog post, but nonetheless I’m going to try.

A hero is an ordinary individual who finds the strength to persevere and endure in spite of overwhelming obstacles.” Christopher Reeve

The Historical Perception of Parkinson’s: Sir Richard Gowers, in 1886, used this drawing (below left panel) to depict a person with Parkinson’s. When you perform a Google search for a ‘picture of Parkinson’s disease’, these sorts of images are still very prevalent. Yes, the average age of someone with Parkinson’s is 60 years of age and older. And yes, Sir Gowers does accurately show the Cardinal signs of Parkinson’s: tremor, rigidity from muscle stiffness, bradykinesia (slowness of movement), postural instability, and masking (reduced facial expression).  Furthermore, Dr. Charcot’s  drawings, from 1888, also depict a typical Parkinson’s patient compared to an atypical patient with Parkinson’s (bottom right panel).  While these drawings are accurate, these images portray to many who see them that all people-with-Parkinson’s must look and act like this. 

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“In all human affairs there are efforts, and there are results, and the strength of the effort is the measure of the result.” James Allen

The Emerging Perception of Parkinson’s: The reality today is that available treatment strategy and approach to life for someone with Parkinson’s are very different than what was possible for the people portrayed by Sir Gowers and Dr. Charcot. Today, we have well-trained neurologists that are specialists in movement disorders. We have a growing appreciation and understanding of the pathology and biology of Parkinson’s disease.  We have learned about vital lifestyle changes needed to thrive in the presence of this disorder. We have a growing list of therapies [both traditional and complementary and alternative medicine (CAM)] to treat Parkinson’s; we even have deep brain surgery (this surgical technique itself is undergoing new advances and is further evolving in its attempt to control/modify symptoms). We have an increased awareness of the importance of exercise to try to slow progression of this disorder. There is clearly a subset of people with Parkinson’s that present at an earlier age than 60 years old (and this is what Mr. Leines and his exhibition is highlighting).   No doubt, we are living longer and we are likely healthier than someone from the 1880’s; however, that also implies we’re living more years with our Parkinson’s.

This is not saying that Parkinson’s today is either a benign or a tame disease; in fact, it’s an insidious disorder.  Having Parkinson’s is like trying to get rid of cockroaches in your house.  You’ve done all you can to eliminate the roaches from your home, and you don’t see them for weeks; subsequently one day, they’re back. Likewise, Parkinson’s creeps around in the background of your daily life by stealthily altering physical/movement functions, by slowly uncoupling your crucial autonomic nervous system, and surreptitiously in ~50% of people with the disorder, they can develop psychotic tendencies.  The image of Parkinson’s today is clearly evolving due to improved treatment, better understanding of the disorder itself, and improved strategies for living with it; however, under any guise it is still a disagreeable disorder.

“With everything that has happened to you, you can either feel sorry for yourself or treat what has happened as a gift. Everything is either an opportunity to grow or an obstacle to keep you from growing. You get to choose.” Wayne Dyer

A Change is Happening in Our Perspective of Parkinson’s Today:  It is my belief that the perception of Parkinson’s today has changed and is becoming much different than the historical views as described above. I truly believe that the effort most people are using to handle their disorder puts them in a healthier and better lifestyle to manage their symptoms. An emerging predominate picture of Parkinson’s today is a person striving to live strongly. They’ve embraced the appropriate lifestyle, and they are trying their hardest to not become as depicted by the images from the 1800’s. When you do a Google search for ‘images of Parkinson’s disease 2016’, you will likely find more positive and dynamic pictures of people similar to those portrayed by Mr. Leines.

“Let me tell you the secret that has led me to my goal. My strength lies solely in my tenacity.” Louis Pasteur

A Personal Perspective of Parkinson’s Today: With the “This is Parkinson’s” video from Anders M. Leines as an inspiration, I’ve included two sets of pictures of my life with Parkinson’s (photos are below). If my disorder fully progresses, and it is a progressive neurodegenerative disorder, in advanced age (I’m currently 62 years old) I may possibly appear like the drawings above from Sir Gowers and Dr. Charcot. However, as a research scientist, I truly believe in the words of Dr. Claude Levi-Strauss who said “The scientist is not a person who gives the right answers, he is one who asks the right questions.”  I am trying to improve my own knowledge about Parkinson’s; after all, there are still so many questions I want to ask, there are so many new scientific advances that I need to better understand, and there are some emerging treatment strategies that I’d be willing to consider in the future. In other words, Parkinson’s is a reluctant and unwelcome visitor in my body and I’m doing as much as I can to manage the disorder.

With substantial effort, I’m going to do all I can to resist progression; I’m going to stay hopeful, be positive, and remain persistent for many years to come. Importantly, I will take time to stretch every few hours and really make an effort to exercise every day. I will try harder to get an adequate amount of sleep every night.  I am also trying to be mindful and live within the moment by not fretting about what the future could bring.

Thus, this is what I consider to be true of myself (many other people with Parkinson’s would also fit this description): I’m a healthy person that just happens to have Parkinson’s. As I’ve said before, we both have much left to accomplish. We are both still here. Stay focused and stay hopeful.

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“We live in a time when the words impossible and unsolvable are no longer part of the scientific community’s vocabulary. Each day we move closer to trials that will not just minimize the symptoms of disease and injury but eliminate them.” Christopher Reeve

Cover photo credit: http://epod.usra.edu/.a/6a0105371bb32c970b015438c5312a970c-pi

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Catching Up, Life-Stories, and Future Posts in Journey With Parkinson’s

“One isn’t necessarily born with courage, but one is born with potential. Without courage, we cannot practice any other virtue with consistency. We can’t be kind, true, merciful, generous, or honest.” Maya Angelou

“Life is not a problem to be solved, but an experience to be had.” Alan Watts

Don’t You Get The Summer Off?: My favorite check out guy at Whole Foods asked me recently, “Don’t you get the summer off from teaching medical students?” And one of my  weekend golf buddies routinely jokes about the fact that I’m in academics and says “I only have to work nine hours a week.”  In reality, being at a medical school has always meant to me to work essentially everyday. As long as my brain is functioning, I will continue to follow this lifestyle.  I have spent the summer getting ready for the fall semester, catching up on my research in the laboratory, and doing all the things I neglected to do during the school year.  Yes, in the summer I do take more opportunity to play golf during the week; however, I make up the hours working either early in the morning or late in the evening.   I realized today that I had not posted a blog in over a month; I have been busy and just not had time to sit at my computer to plan, research, think and write. The goal of this current blog is meant to be an update including future planned posts.

“What I have learned from life is to make the most of what you have got.” Stephen Hawking

Letters of Recommendation:  One of the obligations of a university professor that teaches undergraduate students is to be willing and able to write supportive letters of recommendation (well, that’s my opinion).  Many of the students I’ve taught in the past year are applying to medical school, dental school, graduate school, physician assistant school, pharmacy school, nursing school, and postbaccalaureate programs.   Several of my former students are also reapplying to some of the same programs. In a typical year, I will write 40 to 50 letters of recommendation.  And of course, the goal is to write a uniquely different letter for each student; to describe their key highlights, give evidence of their potential, and to find the most appropriate descriptive adjectives for each person.  Thus, each letter becomes its own journey from my perspective, and it takes time and considerable attention to compose such a supportive type of letter. And writing for me is always a struggle, because I have to be in the right mental  frame of mind to compose any document. My goal for the rest of  July through August is to try and write one or two letters of recommendations every couple of days.

“Life is not easy for any of us. But what of that? We must have perseverance and above all confidence in ourselves. We must believe that we are gifted for something and that this thing must be attained.” Marie Curie

Parkinson’s Empowerment Symposium: Options for Care and Living Well for Patients and Families (June 18, 2016, Asheville, North Carolina): The UNC Movement Disorders Center hosted a 1-day symposium on Parkinson’s. The focus was described as follows: “This educational program is intended for individuals diagnosed with Parkinson’s disease and/or PD care partners, with the goals of reviewing treatment and therapy options, discussing effective coping, and providing a space to ask questions.” Seeking refuge from the summer heat, we combined a fun weekend in the cool Smoky mountains in the wonderfully eclectic city of Asheville with great cajun food for dinner, cool dry mountain air to play 18-holes of golf and just relaxing fun; we also attended the Parkinson’s symposium (see pictures below; the tattoo shop story will be reserved for a future blog post).  Being around a large group of people with Parkinson’s was inspiring and motivated me further to work managing/dealing with my Parkinson’s.  All-in-all, a great experience.

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“Life is like riding a bicycle. To keep your balance, you must keep moving.” Albert Einstein

Awakenings:  Awakenings is a 1973 book by Oliver Sacks; he found beneficial effects of the drug L-Dopa when given to catatonic patients with encephalitis lethargica. Awakenings is also a 1990 American movie on the same topic staring Robin Williams and Robert De Niro. Use of L-Dopa ‘awakened’ the patients after years of being catatonic and now they are confronted with renewed life many years beyond their comprehension. The idea behind the treatment came from the success of using L-Dopa for treating Parkinson’s.

For the past few months, I’ve been feeling more stiffness, moving less-well and generally had a slight foreboding sense of dread.  My Neurologist, during my recent visit, decided that my treatment strategy had become less effective and we needed to ‘add-on’ something.  After several minutes of options and dosing of various compounds, I made the decision to move to Sinemet (the generic formula of Carbidopa-Levodopa 25-100 tablets); in addition to the dopamine agonists (Ropinirole extended release tablets and  Rotigotine transdermal patch).  My ‘awakening’ moment happened with the first small dose of the generic Sinemet. Absolutely felt better, less stiff, more flexible, and totally different.  I am excited to see what the future brings in continuing my new group of drugs; ready to keep exercising with renewed hope and ready to keep the rest of my life moving more efficiently.  So far the addition of the generic Sinemet has been simply positive and my own awakening.

“Life’s challenges are not supposed to paralyze you, they’re supposed to help you discover who you are.” Bernice Johnson Reagon

Coming Attractions: There are 4 categories to posts for this blog: i) “Life Lessons” (describe living with Parkinson’s); ii) “Medical Education” (report emerging medical strategies for treating/managing/curing Parkinson’s); iii) “Strategy for Living” (support mechanism to anyone with Parkinson’s or other neurodegenerative disorder); and iv) “Translating Science” (educate by presenting scientific aspects of Parkinson’s).  Listed below are the posts that are coming later this summer (my hope/plan is to get ~2 posts finished/week):

Medical Education
Immune System and Parkinson’s (Part 2): Role of Innate Immunity.

Anatomy of Parkinson’s.
Traumatic Brain Injury (TBI) Associated with Increased Risk of Parkinson’s but not of Alzheimer’s.
Update on the Anti-leukemia Drug Nilotinib and Treatment of Parkinson’s.

Strategy for Living
Parkinson’s Wellness Recovery (PWR!) Exercise Program and Neuroplasticity.
Part 5: Journey to Parkinson’s and Transradial Cardiac Catheterization.

Part 4: Journey to Parkinson’s and Electromyography.
Part 3: Journey to Parkinson’s and Polysomnography.
Part 2: Journey to Parkinson’s and Magnetic Resonance Imaging.

Life Lessons
New Face of Parkinson’s and the World Parkinson Congress.
A Simple Plan.
Where Were You When?
Love in the Presence of Parkinson’s.

Translating Science
c-Abl and α-Synuclein Interactions Linked to the Development of Parkinson’s.
Less Clueless About Parkinson’s.
Genetic Profiling of Parkinson’s Disease and Parkinson’s Dementia.
Arginase in Alzheimer’s: A New Hope.
Deletion of Huntingtin Gene in Adult Mice Suggests a New Treatment Strategy for Huntington’s.
NAD+  is Neuroprotective in a Drosophila Model of Parkinson’s.

“Life is an opportunity, benefit from it. Life is beauty, admire it. Life is a dream, realize it. Life is a challenge, meet it. Life is a duty, complete it. Life is a game, play it. Life is a promise, fulfill it. Life is sorrow, overcome it. Life is a song, sing it. Life is a struggle, accept it. Life is a tragedy, confront it. Life is an adventure, dare it. Life is luck, make it. Life is too precious, do not destroy it. Life is life, fight for it.”  Mother Teresa

Cover photo credit: http://www.pixelstalk.net/wp-content/uploads/2016/05/HD-Summer-Desktop-Wallpaper.jpg

Parkinson’s Treatment With Dopamine Agonist, Complementary and Alternative Medicine (CAM), and Exercise

“Stop taking identity in illness and start taking identity in wellness” Nina Leavins

“The thought of hope is the seed to healing.” Shilpa Menon

Précis: Several of you have asked for an update on my strategy for treating my  Parkinson’s.  My current plan consists of traditional Parkinson’s medication,  augmented by a complementary and alternative medicine (CAM) approach, and supplemented by exercise.

Is current Parkinson’s therapy similar to the new models of personalized medicine?:  Those of us with Parkinson’s have a  constellation of symptoms that vary from person-to-person.   There is no doubt that people with Parkinson’s have a movement disorder with unifying clinical features. However, expression and rate of progression of the common physical symptoms (rigidity; slowness of movement; postural instability and gait problems; and tremor) differ in each of us. This degree-of-difference in how we express our Parkinson’s is likely a combination of environmental  influences [both internal (physiologic) and external (life-style)] and genetics.

Ask 10 people with Parkinson’s to describe their symptoms and their therapy; I wouldn’t be surprised if you get 10 (slightly) different answers. In someway we are lucky (okay, relieved is likely a better word choice) because we received the diagnosis, we began being treated, and probably we started feeling better.

There is a new (and developing) trend in treating patients using a more personalized approach aimed at preventing disease with individualized treatment once the disease is diagnosed (and includes individual genetic tests). This is called personalized medicine or precision medicine (‡given at the bottom is a fuller definition).   Although there is no specific genetic test for the most common form of Parkinson’s (termed idiopathic or sporadic), I believe our neurologists are already using a form of personalized medicine to manage our individual and varied (but still somewhat similar) symptoms.

“When you got a condition, it’s bad to forget your medicine.”  Frank Miller

“If you suspect that you have Parkinson’s, knowing for certain will be much better than uncertainty.” Glenna Wotton Atwood

My Parkinson’s treatment strategy involves traditional drugs, complementary and alternative medicine (CAM), and  exercise: Compared to others, my treatment plan may seem relatively simple. It has been devised by many conversations with my Neurologist and Internist. Combined with a lot of reading and internet searching of the medical literature on what has worked in Parkinson’s treatment, the CAM list continues to evolve and be refined [e.g., I believe that NAC travels to the brain in a usable form to then boost intracellular  glutathione levels.].  The diagram below  presents an overview of the strategy for treating my Parkinson’s.

16.04.28.Brain.Med.CAM.Exercise

-Dopamine agonists: For the past two years I’ve been taking the dopamine agonist Ropinirole. Recently, we decided to add the Neupro transdermal patch, which is another dopamine agonist (Rotigotine).  By  using the dopamine agonist patch, the thought is to normalize the amount of dopamine agonist in my body throughout the day (i.e., smooth out the peaks and valleys). I have tried to  draw it schematically below.

16.05.02.Normalizing.DA.Levels

Isradipine: An FDA-approved calcium-channel blocker (CCB) named Isradipine penetrates the blood brain barrier to block calcium channels and potentially preserve dopamine-making cells. Isradipine may slow the progression of Parkinson’s. The primary use of Isradipine is in hypertension; thus, to treat my pre-hypertension I switched from the diuretic Hydrochlorothiazide to the CCB Isradipine.  A CCB is a more potent drug than a diuretic; importantly, my blood pressure is quite normal now and maybe I’m altering the progression of my Parkinson’s. [Please consult with your physician before taking any type of new medication.]

-Complementary and Alternative Medicine (CAM): “Complementary and alternative medicine (CAM) is the term for medical products and practices that are not part of standard medical care. ‘Complementary medicine’ refers to treatments that are used with standard treatment. ‘Alternative medicine refers to treatments that are used instead of standard treatment.”  (http://www.cancer.gov/cancertopics/cam). My CAM strategy for treating Parkinson’s goes as follows: compounds (reportedly) able to penetrate the blood brain barrier; compounds (possibly) able to slow progression of the disorder; compounds that are anti-oxidative and anti-inflammatory; compounds that don’t adversely alter dopamine synthesis/activity; and compounds that support general brain/nervous system health. [Please consult with your physician before taking any type of supplements.]

-Exercise: Exercise improves flexibility, builds muscle mass,  aids sleep, and reduces stress. Exercise is neuroprotective in Parkinson’s (see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3136051/ and http://www.neurology.org/content/77/3/288 and http://www.ncbi.nlm.nih.gov/pubmed/21375602 ).  For anyone with Parkinson’s, it is important to stretch and exercise on a very regular basis. Brian Lambert remarked: “With Parkinson’s, exercise is better than taking a bottle of pills. If you don’t do anything you’ll just stagnate.”  My strategy is relatively simple, make time in each day to exercise (it’s that important): stretch every couple of hours (the exercises in LSVT BIG are fantastic); and try to exercise every day for 30-60 minutes (playing/walking 18 holes of golf takes ~4-5 hr). I do a lot of exercises with range of motion sports like golf and boxing on a reflex bag (more tennis this summer).  Most importantly, I do exercises that I really enjoy doing and it brings a lot of enjoyment to the way my body feels. [Please consult with your physician before beginning any new exercise routine.]

 -The Table below summarizes my  approach to managing my Parkinson’s:

16.05.04.DailyTherapy*Footnote to Table: Medical (MED), Experimental (EXP), Complementary and alternative medicine (CAM), Exercise (EXERC).

 -Past References: In previous posts linked here, I have described various aspects of my treatment strategy (click on word/phrase):  first treatment plan; complementary and alternative medicine (CAM); Isradipine; exercise-1; exercise-2; exercise-3; LSVT BIG.

“Exercise is king. Nutrition is queen. Put them together and you’ve got a kingdom.”   Jack LaLanne

“There’s always a moment that separates the past from the future, and that moment is now.” Aniekee Tochukwu

Managing Parkinson’s: While we wait for a cure, we manage our disorder by many methods. While we wait for the potion that slows progression, we exercise and remain hopeful. While we live with a neurodegenerative disorder, we strive to remove the label and we stay positive.
Please stay involved in managing your disorder.
Please work with your Neurologist to develop your own ideal strategy.
Please stretch and exercise, it’ll make a difference.
Please use hope and positivity to remain focused and persistent.
Please use loved ones and support team to help sustain your treatment plan.
What you do in managing your disorder will help you today and for many more future days.

 “We look for medicine to be an orderly field of knowledge and procedure. But it is not. It is an imperfect science, an enterprise of constantly changing knowledge, uncertain information, fallible individuals, and at the same time lives on the line. There is science in what we do, yes, but also habit, intuition, and sometimes plain old guessing. The gap between what we know and what we aim for persists. And this gap complicates everything we do.” Atul Gawande

‡”Personalized medicine is a medical model that separates patients into different groups—with medical decisions, practices, interventions and/or products being tailored to the individual patient based on their predicted response or risk of disease.” (https://www.google.com/search?q=personalied+medicine&ie=utf-8&oe=utf-8#q=personalized+medicine)

Cover photo credit: http://az616578.vo.msecnd.net/files/2016/03/19/635940149667803087959444186_6359344127228967891155060939_nature-grass-flowers-spring-2780.jpg

Brain image modified from: http://cdn.playbuzz.com/cdn/bb0810a8-aeff-403b-b38a-e1e9fc9f7c81/79502c61-ec41-4802-8e22-92a0ddc0cc20.jpg

 

 

Déjà Vu and Neuroplasticity in Parkinson’s

“Continuous effort – not strength or intelligence – is the key to unlocking our potential.” Winston S. Churchill

“…remember that what has once been done may be done again.” Alexandre Dumas

Introducing the terms:
D
éjà vu: “A feeling of having already experienced the present situation.” (http://www.oxforddictionaries.com/us/definition/american_english/)

Neuroplasticity: “The brain’s ability to reorganize itself by forming new neural connections throughout life. Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.” (http://www.medicinenet.com/script/main/art.asp?articlekey=40362 )

Do you remember learning how to ride a bike, throw/catch a baseball, and/or hit a golf ball? Yes, yes, yes; when I was a child with my father.
Learning to ride a bicycle
–  training wheels, then two wheels with support from my dad going down the street, and then he let me go on my own; never to forget how to balance and pedal the bicycle.
Learning how to catch and throw a baseball– wrapping up the ball in the mitt to get it conditioned, the  correct throwing motion, watching the thrown ball into the mitt and working on my hand-to-eye coordination.
Learning the basics of the golf swing– the complexity and intricate timing of swinging a golf club with my dad showing me how to do it from grip, set-up, back swing to follow through.
We likely all have childhood memories of activities where our brain and body were trained/taught to do something.

“Neurons that fire together wire together. Mental states become neural traits. Day after day, your mind is building your brain. This is what scientists call experience-dependent neuroplasticity,” Rick Hanson

Déjà vu and physical activity with Parkinson’s: As someone who has loved to exercise almost every day for most of my life, Parkinson’s is a most disagreeable disorder. Why? Let me give you an example of playing golf. I think about playing golf almost every day although I play maybe once a week and try to practice a couple of times per week. It used to be, every time I addressed the golf ball, my body remembered what it’s supposed to do while waiting for the signals from the brain. Now today, approaching the golf ball I remind myself this is a golf shot. As Yogi Berra said “It’s like déjà vu, all over again” and I remember I’ve been here many times before. It’s as if a short circuit exists and I’m realigning this circuitry every time I swing the golf club. For the most part, my brain-body connection still works and I successfully hit the golf ball; but not every time (maybe I just need to practice more?). This might be analogous to a car running very low on transmission fluid (i.e., in my case low on dopamine); the gears are still working but just not working very smoothly.

“Never give up. It’s like breathing—once you quit, your flame dies letting total darkness extinguish every last gasp of hope. You can’t do that. You must continue taking in even the shallowest of breaths, continue putting forth even the smallest of efforts to sustain your dreams. Don’t ever, ever, ever give up.” Richelle E. Goodrich

Neuroplasticity and physical activity: Kleim and Jones (2008) and Petzinger et al. (2013) describe neuroplasticity as a process where the brain encodes experiences and is able to learn new behavior. They define neuroplasticity as the modification of existing neural networks by adding or modifying synapses in response to changes in behavior or environment, especially when done with exercise. Thus, neuroplasticity can help repair and strengthen the circuitry of the brain.  There is substantial evidence in human studies and in rodent-experimental models that have validated numerous exercise-associated effects on “brain health”.  A regular aerobic exercise program likely helps to promote the appropriate conditions for the injured brain to undergo neuroplasticity. 

“Among other things, neuroplasticity means that emotions such as happiness and compassion can be cultivated in much the same way that a person can learn through repetition to play golf and basketball or master a musical instrument, and that such practice changes the activity and physical aspects of specific brain areas.” Andrew Weil

Neuroplasticity and physical activity in Parkinson’s: [Please remember I am not a physician; I’m not making recommendations for you to do something.  Please talk with your neurologist and/or family practitioner before beginning any of these exercise programs.]  Balance, gait-improvement and flexibility are some of the obvious things a person with Parkinson’s needs to address on a frequent basis, in fact, on a daily basis. Clearly this needs to be self-motivated in the interest of possible neuro-rehabilitation. Most experts suggest that the exercise program should be repetitive, intense, and challenging.   Of course, you must enjoy the exercise program.   Ultimately, exercising should hopefully improve motor functions  and also assist  in improving cognitive function.

The exercises that have been most widely studied and proven to be the most beneficial in promoting neuroplasticity are  treadmill training, amplitude training, tai chi, tango dancing, boxing and cycling  (there are many other exercises to consider, don’t be limited by these above). In my opinion, it’s doing the aerobic exercise you enjoy on a daily and sustained basis,  it’s getting range of motion, and its challenging to you mentally.  As a scientist, I’m impressed by the data in rodent Parkinson’s models and the ability of exercise to promote neuroplasticity, to provide neuroprotection, and even offer neurorestoration. In human studies, the results are remarkably strong as well; showing that sustained aerobic exercise induces neuroplasticity in a damaged brain to improve overall brain health.

“Things don’t go wrong and break your heart so you can become bitter and give up. They happen to break you down and build you up so you can be all that you were intended to be.” Charles Jones

Neuroplasticity and physical activity on overall brain health in Parkinson’s. There is substantial scientific evidence that goal-directed aerobic exercise can improve and strengthen motor circuitry. This is due to structural modifications of synapses and overall improved brain health (increased blood flow, enhanced innate immune system and possibly neurogenesis). Overall brain health initiated by exercise-dependent neuroplasticity alters behavior (affecting many areas of the brain, e.g., the basal ganglia,  cortex, thalamus, and cerebellum). Ultimately, the net effect of sustained exercise and neuroplasticity results in improved motor skills, executive function, cognitive function and mood and motivation.  The diagram below illustrates the changes that can occur with exercise-induced neuroplasticity in Parkinson’s.

Neuroplasticity_4.16.03.13

“Any man could, if he were so inclined, be the sculptor of his own brain.” Santiago Ramón y Cajal

Three comments on déjà vu, neuroplasticity  and physical activity in Parkinson’s:
#1,  Maybe you’re thinking that I’m 62 y.o. and just less coordinated on the golf course with or without Parkinson’s. No doubt this is true but I have my déjà vu feeling, there’s clearly some brain-body disconnect with Parkinson’s (I do need to keep practicing to get more consistent).
#2,  Exercise-induced neuroplasticity will not reverse the effects of Parkinson’s. However, many different studies suggest some restoration of brain circuitry due to exercise-induced neuroplasticity. This implies with time and effort to exercise one could somewhat improve motor learning and behavior performance.
#3, We have much to learn about neuroplasticity and yes even déjà vu. The brain is a powerful organ capable of many different changes when impacted by damage. As we further delineate the mechanism of exercise-induced neuroplasticity, we will better understand Parkinson’s.  Hopefully, from this research (some references are below), there exists the prospect of improved treatment of Parkinson’s. Always remember, a regular aerobic exercise program is good for both your heart and your brain.  Stay positive, be focused, remain hopeful and enjoy your daily exercise.

“Be patient toward all that is unsolved in your heart and try to love the questions themselves, like locked rooms and like books that are now written in a very foreign tongue. Do not now seek the answers, which cannot be given you because you would not be able to live them. And the point is, to live everything. Live the questions now. Perhaps you will then gradually, without noticing it, live along some distant day into the answer.” Rainer Maria Rilke

Cover Photo Credit: https://c1.staticflickr.com/9/8210/8205735122_25302e7cce_b.jpg

References-

Alberts JL, Linder SM, Penko AL, Lowe MJ, Phillips M. It is not about the bike, it is about the pedaling: forced exercise and Parkinson’s disease. Exerc Sport Sci Rev. 2011;39(4):177–86. [PubMed]

Combs SA, Diehl MD, Staples WH, et al. Boxing Training for Patients With Parkinson Disease: A Case Series. Phys Ther. 2010;91(1):132–42. [PubMed]

Corcos DM, Comella CL, Goetz CG. Tai chi for patients with Parkinson’s disease. N Engl J Med. 2012;366(18):1737–8. [PubMed]

Farley BG, Koshland GF. Training BIG to move faster: the application of the speed-amplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Exp Brain Res. 2005;167(3):462–7. [PubMed]

Fisher BE, Wu AD, Salem GJ, et al. The effect of exercise training in improving motor performance and corticomotor excitability in people with early Parkinson’s disease. Arch Phys Med Rehabil. 2008;89(7):1221–9. [PMC free article] [PubMed]

Fox CM, Ramig LO, Ciucci MR, Sapir S, McFarland DH, Farley BG. The science and practice of LSVT/LOUD: neural plasticity-principled approach to treating individuals with Parkinson disease and other neurological disorders. Semin Speech Lang. 2006;27(4):283–99. [PubMed]

Gajewski PD, Falkenstein M. Physical activity and neurocognitive functioning in aging – a condensed updated review. European Review of Aging and Physical Activity. 2016;13:1. doi:10.1186/s11556-016-0161-3.

Hackney ME, Earhart GM. Effects of dance on movement control in Parkinson’s disease: a comparison of Argentine tango and American ballroom. J Rehabil Med. 2009;41(6):475–81. [PMC free article] [PubMed]

Heremans E, Nackaerts E, Vervoort G, Broeder S, Swinnen SP, Nieuwboer A. Impaired Retention of Motor Learning of Writing Skills in Patients with Parkinson’s Disease with Freezing of Gait. Allodi S, ed. PLoS ONE. 2016;11(2):e0148933. doi:10.1371/journal.pone.0148933.

Kleim JA, Jones TA. Principles of experience-dependent neural plasticity: implications for rehabilitation after brain damage. J Speech Lang Hear Res. 2008;51(1):S225–39. [PubMed]

Li F, Harmer P, Fitzgerald K, et al. Tai chi and postural stability in patients with Parkinson’s disease. N Engl J Med. 2012;366(6):511–9. [PMC free article] [PubMed]

Petzinger GM, Fisher BE, McEwen S, Beeler JA, Walsh JP, Jakowec MW. Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s disease. Lancet Neurol. 2013; 12(7):716–726. doi: 10.1016/S1474-4422(13)70123-6 [PMC free article] [PubMed]

Voss MW, Vivar C, Kramer AF, van Praag H. Bridging animal and human models of exercise-induced brain plasticity. Trends in cognitive sciences. 2013;17(10):525-544. doi:10.1016/j.tics.2013.08.001.

 

Golf And Parkinson’s: A Game For Life

“One of the most fascinating things about golf is how it reflects the cycle of life. No matter what you shoot – the next day you have to go back to the first tee and begin all over again and make yourself into something.” Peter Jacobsen

Précis: The goals are to describe the overall benefits of exercise to our health, the neuroprotective effects of exercise in treating Parkinson’s, and to highlight the game of golf for exercise (in the absence/presence of Parkinson’s).

Introduction:  If you’ve been following this blog, you already know how much I value exercise.  If this is your first visit, it’s really simple; any kind of exercise is a wonderful way to feel better, maintain your health, and to have a lot of fun. And if you’re lucky, exercising outside offers even more benefits.  With the backdrop of having Parkinson’s, exercise (physical activity) is essential for living-forward and for maintaining a grip on the miniscule progression of this disorder.

“Golf is a science, the study of a lifetime, in which you can exhaust yourself but never your subject.”  David Forgan 

Benefits of Exercise: One of the healthiest things you can do is exercise (physical activity), and every day if possible! The Mayo Clinic gives 7 benefits of regular physical activity (http://www.mayoclinic.org/healthy-lifestyle/fitness/in-depth/exercise/art-20048389 ): #1, exercise controls weight; #2, exercise combats health conditions and diseases; #3, exercise improves mood; #4, exercise boosts energy; #5, exercise promotes better sleep; #6, exercise puts the spark back into your sex life; and #7, exercise can be fun.

“Golf is deceptively simple and endlessly complicated; it satisfies the soul and frustrates the intellect. It is at the same time rewarding and maddening – and it is without a doubt the greatest game mankind has ever invented.” Arnold Palmer

Neuroprotective Benefits of Exercise: There is ample evidence to suggest that exercise (physical activity) should be given a role in treating Parkinson’s.  Many different types of exercise have been shown to help those of us with Parkinson’s. The key for you is to find the type(s) of exercise(s) you enjoy and are willing to do on a frequent basis.  Anyone with Parkinson’s should be encouraged to participate in routine exercise that allows one to establish and/or maintain physical fitness (please consult your healthcare provider before beginning a new exercise program).

See these websites for information on exercise and Parkinson’s:
http://www.parkinson.org/understanding-parkinsons/treatment/Exercise/Neuroprotective-Benefits-of-Exercise
http://www.parkinson.org/understanding-parkinsons/treatment/Exercise
http://www.pdf.org/en/exercise
https://www.michaeljfox.org/exercise
Examples of research showing the benefits of exercise in Parkinson’s:
Enhancing neuroplasticity in the basal ganglia: The role of exercise in Parkinson’s disease” (http://onlinelibrary.wiley.com/doi/10.1002/mds.22782/full )
“Tai Chi and Postural Stability in Patients with Parkinson’s Disease” (http://www.nejm.org/doi/full/10.1056/NEJMoa1107911 )
“The effectiveness of exercise interventions for people with Parkinson’s disease: A systematic review and meta-analysis” (https://www.researchgate.net/publication/5669549_The_effectiveness_of_exercise_interventions_for_people_with_Parkinson%27s_disease_A_systematic_review_and_meta-analysis )

“Golf is the closest game to the game we call life.  You get bad breaks from good shots; you get good breaks from bad shots – but you have to play the ball where it lies.”   Bobby Jones

A brief history of golf: An interesting historical timeline for the game of golf: http://www.igfgolf.org/about-golf/history/

A personal perspective of golf: At the age of 11-12 years old, I discovered my 2 favorite sports of tennis and golf.   Part of this was from my dad’s fondness of golf; it gave me some wonderful father/son time on the golf course.  Off-and-on for the past 50 years, I’ve played/loved the game of golf.  If you’ve read the quotes here, you realize that golf is both an honorable game and incredibly hard to master (I’m still learning how to play).  Golf is sometimes incredibly frustrating; yet it still very relaxing and always fun. You use every muscle/joint/ligament/tendon in your body to hit the golf ball. You can substantially boost the level of exercise if you are physically able to push a golf cart or carry your golf bag and walk. You frequently play golf with others; however, you mostly are competing against your most recent good/bad-scoring round of golf.  Finally, there is usually a fun and supportive social aspect to golf.

Below are pictures of several of my ‘golf buddies’ (friends, colleagues, and relatives).

Image“In golf, the player, coach and official are rolled into one, and they overlap completely. Golf really is the best microcosm of life – or at least the way life should be.”  Lou Holtz

Golf and Parkinson’s: Many people think of golf as a passive sport that doesn’t offer much in terms of physical fitness.  Golf actually provides cardiovascular exercise, strength training, flexibility, balance and coordination.  As a form of exercise, here are some benefits of playing golf for managing Parkinson’s: (a)  tremendous benefit for balance; (b) positive effect for range of motion; (c) increase in lateral flexibility; (d) walking 18 holes of golf is ~5-7 miles; (e) provides strength training; (f) great way to exercise your brain (concentration); and (g) golf is relaxing and fun.

The video below (entitled “Putting with Parkinson’s”) says it all because these golfers believe in the positive effect of golf on their Parkinson’s and they really enjoy playing golf.

“Golf is a puzzle without an answer. I’ve played the game for 40 years and I still haven’t the slightest idea how to play.” Gary Player

Golf and Parkinson’s- A game for life: Parkinson’s is insidious and primarily presents as a movement disorder; it advances with indifferent ‘baby-steps’ that slowly evolves over many years. Until a cure for Parkinson’s is reported, exercise is an essential life-advancing-salve to help shield you from your disorder.  There are so many positive benefits to exercise; for someone with Parkinson’s, exercise is even more life-preserving and health-affirming. Find an exercise that works for you, and embrace its health benefits. Use exercise to provide a neuroprotective net over your Parkinson’s. Stay active. Remain dedicated. Be strong. Strive for health and happiness. Keep going. Don’t ever lose hope.

My doctor, who happens to be my old college roommate, tells me the Parkinson’s shouldn’t affect my golf game at all, which really surprised me. His explanation was very interesting. He said I’ve never been able to putt and since it was impossible for my putting to get any worse, there was actually a chance it might improve.” Vince Flynn

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