Dan Keller 0:02 Welcome to this episode of Substantial Matters: Life and Science of Parkinson's. I'm your host, Dan Keller. At the Parkinson's Foundation, we want all people with Parkinson's and their families to get the care and support they need. Better care starts with better research and leads to better lives. In this podcast series, we highlight the fruits of that research, the treatments and techniques that can help you live a better life now, as well as research that can bring a better tomorrow. The Parkinson's Foundation always recommends putting together a multidisciplinary care team for people to manage their disease. In addition to a movement disorders neurologist, the team can also involve a speech language therapist, an occupational therapist, and a physical therapist. In this first episode of our Allied Health Spotlight series, I speak with Tricia Brown, a physical therapist certified as a neurologic clinical specialist who has a particular interest in Parkinson's disease. She leads several exercise programs for people with Parkinson's, and highlights the importance of staying active. Exercise can help to maintain balance, mobility, and activities of daily living, and may be the one intervention that can slow progression of the disease. I first asked her, How she came to specialize in neurologic disorders, and particularly in Parkinson's. Why don't we just start by having you tell me a little bit about who you are and what inspired you to work in the Parkinson's field?

Tricia Brown 1:55 I am a physical therapist. I had an interest in working with a population of people with neurologic health conditions since I pretty much started back in a long time ago, 1990 as a physical therapist, and my practice has weaved in and out of neurologic practice arenas, and I have always just enjoyed this population with Parkinson's disease. I find that the potential that they have to make improvements is very exciting and rewarding to see the changes. I kind of just fell into it just by the nature of my day-to-day patient population. Would get them in the old days, we get them in the hospital when people would come off medication, and we didn't get people with Parkinson's until they were really severely immobile with difficulties with mobility and things like that, all the way to the spectrum of now, when we're getting people right at diagnosis and working with them on very high intensity activities and things like that. So, I've seen the scope of practice change over time, and I have just fallen in love with the population, and has led me to go into further training in that area, and to work with a nonprofit working with that population, as well as doing some teaching in that area. So it's just really kind of blossomed into a nice sub specialty within the neurologic clinical specialty that I have.

Dan Keller 3:20 So, do you generally recommend that anyone with Parkinson's get a physical therapy consult and plan for them?

Tricia Brown 3:30 So, I highly recommend that people, when they are first diagnosed, that they're handed a prescription and encouraged to go to speech therapy, physical therapy, and occupational therapy to get evaluated for one at baseline, so that we can periodically assess to see if there are starting to be some changes from a functional mobility or activities of daily living standpoint, so that we can intervene to keep people as independent and functional as possible, but also because we want to get them on the best fitness and exercise activity level for them, because we know that exercise and activity is very helpful in slowing the progression of this disease and the functional challenges and mobility challenges that come with Parkinson's. So, even better would be if we could get people on an exercise program, even before their diagnosis, and hopefully even stay some of the challenges, because we know a lot of physiological changes have already occurred by the time people are diagnosed, so if we could get people exercises vigorously even before that, that would be awesome.

Dan Keller 4:36 What does an evaluation typically look like?

Tricia Brown 4:40 So, an evaluation would be a physical therapist would probably start by screening some basic systems, such as cardiovascular, heart, and lung, just to get baseline vital signs and things like that, and then looking over, you know, skin and your strength and range of motion, your posture, you. Then basically coordination and balance usually always includes some sort of fall risk assessment and balance assessment, and we look at walking, fall can be a huge problem, and walking changes can occur in this population quite readily, so we like to get baselines of those, and we look at functional measures to see how people are doing, and we also really sit down before we start all that, and ask the person that we're seeing and evaluating what their goals are, and what is important to them, and what they want to keep doing well throughout their life, so that we can tailor our assessment to monitor those types of activities.

Dan Keller 5:38 Are there certain situations where you'd recommend an at-home evaluation, or is that more in the realm of occupational therapists?

Tricia Brown 5:49 It's certainly in the realm of occupational therapy, but it's also in the realm of physical therapy for us to go either go out to the home, if that's a possibility, if the practice arena environment allows it, some facilities, the procedures don't allow for that, some payers wouldn't allow for it, that sort of thing, but if it is a possibility to go out, it's especially if somebody's struggling to do maybe home activity program or home exercise program, or they're having falls, you're concerned about falls, having the clinician go out to evaluate the home for safety concerns, but also for can we set you up in a way in your environment to help you be successful in being active and doing your exercise program. If we can't do that in person, one option is to do it through telehealth or through Zoom or some other platform where the person with Parkinson's can kind of show their home, and they can walk through it together with the clinician via that telehealth method. Another option would be the person walking through with a video camera on their phone, taping their house, filming their house, or at least at the minimal, taking pictures of areas, so that we can see, "Oh, I want you to set up doing your balance exercises near that counter with a chair, or in that corner with a chair in front of you, or by that couch, or whatever it might be for their individual environmental situation.

Dan Keller 7:11 You had mentioned a cardiovascular assessment. Obviously, exercise is good for everybody, but why is it especially important for someone with Parkinson's?

Tricia Brown 7:21 It's especially important for someone with Parkinson's, since Parkinson's impacts the motor system so significantly, as well as other non-motor systems as well, and the literature has shown, both in animal and now in human studies, that exercise can help delay the progression of the disease and delay the onset of functional mobility challenges that come with those movement difficulties, as well as the thinking difficulties, the cognition that comes along sometimes and can be impacted with Parkinson's disease. So a lot of the challenges with Parkinson's, like posture that tends to be a little more stooped, short shuffling steps, lack of arm swing, lower voice, and increased rigidity in the trunk can impact the breathing, their voice, their ability to participate in activities that they enjoy. So, getting on a regular exercise program that stresses those systems in a systematic manner is very, very beneficial.

Dan Keller 8:21 I've known a few exercise freaks, workout freaks, and they live for it, but most of us need motivation. Would it help for someone to join a group that exercises, or at least have a workout buddy?

Tricia Brown 8:34 Oh, that's a great question. And absolutely, yes. Not everyone loves groups, but many people do, and many people benefit from it. As somebody who has led Parkinson's exercise groups for over 20 years, I can tell you that the benefit of having regularly scheduled outside of the home group exercise or group activity type of event to go to on a regular basis not only benefits the physical aspect of because you're out there doing it, but the psychosocial aspect of it is equally as benefited by those type of group activities, the camaraderie, the talking about, you know, not feeling alone and seeing the possibilities, how other people are doing so well, you know, even many years post disease diagnosis, or how they progress with that, and can still be very active and enjoy, and the friendships that are made are huge, and plus with the group classes, you can pick something that's fun. So, let's say you really enjoy dance, maybe you would go to a group exercise for people with Parkinson's for dance, and there's classes, maybe you enjoy boxing, maybe you enjoy tai chi, or very popular now, pickleball, and so, for an example, in one of the nonprofits that I work for, where we provide exercise classes to people in the community, a lot of the members on their own formed a pickleball group after we had one pickleball event, just to kind of get people started, they formed a group, and they meet every week and play pickleball now, so they even formed their own groups on their own, and it's worked out really. Well,

Dan Keller 10:01 the great thing about the internet is you can find almost anything there, including exercise routines and programs and classes, but for someone with Parkinson's, what are some safety precautions to be aware of to make sure the class that they find is safe for someone with Parkinson's?

Tricia Brown 10:20 That's a great question. The things that I would look for if I had Parkinson's disease. First of all, you want to make sure that you are at a place that's safe. Just because you have Parkinson's disease doesn't mean that your other systems are immune from having challenges as well. So, maybe you also have a heart condition, or blood pressure, or diabetes, or something in addition. So, you want to make sure from a medical standpoint that you are safe to exercise in regards to those just in general, then your primary care physician or neurologist can certainly give you that clearance. So that's one consideration. The other one is looking for people who are somewhat familiar with Parkinson's, can be helpful, although it's not 100% required. If so, if the instructor is familiar with the unique challenges that come with movement disorders, such as Parkinson's, that can be very beneficial. So, asking if they have any background, or how do they know, you know, what do they understand about Parkinson's? The person who leads the class, looking for the surfaces, so let's say, for example, you're going to a class that does a lot of high moving or balance exercises. You might want to look for a class that is on maybe a wood floor or a floor that has some sort of give to it, versus like a concrete surface type of thing, just in case there was an issue. Then it's not as dangerous if you were to end up landing on your knee or your hip or something at some point, hopefully that wouldn't happen, but those are things we want to look at as a surface. We want to also consider that if you're going to be doing some standing activities, that there is some sort of support available, because even most of us, you know, if we want to challenge our balance a little bit, we want to be able to be where we're challenged, we want to have something just in case we need to touch, so having a stable chair, having a bathroom nearby can be very helpful and an adequate source of water. So you either need to make sure you bring your own water or that there is a water fountain nearby. Those are really helpful activities and things to do. The other would be temperature regulation, sometimes because of the autonomic changes in their autonomic nervous system, temperature can be a challenge. So, making sure that the room can be somewhat controlled for temperature, if it's inside, if it's outside, is there a place to get out of the sun and in the shade, and that sort of thing, because a lot of community classes might be held up outside as well. So, those are some of the basic things, as far as a structure or room, and what to look for? I think for safety,

Dan Keller 12:46 are there cost considerations? I mean, people buy footwear, the cost of the class, any sort of equipment necessary, transportation, and I guess it boils down to, are there community resources that can keep the cost down?

Tricia Brown 13:01 Those are great, great options. Absolutely, you want to definitely look to see, can you even get to a class? Transportation can be difficult. Absolutely, a lot of local resources can help with that. Senior centers and some insurance companies will pay for people to get to classes, calling the class instructor and asking if they know what resources are available. The local Parkinson's support groups and Parkinson's Foundation sections for the area would be really helpful to reach out to and find out about transportation cost of the costs. Many places do offer some classes that are for nominal fee or no fee, and all the way up to a few $100 per month, like a subscription to a gym type of things, there's definitely a continuum of cost, and there's a continuum of the intensity of exercise classes that are out in the community, typically. So, definitely searching online for that, asking those type of questions would be very, very helpful, and again, having some sort of connection with the Parkinson's community and knowledge of that diagnosis or movement disorders in general would be very helpful for the instructor to have that,

Dan Keller 14:09 I think. Probably the helpline specialists at the Parkinson's Foundation can be a good resource. If they don't know exactly where to find a place to exercise, they probably know who to call to get it, and also there's all the county agencies on aging, which know a lot of this stuff, so those might be good resources.

Tricia Brown 14:28 Absolutely, very good point, very good point.

Dan Keller 14:33 What happens if someone wants to exercise at home? Are there considerations there for safety, and maybe having someone by your side in case you need something,

Tricia Brown 14:44 definitely considerations for safety, and I think it depends on the level of the person, whether somebody needs to be there, but there are usually ways that the environment can be set up to make it safe, so some people maybe they have a memory problem and might need to. Follow a video for exercise to remember all the exercises. Somebody else might need something nearby for balance or safety. So, a lot of times I'll have people set up in their home what we call like a zone of safety, where maybe they do their exercises that are standing, they set up maybe like in a corner where there's nothing in the corner, if you can find it, no plant or anything in the corner of furniture, and then put the back of a chair in front of them, so they're kind of surrounded on all three sides, so that if they lost their balance, they can easily touch the wall or the chair. That's one example. The other example was, if you were going to do standing exercises, to be near your bed or a couch, so that if you were to lose your balance, you would land up on that with maybe a chair involved, or you can be near a counter, so there is definitely places you can set up. You always want to look around you if you're going to be doing exercise in the home. I always call it like defensive planning for exercise, that if I was to lose my balance, where would I end up, and what's in my area and space? So I wouldn't want to do it right near the sharp edge of a coffee table, where my head might hit the edge of a counter, or something like that. You want to be near the counter, but where you can stop yourself and fall. But you were to fall, would you hit something in your area? So you want to make sure it's clear. If you're going to be doing exercises down on the floor, make sure that you have typically a yoga mat, or some sort of krishy surface that you can go down on to protect you, and do that near a couch or a chair or a piece of furniture, so that you can utilize that furniture if needed to get up and down for safety. It's always a good idea if you're going to exercise, especially if you have any other conditions that might impact you. It's always optimal to have somebody around, obviously, because that way, if there was a problem, you can call out, but if you didn't, you could always put it on your calendar when you're going to exercise and let somebody else know that you're exercising at that time, so they can check on you before and after. That's another option as well. One thing I do want to mention, that's a common challenge, we call it orthostatic hypotension, where blood pressure can drop, either related to the disease itself or due to the medication. So, if somebody experiences a drop of blood pressure, they might get lightheaded or dizzy. If somebody tends to experience that, that's someone who might best be served by having somebody near them while they're exercising. There are some techniques that can be done to help keep the blood pressure up, like wearing compression stockings, and maybe an abdominal binder, or doing some exercise, like a clenching type of exercises, to contracting the muscles to help get the blood pressure higher, and things like that, but if somebody is experiencing that, that's somebody who I highly recommend that they have someone with them when they're exercising for safety reasons.

Dan Keller 17:43 If somebody is prone to orthostatic hypotension or just wants to guard against it, would it be a good idea to adequately hydrate before exercise rather than afterwards?

Tricia Brown 17:56 Yes, definitely. Want to be well hydrated, because orthostatic hypotension can be impacted by the volume of the fluid in our system, so having adequate fluid on board before you start exercising is a great way to minimize that potential, but even sometimes people are very hydrated and it still might occur, so you still definitely want to take other precautions as well, but hydrating is one of those absolutely that you want to make certain that you're not low on your fluid.

Dan Keller 18:28 Have we missed anything interesting or important, or that you want to share with our listeners?

Tricia Brown 18:34 One thing I do want to say important is, I think that exercise, it's important that you include all types of exercise, not just stretching, but maybe aerobic balance training, strength training, and some sort of flexibility training, all into your program. It can be different activities, the exercise people do the most thing that they enjoy. So definitely searching to find the activity that is enjoyable for you is very important. However, keep in mind it's good to be well-rounded, and that you do definitely want to stress your system to some degree, so that you're getting that benefit that comes with general exercise for people with Parkinson's disease.

Dan Keller 19:18 Well, I really appreciate it. Thanks a lot.

Tricia Brown 19:20 You're welcome. And thank you for being so professional, and you made it easy. I was kind of nervous, I don't know if you could tell.

Dan Keller 19:27 Take care. You can find more information on today's topic by visiting parkinson.org/exercise's There you will find a link to our exercise recommendations created in collaboration with the American College of Sports Medicine to provide people with PD safe and effective exercise programs. We also have fact sheets. Called exercise or physical therapy and PD available on our website to find a physical therapist or an exercise program near you. Contact our Parkinson's Foundation helpline. You may also visit the American Physical Therapy association@apta.org and click Find a Physical Therapist. It will take you to a page where you can put in your location and specify that you want to find a physical therapist experienced in treating people with PD. If you want to leave feedback on this podcast or any other subject, you can do it at parkinson.org/feedback's If you enjoyed this podcast, be sure to subscribe and rate and review the series on Apple Podcasts, or wherever you get your podcasts. At the Parkinson's Foundation, our mission is to help every person diagnosed with Parkinson's live the best possible life today. To that end, we'll be bringing you a new episode in this podcast series every month. Till next time, for more information and resources, visit parkinson.org's or call our toll-free helpline at one 804 pd info. that's 1-800-473-4636 Thank you for listening,

Patricia S. Brown, PT, DPT is a licensed Doctor of Physical Therapy. She has over 30 years of experience in rehabilitation of persons with neurologic health conditions and certified by the American Board of Physical Therapy Specialists in Neurology since 1999. Currently, she is an Associate Clinical Professor teaching future health care professionals in the Doctor of Physical Therapy Program at Chapman University’s Rinker Health Science Campus in Irvine, California. 

She has a passion for both rehabilitation and wellness applied to those with Parkinson’s disease. She is a certified LSVT BIG clinician and a faculty trainer for LSVT Global. She is also a certified PWR! Clinician, a graduate of the Parkinson’s Foundation Team Training for PD, and a graduate of the Parkinson’s Foundation Faculty Training Workshop. Dr. Brown is currently active with PEP4U, a non-profit providing no-fee exercise, education and social support to people impacted by Parkinson’s disease in Orange County, California.