Pre-habiliation is about stopping falls before they begin, and it’s always the best option. There is enough research and evidence to know that we should be exercising whether we have Parkinson's or not. But what can we do once we start to fall, what is freezing and how can we protect ourselves from injury?  

Falls are caused from a multitude of reasons, and those with certain neurological conditions may be more at risk.  However, today we are going to specifically look at Parkinson's disease, and focus on the risk of falls, impaired balance and why this may be happening. By addressing the reasons falls occur, you can reduce the number of falls you are having and  prevent further falls. 

Some of these reasons include, freezing, reduced muscle strength, postural hypotension, cognitive decline, fear of falling, reduced postural responses, and environmental hazards. 

If you are experiencing falls the best place to start is with using a ‘Falls Diary’.  This is a useful tool to identify when falls are occurring and in what situation.  For example, is it often when getting up to the toilet at night, or are you tripping over the front step, or could it be that you are falling in the kitchen when you turn around too fast?  By noting these in your Falls Diary, this can help you to identify where you need to focus your falls prevention. To help support falls prevention, click here to access your own copy to complete.  

For those with Parkinson’s, you may have experienced a period of Freezing.  This is when there is a delay or complete inability to initiate a movement, most notably seen with walking. This could be when a person cannot take a step on first moving or when turning.  It can also happen when rolling in bed or getting out of a chair. 

The reason freezing occurs is not well understood, however we have a number of strategies which can be very useful to manage this.  This includes gait retraining, use of cueing, which is external or internal cues that help you overcome freezing episodes, and counting or having lines on the floor. Specific practice and exercises help with freezing as well. 

Muscle weakness in Parkinson's is related to the impaired activation of the muscle itself, however as the disease progresses and we become more sedentary we can get secondary muscle weakness. Keeping strong muscles in your bottom, thighs and ankles is important, as are targeted exercises to maintain good balance and good postural control.
 
Fear of falling, can potentially lead to more falls.  I often talk about the ‘cycle of falls ‘ and how a fall can subsequently lead to a fear of falling.  This can then result in reduced activity levels, lack of confidence and reduced mobility, exacerbating the issue.  A great way to overcome the fear, and regain control, is to break the cycle and improve confidence around mobility.  Learning how to get up of the ground, improving muscle strength and challenging your balance are key ways to feel stronger physically and confident in different situations. 

Other medical conditions, such as Postural hypotension, which can be related to your Parkinson's can have an impact on your balance, as can medications. It pays to have regular reviews with your GP to make sure all your medications are needed and that your Parkinson's medication is at its optimum.
 
Cognitive decline can have an impact of falls, as you may not be aware of your environment or how you are moving within your environment. We know exercise is one of the most beneficial tools to help with cognitive abilities, as is learning new activities and brain training can also be implemented. Continued practice from diagnosis of key movement strategies such as sit to stand and stand and turn can help maintain function with cognitive decline. Therefore practical neuro active exercises can help to prevent further issues, and maintain current levels of activity. 

As Physiotherapists, another important aspect in falls prevention is Balance Retraining.  This is completing specific exercises and activities to improve balance, and to retrain balance, which means we need to stress and challenge the internal balance systems.  Just think how a baby learns to walk – it is through repeated stepping and falling down that they learn to move, as our brain and body use a feedback loop to make adjustments to keep us upright against gravity.  So when we retrain our balance we target specific individualised exercises that challenge a persons’ balance at the correct level to lead to better improvements. 
 
Falls prevention is important as this contributes to your health, wellness and independence.  There is help available, so if you need help or would like to chat for advice, call Sarah on:  (09) 424 3254  or e-mail:  sarah@hibiscusneurorehab.co.nz

In this blog we outline the difference, between general cardiovascular exercise which we class as Neuro passive exercise and Neuro Active exercise which we recommend for you to manage your Parkinson’s disease.
 
It’s now widely documented that when living with Parkinson’s you need to keep active and exercise. As a blanket statement for wellbeing that is fantastic. But what does it actually mean to be active? And what type of exercise do you need to do?
 
Often, we hear “I exercise every day and I am very active”. That’s is a great start! You should congratulate yourself on having a healthy lifestyle that supports your metabolic system and wards off heart and lung disease. But often this active lifestyle isn’t enough to slow down the progression of Parkinson’s.
 
What we have come to realise is that exercise needs to be Neuro Active. Simply put; Neuro active exercise is exercise that promotes not only brain health but also creates neuroplasticity. The brains ability to rewire and make new connections, opening dormant pathways.
 
SO what is the magic formula?
 
Thomas gardens every day, potters around in his shed, mows the lawns and keeps his property tidy. He doesn’t sit down much but might have a short nap in the afternoon. Overall, he remains mobile and “active”. The problem is that his movements will still be done on a smaller scale than normal, unless he is conscious and planned with how he moves every time he moves.
 
And what about Brendan, he goes to the gym four days a week, he is on the bike doing a gentle cycle for 10 minutes and then does weights for 30 minutes. This is helpful to build strength in his muscles. However, we know that with Parkinson’s there is not a primary problem of weakness, yes you get secondary issues with weakness because you are not moving properly and more sedentary. So what if we treated the primary reason, the fact that the brain is not activating the muscles through the correct range or with enough force?
 
Bronwyn walks every day on her local beach for about 30 – 45 minutes at a reasonable pace.  However, she has noticed that she is walking shorter distances than she has in the past. Bronwyn has a great exercise behavior pattern, but this is still not helping her maintain her desired level of function. With Parkinson’s as the condition develops the brain recalibrates itself, movements become smaller and slower and it takes more time to walk along the beach.
 
If you see yourself in these made up cases, then please don’t stop what you are doing! Just make it work better for you. It is important that you maintain an active lifestyle but to change your brain your activities need to be neuro active.
 
As Physiotherapists we aim to teach patients the principles to be neuro active and how to put these into everyday life. We help you make the changes needed to slow down the progression of Parkinson’s. We show you how your activity choices need to be very deliberate and this can take a lot of hard work and effort.
 
This ‘hard work’ is more than just exercising. Its about committing to a new way of life that you need to control and keep working at it 24 hours a day. Unfortunately, Parkinson’s doesn’t take a day off, so to be neuro active in all parts of your life you need to be working at it constantly. This may seem like a lot of hard work, but it is achievable when you are willing to go to any length to slow down the progression of your disease and live your best life!
 
When we prescribe exercise programs, we incorporate seven core principles;
 
Power – Moving big and forcefully
High Effort – each movement needs to be at an 80% effort level to obtain the correct output and make brain changes
Challenging – Exercises need to challenge you both physically and cognitively to stimulate brain changes
Specific – The exercise you do needs to be specific to your impairments, working on what is hard for you will make the most changes that are going to improve your life. It also needs to be adapted to your body and specific injuries or health concerns.
Salience – The exercises must bring meaning to your life and your reason for exercising
Fun – You can put the principles into your favorite routine once you know what you are doing, if you enjoy it you will stick with it.
Frequency – Exercise must be done daily, unfortunately with a progressive condition it doesn’t stop so you can’t.
 
Our role is to incorporate these principles into specific exercises, and work with you to help you recognize and self-reflect on how to put these principles into your daily life it is these little, deliberate and constant movement changes that create the change you too can have.
 
In addition to becoming more neuro active, it is also recommended that you also participate in cardiovascular exercise that gets you out of breath. This type of whole-body exercise is thought to be Neuroprotective or Brain protective, potentially rther slowing down the progression of Parkinson’s.

​Our first recommendation is that you see a Physiotherapist skilled in managing patients newly diagnosed with Parkinson’s disease so you can partner with them and learn the skills you need to effectively manage your condition.

Our brain is super-efficient it is constantly rearranging and throwing out what it doesn’t need. When we become less active our brain tends to look a bit like an Autumn tree, the leaves are brown and withered and there are lots of gaps. The way our brain works is that we have certain areas that are assigned jobs. The front part for personality, the middle part for movement activities or sensory activities like feeling the heat from a fire, and the back part for seeing (well that’s a rough guide and tends to be a tad more in depth than that). But what happens say if we don’t use a part of our body or we stop performing a hobby (Like me I once played the clarinet, but I now could not read one single line of music to save myself) the brain prunes away the unneeded part and most often uses it for something else. Now that’s fine when it comes to me not being able to read music, I don’t have a need or want these days to play the clarinet.
 
But what happens when it’s something like your foot being able to lift up or your fingers being able to move well individually?? Then you get into trouble with tripping over objects or not being able to use cutlery to eat. This can then lead to not wanting to go out due to risk of falls or embarrassment when eating. We know that a person with Parkinson’s disease is 30 % more sedentary than that of someone the same age with out Parkinson’s. Not only are we working against a brain that is degenerating we have the secondary complications of sedentary behaviour, which can lead to other issues. What we want and need is for people to be active and not just plain old active we need you to be neuro active. We want to activate all those areas of the brain and turn those autumn trees into leafy green ones again. 

We all know it by now and if not you might have been under a rock, time and time again I have heard that exercise and being active is important.
 
But I am active I hear you say……..  My answer to that is yes you maybe active but is it the right type of activity.


​People are 30% less active than their peers with Parkinson’s.
 
Research indicates that at diagnosis a person with Parkinson’s is 30 % less active than that of age matched peers 1. And merely being active is not enough, the activity needs to be neuro active. When it is neuro active then you change your brain.
   
A walk around the block will not be enough to change your brain.
 
We talk about seven key principles that guide a neuro active exercise program. These are what we use to guide our treatments. These principles are based on the evidence of experience based plasticity2 which has been shown to change the brain and for Parkinson’s this has the potential to slow disease progression and help you move easier.
 
The seven principles are:
 
Amplitude – Move big, move with intention to create larger movements as normal movements in Parkinson’s are undersized. By moving BIG you are creating normal sized movements.
Power – Moving Strong, move with intention to create force and power behind even the smallest movement with help create normal movements. Think brushing your teeth or pulling on your socks.
High Intensity – Moving at 80 % of your maximum effort helps drive the change needed to change your brain.
Complexity – Now this is where it gets interesting, 
by combining more than one task you help cement these changes in your brain. Think walking and saying the alphabet backwards or doing your times tables while cycling ( just watch the traffic if you are on the road) throwing a ball to your grand kids while standing on one leg, reciting your favorite poem while cooking dinner.
Daily – Unfortunately your Parkinson’s does not take a break so its up to you to move daily with intention and in the correct manner that is going to make the changes and continue to see you have a long and happy life. Exercise and activity is as important as taking your medication and needs to be a non-negotiable part of your day. It also needs to be that you are moving in a deliberate manner every time you move. The best thing is the more you do this the less you will have to make yourself move in the correct way it will become habit.
Fun – Choosing a fitness activity that you enjoy insures that you stick with your program, once you have learnt the principles as described here, as long as you move with intention you can adapt any activity to make it work for you, if you need to be doing something everyday you at least need to enjoy it.
Specificity – We all know that Parkinson’s takes on many forms and no two people experience it the same way. Having an exercise program that focus’s on your main issues is what will make the difference for you. It maybe focusing on amplitude for Bradykinesia (small movements), High Intensity for tremor, or complexity for those newly diagnosed.

Moving in a deliberate manner throughout the day at all times helps you fight Parkinson’s
 
Learning how to use these principles is important. As well as education and teaching the principles when you see a physiotherapist that has expert training in Parkinson’s disease, they will be able to identify the key areas that you need to work on to make your life easier. They will set you an independent program that motivates and excites you. Teach you how to move correctly and effectively. And not to mention helps you fight back against your Parkinson’s.
 
For further information check out our website at www.hibiscusneurorehab.co.nz

1 Ellis T & Motl R (2013) Physical activity behavioural changes in persons with neurological disorders: overview examples from Parkinson disease and multiple sclerosis JNPT 37:85-90.
2 Kliem JA  & Jones TA  (2008) Principles of experience-dependent neural plasticity: Implications for rehabilitation after brain damage. Journal of speech, language and Hearing research 51:S225-S239

​Everyone presents differently with their Parkinson’s disease it is therefore important that you are working on the aspects of these exercise principals that are pertinent to you.
 
Some people have trouble with tremor or anxiety or it may be that you have trouble with falls or bradykinesia. It is important to really think about what your biggest challenges are and apply the principals of exercises to help your needs not the persons next to you.
 
We try to teach you all the same information so that you can use it to help you, and tailor your exercises, so that way you do an exercise it will be different to how someone else does their exercises.
 
If your main problem is tremor, you may find it helpful to focus on the force component of the training so power and high effort principals. These principals help adapt your body to stress, which can be a factor that affects tremor, therefore if your body is better able to cope with stress it could help reduce your tremor
 
If your main problem is bradykinesia or small movements it may be helpful to work on the principal of amplitude, so focusing on big movements to help recalibrate the brain and change what the brain sees as normal movement.
 
If your main problem is co-ordination, it may be helpful to work on dual tasking as this will help you complexity of tasks.
 
If your main concerns is balance it may be helpful to complete more balance tasks and work on power to help with muscle strength.
 
Ultimately it is about you using the knowledge we give you to help empower you to make the choices for your exercise to help improve your daily living.

 
Have you noticed yourself feeling weaker? There is evidence that weakness is one of the primary impairments in Parkinson’s disease. The thought behind this weakness is that there is a signaling problem from the brain to your muscles.
 
In a normal muscle our brain tells a motor unit in our muscles to move and this in turn tells the muscle fibres to contract so we can move our limbs. It is felt in Parkinson’s that there is a weak signal to the motor unit which causes inefficient recruitment of the muscle fibres and a decrease in speed of muscle contraction. This over time leads to slow movements and a loss of power in the muscles and the muscles not being used to their full potential again contributing to the slow and small movements that occur.
 
So it is important that we are bringing power back into our exercises and generating force behind our movements. And this needs to be brought into everything you do.
 
A great example is racket sports or cricket since is current the cricket world cup. If you do not put enough effort in to swinging your racket or bat the ball will go nowhere.
 
Last week we focused on amplitude and today we are working on making our movements powerful and big so I want to see force behind your big movements it will be challenging and difficult but with practice it will get easier we are working to change your brain and be at your best.

Amplitude refers to the size or range of movement. What we see with Parkinson’s disease is movements become small; and small movements make movements hard to do, think small shuffling steps, difficulty writing or doing up buttons,  reduced arm swing.
 
So when you are exercising you need to concentrate on making your movements as big as your full available range of movement in your body, and this will be much bigger than what you actually perceive.
 
Over time your movements are likely to or have become under scaled and research is indicating that this is caused by sensory changes within the brain and that you perceive that your movements are normal size when they are small.
 
By focusing on the size of your movements you can overide these changes but it takes a lot of effort and concentration on a regular basis. Sometimes it requires a friend or family member to help you see if you are changing how you move. Often when we move big it feels abnormal as if you are moving too big, but this is a normal response as your sensory perception has changed. SO remember if it feels too big its probably just right. 

Research is now showing that people with hearing loss are more likely to develop dementia that those with normal hearing. 
READ MORE HERE  Hearing loss and dementia or untreated hearing loss makes the brain shrink.

While this is been shown it has been shown that the use of hearing aids reduced cognitive decline and could delay the onset of dementia. 
READ MORE HERE Hearing aid reduces cognitive decline or hearing aids stimulate brain activity.

Why may hearing loss cause decline in brain health and function? 
The auditory process of hearing is processed in your brain, when a sound is heard and registered messages are sent by a network of neurons and synapses in your brain to recognition centre so you register and comprehend sounds and conversations.
When you no longer hear well you are not stimulating these pathways in the normal way, these pathways can become inactive, which causes changes within the brain, in the same way the loss of a limb affects the brain function. Loss of hearing can also cause social isolation, which leads to a cascade of other health issues both in mental health and physical function. With an overall impact on quality of life. 
​
If you or your loved ones suspect hearing loss it is best to have your hearing tested early and regularly as restoring hearing will impact your overall brain health and quality of life. 

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While being a physiotherapist I advocate physical activity over brain training for brain health. I definitely believe there are benefits to completing brain games and puzzles. Now this does not mean endless sessions on the play station or solitaire on the computer. The research is definitely stacking up in favour of researched and carefully planned activities. One great website I have found is BrainHQ which is heavily based on research in the field of neuroplasticity.  New research is also showing that specific brain training is having an impact on dementia and improvements in executive functioning. 

Brain HQ was started by Michael Merzencih, he is the founder of a great website Posit Science and prominent neuroscientist that works in the field of Neuroplasticity.

One study called the ACTIVE trial has shown that with just 10 hours of speed training ( a type of brain exercise offered by BrainHQ) dementia risk is almost halved. There was a 33% reduction in the incidence of dementia with 10 hours training and 48% reduction in the study participants that practised for longer than 10 hours. For more information on Speed training you can read the results on Posit Sciences Blog here, for full details do check out the FAQ. 

Other studies have also shown how the use of brain training from Posit science have had benefits in executive functioning including speed, attention, working memory and useful field of view. This independent research was published in Plos one. For a summary and information on other research into BrainHQ brain training exercise read this blog article on Posit science. 

See what you think is it time to add some brain training to your day on top of your physical activity.