Chapter 5: The Amazing Brain (slowing disease progression / retraining the brain for improved movement and cognitive skills)
We know that exercise is good for us, right? We read about and hear about it all the time. For most of us, when we begin an exercise program and stick with it, magic starts to happen. Here are some examples:
- our energy level increases
- our mood improves
- we sleep better
- concentration improves
- comprehension improves
- constipation may be relieved
- we shed extra calories
- we get stronger
- cardiovascular health improves
- we FEEL better
- we improve our health
- our quality of life improves
That’s a short list of benefits, but what other benefits are there? The answer is, MANY! Let’s take a look.
Exercise and THE BRAIN (our human pharmacy and the supercomputer of all super computers)
When we think of exercising, we generally think about building muscle, improving balance and cardiovascular health, and maybe adding in some flexibility.
But what if I tell you that targeting the brain is at the very top of the list when it comes to helping to slow disease progression and more effectively manage disease symptoms?
As you know, in PD, the substantia nigra is losing brain cells and less dopamine is produced. Author, Dr. Deepak Chopra describes the brain as a human pharmacy because of its ability to create a multitude of chemicals and hormones which help to keep us healthy and moving well.
First, we will learn how cardio and aerobic exercise can help to slow disease progression. This is one of the top three staples of our education and training sessions.
Next – as we discussed in the part 2 introduction, the brain has what is called neuroplasticity, the ability to develop new neural firing pathways via electrical synapses between neurons. We will learn training concepts that take advantage of the brain’s neuroplasticity, how “neurons that fire together wire together,” (Norman Doidge, 2007) and how this helps people with PD to move better and reduce the risk of falling.
Benefits of cardio & aerobic exercising, creating BDNF (brain-derived neurotrophic factor), and slowing disease progression
Exercise causes the creation of a multitude of chemicals and hormones that benefit our brain and help to slow disease progression.
In fact, the number one known way via exercise to slow progression of diseases such as Parkinson’s, Alzheimer’s, and dementia is to do cardio – every day.
Aerobic exercise will help to develop a stronger, more fit heart and cardiovascular system. It helps to get blood and oxygen to the brain, but it offers an additional benefit unknown to a majority of people. I’m talking about the creation of brain-derived neurotrophic factor, or BDNF, in the brain. Cardio is the fastest known way to create BDNF.
We learned in chapter one that dopamine is a neurotransmitter responsible for sending signals between neurons in the brain. With brain cells dying in the substantia nigra, less dopamine is produced, and movement becomes awkward or challenging. BDNF helps to slow the progression of these dying brain cells.
As described by Harvard professor, Dr. John Ratey in his book entitled, “Spark” – as fundamental as neurotransmitters are, there’s another class of master molecules that has dramatically changed our understanding of connections in the brain and specifically, how they develop and grow. I’m talking about a family of proteins called, factors, the most prominent of which is brain-derived neurotrophic factor (BDNF). Whereas neurotransmitters carry out signaling, neurotrophins such as BDNF build and maintain cell circuitry – the infrastructure itself. (John J Ratey, 2008)
In conversations during my visits with Stony Brook University Clinical Associate Professor, Dr. Lisa Muratori, she explains that elevating your heart rate will cause the creation of BDNF. Elevation of heart rate is best achieved while performing some form of cardio or aerobic exercise. However, to ensure creation of BDNF, we have a couple of requirements to meet.
The brain will best produce and circulate BDNF by elevating the heart rate for at least 30 minutes at the equivalent intensity of walking as fast as possible.
While everyone with PD is uniquely affected differently and some may have difficulty performing cardio to these requirements, there are many who are plenty capable of meeting or exceeding what is required to create BDNF.
In fact, whatever keeps the heart and blood vessels fit will invigorate the brain (this includes a healthy diet) and stimulate the production and release of neuronal growth factor, BDNF. (Norman Doidge, 2007)
While a brutal workout is not necessary for production of BDNF (Norman Doidge, 2007), higher exercise intensity and longer duration will cause increased production of BDNF.
So, why is BDNF so special? There are a multitude of reasons.
Thousands of research papers and books have been published about benefits of BDNF and it is often referred to as Miracle Grow for the Brain.
It works something like this: we begin exercising and increasing our heart rate. Once we’ve exercised at the appropriate intensity for 30 minutes (a statistical benchmark that will vary between studies, but we’ll use 30 minutes as our baseline), BDNF will have been created and circulating in the brain.
BDNF promotes neuronal protection, neurogenesis, cell survival, cell remodeling, axonal and dendritic growth, and synaptogenesis (the formation of synapses between neurons in the nervous system). (da Silva Germanos S., 2019)
BDNF also helps to improve the uptake of medications and keep them in the system for longer. At our live workshops, we often hear from people with PD and their caregivers that regular aerobic exercise helps to promote longer on periods (that window of time when dopamine replacement medications have kicked in and the patient realizes improved movement).
In my 2016 interview with New York University neuroscientist, Dr. Wendy Suzuki, she explains that regular physical aerobic exercise can be transformative to your brain and your life. Aerobic exercise does many positive things and it does them immediately. A great way to notice this is to note the change in your mood during and after exercising versus prior to exercising. You can watch my interview with Dr. Suzuki on the book support website at www.thepdbook.org.
Dr. Suzuki explains that we want to have as much BDNF in our brain as possible and states the following additional benefits of aerobic exercise and BDNF creation:
- improved ability to focus attention (an immediate benefit of aerobic exercise)
- improved memory (a benefit resulting from long term aerobic exercising)
- slowing the progression of neurodegenerative diseases and dying brain cells
- birth of new brain cells may occur in the hippocampus (a key structure that allows for formation of new long-term memories) and the olfactory bulb (a structure critical for the ability to smell and discriminate between smells)
On a side note: the hippocampus (important for memory) is the first target of Alzheimer’s disease. This is why early Alzheimer’s disease patients have memory impairments. Additionally, regular, and long-term production of BDNF can help those with dementia and early stage Alzheimer’s to strengthen the hippocampus and improve memory.
While aerobic exercise is the most effective way to produce BDNF, there are other ways, such as doing activities you like to do:
- enriching your environment
- visiting with family
- visiting with friends
- attending social functions
- social interaction
- drinking a cup of coffee or tea
- playing games
- attending a concert
- attending a game (Sakata, 2014)
I repeat what bears repeating: while aerobic exercise and creation of BDNF can be a game changer and help to improve memory and quality of life, by no means are we saying that this is a cure for any neurodegenerative disease.
At the same time, countless research studies tell us that regular aerobic exercise can help to delay or possibly eliminate onset of diseases like Parkinson’s and Alzheimer’s for those who are genetically predisposed.
My takeaway message for this section: do some form of aerobic exercise (cardio) every single day! If you’re anything like me, you might not feel like exercising. So often, I find myself wanting to avoid exercising. How can we get off that couch and get started? Here’s an idea: do exercises you like to do, and you’ll be more likely to get started.
We’ll talk about getting started later in part two of the book, but for now, I’ll share a couple thoughts based on my own experiences getting started with each workout.
I have learned that once I get started, I get the energy to keep going. When I’m done (or often times during my workout), I feel better in so many ways (physically, mentally, and emotionally).
I realize other benefits, as well:
- I have more energy to get through the rest of my day
- I sleep better
- I wake up feeling more energized the next day
- My mood always improves
- My attention and mental focus improve
As I say when in Mexico (where I’ve taught over a dozen times), “cardio, cardio, cardio – todas las dias (cardio every day).
Just get started! Do this, friends – every day. Your brain and body will thank you.
Retraining the Brain (our human supercomputer)
Until just a few decades ago, it was thought that whatever you’re born with in your brain – that’s all you get and after the brain matures, the wiring is fixed for life until brain disease or degeneration begins to occur.
Thankfully, this isn’t true. In fact, the brain is highly moldable, malleable, and has the ability to remodel and reshape itself by creating networks of new neural firing patterns. The human brain is more complex than the
most sophisticated supercomputer you’ll ever find. The potential for retraining the brain seems nearly infinite.
This area of focus is among the top three staples in our education and training sessions. In this section, we will talk more about neuroplasticity and introduce training concepts that will be put into action in part four of the book.
While there’s plenty of science, imaging, and research to describe how all of this works, let’s look at an example that most people can relate to in terms of training the brain and creating neural firing patterns: learning to ride a bicycle
Who hasn’t ridden a bicycle? I’m sure there are some folks out there who haven’t, but most of us have probably learned at some point.
Do you remember the first time you rode your bicycle? I don’t, but my parents sure remembered. And, as a parent myself, I vividly remember my children learning to ride their bicycles. It’s quite something to watch. Both of them learned quickly, but do you think they jumped on those bicycles and started riding like a seasoned professional right away? Why, of course not.
So, what happened? The first challenge was being able to swing a leg over and straddle the bar that connects the handlebar to the seat post and placing both feet on the ground and standing without falling. Now, it’s time to try and sit on the seat while placing a foot on a pedal, but which foot? Well – this wasn’t going to happen right away in the beginning.
Next task – getting that bicycle to move while you balance and attempt to avoid falling or crashing. I remember this so well. Like most children, neither my son nor daughter got started on their own for the first few trips. Like most parents, I took hold of the handlebar with one hand while grabbing the back of the seat with the other, steadying the bike in starting position. From there, my child could safely get on the seat and put their hands on the handlebars and feet on the pedals.
From starting position, I began moving the bike forward while my child remained terrified. Each time, however – we would go a little farther and faster while I slightly loosened my hold. After several trips back and forth on the front lawn, my children started to get a bit of a feel for things and their confidence began to build. I could now let go for 1 or 2 seconds while they moved forward balancing on their own.
Like the old saying goes: repetition is the mother of skill! This is so true, and it took very little time before they were riding on their own!
With both children, we spent a couple of hours on the front lawn, several falls occurred, but helmets and the soft-landing surface of the lawn made for a relatively safe place to fall. We kept practicing and practicing and each time, they would travel a little further on their own. Before you know it, I let go of the bicycle and they didn’t even know it. They were officially riding the bicycle all by themselves! What an amazing experience and feeling, both for each of them and for my wife and me.
So, how does this work? How do we develop skills like these? The answer is – the amazing neuroplasticity of the brain.
One of the world’s leading neuroscientists, Dr. Michael Merzenich talks about brain plasticity throughout the lifespan in his book, Soft-Wired.
In infancy, and progressively staged across those higher and higher brain levels throughout childhood, plasticity goes through a critical period, a time of massive changes within the brain. During this time period, each functional zone of the brain is remodeled to make its own special contribution to that long, slow process of creating an effective, operational person from the blank slate that begins to organize itself functionally. This critical period begins in utero around the beginning of the third trimester. (Merzenich, 2013)
During these early and formative years, the brain plasticity switch is always turned “ON.” As the brain matures and generates more reliable and coordinated responses, it undergoes physical and chemical changes that increase the power of the “OFF” switch. Over time, the balance of power changes, the “OFF” switch dominates, and plasticity is only flipped to “ON” with permanent changes to the brain being permitted only under certain circumstances. (Merzenich, 2013)
So, as you can see, in the formative years as the plasticity switch is always ON, a child learns to do countless things: roll over, crawl, walk, use a spoon, use a fork, drink from a cup, learn to talk, to name a few. As the child learns each new skill, including riding a bicycle, millions of brain cells are experiencing electrical synapses between neurons and quickly develop connections between these neurons. Frequent and repetitive training will further develop each new ability and skill. This repetition causes the formation of stronger synaptic firing patterns between neurons in the brain and these neural firing patterns will become increasingly reinforced. The more solid the connections between neurons, the better we can perform each new skill.
And how about that old saying, “it’s just like riding a bicycle?” I’m speaking to the occasion when you haven’t ridden your bicycle for a few years, and then get back on. Do you have to completely relearn how to ride again? NO! Chances are – those neural firing patterns are still connected. Let’s call them your “bicycle riding firing patterns.” You haven’t ridden in quite some time, but you jump on a bicycle after many years and BINGO – within a few minutes, you’re riding as if you never stopped. During the years away from riding the bicycle, those neural firing patterns weren’t firing. Let’s say they were a bit rusty because of inactivity. However – the connections were still there. They just needed to be fired up again and that helps to explain why it’s generally so easy to ride a bicycle again even after several years of not riding.
We learned that later in life, the plasticity switch is generally turned “OFF” but can be turned “ON” when we desire to learn a new skill or task – and rest assured, that’s what we will be talking about, extensively in the following pages.
With our knowledge of how Parkinson’s can affect a person and with an understanding of neuroplasticity, we can now dive into concepts that help to retrain the brain to help a person to reduce fall risk and realize improved balance, mobility, stability, movement, multi-tasking abilities, and overall functionality.
BRAIN and COGNITIVE TRAINING CONCEPTS
Cognitive training (brain training) is referred to as a program of regular activities which claim to develop, improve, or maintain cognitive abilities. These abilities may include attention, working memory, problem-solving, direct recall, decision making, executive function, to name a few.
Countless studies indicate that cognitive decline commonly occurs as we age. We also know that cognitive decline often accompanies Parkinson’s disease and people with PD are at greater risk of being affected by dementia. Dementia in Parkinson’s disease affects 50% of patients within 10 years of diagnosis but there is wide variation in severity and timing. (Juliette H Lanskey, 2018)
Cognitive Training during focused movement is a staple of our education. In this type of training, we challenge the person with PD by implementing some form of cognitive training during focused movement in a safe environment.
Our goals: develop improved movement skills that transfer to activities of daily living. This will involve a number of combined movement and cognitive challenges. During training sessions, it will lead to a number of near falls (almost falling but not actually falling – also known as fall recovery. When you almost fall, but don’t – this is called fall recovery). While this may sound frightening, this is exactly what we must do to help people with PD to recover from a fall during daily activities. The training we practice must translate to daily activities outside the gym.
In Parkinson’s disease, we know that the substantia nigra has diminished functionality. Plasticity allows the substantia nigra to outsource to the cerebellum and other areas todevelop as movement control centers. Neuroplasticity allows the ability for the brain to reorganize and create new neural pathways to adapt, as it needs.
We heard this before and it bears repeating,“Neurons that fire together, wire together!” (Norman Doidge, 2007)
Let’s examine a few cognitive training concepts, how they vary from each other, and how they can help to create and fire up new neural pathways. Each concept can be exercised on its own (without movement), however – using cognitive training concepts while performing a focused movement will help to improve dual-task and multi-tasking abilities and reduce fall risk.
In part four, we will talk more about building layers into the exercises we choose. It is important to choose movements our clients can do, but equally important to choose movements that present some degree of a challenge. Once we add a cognitive task during these movements, the challenge will become greater.
A bit later in the book, we will learn how cognitive training concepts are part of an overall concept known as neuropsychomotor training. Neuropsychomotor training uses a holistic approach towards exercise intervention. Within this concept of training, we can be creative, build layers of complexity during exercises, realize more optimal results, and have fun!
Choosing a movement can include any number of exercises. Below is a short list of examples. Video demos of each (and many more) can be found on the book support website at www.thepdbook.org
- Walking (walking presents a challenge for some people)
- Side stepping
- Skipping sideways
- Walking backwards
- Walking a line (one foot directly in front of the other while walking a line)
- Walking a line backwards
- Infinity walk
- Infinity walk modifications
- Ladder drills
The list can go on and on and to make it more fun, I like to find out what hobbies or interests they have.
For example, I love cars, especially late 1960’s muscle cars. I have a client who likes them, as well. I sometimes challenge him to name every muscle car he can think of and tell me details about each to the best of his ability – all during focused movement.
Find out interests and hobbies and get creative with additional direct recall challenges. Here are examples of a few interests I’ve encountered:
- Sports (teams, players, stats)
- Music (musicians, songs, bands, etc.)
- Broadway shows
- Television shows
- Politics (be careful with this one – haha, but it can be fun)
As you can see, direct recall training offers the opportunity to be very creative. You’ll find more examples of direct recall on the book support website and in part four of the book.
Spatial / Visuospatial Performance: Cognitive Training Concept #2
Spatial awareness is the ability of a person to understand where they are in relation to objects or where objects or structures are in relation to each other. (Quinsey, 2017) This training concept covers a wide array of thought processes and challenges the patient’s proprioceptive awareness.
Visuospatial is defined as: Relating to or denoting the visual perception of the spatial relationships of objects. (Lexico, n.d.)
In Parkinson’s disease, we often see diminished visuospatial skills. Cognitive decline diminished executive function, and/or lack of dopamine in the retina can cause depth perception and visual contrast challenges. This leads to an increased risk of falling. Here are some examples of challenges we often hear about:
- Approaching an object or obstacle (a chair, doorway, surface change on floor, object on floor) and having to slow down as they get closer to the object as they are unsure of their distance from the object
- Walking in crowds of people and experiencing difficulty navigating as they’re unsure of their distance from others
- Driving a car and judging proximity to oncoming traffic (at which point many people with PD stop driving in the interest of safety)
- Parking a car in a parking space
- Planning a route or task
- Assembling an object
Spatial training offers countless ways to get creative and fire up new neural firing pathways in the brain. Here are some examples where spatial and/or visuospatial abilities are used:
- Describing or planning a detailed route to get from one place to another
- Rearranging furniture
- Using graphs
- Using a map to navigate
- Assembling a jigsaw puzzle
- Assembling something using a diagram with pictures or drawings (i.e.: assembling a bookcase, a model, a bicycle, etc.)
- Video gaming
- Virtual reality games
- Augmented reality games
In part four, we will introduce several examples of spatial training exercises and games. Right now, let’s take a look at a few spatial and visuospatial training examples. Remember, these can be done on their own, but visuospatial performance training will be more effective when paired with some type of focused movement.
- Street names
- Number of blocks or miles to the next turn
- Is there a stoplight or stop sign at each turn?
- Which direction will they go at each turn?
- What landmarks do they pass on the way?
Example #2: During an exercise or focused movement, have your patient describe (much like above) how to walk from one place to another. For example: I have a client who teaches at a university. His office is in one building. His classroom is across campus in another building. I have had him describe the walk between these buildings using different pathways and naming other buildings and landmarks along the way. We’ve also had him walk from the office or classroom to other locations, i.e., library, gym, coffee shop, etc.
Exercise #2: Proprioceptive awareness
In this challenge, we’re testing the sense of your own body in space (your proprioceptive awareness). We’ll have the patient stand in place (no movement for this challenge). The game goes like this:
- Put your arms straight out to the side
- Keeping elbows at shoulder height, bend elbows to a 90-degree angle with forearms perpendicular to floor and all fingers pointed towards ceiling. This will be your starting position for the game.
- Spread the fingers of your left hand wide apart leaving your left arm and hand in starting position, touch your right index fingertip to your nose
- Return right hand to starting position
- Then, without looking and without moving your left hand, touch your right index fingertip to your left thumb
- Return right hand to starting position
- Touch your nose again
- Return right hand to starting position
- Without looking and without moving your left hand, touch your right index fingertip to your left index fingertip
- Return right hand to starting position
- Continue this exercise by touching all five fingertips, touching the nose in between, and each time returning right hand to starting position
- Repeat on other side using the left hand
This might not have been too difficult, but now, let’s progress the game – close your eyes and do the exact same game all over again. See how you do. Was it harder than you thought it would be?
Taking away vision usually makes it more difficult to precisely feel where your body and fingers are in space.
Exercise #3: Obstacle course
Here’s another exercise to train visuospatial and proprioceptive awareness.
- Set up an obstacle course
- Include objects to step onto
- Include objects to step over or to go around
- i.e., cones and hurdles of various heights (perhaps 5-8 inches in height)
- a wobble board
- an airex pad
- include some type of step-up platform or stairs
- include a doorway
- set up an agility ladder
The list of objects could go on and on. Get creative (with safety in mind) and try various surfaces and objects.
Exercise #4: Hand-eye coordination
Hand-eye coordination offers a multitude of training benefits and is a mainstay in our education and training sessions.
During a focused movement like those discussed previously, add in an exercise such as throwing and catching a ball (perhaps a basketball, tennis ball, lacrosse ball). This stimulates activation of the visual system while the patient is moving. In addition, if the coach is moving around the patient during this exercise, the patient will engage in turning their head and this activates the vestibular system. Now, you’ve simultaneously activated the visual and vestibular systems during focused movement. Adding a cognitive challenge on top of all of this creates an effective brain training exercise. You have now built layers into the exercise which will stimulate the deeper brain.
Try playing the games listed below. Adding a cognitive challenge during the games will stimulate the deeper brain:
- Play badminton
- Play basketball
- Play tennis
- Play volleyball
- Play ping pong (or table tennis)
These games and exercises offer numerous benefits to the brain and have the potential of helping to improve:
- Visuospatial awareness
- Reaction time
- Cardiovascular conditioning
- Dual-task and multi-tasking abilities
Exercise #5: Virtual reality and augmented reality
Virtual reality and augmented reality games offer benefits in several areas including visuospatial training. In London, U.K. at The Royal Institution, brain imaging has been conducted as patients play virtual reality games. In the lab, a split screen shows the game on one side of the screen and brain activity on the other. As the patient encounters challenges and makes decisions while playing the game, scientists can simultaneously watch brain activity. Imaging shows that numerous areas of the brain light up and become active throughout the duration of the game. The more the brain lights up, the more likely new neural pathways are being created.
Additional benefits of virtual and augmented reality games have included improvements in:
- Step and stride length
- Quality of life (Dockx K, 2016)
Decision Making / Reactive Training: Cognitive Training Concept #3:
Decision making cognitive training is a form of reactive training. Many people with Parkinson’s experience cognitive decline, diminished (slower) cognitive processing, and slower reaction time.
In this concept of training, the primary goal involves speeding up reactive decision-making abilities. Here are a few examples:
Boxing: using a heavy bag or with the coach wearing boxing mitts, the patient wearing boxing gloves, and the coach cueing each punch, try a few of the following reactive decision-making ideas:
- When the coach cues “right” the client executes a punch using their right hand. When the coach cues “left” the client executes a punch using their left hand. If the coach is wearing mitts, establish a protocol for punching, for example: when the patient punches with their right hand, they’re crossing over to hit the right mitt and vice versa for left side punches.
- Try putting colored tape or a colored sticker on the mitts. On my mitts, I have yellow tape on the left mitt and green tape on the right mitt. We now have the option of cueing the patient to hit right, left, yellow, or green.
- Progress this as follows: “everything the coach cues, the client does the opposite.” For example, when the coach ques to hit right, the patient hits left. When the coach ques to hit yellow, the patient hits green, etc.
In each case, the client has to make the decision of which hand to punch with. Progressing to opposites creates a greater challenge as the client must think, decide, then react with the correct punch.
Try progressing this activity further. Here are some examples:
- Enrich the proprioceptive environment by having the client stand on an airex pad, a wobble board, a Bosu (bow sue) ball, or some other somewhat unstable surface while boxing.
Add a cognitive challenge:
- with each punch, have the patient name a city they’ve traveled to
- have them tell you how to get from their current location to another location
- have them imagine they’re going on vacation and ask them to name every item they would pack that begins with the letter “S” (i.e., sneakers, shoes, sweater, socks, etc.)
Agility dots: agility dots come in multiple colors, anywhere from 6-24 dots per package.
- Set up a pathway of dots on the floor and try cueing your client in various ways, i.e.,
- Rotations: (Rotations are often a trigger for freezing of gait and these increases fall risk. Rotation training is highly beneficial).
- With each step, have your client rotate to step on the next dot. They can take their time and do this at a comfortable pace
- Progress this by cueing each step, i.e.,
- Right foot blue
- Left foot red
- Try cross over rotations. Have your patient cross the left leg in front of the right leg to. Rotate right and vice versa for the opposite direction, i.e.,
- Cue left foot blue: the blue dot will be to the patients’ right side. The left leg crosses in front of the right leg to step on the blue dot and vice versa for other side
More examples can be found in part four and on the book support website.
Problem Solving: Cognitive Training Concept #4:
In an interview with my friend, Dan Edwardes, the idea of problem solving was introduced to me as a training concept. Credit goes to Dan for this concept. You can watch our interview on the book support website.
Dan owns an amazing facility in London, Chainstore Gym – also the home of Parkour Generations, founded and created by Dan.
I’ve had the opportunity to teach at Chainstore Gym on several occasions. Each time, I’m amazed to watch Parkour athletes as they beautifully and almost magically navigate multiple obstacles.
Practicing parkour requires a participant, called a traceur, to see obstacles and overcome them as quickly as possible using only the body and no other tools. The most common movements in the practice of parkour include running, sprinting, jumping, and climbing over, under and around the obstacles. As a participant practices parkour, she will increase her speed, flexibility, stamina, and endurance. Many traceurs practice alone, as part of a class or with a one-on-one personal trainer. The method you choose depends on your ability level and how serious you are about improving your parkour skills. (Ipatenco, 2018)
On every occasion I have taught the Parkinson’s workshop at Chainstore Gym, we implemented Parkour training and wow, we had fun! While Parkour is considered to be an extreme sport, we can easily modify movements to work with people with Parkinson’s of all levels of ability.
The picture below (a photo of Chainstore Gym) will give you an idea of what obstacles we used during our Parkour training.
Problem solving in Parkour involves multiple cognitive training techniques that are implemented simultaneously, including spatial and decision making.
When encountering an obstacle, the goal is to get to the other side. When the client (or traceur) reaches each obstacle, they will examine it spatially and then decide how to get to the other side (over it, under it, around it, or through it). Spatial and decision-making training are simultaneously activated, and the problem gets solved as they reach the other side of the obstacle. This makes for a great way to fire up the brain and create more new neural firing patterns.
See videos of Parkour for Parkinson’s training on the book support website.
Working Memory: Cognitive Training Concept #5:
Working memory is a cognitive system with a limited capacity that can hold information temporarily and is often used synonymously with short-term memory. It’s important for reasoning and the guidance of decision-making and behavior. Working memory is that part of our consciousness that we are aware of at any given time. It provides the arena for a number of thoughts, facts, and theories to be considered together. (Memory and Levels of Explanation, n.d.)
Let’s look at two examples that can help to improve and expand working memory.
Example #1: Word List
This exercise example comes from the neurology world and is often administered before and after a subject partakes in a neurological research study.
The test includes four learning trials of 12 unrelated words, an interference learning trial of 12 new words, and a delayed recall trial of the initial 12 words 25-35 minutes later. Patients are told they would be tested after a delay. (Laura B. Zahodne, 2011)
For the sake of our education and training, we will modify this slightly.
Prior to beginning a focused movement, the coach will recite a list of words. 12 words is used in the standard memory test mentioned above. However, 12 words may be far too many for a person to memorize.
I would suggest starting with 4-6 unrelated words, i.e.,
Ask the client to recite the words back to you. Repeat the list of words, as needed – each time having the client recite back to you until they recite without errors.
Next, have the client begin some type of focused movement. During the movement, ask the client to recite the list of words.
Change cognitive focus and ask the client to perform another task during movement, i.e.,
- Name every vegetable and fruit they can think of
- Name breeds of dogs
- Name types of trees or flowers
Return to the word list and ask the client to recite it again.
Add a second (interference) word list into the mix, i.e.,
Ask the client to repeat back to you. When they recite without errors, return to the first word list, and ask them to recite.
Later in the training session, return to the word lists and have the client recite again to the best of their ability, preferably during focused movement. It is always interesting to see what we remember later in the session.
This type of training should be individualized and appropriate for each client with respect to their working memory abilities.
Example #2: Logical Memory
The first example we’ll use in this section represents a simple technique that works towards training and improving a patient’s working memory. In the neurology community, this story, the Anna Thompson story, is often used for logical memory testing. The story is presented orally. Patients are asked to freely recall the story immediately after it was read and again 25-35 minutes later. (Laura B. Zahodne, 2011)
Here’s the Anna Thompson story. Read this to your patient:
“Anna Thompson of South Boston, employed as a cook in a school cafeteria, reported at the City Hall Station that she had been held up on State Street the night before and robbed of fifty-six dollars. She had four small children, the rent was due, and they had not eaten for two days. The police, touched by the woman’s story, took up a collection for her.” (Unknown, n.d.)
Now, have your patient recite the story back to you in as much detail as possible.
Next, read the story again and then have your patient begin some type of focused movement.
During focused movement, ask your patient to recite the story again in as much detail as possible. If they leave out details, that’s fine, but don’t help them.
The Anna Thompson story comes from a logical memory exam. This exam includes a specific set of tests given in a specific order with detailed instructions. A scoring system accompanies the exam. To access the entire exam and scoring system, visit the book support website.
The Anna Thompson story is an example I like to give. Using the scoring system protocol in the logical memory exam found on the book support website, you can get creative and write your own stories.
Additional Brain Training Research: Speed Training, Reasoning Training, Memory Training
The ACTIVE study was the first large-scale, randomized trial to test the long-term outcomes of cognitive training effects on prevention of decline in daily function. (Sharon L. Tennstedt, 2015)
In the training concepts we introduced thus far, our primary goal involves working towards improving multi-tasking abilities and movement and reducing fall risk. The faster our cognitive processing, the greater the likelihood of improving these areas.
The ACTIVE study shows the speed training, reasoning training, and memory training interventions transfer to improvements in activities of daily living.
The goals of training interventions in this study included:
Speed training focused on visual search and the ability to process increasingly more information presented in successively shorter inspection times.
Reasoning training focused on improving the ability to solve problems that contained a serial pattern
* Memory training focused on improving verbal episodic memory through instruction and practice in strategy use.
Results of the ACTIVE study show that each type of training produced its largest effect immediately after the intervention and with some dissipation over time; however, training gains remained statistically and practically significant at the 5-year follow-up. (Sharon L. Tennstedt, 2015)
Cognitive training concepts can be overlapped, and implementing speed, reasoning, and memory training within the concepts we already know can help to improve the outcome for our patients.
Visit the support website to access the full ACTIVE study.
Chapter summary / take away message:
- CARDIO and aerobic exercise are the best way to create BDNF.
- BDNF helps to slow the death of dying brain cells and may help give birth to new brain cells.
- BDNF can help to slow disease progression and possibly delay disease onset for those who are predisposed.
- Neurons that fire together, wire together.
- Cognitive training comes in many forms. While we’ve delivered several brain training concepts and multi-task training examples, this is just the tip of the iceberg and many more examples of each training concept can be found in part four and on the book support website at www.thepdbook.org
- Be creative and use the concepts delivered to create your own exercises.
- Cognitive training done without movement can help to create neural pathways in the brain and help to improve cognition.
- Cognitive training during focused movement creates more neural firing patterns helping to reduce fall risk, improve dual task and multi-tasking skills, improve cognition, and improve movement.
- Cognitive training during focused movement and paired with visual system activation, vestibular system activation, and hand-eye coordination will activate the deeper brain and create additional neural firing pathways.
- The more frequently these exercise concepts are practiced, the stronger and more solid these new neural pathways will be.
- When an exercise becomes too easy for the patient, be creative and progress with new movement and cognitive challenges.