Muoviti: esercizio per un cervello sano - J Fox Foundation 22052023

good morning I want to thank everybody this morning for joining us um my name is Maria delion and I'm a fellowship trained movement disorder specialist and I'm also a patient for the last 16 years and it's great to be here today we have a great panel and we have a great uh topic get moving exercising for a healthy brain so I know all of you are very excited we have a lot of people joining us today so we will be discussing ways to improve our brain health through exercise we'll also cover the valuable uh role people with Parkinson's and also caregivers can play uh in Parkinson's research if you have any questions you can type in the Q&A Box near the middle of your screen and the foundation staff and our panelists will also be getting to as many questions as we can and if you want other helpful information or want to download some of the slides check the resource list on your screen to put on captions in English please click the CC button on the bottom right of the media player on your screen like Oliver webinars this session will also be recorded So if you think you missed something you can always go back and listen to it again and you can watch it and share with others it will be on demand so with further Ado we might we got a lot to discuss and I want to start by introducing our panelists first of all I want to thank everybody thank you to the Michael J fox foundation for being here for all the sponsors and I also uh want to introduce first Dr uh Daniel Cross caros sorry caros um he's a professor of physical therapy and human movement Sciences at the Northwestern University he's a principal investigator in the SP spx3 and also I want to introduce Lori Quinn who is a physical therapist professor of movement science and kinesiology at Columbia University and further I'd like to also welcome Lynn Hager mjf uh patient Council co-chair living with PD since 2010 thank you so so much and I think we're ready to get started with a wonderful session so why is exercise important first exercise plays a key role in maintaining and improving brain health and we are going to ask one of our expert panelists to discuss how exercise can help those with and without PD Dr carcus can you tell us how exercise impacts PD so thank you very much and thank you very much to Michael J fox I'm very honored and privileged to be here with my three distinguished colleagues exercise is clearly very beneficial for everybody with whether you have health or disease it is especially beneficial for people with Parkinson's disease you can ask any practicing movement disorder specialist whether they can tell whether they patients have or have not been exercising and living healthily and they can tell you many people find it a little hard to motivate themselves to exercise so I'm going to give you 10 reasons why chronic that means continuous every week sustained exercise is really really good for your brain because Parkinson's disease is a neurod degenerative disease so the first reason is think about blood flow so imagine a tree in Winter and so you can think of your brain has lots of blood vessels and you can imagine a tree which has very few leaves you can imagine your blood vessels are not getting much blood through and you now go and exercis and then think of your whole brain now lighting up you need to get oxygen to nerve cells so the first reason why it is great is it increases blood flow for those of you who read a lot you're going to read about nerve growth factors there are three there there many more than three but three you'll read about are bdnf gdnf and neine and as you can tell nerve growth factors help nerves grow exercise is good for nerve growth second reason Parkinson's disease is a dopamine deficiency there's lots of evidence that you increase dopamine signaling when you exercise the fourth reason is if you look at a brain of a person who has a neurod degenerative disease starts to shrink you look at a healthy brain it hasn't shrunk you exercise and you reduce atrophy or you increase thickness a fifth reason is exercise activates the brain the sixth reason is it helps connectivity within parts of the brain the seventh re reason is it facilitates connections across the brain we need the basil gangling to talk to parts of the other other parts of the brain motor cortex prefrontal regions an eighth reason is if you look at animal models of Parkinson's disease they have few dendrites dendrites talk to other parts of the nervous system you exercise and you increase the number of dendrites the ninth reason is that brain immune function the brain immune system improves when you exercise and the 10th reason is that you decrease oxidative stress this is a lot to remember remember every time you go out to exercise you're doing at least 10 good things to your brain and imagine the blood flowing through your brain also I've talked about the long-term benefits week in week out year in year out every time you exercise you raise your own within system endogenous levels of dopamine I hope I've given you good reason to think that exercise is important for you and actually if you're looking at the screen we have two people who have Parkinson's disease and they seem to be nodding along that what I'm saying makes sense to them so it's probably easier for those of you who have the disease to watch and listen to people who have the disease because they can tell you that it has worked for them thank you Dr cross that was very um important information sorry my brain sometimes doesn't work well uh first before we get to that I know there's some people that having some trouble hearing so maybe the the IT Tech could help you know those people but also those that want some close captioning again uh the CC button on the bottom right of the media player on your screen should help you with that so hopefully that would help some of the people having some trouble but as Dr cross was saying yes the reason that um we feel that exercise is important to the brain to um summate is that it increases blood supply and oxygen and particularly the basal ganglia is very sensitive to um areas of stress and Trauma and decrease and oxygen and blood supply so by doing that uh we're we're increasing uh that area and keep it in nice and plump uh along with you know the other endorphins and chemicals so moving along I hope that answers my question we're going to get to more questions later on after we go through all the slides and hear from all our presenters um so next slide so what exercise is best for me I know that everybody has questions Sometimes some of you are wheelchair bounds some of you you know have limited capabilities um or have Donia and have difficulty walking so let's ask first Lori Quinn to discuss the different types of exercise um that you could possibly um engage in strength flexibility balance and tell us a little bit more of how this can uh be used or you can be using this uh in your situation depending on what your uh capabilities are sure thanks so much Maria thanks everyone I'm really happy to be here so yeah as Maria said there are four different U main types of exercise that people can engage in and uh there's a difference between physical activity and exercise so physical activity is sort of what you do on a day-to-day basis sort of moving and not sitting having less sedentary Behavior but exercise is sort of planned activity that you do and we separate exercise into these four main components so aerobic strengthening balance and flexibility and I'll just give a quick example of each of them uh so aerobic exercise is where we have sort of continuous rhythmic activities where we get our heart rate up to a certain amount and I'm sure we'll talk later about those exact percentages but it is important to get your heart rate up so that you're actually feeling like you're working out maybe breaking a sweat and ideally using some sort of monitoring device to get an idea about how hard you're working some activities of aerobic exercise are things like cycling or walking at a Brisk pace like up a um potentially up an incline or walking on a treadmill um doing aerobics types of classes or swimming uh strengthening is where you're using um your muscles against a form of resistance to try to increase the um strength of your muscles Um this can be done with the upper extremities the lower extremities or what we call the trunk sort of the core musculature and it's really important um as we age and just generally to have uh a strengthening Pro program as part of your exercise program um so some things that you can do that increase your strength are just literally using some simple handheld weights as you do um General upper extremity activities many people use them if they're going uh walking you can use light resistance band and even doing some very simple activities that are using your body weight like squats um is a really great form of a strengthening exercise um balance uh what we call sort of agility training is also really important component in Parkinson's because it's an area that um M much of the medication actually doesn't address so people can do well with medication but can still have a lot of balance problems and so what you need to improve your balance is actually try to challenge your balance and in in U many different ways so things like boxing can do that um certain forms of of yoga or taiichi and dance can be a really nice way to also challenge your balance but it does need to be challenging so make it a little bit difficult and um uh it almost might make you a little bit off balance but in a safe environment it's really important to do and then finally flexibility or stretching where you actually try to counteract some of the um negative effects that might have happen from Parkinson's or even just from being sedentary so as if we sit for long periods of times our hamstrings might get tight or if we're sitting over a computer some of our um upper extremity muscles might get tight so you can do stretching exercises to try to counteract that um and those can be just general stretching exercises or they can be incorporated into things like yoga wonderful thank you so very much that's very uh good information and we're now gonna go ask Lynn um to share her personal experience with exercise and what she enjoys and she also has been living with Parkinson's for some time now yes um I really believe for myself that exercise is medicine um I take my medicine so I can exercise that's the way I think about it I have um always exercised my entire life but I've ramped it up since I was diagnosed in 2010 and I just encourage anyone out there who has Parkinson's to find something they're passionate about doing and what they enjoy doing and look forward to doing and it it really has made a significant difference in my Parkinson symptoms um I I also see and others who have Parkinson's um those you can see see the difference in those who work out who exercise who basically um do all the four different kinds of exercise that Lori Quinn pointed out I just um so it it's a significant part of my life wonderful thank you very much um Dr um clus how much exercise do you think one needs to do uh in a day or per week to really see the benefit or the effects um when dealing with Parkinson's do you think thank you for the question um the most important thing really is to try to exercise what I will tell you next is what I consider to be the scientific prescription for exercise and there is an immense amount of evidence behind it if you can one should work out with an elevated heart rate preferably close to 80 85% of your Peak heart rate for 30 minutes four times a week there have been three studies which have shown that I published the paper in 2018 my very good friends in Holland published the paper in 2019 and there was a paper published in 2021 so there have been three studies each conducted over six months showing that if you can exercise size three to four times a week for 30 minutes with an elevated heart rate close to 80% you will be able to slow down the rate that your disease progresses Point number one now I realized many people find that hard I realize some people are much further along in the disease and later on we can look at um other approaches but certainly If you're diagnosed youngish and you can do that that is what is best for you the evidence is crystal clear now a lot of people ask the question well what is the best exercise for me well that's like asking should I eat protein should I eat fat should I eat carbohydrate you need a well-balanced exercise program resistance training which Dr Quinn referred to is very important it's very important for bone it's very important for osteoporosis it turns out and this is hard to believe but there's a lot of evidence that it may also be the best exercise for improving cognition so for those of you who do not do resistance exercise it should be part of your exercise portfolio and it will be very good for your bone very good for your brain it will also help with your function and as your disease progresses staying strong is important the unfortunately is a fact the best predictor of mortality across all diseases and health is loss of strength so do everything you can to keep your strength up and then thirdly the Dr Quinn talked about and many people do this daily is stretching and balance it's a very simple test you can do for yourself stand on one leg if you're holding it for a minute you're in great shape if you're holding it for a second you really need to see a PT somebody such as Professor Quinn and you need help because there is a problem so in a nutshell endurance your cardiovascular system resistance for your neuromuscular system and posture imbalance because people with Parkinson's unfortunately have a propensity to fall over and when they do they fracture bones and it's a much higher rate than for people who are healthy thank you that's that's very important uh that you always talk to your doctor about what is the best uh therapy for you because everybody has different um medical issues and different stage of Parkinson's and what is good for one person may not be necessarily good for another so the best exercise is the one that you'll do and it'll be good for you to improve your symptoms uh and motivate you to do so but you don't have to do the same thing and we can ask Dr uh Professor Quinn what are some practical tips for incorporating more movement into your daily routine yeah sure so I have a three tips that I'd like to share but I first do want to say on that last point about um the best exercise being the one that you'll do I think what is really important is within the guidelines that we've just discussed to find activities that do bring you Joy or that you do enjoy doing um any exercise that feels like a slog or is not enjoyable is going to be more difficult to do if you know the benefits of it you know there's many things that we do in our life that we probably don't like to do but we know they're good for us so we do them uh this is one of them but if you can also find something that you love to do and that you have passion whether it's getting into the pickle ball craze or you know you enjoy the you know breaking a sweat on a treadmill those are um it's really important to take that into consideration so my three um main tips for incorporating exercise into your into your daily routine um would be setting a schedule having a buddy and setting up your environment um there's many tips but I think these are the three most Salient ones and things that seem to resonate with the patients that we or the individuals that we work with who have Parkinson's disease so setting a schedule um you know however that might might be but something like every Sunday you look through your week and you say where is exercise fitting into my routine and making sure that you're getting all of those four components um one of the things that can be overwhelming for people that we work with is oh my gosh I have to exercise doing aerobic exercise five days a week and strengthening three I don't I don't have enough time to do this well there's a lot of ways that you can pair exercises together I know Lynn really enjoys boxing that gets out both aerobic and strength strengthening um so trying to to do activities that can can do both things was really helpful and I would um try to schedule those um throughout the week and and stick to a schedule just as if you had an appointment to to see a doctor um having a buddy having someone who um helps to hold you accountable and maybe you even exercise with I think can be really beneficial um whether that's um a spouse or a friend or a child child um a grandchild or even someone in an online community there's many online communities that you can collaborate with um and you can share and sort of motivate each other and then finally I think a big thing is setting up your environment um many people may not have um a lot of space to exercise I live in a New York apartment we do not have a lot of space but I have a math set up and a in a spare bedroom um and some my exercise things right out so that it's very easy for me to to exercise my environment sort of affords the ability for me to to exercise um and trying to find resources within your community that are close by and that you'll know you will be able to engage in so those are my my three main tips thank you Professor Quinn um I think that that's very important the Buddy having a buddy that's somebody that keeps you accountable and somebody that can drag you out even when you can't or don't feel like going out or can't drive or can't you know take yourself somebody that will take you uh and that also increases those endorphins and uh neurochemicals in your brain having someone to socialize with and uh having someone to compare um later on we'll ask Lynn to discuss her her own uh routine uh of what she does but the other thing that I like to mention is that um doing exercises in a pool is extremely uh beneficial for parking especially those that have mobility issues and also for those that have uh a lot of balance issues and flexibility problems uh is extremely uh beneficial is something that I have done for years and it really uh helps tremendously and I'll discuss later also what kind of exercise I do so uh we can keep moving on so uh next we will discuss uh managing disease through exercise so uh we're going to pause to let you know first of all that the Michael J fox Foundation has um landed the Parkinson's progression markers initiative and I'm so glad that I'm part of this um Foundation because they're doing such extremely wonderful work and the ppmi is currently recruiting volunteers and we need both uh patients and uh controls uh people that don't have the disease um so if you tune into the webinar last month you learned that the ppmi helped discover biological tests uh now there was just soon uh recently discover they can detect Parkinson's the first biomarker so that is extremely exciting uh that I think is going to revolutionize the way we diagnose and treat Parkinson's in the future um and this was made possible by thousands of people like yourself that volunteer and participated uh now we need more volunteers so if you are so inclined uh we would like you to uh click on the take action box to join the study that's changing everything so um if you could do that that would be wonderful if you like to participate and you don't have to do anything outside of your home you can just do it on your computer um so all right so next slide um common barriers and ways to overcome them so I like to hear um from Lynn um the barriers people have face you know and solutions to overcome you know with your balance with your movement you know Tremors how has exercise played a role uh in this um control of your symptoms um well I I feel that I have not only studied the data and the research about how important exercise is I actually feel it you know myself so I am a total believer in this I mean I I um I take exercise very seriously as Maria as you know I think Lori mentioned both of you mentioned that I actually schedule my I schedule around my exercise I don't do anything before you know in the mornings typically till like 10 o'clock after make sure that I exercise during that period of time um as far as lack of motivation um I I basically prioritize it I tend to you know for myself and everybody's got to feel like what what motivates themselves I tend to do better in a class with others um I I I work out longer and harder with other people so a community based program is very important to me there's other people that I know with Parkinson's that do fine by themselves but I tend to be more motivated in a group so that helps I know for a fact that helps with me my motiv keep me motivated and encouraged to keep exercis so I think making it a routine um making it a habit and and really kind of um taking it seriously is is very important in the management of Parkinson symptoms yes thank you and and as we see I think one of the biggest things is this lack of motivation reluctance to join uh and then you know we had the pandemic so we were all stuck at home so you know how do you do this so uh Dr cross um what are the best ways to get started uh especially if you've never exercised regularly I'm not a big exercise buff like Lynn like I am I'm not one to say sign me up for the gym so uh what what do you suggest what do you recommend but the best way to get started is just to tell yourself to be to do a little bit so one can just start to walk a little bit some people like a Fitbit to track their number of steps but if you're not doing any exercise at all if one just can get out of one's house or out of one's apartment and just take a walk around the block and just get into the idea so uh Dr Quinn hit the nail on the head with her three pointers so if you if you set a schedule find a bu and get your environment right and then start very very easily I can see in the notes that um in the chat that some people don't like to exercise we don't we know that but some people don't even use the word exercise just think of it as the ew and you never talk about it okay and now think think about activity and so start easy if you jump into some of the things I told you about the prescription and you've never exercised your muscles will hurt and I don't want anybody to do that so start very easily now um if I had Parkinson's disease I for sure would look at dancing most people actually do like to dance um I know some of you will say you won't get me anywhere near a dance place but um the music helps the Rhythm helps the excitement of being out helps and so dancing is uh it's a wonderful activity and the published articles are clear it is beneficial for posture gate balance and cognition um um the boxing programs around the country you look at pictures of people they are really engaged and the issue here is to try to empower yourself so the people who tend not to do well are those who take their medication sit back and don't take the disease on okay and those who do well are those who just get get on with their life so start easy and try to find something that you really enjoy um I talked to the Sonoma group in California recently they're out by redwoods now can't be too hard to take a walk through the Redwoods and there's a lot of evidence coming out of uh England and other countries that activities in green areas are very very good for one so the issue here is if um the ew is a bad word and it is for many people then tune up the a word for activity or the DW for dance or the F you know for fun and um try to find something that works for you and in many of my talks I ask people the following question when I'm in the live audience I ask people put your hand up if you have a dog more than half the people put their hand up and ask the question how many of you would consider not taking your dog for a walk and nobody's hand is up so for those of you who have dogs for example will you get your activity in and if it's good enough for a dog to be active it has to be good enough for you thank you so very much those are inspirational words that you know I often say that you know running water does not freeze so we just have to keep moving have to do something and we don't have to think of it as exercise the evil word you know just do something fun that you like even the exercise you know cleaning your house put a little movement put a little music and then before you know it you're having fun and you're moving and exercising and doing all those things so um doctor Professor Quinn uh what would you say you know for people that have some physical disabilities some mobility issues how would you modify uh or you know work within the limitations of that to to still be able to do some of these um exercises that we've been talking about yeah thanks Maria um there's um many different ways that exercises can be modified and I think the really important thing is just to to find um any exercise that you enjoy and there's ways to modify it so um I think one of the easiest ways is to do exercises in a sitting position versus a standing position um so treadmill might be um you there's a lot of good research on on walking and treadmill but um if that doesn't work for an individual um doing activities in a seated position so even cycling or on a recumbent bike um can be just as effective and you can really get your heart rate up um in that in that position um for walking there's some uh really good accommodations that can be made so um some people choose to use an assisted device something like a a wiel walker to help um a lot of people don't like to use that um but I think if it enables you to be able to get some mobility and exercise I think it's something really important to consider um that that could be part of the exercise program is walking um and if it enables you to walk a little bit further then I think that's an important consideration um also things like walking sticks or walking poles um those can be really helpful especially um on walking on uneven terrains so um it's really important to try to as I talked about earlier about the challenging your balance a little bit so maybe not just walking on level surfaces but walking on uneven surfaces or you know going for walks um out in the country uh that uh you know using a walking pole to be able to help support and provide a little bit of balance can be helpful um and then lastly I would just say with there's a lot of really great um exercise classes that are online um that can be found for people with parkon and many of those can be um accommodated they show people standing and people sitting and doing exercises um in a modified way and I know dance for PD does that as well so looking for those PD specific exercise programs they often have modifications built into them thank you so much dance for PD is one of my favorite classes uh to join so um the micro J fos Foundation has online platforms that are designed for Parkinson's community so they can connect and shared interest and topics and you can probably find something they're looking for somebody as support that can help you um get to know and what what they're doing um to get started and what kind of activities they're doing um Lynn what would you say um to someone that has a hard time getting started what would you tell them how to get motivated to to begin exercising or begin a you know activity program of at least trying to move a little bit right so what I would recommend to somebody who does an exercise is to basically start small which was mentioned before from the other panelists and and you know take a like take a walk start with walk and then also you know look for a buddy or communitybased program there there's so many advantages to that I mean there's there's not only is there um you know their trained instructors but there could be support from others and it prevents isolation I see a lot of isolation with people with PD and it makes a big difference to get out in the community get outside you know um you know get get get be in nature take a take hikes and walks so and I think too it's a good idea to reflect on what you enjoy doing such as you know which is brought up dancing it could be or like Maria you said you like to be in the pool I mean so all you know really tap into what you enjoy um and and really kind of and really look into that there's so many ways to to exercise um there's um many ways to work on balance and just kind of incorporate all this in a gradual way so you don't get hurt and don't get injured but just gradually increase it to um and I I I really believe that you're G to definitely feel the difference it it it means it's made a significant difference in my life to incorporate all of the uh exercise strength and balance um it really it's it's amazing what exercise can do that's wonderful yes and I would really suggest for those of you that have never really you know had a formal exercising program or not really excited about the ew uh you know just start with with simple stretching you know when you get up when you wake up in bed before you get out of bed stretch do some stretching exercises of all your muscles your neck your hands everything and slowly start building that way so that you get your your muscles moving and start getting some more flexibility and you don't injure yourself if you do happen to stumble and fall because you're more flexible and not so rigid so start slow small steps but then once you really get going uh I know that people have asked about the loud program the big program uh and yes we have to do things in a big way because you know sometimes we want to kind of you know start getting smaller knows space so in order to to really walk sometimes it does help walking with somebody that will increase the the pace and so that you can walk faster otherwise you know we tend to shuffle and go down you know so having some of those programs is very beneficial so so thank you so I think we'll go to the next slide um and as we mentioned everybody has had wonderful ideas and comments and thoughts about you know ways to exercise and what to do but remember this is a lifestyle uh part kinson is here to stay unfortunately until we find a cure uh it is Progressive but doesn't mean it's the end of our life so in order to do well we have to own it and we have to make it part of us and by being doing that we have to change our life our lifestyle and incorporate so that's what this is about making our lifestyle healthy um and you know one component of it lifestyle is exercise so um Professor Quinn so can you tell us how lifestyle medicine encapsulates movement nutrition socialization sleep and all the wonderful risky substances and stresses that we have in our life you know to to be also that's life and now we have Parkinson so how do you mesh it all together so that we're able to you know to thrive and and live the best life we can yeah so this is great so uh look this General concept about lifestyle medicine and what we're talking talking about here with Parkinson's disease it really can be encompassed by the term brain health and this is something that we've been spending a lot more time thinking about in terms of how can we potentially prevent a lot of the neurodegenerative diseases like Parkinson's disease but also how can we help people live their optimal lives with Parkinson's and and it's part of a comprehensive program we're all here because we probably think exercise is the most important piece of this puzzle um and I also think that exercise actually influences a lot of these things so I also think like when people exercise they tend to eat better that might be anecdotal I don't know if there's research to show that but um I think that you know I certainly know that when people exercise there's building evidence on the benefits of on sleep um so these all integrate but exercise I think is one of the the pillars um I'll just talk about a couple of them so sleep hygiene is very important getting six to eight hours of sleep um some people do benefit from tracking their sleep and knowing if they are having fitful sleep and that can be something that sometimes can be treated medically but also can just be treated with um what we call Sleep hygiene right having better behaviors around sleeping not watching television at night limiting your um screen time uh having nice comfortable environments those sorts of things um I'll also say socialization is a really key piece of um you know overall lifestyle management and brain health having people that you interact act with that you enjoy being around I think exercise can also be a part of that because as Lynn said she enjoys exercising with other people that can be a tremendous source of socialization for individuals and lastly I'll just say on nutrition um uh I think you know there's several diets that are really coming to the Forefront the Mediterranean diet or the Mind diet um you know have have some decent evidence again that's building but what I would just say is it's just about more fruits and vegetables and and healthy foods and less processed foods um I won't say too much on avoiding risky behaviors I do love my glass of wine and I did see in the chat somewhere that someone asked if it was neur protective I really hope it is um uh but I think we have to be really mindful of uh of avoiding uh you know too much alcohol and certainly um other substances that can negatively impact uh not just our our thinking and our body but also potentially might interact negatively with thank you that's very Sound Advice um and um Dr um cus what do you see this lifestyle medicine how does it play out in the um managing Parkinson's disease and you know nutrition and and moving and exercising well I always agree with Professor Quinn and I see no reason now to disagree I think she hit all the bases very well and there's a very famous Dutch neurologist Professor Bastian Bloom who's a good friend of mine and for those of you who've listened to Professor Bloom he um makes the case that if one can one should think like an athlete now I realize we're talking to 67,000 people and for some people the ew is forbidden but for others um exercise has changed their life and I zoom with a group of people with Parkinson's disease and it has changed their life and when you see and talk to them it is lifechanging and so one size does not fit ball but if you go through the literature which is now crystal clear but if you really want to have uh a good lifestyle then one has to invest in oneself and athletes do and the lifestyle medicine here is very important to look at and so you know we've talked a lot about the movement uh the sleep is a problem in PD and that was talked about Stress Management is a big deal we haven't really talked a lot about uh apathy depression anxiety um if you are struggling with those three and it is causing you not to be able to exercise then to see a good movement disorder specialist to really address that issue possibly pharmacolog possibly using pharmacology so that one can reach a point that one can exercise is is very important because once you get into the exercise the evidence that it can help depression and anxiety is really quite compelling and if you look at all the mood disorders they all talk about exercise and they all talk about how it changes the underlying biology now for those of you who can see our three uh other panel members forget me at this point when I say this but if you can find people to socialize like those three and go and do activities so that's what you have to do and the evidence is Crystal Clear when you look at the literature on dementia those people who are actively social who have good networks who meet people who talk to people who are engaged with people do very well nutrition is clearly important you talk to all athletes we haven't discussed this and perhaps Dr Leon may want to comment a little bit um for those of you who take cin dopamine uh the food you eat and the timing of your food Visa your medication becomes very very important and she may also want to address a question which I'm always asked but I have no expertise and that is uh Visa cannabis so on the one hand it can be very relaxed ing for people and it can be very very helpful I've also had my physician colleagues make sure people realize a subset of people and with 6,000 people listening one or two of you fall in the category of hallucinating I think if you do hallucinate then avoiding risky substances becomes that much more important so um turn it over to somebody else wonderful thank you good advice um you know it does play uh a one thing feeds to another you know the whole goal of uh having a well managed lifestyle healthy lifestyle brain health has to do with both in and out body and mind and soul and something that we are now going back to trying to do holistic care uh because in the past we were so focused on the body and forgetting about about you know the mind the psyche and everything else so I think that link could probably tell us how you know doing all these exercises and has helped her with her sleep uh her stress um you know depression so I would like to hear a little bit from you how this has helped and if there's a time a better time to exercise that will not that would improve sleep or interfere with sleep you know so there's always that that question so like to hear a little bit of from you thank you Marie um well I you know I it's multifaceted I I think that you know um it's not just exercise I think there's several components it's it's basically incorporating uh this is what I really want to get across to everyone Parkinson's treatment is more than taking your medication you know I when I first was diagnosed I looked to medication I Look to medication to manage my disease gradually over the years I realized that I need to basically Embrace Parkinson's and do something about it which takes more work than taking my medications it takes commitment it takes you know my my drive to to to um you know to exercise when I don't feel like it it it it requires motivation it requir you know so I believe that if you basically Embrace exercise and take it step by step you are going to B basically notice a significant difference in your symptoms that's basically encourage you to keep exercising and also Stress Management is extraordinarily important important with Parkinson's you know there's so much guided meditation online you know I basically incorporate guided meditation into my life I I wasn't into meditation before I was diagnos diagnosed with Parkinsons but I am now if you calm down your central nervous system and you focus it really makes a big difference with your Parkinson symptoms um and it helps with sleep I use guided meditation to go to sleep at night when I have trouble so I try to avoid medications if possible I mean that said if you do need medications and a physician prescribes it by all means use it but also incorporate some of the non-pharmacological means to basically manage some of these symptoms such as um you know um stress anxiety and depression thank you thank you link is this is we we running a little bit short now so I just wanted to keep everybody appreciate all that uh and I wanted to say that there is a free die guide available in the resource list it provides pract practical tips to start incorporating more nutrition into your routine um and so want to encourage you to answer some more questions we have a lot of questions we're probably not going to give uh to answer all of them but you can always um talk to the staff and we'll try to get as many I also like to thank um uh the Michael J fox weinar series that has been made possible through the leadership of members of our Parkinson's disease education Consortium in conjunction with the Albert B Glickman Parkinson's diseased education program uh and the editorial control of Michael J fox has published cont rolely on the foundation so now we're going to try to get to some of these questions a little bit we've been talking about um a lot of things what's the best exercise find the one that works for you talk to your doctor um the diet that works for you A lot of people are concentrating and worried about this heart rate issue um talk to your doctor but in reality as a as a Parkinson's uh doctor I tell you that the best thing is to focus everybody is different what your symptoms are what you're dealing with and and find the routine the plan that is going to solve your issues whether it's balance whether it's pain whether it's stiffness and and work with your phys I with the um PT OT you know speech therapy if you're having uh problems with your voice and then find support groups that will help you you know um get into some routines and start slow you don't have to go all in um the the as Doctor Cross has said there's a lot of studies that show that increasing the blood flow uh into the brain by just walking 15 minutes a day for three times a week in Alzheimer's and other patient can help uh decrease the rate of Alzheimer's and Dementia so it's not been shown in Parkinson's that I'm aware of Dr cross may know something different but um you know that could just start slip so um let's see some of the questions that people are just dying to to find out um I think we covered a lot of them um does more exercise mean better uh by doing more are we doing ourselves you know more more um effect or are we cring more problem uh Dr cross what are your thoughts on that there is a point of diminishing returns so certainly more is not better and the most important thing just like an athlete listen to your body so a great coach for an athlete knows when to encourage an athlete to work a little harder they also know when to encourage an athlete now's the time to rest Now's the Time to take a day off I think if you can set up a schedule very close to the prescription you don't need to do any more than that and there's no strong evidence at the moment that you will get a noticeably greater benefit the other thing that's very important to realize is that one can get injured one can get hurt in the the comments many of you talk about having an injury so I do not want you to think that more is better there is definitely what they call in science a sealing effect and which point you get no greater benefit I did see one comment which I want to comment and I think it was from the last name was Manchester who wanted me or somebody to talk about the p word absolutely being playful is great so one of the things I like to do is I like to cycle with my friends and yes we're very playful there's a group who plays at pingpong and so uh you can read books on why people play and bringing a playful element to life is important so yes the science tells you that if you do certain things to your heart and muscle it's good for you but to take a playful approach and you look at people dancing um they are at some level playing so I think part of it is a mindset and it's a mindset that I'm going to do this for myself and I'm going to find ways to enjoy it I'm going to be playful I'm going to have fun and yes if you're at the last five minutes of a hard workout possibly that's not playful I agree but at which point you tell tell yourself think of my brain think of all the blood going through think of what I'm doing for my neurons and so this is really it's all about a mindset what helps some people and I had this very clearly articulated to me it doesn't work for everybody but some people who have Parkinson's disease want to minimize the impact or burden they have on others they are aware and so they do everything they can to keep themselves in the best shape not only for themselves but for their family partner caregiver and so the uh trick here is to find what works for you and what works for one will not work for another thank you very much that is so true you have to find that balance and talk to your team of Physicians um professor qu what would you recommend or think is the best foods to eat or uh before you're going to engage in a you know active exercise routine or before or after um people are really wanting to know what is the best meals or nutrition plan oh okay so I'm we'll just preface it with saying I'm not a nutritionist and I think it's this is an area of of interest um although my daughters would argue against that but um uh then I would definitely consult a nutritionist who who's got information on this I mean I think it is important there's been a lot of questions about timing of food and medication and exercise and Mar maybe you could touch on the medication and I will talk about that yes but but um look you don't want to eat right before you exercise um because that just is too much competing uh resources for the energy that's required to digest your food so we recommend at least an hour before that you um eat something um you you uh you know there's a you know big push towards sort of having sort of higher protein um and eating like fruits and vegetables and certainly veeg uh fruits in the morning and maybe a little bit less so later in the day because it's got high sugar content um but I would just say trying to eat about an hour beforehand and trying to eat good healthy Whole Foods and uh less processed foods are kind of I think some of the Main Stays another really big piece of this is water water water water so carrying a water bottle around with you all the time having it readily available again this is part of the environment set up your environment so that there's water um around so that you stay hydrated and I think that is a really another important component related to um uh these lifestyle factors thank you very much yes water is extremely important because we get uh you know one very constipated we have all the autonomic problems and then depending on where we live it could be extremely hot extremely cold and then we're more likely to get dehydrated and that's going to worse in our Parkinson symptoms but uh what we've been talking about is having um a healthy connection of who we are and what we like to do and what our needs are so that means that we have to know ourselves and listen to our body sometimes you know we could be a little stubborn and say well I need to exercise even though you can barely get out of bed you're falling just tripping on your PJs tripping out a bed so you need to really think about when is your best time uh and Maxim ize your your medication some people are morning people I am a night out I'm always best at night no matter how I am during the daytime so you know exercise but unfortunately exercising at night time then that's going to disrupt your sleep wake cycle so you know so we have to think about that that it's better to exercise in the morning earlier so it's not going to impact uh your sleep but also taking into consideration that you don't have to exercise every day or you don't have to go all out every single day you know some days maybe you're you're having you know you're dehydrated you're having some upper respiratory issues you're having other problems your fatigue listen to your body and and rest if you have to and then you have the energy to go and do the activities and make take make sure that you are optimize on your medications so that you if you're having a lot of apathy and I'm glad you know I'm going to take a little chance to talk about apathy apathy is is two things one is the apathy that you don't feel like doing anything because you just don't have the UMP to do it it takes so much effort you want to do it you want to go out you want to exercise but just the thought of doing it is just so exhausting and overwhelming and that is lack of dopamine you need more dopamine and need to talk to your doctor and yes once you're exercising go that's going to boost up your your dopamine you're GNA feel great but then you know it's going to go down so we need to work both ways exercise but also increase more dopamine if on another hand you don't feel like doing anything and you know even if you um love to go you know whatever fishing or like to go shopping or you just have no interest in doing that then you're probably more depressed that even though you know you could do it you just don't want to do it you don't care as opposed to you know you know you want to go out you want to socialize you want to exercise but it takes a lot of effort that's lack of NY you don't interest anymore in doing anything you don't care if you get changed you don't care if you get dressed you don't care if you talk to anybody that's depression and we need to talk about increasing serotonin in that case so you need to talk to your physician either way and discuss what is really driving this behavior and then talk take medication before you go do this activities because I've seen lots of people that will go push themselves and you're doing great while you're doing the activity you use up all your dopamine and then what happens you stop and suddenly you drop and you fall and you break a hip you you break you know you you end up in the hospital with concussions and so on so you need to make sure that you listen to your body I am you know I'm also guilty of that initially I didn't want to listen wanted to go you know be a doctor do and I fell several times and I ended up with hernia a disc so now I know that if my body's kind of slow take your medicine rest first then okay let's go and you know do some activities so so it's important uh that you time it what you're going to do and if you're going to push yourself like is don't go out in the heat don't go out of extreme weathers because that's going to require a lot more dopamine a lot more stress on your body so try to do your routines in a time that is going to maximize your medicine and also make it safe for you okay so I hope that helps them so any other questions um I know there's a million questions about you know medicines and does DBS affect exercise um it depends how you know you're you're controlled again you know how the dopamine levels are how they fluctuating or the control you know but you should be able to to do some activities and always start slow I like water therapy uh because it's a great um it's great for balance and it's great for pain and flexibility and um and so you don't really feel like you're putting a lot of effort but you really are in the deep water you have to be in the deep water to get the balance uh usually what I do is grab one of those sticks that um that they use you know those those floating poles you know you hold on and put you know make sure you wear vest I don't want you drowning and and then grab those sticks and try to stand on that stick with one foot IM balance and then the other foot IM balance and then stand with both feet on that stick like a youu and you stand on it like a swing in the deep water and that is the best balance exercise that I have found and and um you refresh you're in the pool especially if it's indoors you're having fun and and your balance will get uh better other things that will improve your balance walking on Sand uh walking on an incline backwards uh of course don't do this by yourself make sure you have your physical therapist your friends there watching you you don't want to fall but that really helps uh with your balance so um having a lifestyle that incorporates all kinds of activities good nutrition good sleep and as these uh wonderful panelists told us you know stay active brain active physically active and you don't have to do the same thing all the time mix it up make it fun dance one day go you know cycling go uh swimming and I think that that's the best way to maintain that activity um do you guys have any other thoughts you want to add as final uh comments as Before We Say Goodbye well it was a privilege being on the panel with with you three and it was a privilege to be able to talk to the audience thank you all very much it's an honor thank you for being here you guys were wonderful big round of applause for everybody I look forward to seeing you guys again and maybe giving you a big hug and doing some exercises together so thank you joining us thanks everyone bye bye thank you bye bye e