Parkinson's and Exercise: Finding Motivation

In my late 20's I joined my first health club. It was the beginning of the aerobics craze, and I faithfully went to class several times a week. Later, I added a weight lifting regimen, and for the next two decades of my life, exercise became a part of my daily ritual. I can honestly say that I don't think I ever missed more than a week of working out. For me, my trips to the gym have been a way to stay physically and emotionally fit. Then, a couple of years ago, when I established my private practice,  my work days extended late into the night. Exhausted from the challenges of running a new business, driving around town much of the day, and working long hours, I stopped going to the gym. Slowly, and gradually, I noticed the loss of muscle mass in my arms and legs, the emergence of a few more aches and pains, and loss of motivation to exercise. I knew I needed to get back to the gym, but  how could I possibly schedule time to go work out, when I was already so busy and tired?      Where would I  find the energy and motivation?

Sound familiar? Often, when introducing a therapy regimen  to my patients that includes daily exercise, I hear them complain of "no time," "no energy," or  "no motivation." Intellectually, they may understand the need for what I am suggesting, but for many, now in their 70's or even 80's, committing to an intense therapy program or home exercise program may seem overwhelming and unappealing, despite the proposed benefit.

So, how do any of us begin a program of therapy or exercise when we seemingly lack  time, energy or motivation? In the words of Nike, we:

                       JUST DO IT!!

That's right. We begin by doing something, ANYTHING, that starts us on the path. Some days, especially when we're tired, we still show up. Whether we practice for 5 minutes or 50 minutes. A patient said to me this week: "if I get in to the habit, I'll be ok." Establishing the habit seemes to be the key for all of us. So, I have committed to ride my bike to the gym at least 3 days a week for  the next 60 days, and I invite you to join me with your own commitment to perform the exercises prescribed by your therapist,  attend a community based program or  use a home program of exercise. Tell a friend or two who will hold you accountable. I know that it will take me awhile to get back to being as fit as I was  two years ago, and maybe I  will never quite get there, but knowing that I am doing something to honor my commitment already makes me feel better.

Oh, and by the way...I notice I seem to be sleeping better, and for the first time in about 6 months, that chronic pain in my neck has seems to have gone away. I'd love to hear about your progress.

                    

Swallowing Therapy and Magic Tricks: Recognizing the Difference

A friend of mine with Parkinson’s disease, recently sent me a copy of an advertisement that was in their local newspaper. The advertisement, sponsored by a local rehabilitation facility was promoting neuromuscular electrical stimulation (NMES) as a treatment for swallowing problems related to a host of conditions including: trouble taking pills, trouble with certain food consistencies, swallowing difficulties after surgery, head and neck cancer treatment, stroke, and so on.  The promise of almost “magical” treatment for this host of symptoms, prompted my friend to ask my advice re: NMES as treatment for swallowing problems, specifically associated with Parkinsons’s and related diseases.

In responding to her question, I tried to address some of the issues common to all swallowing problems, and then more specifically discuss the research that is specific to  Parkinson’s disease, and finally comment on NMES. Since swallowing disorders can be caused by many different diseases and diagnosis, and symptoms can occur at any phase of the swallow from the mouth to the stomach, a thorough evaluation by a speech-language pathologist (swallowing or dysphagia therapist) has to be the starting point for management decisions. Once this evaluation has been completed and the cause or causes of the swallowing problem identified, treatment can be recommended, which may include some regimen of exercise.

It is known that problems occurring in the oral stage of swallowing, and primarily due to tongue strength and coordination may benefit from tongue strengthening exercises. Multiple studies investigating oral-motor exercise programs (Kays et al., 2004; Logemann et al., 1997; Robbins et al., 2007; Sullivan et al., 2001) have found the exercise is effective in increasing tongue strength and improving swallowing, including  patients with  swallowing symptoms related to Parkinson’s.

Some reports  indicate that patients completing the Lee Silverman Voice Treatment (LSVT®) program, also demonstrate improvements in swallowing, and this may be due to the emphasis on high effort voicing tasks.

For swallowing problems primarily associated with airway protection, expiratory muscle strength training (EMST) is a promising treatment approach that is supported by research led by Dr. Christine Sapienza and colleagues at the University of Florida. * Expiratory muscle strength training (EMST) is accomplished by using a handheld device with variable resistance (think weight training for your breathing muscles). Patients exhale by blowing into the device, which in turn activates the muscles of exhalation (primarily abdominal muscles) which helps to strengthen cough effort. Strengthening the muscles of exhalation may also help strengthen the lung’s natural  mechanism for clearing any foreign bodies that have entered the lungs during eating or drinking, and safeguard against aspiration pneumonia. In addition, when patients have been observed performing EMST training during a video-swallow study (x-ray of swallowing), increased activation of the muscle group responsible for hyoid elevation has been observed. This is an important observation, because the movement of the hyoid bone during swallowing helps close off the respiratory airway protecting it from foreign material traveling the wrong way, and helping to open the sphincter of the esophagus (stomach tube) which then allows food to enter the stomach.

*Impact of Expiratory Muscle Strength Training on Voluntary Cough and Swallow Function in Parkinson Disease Sapienza, et al CHEST May 2009 vol. 135 no. 5 1301-1308

The coordination of breathing and swallowing in Parkinson’s disease  is also the focus of research by Dr Roxann Diez Gross from Pittsburgh.** Dr Gross is investigating lung volume differences  and swallowing in healthy adults and individuals with Parkinson’s and states: “accurate coordination between breathing and swallowing could be the key to safety in Parkinson’s Disease.”  Individuals with Parkinson’s disease may need to swallow at higher lung volumes to maximize activation of swallowing sensory stimulators below the vocal folds. Training patients to generate high lung volumes at the onset of swallowing may counter some of the changes in the respiratory and swallowing system  that have occurred from PD.

 **The Coordination of Breathing and Swallowing in Parkinson’s Disease. Roxann  Diez Gross. Dysphagia Vol  23. Number 2. June 2008

So, now we come to neuromuscular electrical stimulation (NMES). NMES has been used by physical and occupational therapists for a number of years, but it is a relatively recent addition to swallowing (dysphagia) treatment by speech-language pathologist. Its addition to treatment protocols has raised interest as well as concern among researchers regarding efficacy (benefit) and safety. For example, depending on the placement of the electrodes on the patient’s throat, some researchers found a lowering of the hyoid to take place (Humbert et al 2008, Ludlow, 2008). Lowering of the hyoid bone is opposite the normal upward direction of hyoid movement, and may actually increase the aspiration risk for some patients. This may be especially true for individuals with Parkinson’s disease, who have slowness and stiffness of motor function as a feature of the disease, and may not be able to overcome the muscle resistance.

Clearly, many more studies which look at the role of NMES and swallowing in general, and then specific to various disease states, are warranted before recommending its routine use in swallowing treatment.  If recommended as a part of swallowing treatment, NMES should be considered cautiously and only if evidence on a video-swallow study demonstrates more benefit than risk.

In summary, my recommendations to any individual exploring treatment for swallowing problems related to Parkinson’s:

• PREVENTION is always best, through implementing a general exercise program, oral hygiene, and specific swallow exercises if indicated.

• Expiratory muscle strength training (EMST) for improving pulmonary hygiene and, cough effort which must be preserved in individuals with Parkinson’s.

• Breath support and swallowing exercises and strategies which improve coordination of respiration and swallowing may also provide defense against aspiration pneumonia in the later stages of Parkinson’s.

                             

 

Expiratory muscle strength training is a device driven therapy that has shown to have positive effects on breathing, swallow function and cough function in persons with Parkinson’s disease.  Dr. Sapienza’s research group at the University of Florida has numerous research studies to support these outcomes.  Please email Dr. Sapienza at sapienza@ufl.edu for more information .

 www.aspireproducts.co.

                                       

Happy Mother's Day

I am lucky to have a mom , who, although in her 80's, remains beautiful and active. If you asked the secret of my mom's longevity, I would have to say: attitude and activity. She has never been one to sit still for long. She continues to bowl and golf, garden, and only recently has scaled back on her work as a seamstress doing alterations for family and friends. For most of my life, my mom would not share her age. In fact, her adamant refusal to discuss her age was often a source of joking among my brothers and family friends. But, as I have transitioned into middle age, I understand my mom's reluctance to be defined by a number. Her youthfulness transcends her physical body, and although she is attractive, it is her aura and energy that makes her age defying . An energy that reveals her love for life, for activity, and for her family.

My mom and I have had the usual mother-daughter conflicts in our life, and even to this day, the occassional altercation, but, as time goes on, and the realization that our time together is more limited, those conflicts get resolved more quickly. My mom on the other end of the phone is the only person that can cause me to dissolve into tears when I am sad, and she is also the first one I want to call when I have some good news to share.

Bless our mom's everywhere today, and thank them for the women they have helped us to become

May Is Better Speech And Hearing Month

If you are experiencing difficulty with speech, voice or swallowing function, your physician may recommend that you seek help from a speech-language pathologist . Some changes in voice are age related, and often times, a brief period of instruction  from a speech/voice therapist which includes instruction in: proper breathing  vocal health and proper voice use can yield significant improvement. Other times, of course, speech and language and voice changes are due to a neurological disease, and speech therapy treatment may be more intense , and individuals may have to have periodic visits with a speech-language pathologist knowledgeable about their disease. Many diseases that change  voice and speech may also have an impact on swallowing function, and a speech-language pathologist may also  evaluate and provide treatment for swallowing disorders.

Prevention of speech and hearing problems from developing is also important. Even as an adult, there are measures you can take to reduce the likelihood of developing a communication disorders. For example, if you are a smoker, quit, as many cancers of the head and neck are related to tobacco use.  Voice misuse, such as constant throat clearing, can result in symptoms such as chronic hoarseness, and this symptom can often be reduced with instruction in proper vocal technique and habits.  If you work in a noisy environment, wear hearing protection, and check those IPODS on yourself find your children , for it’s known that excessive noise levels can cause permanent hearing loss.

For more information abut speech, language, swallowing, and hearing disorders:

http://www.asha.org/public/

To locate a board certified audiologist: http://webportal.audiology.org/Custom/FindAnAudiologist.aspx