Below is a transcript from the two episodes. Before that though, here's a list of some of the resources to learn more that are mentioned in the episode:
CBS News clip looking at Dr. Corcos' lab where people use exercise to improve
The exercise prescription: Dr. Corcos' article on his advice for people to exercise and the good it has been shown to do.
Dr. Corcos' article on his advice for people dealing with dizziness when standing up.
Dr. Corcos' scientific article on resistance exercise helping with slowness of movement.
Dr. Corcos' scientific article on how medication changes the electrical signals from muscle movement.
PART 1:
[00:00:00] Dr. Corcos: The fitter you are, the healthier you are, the easier it is to deal with any disease. Parkinson's or any other disease
[00:00:08] CPR. It's what happens after someone dies as a last ditch, high intensity effort. Unlike the movies, it usually fails. What if we used that drive while we're still alive to heal ourselves? Welcome to CPR for Life, where we help you understand how to reclaim your health by changing your everyday life. Life.
[00:00:36] I'm Dr. Sagar Doshi, board certified in both lifestyle and emergency medicine, and certified health coach. Even though these conversations are evidence based, they are just for your education, so please, talk with your physician before making changes.
[00:00:53] Dr. Sagar: Dr. Daniel Korkus is a world renowned researcher, primarily interested in helping people with Parkinson's disease, improve their quality of life, improve their mobility and cognition, and slow down the rate at which their disease progresses.
[00:01:07] Dr. Sagar: He has a PhD in motor control and has been doing vital research since he got that PhD in 1982. Particularly in how exercise can improve Parkinson's disease and how people can use that data for their own real lives. He's also quite a humble guy because I asked him how he'd like to be introduced. And he said, as Daniel, we're very lucky to have him on the show today. Dr. Daniel, welcome to the show. Thank you for being here.
[00:01:33] Dr. Corcos: Well, thank you, Sagar, for inviting me. I'm just delighted to be here.
[00:01:37] Dr. Sagar: You have been in this line of work for quite some time and I've seen you around. You're always talking about Parkinson's. You seem to be excited about it. What gives you , that passion to keep studying Parkinson's and keep exploring it?
[00:01:50] Dr. Corcos: But what gives me the passion currently is the energy and enthusiasm I get from talking to people who have Parkinson's. As you mentioned, I talk a lot to people. Groups of people with Parkinson's disease and I get a lot of energy and a lot of passion from them.
[00:02:09] Dr. Corcos: If I look back through my life, it does turn out that my auntie and uncle both had Parkinson's disease.
[00:02:17] Dr. Corcos: My uncle served in the Philippines and in 1950, he was out there in 1954 when he got married. And it turns out that every night he would spray his bed with DDT. And then he would bring over a net to keep out the mosquitoes. And he mentioned more than once that he thought the reason he and his wife had Parkinson's was because of the pesticide.
[00:02:42] Dr. Corcos: And I was very fond of my Auntie Audrey and Uncle Lee, and so that's at a personal level.
[00:02:46] Dr. Sagar: Yeah. a professional level I had the opportunity in 1994 to 1995 to go to England. And study at the Institute of Neurology, where they had a world famous neurologist by the name of David Marsden. And I spent a whole year just studying Parkinson's disease.
[00:03:06] Dr. Corcos: And from then on, it's been a focal part of my academic career.
[00:03:11] Dr. Sagar: So that personal connection from your aunt and uncle who clearly aren't related and yet both came down with having Parkinson's disease. And DDT has been tied into that before. And then that sets you off crossing continents to keep studying it.
[00:03:25] Dr. Corcos: That's about correct, and I'm still studying it. So,
[00:03:29] Dr. Sagar: Speaking of that how do you interact with people and help them today? What are your roles in research or clinical settings?
[00:03:38] Dr. Corcos: I'm a research professor, and my primary job is to conduct research. And I have a lab, and we conduct research on Parkinson's disease. Various exercise interventions. And I also do a considerable amount of work on deep brain stimulation. So people with Parkinson's disease have kind of three main treatment options.
[00:04:00] Dr. Corcos: One is to work really hard on their lifestyle. The fitter you are, the healthier you are, the easier it is to deal with any disease. Parkinson's or any other disease. Being in good shape is just a matter of Good for dealing with all diseases. Secondly, there are a lot of medicines for Parkinson's disease.
[00:04:23] Dr. Corcos: They all work on modifying the symptoms of the disease. They don't slow the disease progression, but they do make you feel better. And it's always good to have a really experienced physician. Help you manage your medication and as the disease progresses and as you take more and more medication For a subset of people deep brain stimulation is a very effective Treatment and so most of my time I spend in my lab with my students and my postdoctoral fellows conducting experiments, but I also Talk to people such as you And enjoy talking to people such as you and I also talk to You Parkinson groups.
[00:05:10] Dr. Corcos: So for those of you listening, you'll find in many big cities, even in smaller cities. There's an annual Parkinson meeting held by 1 of the main major medical centers. Last year, University of California, San Francisco had a meeting where it was attended by about 500 people. I'm going to be talking in Cincinnati on August the 10th.
[00:05:34] Dr. Corcos: And last year, they had 450. So if any of you are listening near Cincinnati, come along this year, and let's see if we can go well over 500. Because these meetings give a chance for physicians, scientists, community advocates to talk to people with Parkinson's disease, and make them aware of what the different options they have for helping themselves.
[00:06:00] Dr. Sagar: Absolutely. Cincinnati, Ohio is not too far from here. I would say there are plenty of people that are listening that would be close by.
[00:06:07] Dr. Corcos: Well, I hope I get to see you there. Okay,
[00:06:10] Dr. Sagar: Early August.
[00:06:11] Dr. Corcos: early August.
[00:06:13] Dr. Sagar: You mentioned that it's great to get a good idea from people that have Parkinson's for people listening that either have early Parkinson's or just want to better understand their loved ones that have Parkinson's. Can you paint a picture of what it's like to move in a body that has Parkinson's disease?
[00:06:33] Dr. Corcos: That is, oh, so I've been asked some difficult questions. I've been asked some really difficult questions, but this is the hardest question of all because I do tell people. I zoom with a group of people every month. We're up at about 80 people now and I do tell them that I understand the disease. I've talked with a lot of people, but I don't have the disease.
[00:06:59] Dr. Corcos: Okay. So I can describe it from an outside part, but for those really interested, at the end of the day, it's good to talk to somebody who can explain. So the disease is diagnosed by visual observation. So, a movement disorder specialist, a neurologist, can even be a PCP, will look at a person. And if the person has a little bit of tremor, which is rhythmic movement, if it looks like they get moving a little bit slowly, so very often they will ask a person to do this.
[00:07:36] Dr. Corcos: And if a person starts to do this, I'm now tapping and I'm tapping with Diminished amplitude, my taps are getting smaller. That's a telltale sign that something is wrong with the nervous system. They would also move your limb. So a healthy person, when you move a limb, it moves effortlessly. There's no resistance.
[00:07:59] Dr. Corcos: Person with Parkinson's disease will have a resistance. Will feel like you're moving like a cogwheel. And so if you have two of those three signs, probable that you have Parkinson's disease. They will certainly ask you to walk, and if you see somebody walking, the telltale sign from walking is actually not in the feet.
[00:08:24] Dr. Corcos: The telltale sign for walking is you look at a person's arm swing, and you look at the difference between their two arms. If you like the symmetry or lack of symmetry, and if a person is walking with reduced arm swing, and one arm is swinging more than the other, or put the other way around, one arm is swinging less than the other, That's also a giveaway sign and what some people have done is they've gone back through all the Michael J.
[00:08:54] Dr. Corcos: Fox movies and have tried to work out when can you first see the first sign that Michael J. Fox may have had Parkinson's disease and the telltale sign is when his arms swing less. You
[00:09:09] Dr. Sagar: And I'm wondering which movie that is. I'm trying to think back through Back to the Futures and Teen Wolf and who knows what else he did.
[00:09:15] Dr. Corcos: are correct when you go back to the future. It gets a little bit more complicated because somebody's pointed out to me that the films may not have been released in the order in which they were filmed. I'm not sure about that. Somebody who's a real movie buff can look into that. But if you go roundabout back to the future, you will find that his movements are certainly to a trained eye discernibly different.
[00:09:38] Dr. Corcos: And then there's how one feels. I think you asked me, how do they feel? And that's the hard part. So, anybody who works with people who have Parkinson's can explain what it looks like. But the difficult part of the disease is, there is a tendency in some people to apathy. And if you're apathetic, then it's really hard to really advocate for yourself and do what you need.
[00:10:08] Dr. Corcos: There is a higher than normal level of depression, which complicates life, and the baseline levels of anxiety. And so these are what they call the non motor symptoms. And then the other part, and one of the reasons that I do push a healthy lifestyle quite hard, and I do push it very hard, is that for many people, certainly some of the people I talk to, tremor is, it's an inconvenience.
[00:10:40] Dr. Corcos: Many years ago it was probably embarrassing. I think we're becoming a society much better at just recognizing people for they are. So you have a mild tremor, so what? But the progression of the cognitive decline. Where you go from normal cognition to mild cognition or mild cognitive impairment, MCI. That is more alarming, I think is the right word to some people.
[00:11:04] Dr. Corcos: And I think there's no question if you look, and I have looked very closely at the literature in Alzheimer's disease. The best current treatment in Alzheimer's disease is in fact also exercise for cognition. And you can actually put exercise against any current drug out there. And I think it would do as well, if not better on a head to head comparison.
[00:11:33] Dr. Corcos: And so that's a general. So when you look at a person, their movements are a little slow. They become a little bit more perhaps hunched. The classic figure of a person with medium to advanced stage Parkinson's disease. With them a little hunched. And then they also have the feelings that I've just described.
[00:11:54] Dr. Sagar: Yeah. And it may be harder for them to do simple things that people on the outside of their bodies may take for granted, like walk and talk. Is that correct?
[00:12:06] Dr. Corcos: Yes, this is one of the complex parts of treatment. This happens medium late stage. This doesn't happen early in the disease. So early in the disease, walking and talking is fine. And so there are really two schools of thought here. And I'm going to give you two extremes to make it crystal clear. One extreme is you teach people Not to talk when they walk.
[00:12:31] Dr. Corcos: Okay. It is a school of thought, but it's good to go walking and talking with your friends.
[00:12:39] Dr. Corcos: So, if you see a good therapist, they can give you strategies for how to do tasks. So, walking and talking in the research world is called dual tasking. There are ways to help people do a task. There may be times when you're Medium stage advanced Parkinson's.
[00:12:57] Dr. Corcos: If you're out at night, for example, if you're turning, are the kind of triggers for falling. And so to perhaps not be talking at certain times, if the lights are low, if the terrain is not good, if you're turning but by and large physical therapists are very good at helping people learn.
[00:13:21] Dr. Corcos: Strategies to deal with your tasking because it is a problem. There's no question of that
[00:13:27] Dr. Sagar: All right. So if you're walking with someone that has Parkinson's and they just stop, yeah, give a minute. Let them,
[00:13:36] Dr. Corcos: now that is you actually raised another question there. Okay, that is not the dual tasking part so the idea is that if they're walking and talking and and their concentration is distracted that may not be good for them but I think they have to learn to do that because we like to go out and walk and we like to talk and we Like to be in the countryside.
[00:13:57] Dr. Corcos: And so I think we have to learn how to do it Some people freeze. It's the hardest part of Parkinson's to treat. So it, it feels as if your feet are glued to the ground. And you come to a point that you just can't walk. That part is very hard to treat. There are strategies physical therapists can give you.
[00:14:21] Dr. Corcos: If you're walking with somebody who's freezing. You can either talk to them or hold them or give them some kind of a little gentle prod or cue. What they really need is a cue to alert their nervous system to get going again. This doesn't happen rarely happens very early in the disease, but towards the middle later parts of the disease, it's arguably the hardest part of the disease to treat.
[00:14:48] Dr. Corcos: And there is no current really great treatment. Although therapists are getting better and better at helping people devise strategies.
[00:14:57] Dr. Sagar: okay. So that leads me into a question about what is so different about when a person with Parkinson's disease. Moves their muscles versus a person without Parkinson's disease is moving their muscles. So
[00:15:14] Dr. Corcos: You're asking all the hard questions this morning, aren't you? If you kind of look at the neurophysiology of muscle activation, you have what are called motor units. And when you recruit a motor unit, it fires and it generates muscle force. And when you're healthy, you can modulate your motor unit recruitment very easily.
[00:15:39] Dr. Corcos: When one has the disease, towards the end, especially, the units firing kind of bursts. So when you look at the electromyogram, or when you look at the muscle activity recorded on the surface of the muscle, instead of it coming across as one clear burst of muscle activity, It comes along as fractionated discreet bursts.
[00:16:07] Dr. Corcos: And so the input to the muscle is not normal, and therefore the muscle doesn't work quite normally, and so the movement's a little bit slower.
[00:16:18] Dr. Sagar: instead of one smooth, significant signal to that piece of muscle, that's going to be contracting. It's a lot of tiny units. So instead of one grenade launching out, it's a lot of little BB guns, little BB pellets.
[00:16:36] Dr. Corcos: Yeah, I think that's, I think that's a nice way to put it. If anybody's listening and they're really interested and they contact you, I can make available to you a film which was shown by CBS from my lab, And then you can kind of see it on a screen and you'll see a person who really benefited from exercise So I actually have a film which actually shows what you've just described.
[00:17:04] Dr. Sagar: Yes. Yeah. We can put that in the show notes. Definitely I can happily help people get to that film.
[00:17:12] Dr. Corcos: That'd be great It's actually fun to watch because the gentleman in the film is very enthusiastic about his exercise program
[00:17:20] Dr. Sagar: Good. Somebody who's taken your message of lifestyle.
[00:17:24] Dr. Corcos: Yes,
[00:17:26] Dr. Sagar: So what happens if we don't take that message of lifestyle? What happens if we don't exercise? Both for the people that already have Parkinson's disease and those who might be at risk for developing Parkinson's disease
[00:17:41] Dr. Corcos: so for the next few minutes i'm going to talk about everybody because you can go to Any disease you like. Okay. I listened the other day to a wonderful talk on people who have heart failure. And essentially, what happens is when we age, and when we disease, when we have a disease, everything decline, and it continues to decline.
[00:18:09] Dr. Corcos: And when it declines too much, you die. Okay. And there are very good kind of predictors of when you're declining too fast. So it's been shown many times over. That if you become weak and really weak and you end up with sarcopenia, the next step is death. And it's been shown in study after study, disease after disease.
[00:18:36] Dr. Corcos: And so the question to ask oneself is, you know, from about the age of 30, 35 onwards, most things we do decline. And one way to look at this is you just think of a slope. And this slope. Is declining. Okay. So now the question is, can we slow the rate at which we decline? So in the perfect world, one would have no change over one's life.
[00:19:05] Dr. Corcos: And then at some point, one would just die. And so the argument here is for all of us to have the healthiest possible life lifestyle for whatever our natural expected lifespan is. And it turns out in Parkinson's, because of the reduction in dopamine, the disease does lead to a decline in many measures.
[00:19:31] Dr. Corcos: Now, there's no strong evidence that it alters life expectancy, but this does affect the quality of life over the duration one is alive. And so the argument here is that adopting a healthy lifespan, sorry, adopting a healthy lifestyle gives you the best chance of living out your life comfortably.
[00:19:54] Dr. Sagar: so that the more you exercise, the more you do healthy things, you take that instead of skiing downhill, maybe we can go cross country skiing until at the very end, we ski off a cliff at the end. It's how the things
[00:20:07] Dr. Corcos: Yeah, no, that's exactly right. That's exactly right. So, one wants to kind of keep oneself. Basically the same for the rest of one's life, which one can now decline is kind of inevitable, but the rate of decline can be modified. And, you know, you can see this in people. Some people you can see on a steeper decline than others, and there are many things we can do about it.
[00:20:31] Dr. Corcos: There's a lot of people, , talking about, , there are many benefits to retirement, for example. But one of the losses is you may lose Community and other things so being socially engaged is very good for the mind So retirement in and of itself can be great But if it is retirement to the couch all day, and that's all you do your physical mental You will physically and mentally decline faster than the person who is actively engaged
[00:21:05] Dr. Sagar: if they're still going to that job, they don't like so much. At least they're going somewhere
[00:21:10] Dr. Sagar: with people doing things
[00:21:11] Dr. Corcos: to I'm certainly not advocating. I'm a big fan of stress reduction. So I'm certainly not advocating staying with a job, which is stressful to one. , but I'm also pointing out that work gives people a purpose. And as one ages, a purpose is important.
[00:21:28] Dr. Sagar: now.
[00:21:29] Dr. Sagar: So how does exercise actually potentially prevent Parkinson's disease if it does that at all?
[00:21:37] Dr. Corcos: well, there are many studies
[00:21:38] Dr. Corcos: now being designed to do that, whether it actually prevents Parkinson's disease. I think. Probably not. Okay. whether it delays the onset, there is very clear epidemiological evidence that it probably does. Okay. How it does it. nobody really knows. Okay. one argument is that.
[00:22:06] Dr. Corcos: Certainly when you do endurance exercise, some people call it aerobic, some people call it cardio, any time that you elevate your heart rate quite high, you are increasing the blood flow. Throughout the whole body, and this includes the brain, and if you look at blood flow through the brain , as people age, the blood flow through the brain decline.
[00:22:34] Dr. Corcos: So when the blood flow through the brain declines, you're reducing the oxygen, oxygenation of the brain, you're reducing the number of nutrients that are getting into the brain. And then the neurons in the brain need that. And so, many people think that that is the reason why exercise might delay the time at which you get the disease.
[00:22:59] Dr. Corcos: And also why exercise may well slow the rate of decline. So I don't want people to think that I'm saying it's a magic cure. I'm not. But I am saying that we have people in my Zoom group who meet every month. Who have not yet been diagnosed, but they have many biomarkers that have been measured on them, which indicates that they are possible for the disease.
[00:23:27] Dr. Corcos: And so they are exercising to delay, postpone or hopefully never get the disease.
[00:23:33] Dr. Sagar: So they're vulnerable to it
[00:23:35] Dr. Corcos: Yes, they are vulnerable to it. And there are measures now, which have been taken on many people. Which do suggest you might be vulnerable to
[00:23:45] Dr. Corcos: it.
[00:23:46] Dr. Sagar: and I assume by that you mean genetic markers or do you mean something else?
[00:23:49] Dr. Corcos: I mean both. So, within Parkinson's disease, there are, number of genes which have been linked to Parkinson's disease. The GBA mutation, the Lark2 mutation, to name but two. There are others. But these are not strongly causal. So just because you have a mutation doesn't mean to say you'll get the disease. it's a very weak association, but it is there. There's no question it is there. Then as we learned in COVID, Lack of smell is bad. Okay. It's kind of indicative. There's something wrong in the brainstem or might be something wrong in the brainstem. And so lack of smell hyposmia is certainly looked at. people who have trouble sleeping and who have REM behavioral disorder, rapid eye movement, behavioral disorder. They also have a higher risk of Probability, and there are other markers which are now being investigated in both blood and urine, which may indicate that a person has a higher probability.
[00:25:00] Dr. Corcos: I'm choosing my words carefully here because I don't want people to get overly concerned.
[00:25:06] Dr. Corcos: Lack of smell may have nothing to do with Parkinson's disease. It's what is called a very, non specific biomarker. So if you can't smell your red wine, what it tells you is Something isn't quite right. It doesn't tell you exactly what isn't quite
[00:25:21] Dr. Corcos: right.
[00:25:22] Dr. Sagar: Yeah.
[00:25:22] Dr. Corcos: And the smell may come back because certainly in COVID 19, I've had friends who lose it and it comes back and, these are the kind of biomarkers which are being studied, by many, many people. It's a very fertile line of study at the moment.
[00:25:37] Dr. Sagar: these people in your zoom groups have found that they've had these markers, they're vulnerable to it. So they're taking on the, the duty to exercise, to try and slow down whatever is coming their way. If at all, it is coming their way. And the hypothesis is that the way that exercise might be helping is by increasing blood flow so much. To including the neurons and all the cells in the brain, letting them have more nutrition, letting them have more oxygen, letting them deal with the damage that Parkinson's might be doing so that they can hold out a little longer.
[00:26:08] Dr. Corcos: Yes, that's exactly right. At least that is the way that I understand it.
[00:26:13] Dr. Sagar: That's what we know so far
[00:26:15] Dr. Corcos: Yes.
[00:26:16] Dr. Sagar: that if anyone's going to know, it's probably going to be you at this point. What can we expect by doing exercise for Parkinson's disease? It sounds like we may be able to delay it, delay the severity of the symptoms. What else can somebody expect from doing exercise?
[00:26:33] Dr. Corcos: Well, for some people, not all, okay, but for quite a few people, they just feel better. So most of the people in the Zoom group and most of the people I talk to feel better. I'm one of those. I exercise and I feel better. Not everybody has that same sense of well being, whether one wants to call it a dopamine high or however one wants to refer to it. some people just don't experience it, but there's no question the exercise is still helping them. So for some people, they feel good. I had a wonderful email yesterday from a lady and she just finished doing her sit to stands, and she's been doing them for a long time now, and she said, boy, my legs are strong.
[00:27:21] Dr. Corcos: And so what you're going to do is you're going to feel stronger. Now, you look at the frail elderly. So how do the frail elderly get out of a chair? Well, they push up with their hands and their legs just can't do it. And then they reach a point that their hands can't help them. So they spend most of their day in a chair and need help getting around.
[00:27:44] Dr. Corcos: But one of the things the strength training does, it keeps your muscles strong because we lose muscle mass. The size of the muscle tissue declines noticeably as we get into our 70s and 80s.
[00:28:00] Dr. Corcos: And the strength training maintains the muscle structure and function. And once you lose the muscle structure and function, then the ability to do simple tasks.
[00:28:14] Dr. Corcos: Starts to decline. And then once quality of life starts to go downhill, because there's a certain things we want to be able to do and be able to get up out of a chair without having to have people help one to be able to walk around one's house to the bathroom, to the kitchen, wherever one wants to do.
[00:28:34] Dr. Corcos: And for many people, one of the highlights of their life is grandchildren. The last time I checked, they have energy. And so it's not a bad idea to maintain one's own energy levels so that one can at least Keep up with them for the first five minutes or so.
[00:28:52] Dr. Corcos: So the activity is all about being able to maintain what are called activities of daily living.
[00:28:58] Dr. Corcos: Occupational therapists, physical therapists, speech therapists spend a lot of time and effort to make sure a person's quality of life doesn't fall by allowing them to do activities of daily living that are important and essential to them. And exercise can help one do that. Do that.
[00:29:20] Dr. Sagar: Yeah, I just brought up that sarcopenia again that you were mentioning, that muscle loss as people get older and if they keep up with the strength training on top of their other exercise, they'll be able to keep doing more of those daily activities, maybe not to totally keep up their grandchildren, but at least get out of the chair, maybe before they pull the bookshelf down on themselves or something like that.
[00:29:39] Dr. Corcos: Well, something like that.
[00:29:41] Dr. Sagar: How much of an effect can somebody that has Parkinson's disease I don't know. Expect to get out of exercise. is it probably a tough question to generalize?
[00:29:51] Dr. Corcos: It is tough to generalize because no two people are alike. When you talk to people, when you talk to movement disorders specialist, the question is, there one disease or are there many diseases? Conventional thinking is that there's more than one disease. Okay.
[00:30:09] Dr. Corcos: you look at average data, when you assess how Parkinsonian a person is, that is, How rigid they are, how much tremor they have, how slow they have.
[00:30:20] Dr. Corcos: And you assign a number to all of those and you add them up, you get a score. It's called the Movement Disorder Society Unified Parkinson's Disease Rating Scale
[00:30:29] Dr. Corcos: Part 3.
[00:30:31] Dr. Sagar: I hope there's an acronym for that.
[00:30:33] Dr. Corcos: Yes. MDS UPDRS part three. I wanted to spell it out because people will be on the side of graphs. Okay. MDS UPDRS part three.
[00:30:43] Dr. Corcos: And typical decline is three to four points a year, which means your signs are getting worse by three to four points a year when you do endurance exercise. You really slow that rate of decline, and this has been demonstrated in three papers absolutely clearly, and these are large studies conducted in, America. I was on one of the studies conducted in Holland and conducted in Hong Kong, and all show high intensity endurance exercise does slow progression.
[00:31:21] Dr. Sagar: Are you able to say what three to four points per year may mean as an example?
[00:31:28] Dr. Corcos: This is really hard. Okay, that's the I can't really explain it to you. I can't, you know, I can't say, you know, it's that the speed has changed my point one meter per second, or the amplitude of the tremor has not increased by point. of the meter or some other measure. So I can't give you objective numbers, but, I can tell you for the people who really have this measured when they go to the doctor and the doctor says you haven't progressed very much.
[00:32:04] Dr. Corcos: It makes them feel good. No,
[00:32:06] Dr. Sagar: yeah, I was just wondering because , on a pain scale of zero to 10, a change of three to four points is massive on a, so I was wondering on a, this movement scale, how big of a change three to four points is noticeably is that can get out of a chair to
[00:32:24] Dr. Sagar: can't get out of
[00:32:25] Dr. Corcos: no, it is nothing like as dramatic as that. Okay. But remember, and this is the important point to remember. So I'm glad you're pushing me hard on this. Okay.
[00:32:36] Dr. Corcos: The important thing is we're all different. . If you're diagnosed when you're 80, you have one set of circumstances to navigate in life.
[00:32:47] Dr. Corcos: When you're diagnosed at 38 and you're working. You have a totally different set of circumstances to navigate. So, one point may not sound very much, okay, but now look at 40 years, that's 40 points. And now if you can drop that 40 to, let's say, 20 or 25 points, that will. So, you know, a, a physician who sees a person with 15 points difference, That's visually obvious to
[00:33:20] Dr. Sagar: okay.
[00:33:20] Dr. Corcos: them.
[00:33:20] Dr. Corcos: And so, It's not as simple as the pain scale.
[00:33:24] Dr. Sagar: That one you can describe with emojis. So that one is
[00:33:26] Dr. Sagar: oversimplified.
[00:33:27] Dr. Corcos: You know, Yes, that is. I wouldn't say it's oversimplified. I think, People with Parkinson's do want metrics that they, at least some people want metrics that they can calibrate themselves.
[00:33:40] Dr. Sagar: And so people can feel it. So yeah, that's. It may be a long term effect to really notice that 15 points that you didn't progress, but that's going to make a massive difference in someone's life and how much they can work, how much they can do with their kids, how much they can go out and socialize. And so remembering for people that, hey, I may be early in the disease, I may be moderate in the disease, but if I push myself for this high intensity, Endurance exercise. I'm going to be in such a better place a few years from now.
[00:34:10] Dr. Corcos: That's right. But I mean, I'm sure you experienced the same thing. So you are an ER
[00:34:15] Dr. Corcos: physician,
[00:34:15] Dr. Corcos: correct?
[00:34:17] Dr. Sagar: Oh, yeah.
[00:34:18] Dr. Corcos: so if somebody comes into the ER with whatever their problem is, and they are in spectacular shape, it may be difficult for you. I mean, if it's a car crash or something else, or if it's an unexpected heart problem, but all other things being equal, your problem is noticeably easier for you.
[00:34:41] Dr. Corcos: And somebody comes in with diabetes, hypertension, a whole lot of other co morbidities, and now you have to go into action. Yeah. Although I'll say these days I'm finding a lot more people that look really fit. And then I go through their health history and there's that high blood pressure. There's that high cholesterol. There's that diabetes.
[00:35:03] Dr. Corcos: Oh, sure, sure, I want to make sure that we get the take home message here. So, just because you look fit doesn't mean to say you shouldn't measure your metrics. Okay, so. Think all of us need to be aware what our blood pressure is at a fairly early age. There are all these vital signs,
[00:35:21] Dr. Sagar: Mm
[00:35:22] Dr. Corcos: uh, blood pressure and cholesterol.
[00:35:25] Dr. Corcos: And physicians are getting very, good at, looking up a table and telling you what your risk factor is. So based on your age, et cetera, you may have a risk factor of two, three for an impending stroke or something. But all other things being equal, I think, It's easier to deal
[00:35:42] Dr. Corcos: with healthy people.
[00:35:43] Dr. Sagar: No, that's a definite fact. I just saw somebody the other day who complained to me. He was in the ED and he complained to me. I go to my doctor. I don't like him because every time I see him, he just tells me to exercise more and stop smoking. I had to go and say, I'm going to tell you the same thing right now. You're going to hear it
[00:36:02] Dr. Sagar: everywhere.
[00:36:03] Dr. Corcos: Well, you know, this this is, very interesting. Yeah,
[00:36:08] Dr. Sagar: Yeah.
[00:36:08] Dr. Sagar: So exercise has been as the only disease modifying therapy. for Parkinson's disease. Would you agree with that?
[00:36:18] Dr. Corcos: to
[00:36:18] Dr. Corcos: date, I am unaware of any research study. there are many, studies going on. They are in different phases. There's a lot of optimism and there's reason to be optimistic, but I am unaware of a study
[00:36:37] Dr. Corcos: to date.
[00:36:39] Dr. Sagar: That would actually qualify exercises, quote, unquote, disease modifying.
[00:36:43] Dr. Sagar: Okay.
[00:36:44] Dr. Corcos: have been a very large number of large failed studies. There have been at least seven failed phase three clinical trials looking for a neuroprotective or a disease modifying agent in Parkinson's, and they've all failed. I mean, it's the kind of holy. Well, the most important thing is to find a cure.
[00:37:06] Dr. Corcos: There's absolute agreement on that. And then. on the way to the cure, if we can find ways to slow the rate at which the disease progresses, that is great. And to my knowledge, and I'm reasonably well informed, because if that study came out, I would get emails. Because I get emails from all the people that I Zoom with.
[00:37:27] Dr. Corcos: . All the wonderful people I Zoom with. Every time there's a study come out, they email me it. And then we go through the study. We're going through a study in the end of April, a very important study on the beneficial effects of exercise. And so I'm pretty sure I would know, not necessarily because I'm searching the literature, which is what I should be doing, but all my friends are and they would email me immediately.
[00:37:52] Dr. Corcos: So no,
[00:37:54] Dr. Sagar: Well, that's your proxy there.
[00:37:55] Dr. Sagar: They're doing it for
[00:37:56] Dr. Corcos: but they are doing it for me. a very nice way to put it. So if any of them ever listened to this, and some of them do, my proxy team are beyond terrific. Beyond
[00:38:05] Dr. Corcos: terrific,
[00:38:06] Dr. Sagar: how, just to go a little bit more, we'll touch on a little bit.
[00:38:10] Dr. Sagar: What is the biology of exercise actually changing our downhill slope to more of a plateau? Is it simply increasing muscle mass or is it doing something? What
[00:38:20] Dr. Sagar: other things is it doing?
[00:38:21] Dr. Corcos: but it's doing a lot. It's doing a lot. So I'll try to walk through a few things because I and others are often asked the question. Oh, I've got very little time. I could only do one thing. What should I do? Should I do cardio? Should I do resistance? And that is the wrong question. is like asking your dietitian or physician.
[00:38:44] Dr. Corcos: Should I only eat protein? Should I only eat carbs? Should I only eat fat? All of us need cardio or endurance, particularly because it keeps the heart in great shape, which allows the brain to be oxygenated. It does something else. It increases your ability to function. Consume oxygen. The technical term is it increases your peak VO2.
[00:39:15] Dr. Corcos: It has been suggested that that should be looked at as a biomarker. So, when you're sitting, you're taking in oxygen, you're expelling oxygen and you need so much oxygen just to be alive. Now, if you want to go quickly up steps, you need more and more oxygen. And as one exercises less and less, one's ability to consume oxygen goes down.
[00:39:41] Dr. Corcos: And this is not good. So what the cardio does is it's very good for the heart. It's very good for respiration. It's very good for transmitting blood to the brain and it's very good for your overall fitness. The other thing it does is it keeps your ability to walk at a good speed high. The ability to walk three to four miles an hour is a very good predictor of how well one is doing.
[00:40:10] Dr. Corcos: Once one's walking speed goes below three miles an hour, drops to two miles an hour, drops to one mile an hour, this is not good. First of all, it means it's very hard to get around. And secondly, it means you're becoming rapidly deconditioned. Independent of that is the integrity of the neuromuscular system.
[00:40:29] Dr. Corcos: That's why you do resistance training. Because you're working both muscles. The nerve and the muscle. So when people think of resistance training, they may think of bodybuilders or they may think of having a nice toned triceps. It's all well and good, but it's really beside the point. The point is that when you look inside the brain, you look inside the various structures inside the brain, including what is called motor cortex, including the basal ganglia, including the nuclei of the basal ganglia which get impaired in Parkinson's disease.
[00:41:02] Dr. Corcos: These are all activated When muscles contract, and so it is the contraction of the muscle, which is very important, and that is very, good for activities of daily living and posture. A third thing, which is really important, and it is stressed more and more is. flexibility training. So, when one becomes rigid, one's muscles become tighter, they become stiffer, one loses range of motion.
[00:41:35] Dr. Corcos: Many people who have Parkinson's will stretch first thing in the morning. Most of my Zoom group will stretch first thing in the morning to kind of take out the extra rigidity which may have occurred overnight. And earlier on, I talked a lot about Dual tasking. So, the fourth part of the exercise prescription is being able to do what is called neuromotor activities.
[00:42:04] Dr. Corcos: This might be walking on a treadmill at the same time as performing a cognitive task. It may be doing any activity outside at the same time as talking with a friend. And so, As the disease progresses, if you go and see a physical therapist, they will give you lots of agility exercises, balance exercises, multitasking exercise, directional balance training, and all of these are very good for you.
[00:42:32] Dr. Corcos: have just recently had the privilege of working with three young movement disorders specialists. They're all terrific. And we have just published at the end of 2023, the exercise prescription in Journal of Parkinson's disease. I can have that made available. Then the other thing I'm going to show you, I've worked with Christine Meldrum, and we now, well, she wrote the book and then I helped her write the book.
[00:42:58] Dr. Corcos: And the title of the book is Parkinson's, How to Reduce Symptoms Through Exercise. You can find it on Amazon. Just Google Meldrum, M E L D R U M, and Exercise and Parkinson's Disease. And it will lay out much of this. It's a very nice read because it is, it's got two parts to it. The first part of it, it is many stories about people.
[00:43:28] Dr. Corcos: Who've embraced exercise and what it's done for them. And then it goes to do the
[00:43:33] Dr. Corcos: science
[00:43:34] Dr. Sagar: fantastic.
[00:43:35] Dr. Corcos: Okay. thanks. So, to go back to your question. When we exercise, we have a lot of changes in our blood chemistry. And these changes are good. So we're very interested in the neuro endocrine system. And so we measure cortisol when cortisol is elevated.
[00:44:00] Dr. Corcos: It's not good. It's a stress hormone and there's evidence that is elevated in Parkinson's and it's reduced with exercise. There are several other hormones. There's one called Clotho. It's an anti aging hormone. And there's also evidence that it is decreased in Parkinson's, and it increases when you exercise.
[00:44:25] Dr. Corcos: Clotho,
[00:44:27] Dr. Sagar: more time? Clotho.
[00:44:29] Dr. Corcos: K L O T H O.
[00:44:32] Dr. Corcos: It's an endocrine hormone. literature, you'll find a lot about trophic factors. You'll read a lot about brain derived neurotrophic factor, BDNF. , it's good reason to want to increase trophic factors, exercise increases trophic factors. And then thirdly, it's becoming crystal clear to a lot of people that it is an inflammatory disease.
[00:45:00] Dr. Corcos: It's a disease of inflammation. And so if you look at measures such as TNF and IL 6 and C reactive protein, these are measures of inflammation. The evidence is reasonably strong that some of them certainly C reactive protein is increased in Parkinson's. It increases with disease severity and it decreases with exercise.
[00:45:30] Dr. Corcos: And so if one kind of looks at one's overall blood chemistry profile and one asks the question, does one want to get it closer to normal and healthy than exercise? It's one way to do it, and it works well, and so the reason why I am, for want of a better term, evangelical about exercise is that you will find combinations of medication, which may be able to do some of what I've mentioned.
[00:46:05] Dr. Corcos: Okay, but to find a pill, which will do all of that, I think is a tall order. And so it's a very pluripotent, Form of medicine and people have kind of written about it as a very pluripotent form So there are ways to reduce inflammation there are ways to work on the endocrine system and the trophic system, etc But exercise does it
[00:46:30] Dr. Corcos: all
[00:46:31] Dr. Sagar: So exercise, somebody with or without Parkinson's disease is going to be able to say. , by doing these different forms of exercise, they get all these benefits. And I love that you compared it to macro nutrients of fat and carbs and protein, because people will ask that question. You know, should I just eat only fat or just eat only protein? And it is very akin to, well, should I just do cardio? And it's kind of, it puts it into a different lens that makes a lot more sense. , I need all different kinds of food. Oh, I need all different kinds of exercise. That's a fantastic example,
[00:47:06] Dr. Corcos: yeah, so I think one can summarize it all it's a question of balance
[00:47:10] Dr. Sagar: figuratively and literally because balance is one of the exercises, but
[00:47:17] Dr. Sagar: the aerobics, they help with the oxygen uptake and spreading the oxygen through all the cells, helping nourish them, helping them getting yourselves used to metabolizing more of it. And then the flexibility because people get stiff, not just with old age, but particularly with Parkinson's, you mentioned it as cog wheeling. And talk more, if you don't mind.
[00:47:38] Dr. Sagar: about the muscle nerve connection and just how the nerves and the muscles interact in a way that's different in Parkinson's and then even more different with the addition of exercise.
[00:47:51] Dr. Corcos: That is again, Yeah, I don't have an easy way of really answering
[00:47:57] Dr. Corcos: that
[00:47:57] Dr. Corcos: question
[00:47:58] Dr. Corcos: So it goes back to the orderly recruitment of muscle. So when a healthy person turns on a muscle, they turn on the motor unit, which I mentioned a little bit earlier. Okay, and they have the option to increase the frequency. So when you make a very fast contraction, you increase the frequency at which you fire the motor unit.
[00:48:22] Dr. Corcos: Okay, you also recruit more motor units. So if you're making a small contraction. You will only use small motor units and a small number when you're making a very, fast contraction. When you move your arm or your leg or you jump up as fast as you can, you're then going to be turning on all of your motor units and you're going to drive them at the highest frequency you possibly can.
[00:48:48] Dr. Corcos: And then there's a third part to activating the muscle. And you can sometimes synchronize the motor units so that the motor units are firing at the same time. And that would also give you an increase in force. So motor units can be, you can recruit more motor units, you can increase the frequency, and you can synchronize them.
[00:49:13] Dr. Corcos: Well, when people become very slow moving. Okay, their ability to recruit motor units is less, they can recruit fewer and fewer motor unit. They can also drive them at a lower frequency and also they're not able to synchronize them as well. So you don't have this high frequency input to the muscle to generate the muscle force.
[00:49:47] Dr. Corcos: And so when you look on the electromyogram recorded on the surface of the muscle, you will have a little little burst. What I will do is I will make available a paper people can read who really want to, look at this when I will show, muscle activation pattern of a person who is off medication and who's off deep brain stimulation.
[00:50:09] Dr. Corcos: This will be the clearest way for somebody to see what it looks like. And what you record on the surface of the muscle is very, little activity. So the motor cortex, which is receiving input from the basal ganglia cannot drive the muscle. For the input to the muscle at a high enough frequency. And so you get a tiny recording on the surface.
[00:50:32] Dr. Corcos: And the movement is very slow. The figure that I will make available to you is people moving at about 100 degrees per second, which is just slow. And then you will see that when you provide medication, this starts to allow the input to the muscle to change. And also when you apply deep brain stimulation, it alters the input to the muscle.
[00:50:57]
[00:50:57] Dr. Corcos: And I'll make that paper available and I'll also show you a paper where I've got a picture of this kind of fractionated bursting muscle activation pattern, which is affected by, , strength training.
[00:51:10] Dr. Sagar: that'd be great. And it sounds like to recap it, there should be a signal going from the basal ganglia deep in the brain to the motor cortex, and then going down to, let's say, somebody's arm
[00:51:23] Dr. Sagar: to hit a ball, for example. And in a regular person, they would be able to recruit as many motor units as they need to swiftly move their arm and hit that ball or make it more frequent. , or synchronize all these different motor units so that they work more efficiently together. But in someone with Parkinson's disease, something is messed up. In signaling between the motor cortex and the muscle so that none of those ways, none of those strategies that the arm and the brain use to hit that ball are as functional.
[00:51:54] Dr. Corcos: that's right. That's
[00:51:56] Dr. Corcos: right.
[00:51:56]
[00:51:56] Dr. Sagar: Dr. Corcus. This has spent much of his life elucidating, the powerful role of exercise in Parkinson's disease. And it's yielded some great information. Essentially exercise will probably make you feel much better in multiple ways in the short term. But it's real power comes in the longterm. We'll get into more details about what to do in the second half of this. But the more you exercise now, the younger and healthier you are later. If you have PD or might get it. Which to be clear is everybody. Then consistent exercise can keep you younger as you get older. It can hold off symptoms from getting worse and maybe even from starting. The kinds of things to be done, include strength, training, endurance, training, flexibility, balance, and multitasking. Go see a physical therapist to get yourself on a good regimen. It's not about which single kind of exercise to do.
[00:52:48] Dr. Sagar: You need them all.
[00:52:50] Dr. Sagar: Also Dr. Corcus mentioned the big meeting in Cincinnati where people can go for even more education. It's called sunflower, rev it up for Parkinson's and it's on August 10th from 9:00 AM to 1:30 PM. It is totally free. I'll put a link in the show notes.
[00:53:05] Dr. Sagar: Remember. The way you live can save your life.
[00:53:09]
PART 2:
[00:00:00] And now, the rest of the conversation.
[00:00:10] Dr. Corcos: I'm going to go off on a complete tangent. Okay. is a game where you can see. the advantages of moving a little bit quickly, and it is called Whack A Mole. So for any of you who have grandchildren who like to play Whack A Mole, and you're finding that they can whack the mole a little bit more quickly than you, well, a little bit of exercise is going to get you back into being able to whack the mole really well.
[00:00:36] Dr. Sagar: absolutely, and that game is still out there,
[00:00:38] Dr. Sagar: which is,
[00:00:40] Dr. Corcos: was told the other day that it still is. A big fan of
[00:00:43] Dr. Corcos: Whack A Mole.
[00:00:44] Dr. Sagar: yeah, I was just setting an arcade with my kids. Definitely there. They didn't have the mallet. So you had to use your own hands, but the game was still working. And then if I'm going to be a slightly tangential as well.
[00:00:55] Dr. Sagar: How does exercise, if it does help the non motor symptoms of Parkinson's disease.
[00:00:59] Dr. Corcos: Well, the how part is, I don't really fully know exactly, okay, certainly on, on, the how part in terms of the various neurotransmitters affected, uh, cetera, we don't really have a clear, clean, crisp answer, but we do have a very clear, clean, crisp answer to the following. does it improve cognition unequivocally?
[00:01:30] Dr. Corcos: And, , I challenge anybody who's listening to send me an article of any study, which has shown clearly better effects from access from any medicine with comparison to exercise. There are studies now coming out showing improvements in cognition. I think they're quite small, but that can be debated, but the comparative group is never against a really rigorous exercise program.
[00:02:00] Dr. Corcos: Okay, it'll be against. Some other comparative group, so you can take it to the bank. It's the best treatment out there for cognition, and if anybody can prove me wrong, I think that would be great. I'm actually delighted to be proven wrong. Okay? Because it means I've learned something. And it also means science is moving fast in that direction.
[00:02:25] Dr. Corcos: For some people, it can be very good for depression. There's a lot of evidence that exercise can be, but this is kind of a circular argument here, because if you're depressed, can you exercise because you may be too pressed or, and at some point, if one is depressed, anxious, and apathetic, discussing that with a physician to have some pharmacological intervention to get you over the hump is something I would certainly consider.
[00:02:53] Dr. Corcos: But exercise and depression, the evidence is remarkably strong across diseases. same is true for anxiety and stress. one of the non motor symptoms which people invariably will talk to their physician about is constipation. constipation is also a result of an impaired motor system. It turns out to be the autonomic nervous system.
[00:03:20] Dr. Corcos: When I was talking earlier on about the muscle activation. That's all part of the voluntary movement system, but there's also the autonomic system, and the autonomic system can be impaired. And there's evidence that exercise can help in constipation. In fact, you can turn your question around. Okay, because I've been talking too
[00:03:45] Dr. Corcos: much.
[00:03:46] Dr. Sagar: that's the point of
[00:03:47] Dr. Sagar: this show.
[00:03:48] Dr. Corcos: I know, but can you tell me something that you don't think exercise would be good for?
[00:03:54] Dr. Sagar: Acutely fractured limbs is where I'm going to go.
[00:03:57] Dr. Corcos: Correct. That is 100 percent correct. There is a time and place. Yes. That reminds me a while back, ruptured an Achilles tendon, which is along the same lines of what you're leading to. Okay. And yes. That was mobilized, and I was a, I did nothing for eight weeks on that limb. And so, yes, there are times when exercise is clearly, contraindicated.
[00:04:24] Dr. Corcos: But I think there are a few, and I want to use the word carefully here, they relate to acute events. So, for those of you who are not quite sure what acute means in this context, I'm talking about something which lasts for a fixed, short, finite period of time. So you have a fracture for six, eight weeks, depending on the fracture to recover ruptured Achilles tendon, depending on your age and whether it is surgically treated or natural history about eight weeks.
[00:05:00] Dr. Corcos: But then, okay, , once you've had that acute fracture, then most people are told now get back to exercise, because if you have a fracture and you're out for eight weeks, you have a significant. amount of muscle wasting. In fact, if you look at astronauts, they're exercising all the time up there because if they don't, when they come back, the atrophy because of being in without gravity is enormous and it's dangerous.
[00:05:32] Dr. Corcos: And for trips to Mars, you can be sure that exercise physiologists are going to be working tirelessly to make sure they exercise vigorously, not to rapidly the condition.
[00:05:44] Dr. Sagar: Yeah, that brings up, let me be tangential once more time.
[00:05:49] Dr. Sagar: Exercise physiologists, you've mentioned just now, physical therapists, you've mentioned should Parkinson's people with Parkinson's disease be seeing one or both of these people?
[00:05:59] Dr. Corcos: for sure. There's no question what best practice is. Unfortunately, 13 percent of people on average follow best practice. Best practice is that when one is diagnosed with Parkinson's, one sees a PT. So the physician makes the diagnosis, gives you a whole set of treatment guidelines, but doesn't really assess your overall well being.
[00:06:31] Dr. Corcos: Physical function, your ability to do tasks, and that's what a P. T. will do. And if you're early in the disease, and when you see the P. T. it may just be that they just get a baseline measure. You can walk. You can do a 6 minute walk this quickly. You can sit up and down so many times in a fixed time.
[00:06:52] Dr. Corcos: They'll give you a whole series of physical tests, and so they will have a benchmark for where you are and you may not need to see them very often, perhaps once a year for a few years. Then as the disease progresses and progresses, you're going to need them more and more to help you with turning, falling, freezing of gate.
[00:07:17] Dr. Corcos: A variety of activities. And so the role of the PT will increase more and more, but it is good to see them on day one. So they have a very, clear picture. And in fact, some people are in such. are so out of condition that they may need PT even before exercising. So, some of my colleagues use the term neuro restorative PT.
[00:07:46] Dr. Corcos: So, you're basically restoring the neurological system to get it ready to exercise. And so, the exercise, now we're all different, okay? Some people are really good. On their own, a small number.
[00:08:05] Dr. Corcos: Okay, the most popular exercise at the moment, I think, is almost certainly what is called Rock Steady Boxing, and people love it.
[00:08:14] Dr. Corcos: Rocksteady boxing and they love it because they're with their friends. They're with their colleagues There are other programs which are kind of circuit based training group exercise is very popular When I go to my health club far and away the most popular activity Is water aerobics aquatic aerobics?
[00:08:36] Dr. Corcos: Because there's no pressure on the muscles if you're a little older if you're a little overweight if you've lost weight Got a balance problem. But if you fall over in the water, the worst that happens is you get wet hair. So there's just no bashing off to the ER to meet Sega and have him put your bones back together.
[00:08:56] Dr. Corcos: You just get up out of the water. Okay. So, yeah, there are lots of different activities.
[00:09:04] Dr. Sagar: Are you able to give a prescription for Parkinson's? a typical person that may have Parkinson's disease. When, what time of day should they be working out? How intense is the right amount of intensity?
[00:09:16] Dr. Sagar: So
[00:09:16] Dr. Corcos: So to be clear, we know the guidelines for the exercise prescription. I used the word carefully guidelines because no two people. Are the same. Okay. As I mentioned earlier on, 30 year old, sorry, somebody who's 38 years old. It's quite different from a person who's in their early 80s, but the principles are the same.
[00:09:44] Dr. Corcos: And so 3 to 4 times a week. A person should be getting their heart rate up to 80 to 85%. It may take a while to practice that. One may need to be in a group setting to do it, and the literature is crystal clear that there's a significant benefit. Does one get a benefit at a lower heart rate? For sure.
[00:10:09] Dr. Corcos: There's no question that both are good for you. But there's no evidence that the lower heart rate modifies progression. There's considerable evidence that the higher heart rate modifies progression. So it's cardio three times, four times a week for 30 minutes with a high heart rate. Then it's weight training twice a week, three times a week if one likes, and that's very, good for the integrity of the muscle and fighting off muscle wasting, which is a key part of aging.
[00:10:46] Dr. Corcos: Then stretching is good to be done perhaps every day. It's very good for one. And then if one's posture, gait, and balance is starting to decline, one needs to do more and more neuromotor activity. Activities which are great are rock steady boxing. Tai Chi. People love to play tennis, table tennis. All activities where you're coordinating eye, hand, limb balance are terrific for you.
[00:11:20] Dr. Corcos: And the evidence for this is clear. It's overwhelming.
[00:11:26] Dr. Sagar: Is there a time of day that's better for people to be working out first thing in the morning, right before bed to make any impact and when they have better movement?
[00:11:38] Dr. Corcos: So again, this is highly personal. I'm going to talk a little bit about myself for a moment. years ago, , could be out on my bike at 5. 30 in the morning, getting up at 4. 20, and that was no problem for me. Recently, I've had a couple of surgeries for atrial fibrillation and atrial flutter, and my best time right now is 9.
[00:12:02] Dr. Corcos: 30, 10 o'clock in the morning. hoping to get back to being able to go out really early in the morning. It just doesn't quite seem to be working for me. I've no idea why. My only point of telling you this is that some of you may be 5. 30am people, some of you may be 9 o'clock, some of you may like it early evening, doesn't matter.
[00:12:24] Dr. Corcos: What matters is your own diurnal variation or your own clock. You're gonna have good times and you're gonna have times where a nap is better for you than going to work out. Just depends on how your body goes. The other part, which gets more complicated. And what I mean by that is that when you're first diagnosed and when you first start taking medication, the medication works well and it is not precisely time locked to when you take it by that.
[00:13:00] Dr. Corcos: I mean, you can take it for example, 6 AM and it may work 4 or 5 hours and it's still working at 9, 10 o'clock, even though you took it a long while earlier as the disease progresses for many people, you need to take your medication more often. And you reach a point where the medication wears off and you reach a point where you have dyskinesia.
[00:13:24]
[00:13:25] Microphone Array (Realtek High Definition Audio(SST))-4: Dyskinesia meaning and uncontrolled involuntary movement. Such as Fidgeting wriggling and head bobbing or swaying.
[00:13:32] Dr. Corcos: so, when you're that far into the disease, then timing your exercise to when you're most on is what one needs to do. One needs to know when to take one's meds. There is a lot to be said for being well medicated when you exercise. The idea of under medicating for exercise is not current best practice.
[00:13:54] Dr. Corcos: Okay, so if you need a little bit of extra medication to get a good workout, conventional wisdom, or should I say the wisdom of my good friend Baz Bloom, is take plenty of medication. He's a world famous neurologist, so he sees patients, he's got an insight into the pharmacology that I don't. His view is extra medication to exercise.
[00:14:17] Dr. Corcos: Can be good. And so the end of the day, it is knowing oneself. Now, the other thing is, I am talking, I'm certain that all of you listening have actually learned
[00:14:31] Dr. Corcos: nothing from
[00:14:31] Dr. Corcos: me,
[00:14:32] Dr. Sagar: Yeah.
[00:14:33] Dr. Corcos: because what happens is I tend to talk to people who already know it all. Okay, the problem is reaching the people who don't turn in to listen to programs like that.
[00:14:47] Dr. Corcos: Now, many of you may go to community meetings. You may meet with other people. You may be ambassadors for Davis Phinney. You may be quite active in your community. And so the message to get out is exercise and don't even use the word exercise. Use the word activity or something a little
[00:15:11] Dr. Corcos: bit less
[00:15:12] Dr. Sagar: Just movement.
[00:15:13] Dr. Corcos: movement. Movement is a great word. the only way this really works, okay, is When you put it 1st, so for me, it is the most important part of my day. Please. None of you never ever tell my dean that tell my dean or Dr. Corker's thinks about is getting another grant. Okay, but the reality of it is.
[00:15:41] Dr. Corcos: The activity and exercise is the most important part of my day, because if it's not, then it can easily go by the way. And so you need to find the time you need to schedule it. Ideally, have friends who make you accountable and that's why Rock Steady Boxing is so good because if you go there and everybody wants to see you because you're so nice and you don't show up, there's a high probability they will let you know nicely,
[00:16:14] Dr. Corcos: where were you?
[00:16:15] Dr. Sagar: yeah. A little
[00:16:17] Dr. Sagar: accountability.
[00:16:18] Dr. Sagar: Always good.
[00:16:19] Dr. Corcos: yeah, and so you have to make it the most important thing, you have to be accountable to yourself. So now let me get it. And again, you know, I'm talking to the converted. But when you talk to other people, it would have to be very gentle here because it is a touchy area here. when one lets oneself go into general decline, the next thing that happens is one becomes more and more dependent on other people.
[00:16:51] Dr. Corcos: And so at a certain level, if one's really struggling to motivate oneself, and I'm just trying to give, I try to give people any possible reason I can because different people are triggered by different
[00:17:02] Dr. Corcos: things.
[00:17:03] Dr. Corcos: But to be responsible for one's own health, another way to look at it is that you are not at the end of the day, leaving it to other people to look after you.
[00:17:14] Dr. Corcos: So if you end up in great shape till you die, okay, then that is terrific. Because you haven't needed anybody's help. And if you let yourself progress, and progress, at some point, you're going to need help. And very few people have the finances that they can just check themselves into a marvellous place which looks after them for the rest of their So there's an element of self and social responsibility in caring for oneself.
[00:17:49] Dr. Sagar: Absolutely. Yeah. People are very afraid of becoming a burden on others or being stuck in a place that maybe is not so nice of a facility.
[00:17:58] Dr. Corcos: Well, yeah. No, I mean, most? Nearly everybody. Would kind of want to age in place at home, okay? And to do that one has to be relatively physically active. So there are stairs, that's the first thing people think about. Then bathrooms is the second thing people think about. Perhaps the third thing is where one cooks.
[00:18:24] Dr. Corcos: And so if one keeps oneself in great shape, then those things don't become part of the
[00:18:30] Dr. Corcos: equation. I go over every morning to see my neighbor, and that's it. She's in her early 80s. Terrific shape. She'll be there till she dies. I have, I want to say I have no doubt anything can happen to anybody, but she keeps herself in great shape..
[00:18:47] Dr. Sagar: Are there any tips for making a person's workout even more effective? So I've heard about things like forced exercise and certain kinds of stimuli like visual stimuli or. Auditory stimuli.
[00:18:59] Dr. Corcos: Okay.
[00:18:59] Dr. Corcos: My really dear friend, Jay Alberts, is a dear friend of mine. Very distinguished professor at Cleveland. Would be the first to admit that he regrets introducing the term forced exercise. So I want to explain to people exactly what it means because it's different to what it sounds. So for those of you who go on a bicycle,
[00:19:26] Dr. Corcos: there is a school of thought that what's really important is how fast you pedal. The cadence or the revolutions per minute. And the idea here is to pedal fast. So you pedal at about 90 revolutions per minute. That's faster than most people pedal and the argument, one argument is that, okay, people a little bit slower with a disease.
[00:19:56] Dr. Corcos: So now let's get them to move a little bit faster. This idea originally came when Jay was on a tandem with a person going across Iowa and on a tandem, you have to pedal at the same rate. As the other person and Jay was pedaling at a high rate. The person was Parkinson pedaled at a high rate and did very well.
[00:20:19] Dr. Corcos: And Jay's published article showing that rate is important. And I would agree with that. And so when you're on a bicycle, for those of you who are spinning or on pelotons or any other device. There is a lot to be said for spinning at a spinning quite quickly, but make sure you have some resistance on because you can go onto a bike and you can just spin your legs at 90 revolutions and not do any work because there's no resistance.
[00:20:48] Dr. Corcos: So you have to make sure you know that there's a resistance. , so the forced here is being forced to go at a particular cadence. And if you're not on a tandem with Jay, then you've just got to. Persuade yourself to try to pedal high. I find that myself, my body is not naturally at 90 revolutions per minute.
[00:21:08] Dr. Corcos: I sometimes try to pedal uh, my preferred cadence turns out to be 70, but the evidence is strong in the literature that getting your cadence up is good. And if you look at elite cyclists, they pedal at high cadence.
[00:21:23] Dr. Corcos: The idea of stimuli, there's a lot of evidence that sound is good. A lot of people complain that activities, exercise are boring. certainly when I work out, I have my playlists and I think if you produce a really great playlist that can help, there is a lot to be said for extra gaming. The work out of Holland is very, very good.
[00:21:46] Dr. Corcos: So the idea here is you're on a treadmill and you have all kinds of games and activities in front of you. So you're having to walk, and you're having to process all the information coming in. I think Exogaming is a way of the future.
[00:22:02] Dr. Sagar: I've never heard of that. Oh,
[00:22:04] Dr. Sagar: so by
[00:22:06] Dr. Corcos: Exogaming is turning out to be more and more popular. I mean, it is the case. I can't really explain it, but you know, you kind of look at little kids, and what do they do? They run around and have a great time. And in fact, the problem is making sure they don't run around too much, running out in the road and everything else. And
[00:22:31] Dr. Corcos: you look in the app,
[00:22:32] Dr. Sagar: exergaming, you just mean go play a game where you move. It doesn't have to, it's not this
[00:22:37] Dr. Corcos: no, No, no. No, No, exogaming is, refers here specifically to, games that you can play whilst you're exercising. So you can So you can get games. , Dr. Bloom has got articles written on ExaGaming. we're not quite there yet, but it's going to be more and more. But a variant of this for any of you listening who cycle, there is software that you can use when you're on your bike.
[00:23:06] Dr. Corcos: It's called Zwift. And so you can get on with your friends and you can be biking through London as a group. And you can be texting your friends, and you can be giving them support. Uh, there are all kinds of ways. There's another software called Strava, where you can upload what you did. So if you went for a three mile walk with your dog today, you can upload that, and then all of your friends can see that you got out and worked.
[00:23:34] Dr. Corcos: And then what happens is if you've been three days without posting to Strava, one of your good friends will say, Hey, Jim, Fred, Susie, whatever your name is, where were you? And, you know, you'll respond, oh, I had a bit of a cold.
[00:23:48] Dr. Sagar: And then time to get
[00:23:49] Dr. Sagar: back to it.
[00:23:50] Dr. Corcos: Time to
[00:23:50] Dr. Corcos: get back to it. No, absolutely. Time to get back to
[00:23:54] Dr. Corcos: it.
[00:23:55] Dr. Sagar: Yeah.
[00:23:55] Dr. Sagar: And while we do have some time, you are uh, conducting what's known as sparks three. Can you tell us about that what came before?
[00:24:03] Dr. Corcos: Yes. So, as a result of COVID, I think many of you know that the way, medicine proceeds, Is from one clinical trial to another. So the most important thing for any study is that it does no harm. So if you're going to give somebody any medicine, or if you're going to give them, uh, COVID, jab, or anything that you give people, the first important thing is do no harm.
[00:24:32] Dr. Corcos: So you do lots of safety studies. They're done first for drugs, uh, on animals. And you make, which is called preclinical work, and you make sure that what you're doing is safe. Once you've shown it is safe, then you want to start to get signs of both efficacy and also whether the study can actually be implemented.
[00:24:59] Dr. Corcos: I published a paper in 2018, which was a phase 2 clinical trial. which showed clearly people with Parkinson's can exercise at 80 to 85 percent peak heart rate. They can do it three to four times a week, and when they do it, at the end of the study, they have progressed less than people exercising at 60 to 65, or not at all.
[00:25:26] Dr. Corcos: So this is a phase two clinical trial. I refer to it as SPARKS 2. And here, we demonstrated that there's sufficient reason to go to a phase three clinical trial. So once you've made sure that studies are safe, and once you've made sure you can implement your protocol, and a lot of people at the time doubted whether people with Parkinson's could exercise at 80 to 85 percent, so you talk to many physicians and they never tell their people to work out.
[00:26:00] Dr. Corcos: At 80 to 85 percent heart rate. So, and and in the background, there was an immense amount of preclinical animal work showing that you can essentially destroy the basal ganglia in animals. Okay, there are various models that you use. There's a, there's a, 6 hydroxy dopamine model, for example, and in these models, the basal ganglia is selectively.
[00:26:28] Dr. Corcos: Lesion, and you then. Before Lesioning and after Lesioning have the animal exercise and they come back remarkably well, So the animal is doing very, very well, even though they've had part of their basal ganglia lesion. So once we had the preclinical data going back 20, 30 years, that it's safe in humans at high intensity, that they will do it at a high intensity.
[00:26:59] Dr. Corcos: We are now ready to go to Spark three. This study is currently underway at 25 sites across America and Canada, and we're going to randomize 370 people to two treatment arms. There is moderate intensity exercise, which is 60 to 65%, which is definitely good for you. There's no question. So, the one thing the public don't like, is randomization, and I get it.
[00:27:28] Dr. Corcos: Because in many studies, you're randomized to treatment or placebo, and you've got a 50 50 chance of getting a placebo. In SPARKS3, we spent two years designing our control group. It may sound, crazy spending two years designing a control group, but we went through all different permutations. A control group which does nothing, Makes the study easiest because those people are going to progress the most.
[00:27:56] Dr. Corcos: So you can find your difference easiest when you
[00:27:59] Dr. Corcos: compare your treatment with nothing. But as my good friends know, they say, Daniel, we know lying on the couch doesn't do you any good. So that's a bad control group. So we went through all kinds of control groups. And in the end, We hit on 60 to 65%. you can call it the control group or you can just call it an alternative treatment group, whichever way you want.
[00:28:21] Dr. Corcos: And then we compare it with 80 to 85% and people exercise over 18 months on a treadmill four times a week. And then we follow them for another six months to see. Whether they sustain doing exercise or whether they think, Oh, whew, I'm so glad I'm at the end. Now, I can tell you people in Sparks3 by and large are very happy.
[00:28:47] Dr. Corcos: I think there's no question. I've got wonderful emails from people saying how much they enjoyed it. Now, I'm fully aware. We give an immense amount of support. I'm very lucky. The people in Sparks3 are just nice. The people like to come in and exercise with nice people. So, it's not quite the same as in the real world, which is why phase three clinical trials then have to be studied in the real world.
[00:29:13] Dr. Corcos: That is what is known as implementation science. And once we get the results of SPARCS3, we will do that. Now, in SPARCS3, we have lots and lots of measures. We have an index of what is going on in the brain, we have a dopamine transporter scan, and the hope is that the decline in the ability to take up dopamine is less in the high intensity group.
[00:29:41] Dr. Corcos: And so at the end of one year, we'll be able to show that those who exercise at high intensity have less decline in dopamine transporter. For those of you who are really interested in the science. You should go and look at nature. Parkinson's disease. It's just been an article out by the lat and colleagues from Yale.
[00:30:04] Dr. Corcos: It's a small but important study had no control group, but it is a very important study because they showed both in terms of dopamine transporter and also neuro melanin that people who did high intensity exercise for 6 months had less decline. In those two measures, now those are measures taken inside the brain in the nuclei inside the basal ganglia, specifically substantia nigra caudate putamen.
[00:30:38] Dr. Corcos: And so this study is, there have been other studies before, but this is probably the cleanest, clearest study to date of a biological change that underpins the neuroprotective effects of exercise. And we have that scan, and we, always careful in my choice of words here, hope, expect, anticipate, predict, hypothesize, all of those, that there will be a difference in the two treatment arms.
[00:31:14] Dr. Corcos: We have lots of gait measures. We're very interested in how people do six minute walk. So, we will be timing them, and we'll be seeing whether they, Can walk further, the hypothesis is they will, because their peak VO2 will go up. And then thing which we're very, very interested in is, But how does exercise make you feel?
[00:31:40] Dr. Corcos: So I can tell you that I will be biking tomorrow morning indoors. I'll be biking very, very hard. And there's a high probability that I will nap most of the afternoon. So one school of thought is that when you exercise really hard, you need to recover and you do less other activity. Okay. So that your overall, it's like you're kind of conserving the overall amount of energy that you spend in a day.
[00:32:10] Dr. Corcos: Another way of looking at it, and they can both be true for different people, is that when you get a little bit fitter from your treadmill work, you now have the energy and fitness to go out and return to activities that you loved doing before. So, your overall activity level goes up and that contributes in addition to your exercise program, to your fitness going up.
[00:32:34] Dr. Corcos: So, we have a lot of evidence, not a lot, but we have anecdotal evidence out of Colorado of people. In the previous study, who stopped hiking in the mountains, got their fitness back, and then went back up in the mountains again. And so, , we're interested in all of this. We also have blood measures. So we will be looking at 2030 of the markers, about 9 of which I talked to you about earlier So yes, so if any of you are listening, if you Google Sparks3, www. sparks3. pd, you will find it. And if you are close ish to a site, we have people 200 miles away from some sites. So, if you're really interested, and let me give you two reasons for thinking about Sparks3. One, I'm pretty confident you'll enjoy the experience regardless of treatment arm assigned.
[00:33:35] Dr. Corcos: Okay. And two, you'll be moving science forward and animal studies are really, important. They allow you to look at biology. They allow you to look at safety and efficacy. They allow you to look at mechanism, but there's no animal identical to the human. And so at the end of the day, human studies become.
[00:33:59] Dr. Corcos: The kind of gold standard for really determining whether interventions do or do not
[00:34:06] Dr. Corcos: work.
[00:34:06] Dr. Sagar: Yeah. So you guys, I didn't realize that you guys are still recruiting. And so if anybody wants to be a participant, their chance.
[00:34:14] Dr. Corcos: Actually, we are still recruiting. So if you read some of the literature, COVID 19 played havoc with clinical trials. So we were shut down for 14 months. I'm not going to bore you with all the details, but COVID 19 was not great for clinical trials, unless it was about COVID
[00:34:35] Dr. Sagar: This is the only area that made
[00:34:36] Dr. Sagar: progress in that
[00:34:37] Dr. Sagar: time.
[00:34:38] Dr. Corcos: case COVID 19 was great for clinical trials.
[00:34:42] Dr. Sagar: We've been talking for a while now. I want to be respectful of your time. This has been fantastic in the amount of knowledge that I think was shared. Even though you said you don't think anyone learned anything. I would argue with that.
[00:34:52] Dr. Sagar: But in the final few moments, what would you leave people with both for those with Parkinson's and those that support them and love them?
[00:35:01] Dr. Corcos: I mean, well, the first thing I would leave is, the people that I've met are all just terrific. It's almost to the point that we kind of share amongst ourselves that if somebody is not nice, And they've been diagnosed with Parkinson's, they don't have Parkinson's, they have some other disease, but it's not Parkinson's.
[00:35:25] Dr. Corcos: It's almost as if there's a kind of a phenotype of really nice people. And so, for those who have Parkinson's, , the message is to, to look after yourself. And if you are, if you are struggling with activities and doing things. Find a support group. There's support groups everywhere. There are four terrific foundations.
[00:35:52] Dr. Corcos: There's more than four. I want to be real careful in what I say here, okay? There are four major foundations which are national across America. But then in particular states, there are also small foundations which are really, really terrific. there's lots and lots and lots of help. On the Internet. So I would reach out for help.
[00:36:21] Dr. Corcos: And for those, whose loved ones have Parkinson's, what I'm learning from a lot of people is
[00:36:29] Dr. Corcos: it's a difficult disease. There's no question. It's a complicated disease. It's a heart disease, but many people talk about how they learn from the disease, how the disease has enriched themselves. And, , I think there's no finer advocate of that than Michael J. Fox. So if you kind of ever listen to Michael , or, hear him talk, you don't see, at least I don't see or hear any self pity. It is simply, let's get on with life and let's make things better for other people.
[00:37:03] Dr. Sagar: Join a support group and if you're one of the support people for that person's Parkinson's, help them find a support group and check out the messages of Michael J. Fox and these other massive organizations that are pushing for a cure.
[00:37:20] Dr. Corcos: Yeah. And so it's very important to understand the foundations. Okay. So the push for the cure is essential. Michael J. Fox. Masters at it. They've raised more than two billion dollars. I just attended the Michael J. Fox event in Nashville last Wednesday. It was terrific. You had three groups, um, singing at a gala and they raised more than half a million dollars.
[00:37:48] Dr. Corcos: And so Michael J. Fox is absolutely terrific. The other foundations are really good for helping people live with the disease today. Okay, the disease can cause significant problems. You know, one question always and I'm asked is, should I let my job? No, then I have the disease. And what protections do I have if I let my job? No, and American Parkinson's Disease Association, a PDA and others. Can put you in contact with experts who can help you navigate that particular challenge because it is at the end of the day, you know, the advantage of letting everybody know is that at some point, , people will ask, well, is there anything possibly, , happening and so it really becomes harder and harder to conceal. And some of the foundations have experts who can help you navigate that because. I understand very, very well why if one has a job, then the last thing one wants to do is to conceal anything which the job may consider might impair or reflect on your performance.
[00:39:03] Dr. Corcos: So,
[00:39:03] Dr. Corcos: the foundations are all great, and they all have different areas of expertise.
[00:39:08] Dr. Corcos: Actually, since I've mentioned two of them, my friends at Davis Phinney, If they ever listen to this would think, Daniel, you must be, mildly cognitively impaired, not to us. And my very good friends at Parkinson Foundation PF would also say the same. So, I want to, I want to be clear. These are not the only 4 foundations out there.
[00:39:30] Dr. Corcos: Okay. I think they probably are the 4 largest national ones. But if you're in Nashville, but if you're in Tennessee, Nashville area, there's a wonderful foundation, the Peterson Foundation, who does great work. It's foundations in Texas. I can't list them all off, but they are everywhere and
[00:39:50] Dr. Corcos: they're all
[00:39:51] Dr. Sagar: There's a lot of resources for people if they
[00:39:52] Dr. Sagar: haven't realized it yet.
[00:39:54] Dr. Sagar: It's out
[00:39:54] Dr. Corcos: immense amounts of resources immense amount. In fact, there are so many resources that part of the problem is navigating to the best resource. For you, it's almost as if,
[00:40:07] Dr. Sagar: It's personalized.
[00:40:09] Dr. Corcos: yes, I mean, there's certainly enough resources
[00:40:12] Dr. Corcos: out
[00:40:12] Dr. Sagar: That's fantastic. Well, Dr. Corkus, thank you so much. So much for your time and your expertise.
[00:40:18] Dr. Sagar: It's been great.
[00:40:20] Dr. Corcos: Thank you. It's just been a real privilege to be here with you. Thank
[00:40:23] Dr. Sagar: Thanks.
[00:40:24] Dr. Sagar: Let's recap this. One of the things that struck me. Was that there are animal studies where the whole of the basal ganglia was knocked out and exercise was still able to make a huge impact. There's still a need for more studies of the human animal. So if you have Parkinson's disease, please go to www.sparksthreepd.com.
[00:40:47] That's S P a R K S. The number three. The letters, pd.com. And sign up to participate in this study. The prescription you heard? Is for cardio activity three to four times per week at 80% of your maximum heart rate. How do you know your maximum heart rate? The crude equation is to take 2:20 AM.
[00:41:08] Subtract your age, then multiply that by 0.8. And you have your goal heart rate.
[00:41:14] Resistance training Is to be done at least two to three times per week. And somewhere in there, add in balanced training, like Tai Chi yoga or anything that requires coordination like table tennis or boxing. If you need some extra medication to make your exercise session doable, then go ahead and do that.
[00:41:31] It's worth it. But clear it with your doctor first. Also, there's still time to register for the Cincinnati symposium on PD. See the show notes for the link or just Google sunflower, rev it up. Lunch is included. If this has been a helpful podcast for you, please leave a five star review wherever you get the podcast. Great previews mean we can continue to interview great guests like Darren corcus.
[00:41:55] Lastly, remember. The way you live can save your life
[00:42:00]
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