Pedalling to fight Parkinson's Disease with Dr. Jay Alberts

In the inaugural episode of the Masters in Exercise podcast, host A interviews Dr. Jay Alberts from the Cleveland Clinic, who discusses his pioneering research on exercise interventions for Parkinson's disease. Dr. Alberts explains the benefits of assisted involuntary cycling and its potential to improve motor function, comparing its effects to those of traditional medication like Levodopa. He highlights the importance of exercise in empowering patients, addressing both motor and cognitive challenges. The conversation also covers the significance of personalized exercise prescriptions, the role of resistance training, and the integration of cognitive training with physical exercise to enhance patient outcomes.

• Dr. Jay Alberts began his academic journey at Central College in Iowa, later transferring to Iowa State University where he completed his undergraduate studies in kinesiology.
• His interest in Parkinson's disease was sparked during a neuroanatomy class where he encountered a patient with Parkinson's, leading him to pursue research in this field.
• Dr. Alberts has been involved in clinical programs, including a concussion program and a health program for former NFL players, though he does not have a direct clinical background.

"I transferred to Iowa State and I finished my undergraduate there in kinesiology. And then I went to Arizona State University and worked with George Stelmach and Jim Bladel."

• Dr. Alberts' educational path led him to work with notable figures in the field, shaping his research focus.

"I was struck by that. And I thought, wow, that's... You know, So I really had a choice to make."

• A pivotal moment in a neuroanatomy class influenced his decision to focus on Parkinson's research, highlighting the impact of patient interaction.

• Parkinson's disease intrigued Dr. Alberts due to its impact on motor control and quality of life, motivating him to explore exercise as a tool for patients to regain control.
• Exercise offers Parkinson's patients a means to actively participate in their treatment, contrasting with medication and surgical interventions where patient control is limited.

"Parkinson's is a disease that really tries to rob one of control. It's robbing you of motor control, which then, by consequence, robs you of quality of life."

• Dr. Alberts emphasizes the loss of control in Parkinson's and how exercise can help patients reclaim some of that control.

"Now with exercise, it gives them really an opportunity to take a more active role in their treatment."

• Exercise empowers patients, offering them a proactive role in managing their condition.

• Exercise may influence the dopaminergic brain by facilitating angiogenesis and increasing dopamine levels, though direct evidence in humans is limited.
• Neurotrophic factors such as BDNF and GDNF, which are proteins essential for cellular repair and angiogenesis, might be elevated through exercise.

"Exercise may be triggering the release of these neurotrophic factors or an elevation of neurotrophic factors."

• Exercise could stimulate the production of proteins crucial for brain health and repair, potentially impacting dopamine levels.

"These proteins still serve as a building block of cells, potentially for repair or even angiogenesis within the br."

• Neurotrophic factors play a role in cellular repair and growth, suggesting a mechanism by which exercise benefits the brain.

• Forced cycling, where patients cycle at a higher cadence than voluntary effort, may enhance motor function in Parkinson's patients by increasing movement quantity and quality.
• The active involvement in cycling, as opposed to passive movement, is crucial for triggering beneficial neurotrophic responses.

"In terms of those movements, if we can possibly increase the quantity of movements, so having them pedal a little faster and the quality."

• Forced cycling's emphasis on active participation and movement quality is key to its effectiveness.

"The patient has to be active. You can't just, you know, like those old images of somebody getting shaken around that. That's exercise."

• Active engagement in exercise is necessary for its benefits, contrasting with passive movement approaches.

• Dr. Alberts' research highlights a lack of specificity in exercise recommendations for Parkinson's patients, advocating for tailored approaches.
• The FITT principles (Frequency, Intensity, Time, and Type) should guide exercise prescriptions to ensure effectiveness and safety.

"In that paper you emphasize that there are frequently exercise recommendations for patients with pd. Lack of specificity in terms of the feed principles."

• Specificity in exercise prescriptions is essential for addressing the unique needs of Parkinson's patients.

"I always show them that video of probably. I'm sure you've watched this video of that old man who cannot walk, freezing gait, and then he jumps on the bike and he can."

• Real-world examples, such as videos of patients benefiting from cycling, illustrate the potential impact of exercise interventions.

• There is a noted lack of consensus in PD exercise literature compared to stroke or Alzheimer's disease, highlighting a gap in specific exercise recommendations for PD patients.
• Clinical advice to PD patients often lacks specificity, with generic suggestions like gardening being mistaken for structured exercise.
• Historically, there has been a misconception that PD patients should remain inactive, which contradicts the nature of the disease's symptoms, such as bradykinesia.
• Ongoing trials, like those involving cycling and the Sparks 3 trial, aim to provide more personalized exercise recommendations for PD patients.

"I think you're 100% right there in terms of lack of consensus and lack of specificity. Because many patients, they go to a neurologist and they're told by the neurologist, well, you should exercise."

• This quote highlights the general lack of specific exercise guidelines provided to PD patients, pointing to a broader issue in clinical practice.

"We've got a lot of good studies that show there's a benefit and there's a positive. And so I think that's the thing. Everyone will agree, oh, exercise is good. It's just what type and such in the dose, which will be critical."

• The quote emphasizes the agreement on the benefits of exercise for PD patients, but underscores the need for detailed research on the type and dosage of exercise.

• The concept of forced exercise originated serendipitously from a tandem cycling experience during a bike ride across Iowa.
• The forced exercise method involves increasing the pedaling rate of PD patients beyond their voluntary pace, inspired by a personal observation of improved motor function.
• The term "forced exercise" is borrowed from animal studies where exercise is induced through external stimuli.

"I would like to say that I had some brilliant idea there, but it was completely serendipitous."

• This quote explains the accidental discovery of forced exercise as a beneficial intervention for PD patients.

"So in essence, I was forcing Kathy to pedal faster, you know, sans the electricity."

• The quote describes the practical application of forced exercise, illustrating how the concept was applied without mechanical enforcement.

• A 2016 study used functional MRI to compare the effects of anti-Parkinsonian medication and exercise on brain activation patterns.
• The study found that forced exercise produced similar patterns of brain activation as medication, suggesting exercise could mimic some of the medication's effects.
• Subsequent studies indicated that forced exercise enhanced connectivity between the basal ganglia and cortical motor regions, reinforcing the concept of exercise as medicine.

"What we found was that after having patients, they would take the medication and we would scan them... the patterns of activation between the exercise and the medication were nearly identical."

• This quote outlines the study's findings, showing that exercise can have similar neurological effects as medication in PD patients.

"We did some subsequent studies that actually showed that there was a greater connectivity then between the basal ganglia, subcortical and the cortical motor regions of the brain following forced exercise."

• The quote highlights the additional finding that forced exercise improves brain connectivity, further supporting its therapeutic potential.

• Levodopa is the most common medication for PD, and its interaction with exercise is a subject of research and debate.
• The literature presents mixed findings on whether exercise affects Levodopa absorption and motor function, with some studies suggesting positive interactions and others indicating delays in absorption.
• There remains a need for more conclusive research to clarify the effects of exercise on Levodopa efficacy and absorption.

"I was wondering if you look at the literature, I mean, some people have investigated if there are interactions in terms of motor function."

• This quote introduces the complexity and variability in research findings regarding the interaction between exercise and Levodopa in PD treatment.

"There is a lot of confusion. I will say, if you look at the literature, some papers reporting that it delays the absorption, some others showing that the interaction is a positive thing."

• The quote underscores the conflicting evidence in the literature, highlighting the need for further investigation into the interaction between exercise and Levodopa.

• The timing of medication, specifically Levodopa, in relation to exercise is crucial for Parkinson's patients.
• Initial exercise may cause discomfort due to rapid medication metabolism, but this effect often stabilizes after a few weeks.
• Understanding the interaction between medication and exercise can improve exercise prescription and patient outcomes.

"What we've talked about is that maybe they're somehow burning through their Levodopa. They're burning through that medication rapidly and probably due to the fact that they're being much more active than they were in the past."

• Patients may initially experience increased medication metabolism due to heightened activity levels, affecting their comfort post-exercise.

"After about four weeks, we talk to them again and they say, oh, I'm not feeling that way anymore. Now I feel good after I exercise."

• Over time, patients generally adapt to the exercise regimen, experiencing improved well-being post-exercise.

• Resistance training, while not traditionally emphasized, plays a role in Parkinson's rehabilitation.
• Core strengthening is particularly beneficial for functional movements like turning in bed or cycling.
• The impact of resistance training on brain function is less documented compared to cardiovascular exercise.

"Charcot, who was considered sort of the father of neurology, actually was the first to say that Parkinson's isn't a disease of a strength deficit."

• Parkinson's disease is not primarily characterized by strength deficits, yet resistance training can still be valuable.

"Core strengthening is probably something that is under utilized or under appreciated when we start thinking about exercise."

• Core exercises are crucial and often overlooked in exercise regimens for Parkinson's patients.

• Combining cognitive training with physical exercise addresses both motor and cognitive declines in Parkinson's patients.
• Dual-task exercises can reduce fall risk by improving cognitive and motor function simultaneously.
• This approach aids in developing strategies for daily living activities.

"We actually showed that we could improve dual tasking, and we actually reduced the frequency of falls."

• Integrating cognitive tasks with physical activities can enhance dual-task performance and reduce falls.

"It's usually some other dual task or some instrumental activity of daily living."

• Falls often occur during dual-task activities, highlighting the importance of combined training.

• Tailoring exercise programs specifically for Parkinson's patients is essential for improving adherence.
• Understanding the unique needs and challenges of Parkinson's patients can enhance compliance with exercise regimens.
• Therapists should adapt treatment models to better suit the specific requirements of Parkinson's patients.

"You have to treat them like Parkinson's patients. Right. And that means that you're not treating them like back baiting patients, you're not treating them like Ms. Patients, you're not treating them like orthopedic patients."

• Individualized treatment approaches are necessary to effectively support Parkinson's patients in their exercise routines.

• Establishing relationships with neurologists and physical therapists is critical for early intervention in Parkinson's disease.
• Early referrals can facilitate dual task training, potentially reducing fall rates in patients.
• Challenging patients and engaging them in beneficial activities is crucial for their improvement.
• Community-based programs, such as those in YMCAs, are essential for patient engagement and motivation, despite challenges posed by COVID-19.

"Because we were getting patients way too late in the disease. We were getting stage three and four. That was very difficult at that point."

• Receiving patients in advanced stages makes treatment more challenging and underscores the importance of early intervention.

"And I think having those discussions and showing them what could be beneficial and challenging them is critically important."

• Engaging patients in discussions about their treatment options and challenging them to participate actively is vital for their progress.

"And so I think you can also, if there's a way to facilitate some levels of community within the medical community or within that group so they're exercising with other people who look like them is fantastic."

• Creating a community where patients can exercise with peers is beneficial for motivation and engagement.

• The social component of patient programs is often overlooked but is crucial for success.
• Community involvement leads to accountability and support among participants.
• Clinical trials have demonstrated the importance of community in patient programs.

"The community part is so important. We did a clinical trial with the site in two or five sites, Denver and also Seattle."

• Clinical trials have shown that the community aspect is a critical component of patient programs.

"It's like somebody who doesn't show up for two classes in a row. Boom, you know, four or five people are calling them and saying, hey, how are you doing?"

• Community involvement ensures that participants remain engaged and accountable to each other.

• Scientists need intrinsic motivation to pursue questions and should not overly focus on statistical significance.
• Failures in research are as important as successes and should guide future work.
• Developing thick skin is necessary to handle rejections from grants and papers.

"We should stop worshiping P values because P values are just only the tip of the iceberg."

• Overemphasis on statistical significance can be misleading; understanding the broader implications of research is more important.

"Those definitive failures are sometimes equally or even more important than successes because those failures are definitive, very clear."

• Failures provide clear guidance on what research directions may not be fruitful, helping to refine future efforts.

"You have to have thick skin. You're going to submit grants, you're going to submit papers, and a whole bunch of times people are going to say, these are rubbish."

• Rejection is a common part of scientific research, and resilience is essential for success.

• Personal success is defined by relationships and family, while professional success involves making an impact.
• Being true to oneself and striving to make a difference, whether in clinical practice or research, is key.
• Providing better information and treatment strategies can significantly impact underserved communities.

"Personally, you know, success is obviously, you know, who you are as a person and your family."

• Personal success is closely tied to one's relationships and family life.

"Professionally, I think the key is really being true to yourself."

• Professional success involves authenticity and making meaningful contributions to one's field.

"If we can provide those providers with better information, better treatment strategies, then it's going to make a real impact for a lot of patients."

• Improving treatment strategies and information dissemination can have a substantial impact, especially in underserved areas.

• The Pedaling for Parkinson's initiative is a grassroots organization aimed at disseminating programs and knowledge.
• The organization focuses on community involvement and virtual rides to engage participants.
• It serves as a platform to share research and community efforts in Parkinson's disease management.

"We have pedalingforParkinson's.org and pedaling, like in the bike pedaling. So you can see some of our work there."

• The website serves as a hub for sharing information and engaging with the community.

"It's really a grassroots organization to help facilitate dissemination of programs and knowledge."

• The initiative is focused on spreading awareness and facilitating programs to support Parkinson's patients.