Category Archives: Physical Therapy

Parkinson’s Awareness Month: The Science Behind How Exercise Slows Disease Progression

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

“To enjoy the glow of good health, you must exercise.” Gene Tunney

Précis: For Parkinson’s Awareness Month, let’s begin with an important reminder/statement that “Exercise is medicine for Parkinson’s disease.”  Coming soon in a future blog post I will review the benefits of vigorous exercise in human Parkinson’s.  In today’s blog post, using an established mouse model of Parkinson’s disease and exercise, the recent paper from Wenbo Zhou and collaborators in Aurora, CO will be described. 

The full citation to this open-access paper is as follows: Wenbo Zhou, Jessica Cummiskey Barkow, Curt R. Freed. Running wheel exercise reduces α-synuclein aggregation and improves motor and cognitive function in a transgenic mouse model of Parkinson’s disease. PLOS ONE, 2017; 12 (12): e0190160 DOI: 10.1371/journal.pone.0190160

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“Health is the thing that makes you feel that now is the best time of the year.”Franklin P. Adams

The Neuroprotective Role of Exercise in Parkinson’s, A Quick Look Back: In my own academic career (during the past 30-something years) studying deep-vein thrombosis (hematology) and breast cancer cell migration/invasion (oncology) we used many different types of experimental techniques, specifically: developing protocols to purify blood proteins; three-dimensional molecular modeling; site-directed mutagenesis and expression of recombinant proteins; blood plasma-based model systems; cell-based model systems of cancer cell migration, invasion, and cell signaling; immunohistochemical (pathology) evaluation of human tissues; mouse model systems of cancer cell invasion and metastasis; and mouse model systems of venous thrombosis, aging, and wound healing/repair. I was very fortunate to be able to recruit some truly amazing graduate students and postdoctoral fellows to perform all of these studies.

Likewise, there are a lot of ways to study a disorder like Parkinson’s disease including model cell systems, model rodent systems, and human clinical trials. However, Parkinson’s is not an ‘easy’ human disease to characterize; even with the four Cardinal motor symptoms, we express our disorder slightly differently from one other.  In the past 20-25 years, from reading the literature, much has been learned and advanced with various rodent model systems of Parkinson’s. Studies began in the early 2000’s evaluating the role of exercise in rodent Parkinson’s model systems.  Four such papers (out of many) are highlighted below; with evidence for neuroprotection, neuro-restoration and neuroplasticity. In a 2001 study, Tillerson et al. concluded “These results  suggest that physical therapy may be beneficial in Parkinson’s disease.” Importantly, recent human clinical trials/studies are clearly showing positive results with exercise in Parkinson’s (depending on the study they have shown neuroprotection, improved motor defect and cognitive function gains).

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“Take care of your body. It’s the only place you have to live.” Jim Rohn

Highlights and Overview of “Running wheel exercise reduces α-synuclein aggregation and improves motor and cognitive function in a transgenic mouse model of Parkinson’s disease”:

  • Gene mutations that have been found to cause Parkinson’s include α-synuclein, Parkin, UCHL1, DJ-1, PINK1, LRRK2, and VSP35. These mutations result in loss of neuroprotection (e.g., DJ-1 and PINK1), or gain of toxic function (e.g., α-synuclein and LRRK2).
  • The protein α-synuclein is a major component of Lewy bodies that are the signature brain lesions in Parkinson’s. A mouse model that overexpresses human α-synuclein is very similar to the human condition.  The most neurotoxic form of α-synuclein are the α-synuclein oligomers, which implies that preventing α-synuclein aggregation could slow disease progression.
  • The focus of this research was the neuroprotective effects of exercise (running wheel) in mice and quantifying the effect from exercise; they found typically the mice ran >5miles/day.

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  • They found that one week of running wheel activity led to significantly increased DJ-1 protein concentrations in muscle and plasma in normal mice (compared to mice not running).  Furthermore, using a mouse model with DJ-1 genetically deleted, running wheel performance was much reduced indicating that DJ-1 is important for normal motor activity.
  • They then studied exercise in a mouse model expressing a mutant human form of α-synuclein that is found in all neurons- they wanted to see if exercise could prevent abnormal α-synuclein protein deposition and behavioral decline.
  • Their results showed that motor and cognitive performance were significantly better in exercising animals compared to control mice not allowed to run.
  • They found that the exercising mice had significantly increased levels of DJ-1, Hsp70 and BDNF concentrations and had significantly less α-synuclein aggregation in brain compared to control mice not allowed to run.
  • Interestingly, they also found that blood plasma concentrations of α-synuclein were significantly higher in exercising mice compared to control mice not allowed to run.
  • They conclude that exercise may be neuroprotective. Their results imply that exercise may slow the progression of Parkinson’s disease by preventing α-synuclein aggregation in brain.
  • Below are presentation of interesting results from Figures 4, 5, and 6:

Figure 4 (above) shows that exercise in the aged over-expressing α-synuclein mice had increased levels of DJ-1 (panel B), HSP70 (panel C) and BDNF (panel D) in their brains, and also increased DJ-1 levels in both muscle (panel F) and blood plasma (panel G), compared to non-exercise control mice.

Figure 5 (above) shows that exercise in the aged over-expressing α-synuclein mice had reduced formation of oligomeric α-synuclein (panel C is specific for human α-synuclein protein and panel D is for both mouse and human α-synuclein protein) compared to non-exercise control mice.

Figure 6 (above) shows that exercise in the aged over-expressing α-synuclein mice had increased α-synuclein concentration in blood plasma (panel C is specific for human α-synuclein protein and panel D is for both mouse and human α-synuclein protein) compared to non-exercise control mice.

“I have two doctors, my left leg and my right.” G.M. Trevelyan

Exercise Slows Progression of Parkinson’s: This was both a straightforward and elegant study that gives mechanistic insight into the positive benefits of exercise in Parkinson’s. Here is how it could hopefully be translated from mouse to man: (1) Exercise prevents α-synuclein oligomer accumulation in brain; reduced in brain and increased (monomers and dimers) in blood plasma.  (2) Exercise significantly improved motor and cognitive function.  (3) The benficial effects of exercise is partly related to increased levels of DJ-1, Hsp70 and BDNF, which are neuroprotective substances. (4)  It is not possible to totally define/describe how exercise alters brain function in Parkinson’s when exercise itself produces such widespread systemic changes and benefits.

In conclusion, this study clearly demonstrates the neuroprotective effect of exercise.  It almost seems that exercise made the brain behave like a molecular-sieve to filter out the toxic oligomeric α-synuclein protein and it accumulated in the bloodstream.  Exercise works by slowing the progression of Parkinson’s. 

“If you always put limit on everything you do, physical or anything else. It will spread into your work and into your life. There are no limits. There are only plateaus, and you must not stay there, you must go beyond them.” Bruce Lee

Featured cover image credit:  https://www.pinterest.com/pin/22025485657771738/?lp=true

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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Help with the Parkinson’s Tremor

“The starting point of all achievement is desire.” Napoleon Hill

“We can’t help everyone, but everyone can help someone.” Ronald Reagan

The Journey With Parkinson’s returns:  The past 2 months have just consumed every waking moment of my time/life, and then some.  I have a back-log of >20 blog posts in some finished-form-or-another. Starting this weekend, I will be able to spend more time researching, thinking, and writing on the blog (and the past 2 month gap between blog posts will be explained in a story entitled “Work in the Presence of Parkinson’s”).

Core movement disorder aspects of Parkinson’s: Most people-with-Parkinson’s have some or most of these manifestations: tremor, bradykinesia, postural instability and rigidity. They are considered the “Cardinal Signs” of Parkinson’s; here is a brief overview.

Resting Tremor: A vast majority of people-with-Parkinson’s will have this ‘type’ of tremor (for a tremor tutorial click here). The tremor consists of a shaking motion, which happens at rest. The affected body part will be in motion when it is not performing an action. The tremor will stop when a person moves this body part. Not all people with Parkinson’s will develop a tremor; or like me, they have another kind of tremor.

Bradykinesia (“slow movement”): A general loss of spontaneous body movement. Bradykinesia causes problems with repetitive motion. Bradykinesia can alter the speed of performance of many everyday events like buttoning shirt-buttons, fastening car seatbelt, or chopping food.

Postural Instability: Postural instability is a tendency to be unstable when standing upright. A person with postural instability has lost some of the reflexes needed for maintaining an upright position.

Rigidity: Rigidity causes stiffness and inflexibility of the limbs, neck and trunk. Muscles normally stretch when they move, and then relax when they are at rest.  By contrast, in Parkinson’s that body part remains taut when it moves and does not relax.

Smart-spoon: The “Google Spoon” came first (click here), and it oscillates to counter the negative oscillation of your hand (click here).  You can check on-line to determine whether or not your tremor can be helped by this spoon.

And now a helping hand:  “The invention that helped me write again” (Click here to see video).  My colleague, good friend and golf buddy Nigel saw the story on BBC News.  Technology is evolving; all it takes is an understanding of the problem, a design strategy, and significant effort to create such a device.  It also takes intelligence, talent and diligence to be able to make a device that allowed someone with Parkinson’s and a significant tremor to be able to write and draw again.  Great story, and simply an amazing device!

“The trouble with much of the advice business gets today about the need to be more vigorously creative is that its advocates often fail to distinguish between creativity and innovation. Creativity is thinking up new things. Innovation is doing new things… The shortage is of innovators…” Tom Peters

Cover photo credit: http://vb3lk7eb4t.search.serialssolutions.com/?V=1.0&L=VB3LK7EB4T&S=JCs&C=TC0001578421&T=marc

Believe In Big Movements Of LSVT BIG Physical Therapy For Parkinson’s

“Notice that the stiffest tree is most easily cracked, while the bamboo or willow survives by bending with the wind.” Bruce Lee

“Only those who will risk going too far can possibly find out how far one can go.” T.S. Eliot

Believe:  I believe that staying positive will help control the course of my Parkinson’s.  I believe that having courage will provide worth in the battle against my Parkinson’s. I believe that being persistent allows me to restrain my Parkinson’s.  I believe that if I don’t ever give up I can master the progression of my Parkinson’s.  I believe that if you pity me it feeds the hunger of my Parkinson’s.  I believe that if you join my team, you can help me stymie the slowly evolving pace of my Parkinson’s. Finally, I believe that frequent exercise will enrich my life while living with Parkinson’s.

Parkinson’s is a movement disorder: The most common symptoms of Parkinson’s include rigidity; slowness of movement (bradykinesis); postural instability and gait problems; and resting tremor.

Exercise and Parkinson’s: Exercise is good for everybody.  In general, exercise reduces stress, builds muscle mass, improves flexibility, aids mood and sleep, and increases oxygen movement through the body. Exercise is crucial for anyone with Parkinson’s, absolutely essential.  In Parkinson’s, you can imagine the general benefits of exercise; now add improving and enabling your flexibility, balance, strength, coordination and gait.  Exercise is also 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 ).  Most internet-based searches mention bike riding, walking, dancing, boxing, yoga, and Tai Chi for the benefits of exercise in Parkinson’s.  Personally, I would add both golf and tennis to this list of helping someone with Parkinson’s.

LSVT BIG physical therapy (PT) for Parkinson’s: The overall goal of LSVT BIG is making big movements. Neuroplasticity is reinforced in LSVT BIG from the repetitive and rigorous PT [“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 ].  LSVT BIG includes repetitive physical exercises that simultaneously engages everything from your fingers to toes, and all parts in between (arms, legs and your core). Go here for more information: http://www.lsvtglobal.com/patient-resources/what-is-lsvt-big and http://www.onthegophysio.co.nz/lsvt-big.html (LSVT = Lee Silverman Voice Treatment).  The diagram below shows the needed effort of an individual with Parkinson’s to approach ‘normal’.

LSVT.BIG.150621LSVT BIG provides a foundation for (re)training an individual to have better posture, better flexibility, better movements, and better balance: The basic exercises begin with two Multi-directional Sustained Movements, Floor to ceiling stretch in sitting, and Side to Side stretch in sitting. Purpose of these exercises: Sustained muscle activation and active stretching. Next, there are five Multi-directional Repetitive Movements, Step and Reach (3) Forwards, Sidewards and Backwards;  Rock and Reach (2) Forward/Backward and Side to Side. Purpose of these exercises: Differentiating starting and stopping, changing directions, sequential endurance, balance, and strengthening. The final two exercises are Sit to Stand and Walking Big.  The Program is 60 min/day for 4 days/week for a total of 4 weeks. The repetitive nature, the intensity, and the homework are all aimed at re-programming your neural network to accentuate bigger movement.  Bigger movement from a Parkinson’s patient will translate into more normal movements.

The challenge of my LSVT BIG program: To challenge me along the way, my PT’s devised obstacle courses, timed-trials, had me wear wrist and ankle weights, use a trampoline, and even do exercises while balancing on CanDo® Instability Pads.  They devised exercises for me using a golf club and tennis racket.  They tested my vestibular system (inner ear/balance) by doing exercises with my eyes closed while balanced on CanDo® Instability Pads, and then by standing only on one leg.  I was fully drenched in sweat 20 mins into each session, it was such rigorous and grueling fun.  And on your own as homework, you repeated the Program later each day (including the weekends). Included at the bottom are photos of some of my exercises.

LSVT BIG results: As I’ve remarked before, Parkinson’s feels as if the ‘gyroscope gizmo’ we were born with, and used successfully for 50-something years for balance and walking and posture, is now out-of-whack and much less trustworthy. Some of my goals for LSVT BIG included: improve my entry/exit to my little car; add stability to every day life tasks; increase range of motion; better control going up and downstairs; improve the task of buckling my car seat belt; walking a golf course again; and hit a golf ball better.  I achieved (improved) all 10 of my goals.  Notably, I’m now walking 18 holes on a golf course; and recently I shot an 88 (44/44) for 18 holes where for the past year or so I’ve averaged between 95-98 strokes for 18 holes.  I am very pleased with all of these positive changes.  Ultimately, my goal is to continue my exercising to sustain these results.

Acknowledgement:  My successes above were made possible by Diane Meyer, an amazing PT, and Lexie Williams, an awesome Doctor of Physical Therapy Candidate.  They devised my daily (and challenging) LSVT BIG Program, they pushed me constantly to improve my form/technique, and they were my daily taskmasters/cheerleaders always there with positive reinforcement (“Think big Frank!” and “Get big Frank!”).  I definitely worked hard, but I succeeded because of Diane and Lexie, thank you so very much!

Believe revisited: I believe in big movements of LSVT BIG physical therapy for Parkinson’s. I believe that Diane and Lexie made a difference. I believe that frequent exercise will enrich my life while living with Parkinson’s. I believe that staying determined will help control the course of my Parkinson’s.  I believe that staying on this path allows me to defy my Parkinson’s.  I believe

“I don’t care how old I live; I just want to be LIVING while I am living!” Jack LaLanne

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