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Research:  A unique way <br />to share your story<br />Renewable Fitness & ABLE Bodies<br />
Tough Love vs Spanking <br />Renewable Fitness & ABLE Bodies<br />
Parkinson’s-Specific<br />Agility Training<br />Sue Scott, MS<br />Renewable Fitness<br />
Role of Basal Ganglia<br />Continuous feedback loops <br /><ul><li>Automaticity of balance
Select, initiate & maintain movement
Sequencing and pace
Sensory Integration
Multi-tasking</li></ul>Renewable Fitness & ABLE Bodies<br />
Today’s presentationis the work of many<br /><ul><li> Fay B Horak, PT, PhD
 Laurie A King, PT, PhD
Researchers
Physical Therapists
 Three PD-focused PhD
 Six Certified Trainers</li></li></ul><li>Achieving Better Living with Exercise<br />Renewable Fitness, LLC<br />With perm...
<ul><li>Postural instability </li></ul>5X age-matched <br />38% fall each year<br />18% falls are fractures<br /><ul><li> ...
 Medications don’t help reduce falls</li></ul>Renewable Fitness & ABLE Bodies<br />Falls are Leading Cause of Death<br />
Renewable Fitness & ABLE Bodies<br /> Cardiovascular Events 2nd -leading Cause of Death<br />Immobility impairs heart, mus...
Strength & Balance
Flexibility
Social Ties
Attitude</li></li></ul><li>HOW does exercise help PD?<br /><ul><li>Prevention
Compensation
 Neuroprotection</li></ul>3<br />Renewable Fitness & ABLE Bodies<br />
Renewable Fitness & ABLE Bodies<br />    Prevention<br /><ul><li> Falls
 Cardiovascular events
 Poor coordination
 Back pain, stiffness
 Fatigue, inactivity
 Apathy, depression</li></li></ul><li>Compensation<br /><ul><li>Improved motor function
“Useful tricks”
 External cues
Visual, sound, somatic
Cognitive strategies
Break down task into parts
 Mental rehearsal
Think BIG
 Use alternative parts of the brain</li></ul>Renewable Fitness & ABLE Bodies<br />
Neuroprotection<br /><ul><li>Increase brain transmitters
Reduce cell death
Improve cell function
Increase brain plasticity </li></ul>Start exercise early in PD to PROTECT & PRESERVE neurons and function <br />Renewable ...
 Exercise & Neuroprotection in PD Rats <br />Aerobic: Treadmill running vs: Dopamine<br /><ul><li>More neural transmitter
Better motor function
Balance & Agility training vs: Strengthor Aerobic
Larger improvements in motor function
More new synapses </li></ul>Renewable Fitness & ABLE Bodies<br />
Task Specific AgilityTraining for Rats<br />Sensori-motor Tasks  Largely controlled by basal ganglia<br />Renewable Fitnes...
Human PD StudiesRandomized Controlled Trials<br /><ul><li>Increased kinematics of gait
 Walking speed
 Stride Length
Improved
 Flexibility
 Strength & Mobility
 Functional abilities
 Quality of life
Reduced
Medications
 Falls</li></ul>Renewable Fitness & ABLE Bodies<br />
What type of exercise is best for PD?<br />           Lance Armstrong (Endurance)?<br />Muhammad Ali <br />               ...
EXERCISE IS MEDICINE <br />Active Ingredient: Mode<br />Strength: Intensity<br />How often: Frequency<br />How long: Durat...
Exercise can target . . . <br />Mobility Constraints of PD<br />Physical Activities/Challenges <br />Improve specific prob...
HELP PD Targets Constraints of Mobility <br /><ul><li> Rigidity -  Stiffness; flexed posture
 Brady- & hypo-kinesia- Slow, small movements
 Freezing -Initiating movement
Coordination - Turning, rolling, quick switching
Sensory Integration - Coordinate sensory input
Executive function – Tasks & attention</li></ul>Renewable Fitness & ABLE Bodies<br />
RIGIDITY<br />Characteristics – increased muscle tone, stiffness<br />High tonic background activity (flexors)<br />Co con...
Strategies to HELP Rigidity<br />Large, flowing moves<br />Spinal suppleness <br />Lengthen flexors<br />Strengthen extens...
BRADYKINESIA<br />Slow, small, weak movements/responses<br />Inefficient muscle recruitment patterns<br />Reduced postural...
Strategies for Bradykinesia<br /><ul><li>Cognitive or central strategies
Self initiated & paced
Get their imaginations to help
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HELP PD - Pd specific agility training compressed pictures

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HELP PD is a unique exercise protocol designed to delay mobility losses in Parkinson ’s disease. Developed at OHSU’s Neurological Sciences Institute by Dr. Fay Horak and her team of researchers, including lead trainer, Sue Scott, MS. HELP PD uses 6 specific physical activities (parts of Tai chi, Kayaking, Pilates, Lunges and obstacle courses) to target 5 key mobility constraints of PD: rigidity, freezing, bradykinesis, poor coordination and sensory integration. This program was presented for the International Council for Active Aging, ICAA, in December 2009

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HELP PD - Pd specific agility training compressed pictures

  1. 1. Research: A unique way <br />to share your story<br />Renewable Fitness & ABLE Bodies<br />
  2. 2. Tough Love vs Spanking <br />Renewable Fitness & ABLE Bodies<br />
  3. 3. Parkinson’s-Specific<br />Agility Training<br />Sue Scott, MS<br />Renewable Fitness<br />
  4. 4. Role of Basal Ganglia<br />Continuous feedback loops <br /><ul><li>Automaticity of balance
  5. 5. Select, initiate & maintain movement
  6. 6. Sequencing and pace
  7. 7. Sensory Integration
  8. 8. Multi-tasking</li></ul>Renewable Fitness & ABLE Bodies<br />
  9. 9. Today’s presentationis the work of many<br /><ul><li> Fay B Horak, PT, PhD
  10. 10. Laurie A King, PT, PhD
  11. 11. Researchers
  12. 12. Physical Therapists
  13. 13. Three PD-focused PhD
  14. 14. Six Certified Trainers</li></li></ul><li>Achieving Better Living with Exercise<br />Renewable Fitness, LLC<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />
  15. 15. <ul><li>Postural instability </li></ul>5X age-matched <br />38% fall each year<br />18% falls are fractures<br /><ul><li> Exercise helps avoid falls and fractures
  16. 16. Medications don’t help reduce falls</li></ul>Renewable Fitness & ABLE Bodies<br />Falls are Leading Cause of Death<br />
  17. 17. Renewable Fitness & ABLE Bodies<br /> Cardiovascular Events 2nd -leading Cause of Death<br />Immobility impairs heart, muscles, social relations, independence<br />Regular<br />Aerobic Exercise<br /><ul><li>CV System & Endurance
  18. 18. Strength & Balance
  19. 19. Flexibility
  20. 20. Social Ties
  21. 21. Attitude</li></li></ul><li>HOW does exercise help PD?<br /><ul><li>Prevention
  22. 22. Compensation
  23. 23. Neuroprotection</li></ul>3<br />Renewable Fitness & ABLE Bodies<br />
  24. 24. Renewable Fitness & ABLE Bodies<br /> Prevention<br /><ul><li> Falls
  25. 25. Cardiovascular events
  26. 26. Poor coordination
  27. 27. Back pain, stiffness
  28. 28. Fatigue, inactivity
  29. 29. Apathy, depression</li></li></ul><li>Compensation<br /><ul><li>Improved motor function
  30. 30. “Useful tricks”
  31. 31. External cues
  32. 32. Visual, sound, somatic
  33. 33. Cognitive strategies
  34. 34. Break down task into parts
  35. 35. Mental rehearsal
  36. 36. Think BIG
  37. 37. Use alternative parts of the brain</li></ul>Renewable Fitness & ABLE Bodies<br />
  38. 38. Neuroprotection<br /><ul><li>Increase brain transmitters
  39. 39. Reduce cell death
  40. 40. Improve cell function
  41. 41. Increase brain plasticity </li></ul>Start exercise early in PD to PROTECT & PRESERVE neurons and function <br />Renewable Fitness & ABLE Bodies<br />
  42. 42. Exercise & Neuroprotection in PD Rats <br />Aerobic: Treadmill running vs: Dopamine<br /><ul><li>More neural transmitter
  43. 43. Better motor function
  44. 44. Balance & Agility training vs: Strengthor Aerobic
  45. 45. Larger improvements in motor function
  46. 46. More new synapses </li></ul>Renewable Fitness & ABLE Bodies<br />
  47. 47. Task Specific AgilityTraining for Rats<br />Sensori-motor Tasks Largely controlled by basal ganglia<br />Renewable Fitness & ABLE Bodies<br />
  48. 48. Human PD StudiesRandomized Controlled Trials<br /><ul><li>Increased kinematics of gait
  49. 49. Walking speed
  50. 50. Stride Length
  51. 51. Improved
  52. 52. Flexibility
  53. 53. Strength & Mobility
  54. 54. Functional abilities
  55. 55. Quality of life
  56. 56. Reduced
  57. 57. Medications
  58. 58. Falls</li></ul>Renewable Fitness & ABLE Bodies<br />
  59. 59. What type of exercise is best for PD?<br /> Lance Armstrong (Endurance)?<br />Muhammad Ali <br /> (Agility, quickness/power)?<br /> Arnold Schwarzenegger <br /> (Strength)?<br /> Guru? (Tai Chi, Yoga, Pilates)<br />Renewable Fitness & ABLE Bodies<br />
  60. 60. EXERCISE IS MEDICINE <br />Active Ingredient: Mode<br />Strength: Intensity<br />How often: Frequency<br />How long: Duration<br />Renewable Fitness & ABLE Bodies<br />
  61. 61. Exercise can target . . . <br />Mobility Constraints of PD<br />Physical Activities/Challenges <br />Improve specific problems with mobility<br />Renewable Fitness & ABLE Bodies<br />
  62. 62. HELP PD Targets Constraints of Mobility <br /><ul><li> Rigidity - Stiffness; flexed posture
  63. 63. Brady- & hypo-kinesia- Slow, small movements
  64. 64. Freezing -Initiating movement
  65. 65. Coordination - Turning, rolling, quick switching
  66. 66. Sensory Integration - Coordinate sensory input
  67. 67. Executive function – Tasks & attention</li></ul>Renewable Fitness & ABLE Bodies<br />
  68. 68. RIGIDITY<br />Characteristics – increased muscle tone, stiffness<br />High tonic background activity (flexors)<br />Co contraction (axial muscles)<br />Results/Symptoms<br />Joint pain, stiffness<br />Flexed Posture<br />Lack of trunk rotation <br />Vertebral flexibility, ROM<br />Difficulty turning while walking, rolling over in bed<br />Enbloc movement <br />Renewable Fitness & ABLE Bodies<br />
  69. 69. Strategies to HELP Rigidity<br />Large, flowing moves<br />Spinal suppleness <br />Lengthen flexors<br />Strengthen extensors<br />Somatic self-awareness<br />Practice difficult transitions<br />Tai chi<br />Pilates/yoga<br />Think BIG <br />Reciprocal, Whole-Body Movement<br />Lunges<br />Renewable Fitness & ABLE Bodies<br />
  70. 70. BRADYKINESIA<br />Slow, small, weak movements/responses<br />Inefficient muscle recruitment patterns<br />Reduced postural stability<br />Gait<br />Weak push-off <br />Delayed, reduced lift-height of swing limb<br />Small stride length, slowed turning <br />Multi-joint reaching, absent arm swings <br />Not improved by medications <br />Renewable Fitness & ABLE Bodies<br />
  71. 71. Strategies for Bradykinesia<br /><ul><li>Cognitive or central strategies
  72. 72. Self initiated & paced
  73. 73. Get their imaginations to help
  74. 74. Go BIG, rehearse
  75. 75. Require postural control & adjustments
  76. 76. Voluntary, reactive, anticipatory, quick
  77. 77. Practice large protective steps
  78. 78. Lunges, boxing</li></ul>Renewable Fitness & ABLE Bodies<br />
  79. 79. FREEZING<br />Movement hesitation<br />Not well understood <br />Major contributor to falls<br />Executive (central) disorder<br /><ul><li>Preplanning movement
  80. 80. Quickly selecting motor program</li></ul>Difficulty/symptoms: <br /><ul><li>Shifting attention
  81. 81. Crowded rooms, doorways</li></ul>Renewable Fitness & ABLE Bodies<br />
  82. 82. Strategies to HELP Freezing<br />Safe practice for difficult scenarios<br /><ul><li>Environments where freezing typical
  83. 83. Obstacle Courses
  84. 84. Quick turns, negotiating narrow or tight spaces – corners or near walls
  85. 85. Ducking , stepping over obstacles
  86. 86. Picking up objects while walking
  87. 87. Quick changes in directions and foot placement</li></ul>With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />
  88. 88. SEQUENTIAL COORDINATION<br />Characteristics<br />Selection & sequencing<br />Inflexible program selection<br />Difficulties/symptoms<br />Complex motor actions<br />Postural transitions <br />New and challenging environments<br />Not improved by dopamine replacement<br />
  89. 89. <ul><li>Complex, sequential patterns
  90. 90. Whole Body Multi-segmental
  91. 91. Quick selection</li></ul>Renewable Fitness & ABLE Bodies<br />HELP for Sequential Coordination<br />
  92. 92. SENSORY INTEGRATION<br />Characteristics <br /><ul><li>Abnormal kinesthesia
  93. 93. Associated w/Bradykinesia –o/estimation of motion
  94. 94. Poor use of proprioception
  95. 95. Decreased perception of movement
  96. 96. Overdependence on vision</li></ul>Renewable Fitness & ABLE Bodies<br />
  97. 97. Strategies for Better SI<br />Reduce visual input<br />Wear dark sun glasses<br />No-body glasses<br />Dim room, slightly<br />Use variety of surfaces<br />Reduce external feedback & cues<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />
  98. 98. External Cues <br />Use initially, then limit<br />As disease progresses, use again<br />Renewable Fitness & ABLE Bodies<br />
  99. 99. COGNITIVE CONSTRAINTS<br />Characteristics & Symptoms<br />Multi-tasking difficult <br />High stress<br />Increased fall risk <br />Renewable Fitness & ABLE Bodies<br />
  100. 100. PD Affects Automaticity of Balance Control<br />Doing Math Increases Falls During Balance Disturbances<br />40<br />No math<br />Math<br />30<br />% of Trials with Falls<br />20<br />No Falls<br />10<br />0<br />CONTROLS<br />PARKS ON<br />PARKS OFF<br />Used with permission; Presented at the Movement Disorders Conference in Paris June 7-11, 2009:  We-215. Effect of cognitive dual-task on balance in Parkinson’s disease, R.M. Allen, P. Carlson-Kuhta, J.V. Jacobs, J.G. Nutt, F.B. Horak. <br />
  101. 101. Cognitive Strategy:Dual Tasks<br />Addition of a second task<br />Dual tasks improve <br /> Attention skills<br /> Automatic Balance<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />Renewable Fitness & ABLE Bodies<br />
  102. 102. Order of Difficulty<br />Verbal Tasks<br />Engage in conversation<br />Easy recitation<br />Motor Tasks<br />Balance something on a tray<br />Toss/catch a ball<br />Pick up object from the floor in passing<br />Cognitive Tasks<br />Word Winks/Tongue Twisters<br />Math<br />Alphabetize words, order numbers<br />Renewable Fitness & ABLE Bodies<br />
  103. 103. Constraints & Strategies<br />
  104. 104. Basal ganglia<br />Neural plasticity protection<br />Renewable Fitness & ABLE Bodies<br />
  105. 105. Renewable Fitness & ABLE Bodies<br />
  106. 106. Renewable Fitness & ABLE Bodies<br />Assembly Required<br />
  107. 107. HELP PD Rx for Agility<br />Tai Chi<br />Kayaking<br />Boxing<br />Lunges<br />Obstacle Courses<br />Pilates & misc.<br />Renewable Fitness & ABLE Bodies<br />
  108. 108. Research <br />Big, flowing, sequential <br />Coordinated, multi-segmental (upper/lower)<br />Weight shifts in multiple directions<br />Sensory integration<br />Mindful of movement, breath, body <br />Upright posture<br />Renewable Fitness & ABLE Bodies<br />TAI CHI<br />Prayer Wheel<br />Cat Walking<br />Cloud Hands<br />Repulsing the Monkey<br />
  109. 109. KAYAKING <br />BIG, flowing, reciprocal, multi-segmental, whole body Axial mobility, rigidity<br />Pictures with permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />
  110. 110. Obstacle Course<br />As comfortable . . .<br />High Knees<br />Tire Course<br />Lateral shuffle<br />Grapevine<br />Quick, fast, flexible <br /><ul><li> Quick weight changes
  111. 111. Quick task changes
  112. 112. Plan ahead, manage obstacles, decisions
  113. 113. Multiple directions, environments
  114. 114. Practice difficult situations</li></ul>Renewable Fitness & ABLE Bodies<br />
  115. 115. BOXING <br />Jab, Cross Hook <br />Ducking Footwork Kicks<br />Shouting!<br />Float like a butterfly . . .<br />Sting like a bee!<br />Quick, light, powerful, flexible, sequential, BIG, endurance, backward walking, mental agility, <br />Renewable Fitness & ABLE Bodies<br />
  116. 116. Lunges <br />BIG, flowing, multi- directional <br />Reciprocal arms, legs<br />Vary direction, size, speed, environment, Trunk rotation<br />In-Place<br />Walking<br />Corrective<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />With permission: ABLE Bodies Balance Training, 2008; Human Kinetics<br />Renewable Fitness & ABLE Bodies<br />
  117. 117. BIG Lunges Multiple directionsCoordinate legs/arms<br />
  118. 118. Arm SwingsReciprocal limb motion around spine<br />Pictures with permission: ABLE Bodies Balance Training; 2008; Human Kinetics<br />
  119. 119. Pilates, misc.<br />Develop:<br />Extensor Strength <br />Spinal Suppleness<br />Somatic awareness, breathing, relaxation<br />Transitional skills (ADLs)<br />From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007<br />
  120. 120. Extensor (Axial)Strength & Length<br />Bridges<br />Bird Dog<br />Heel Slides <br />Paddle arms <br />Pilates Plus; Alan Herdman<br />From: Low Back Disorders; Stuart McGill; Human Kinetics, 2007<br />ABLE Bodies Balance Training<br />
  121. 121. Spinal <br /> Suppleness<br />Knee rolling & Cossack arms<br />Telescoping Arms<br />Cat & Camel & Shell pose<br />Thread the Needle<br />Undulate, Undulate!<br />Renewable Fitness & ABLE Bodies<br />
  122. 122. Practice difficult ADLs<br />Chair Stands<br />Half kneeling to stand<br />Get up from floor<br />Rolling on floor<br />
  123. 123. Tai chi<br />Kayaking<br />Obstacle Course<br />Boxing<br />Lunges<br />Pilates, etc.<br /><ul><li>Develop form, skill
  124. 124. Increase complexity</li></ul>Renewable Fitness & ABLE Bodies<br />The BIG Six<br />
  125. 125. Attention Training<br />My pizza is cold<br />4 31 19 7<br />T__ L__ S__ B__<br />__ F__V __G __R<br />Renewable Fitness . . .imagine the possibilities<br />
  126. 126. Word Winks:Mental Agility<br />T<br />T <br />T<br />T<br />Think<br />Renewable Fitness . . .imagine the possibilities<br />
  127. 127. Word Winks <br />fry fry<br />Renewable Fitness . . .imagine the possibilities<br />
  128. 128. Tongue Twisters<br />What noise annoys an oyster most? Noisy noise annoys an oyster most<br />(Google has bazillions of ideas)<br />Require concentration<br />Help diminishing verbal skills - <br />BIG enunciations, loud voice<br />Renewable Fitness . . .imagine the possibilities<br />
  129. 129. Other ways to assembleHELP PD strategies<br />Renewable Fitness & ABLE Bodies<br />
  130. 130. Strength Training<br />Focus on Extensors<br />Stretch Flexors<br />Upper/Lower body<br />Think BIG<br />Functional <br />Renewable Fitness . . .imagine the possibilities<br />
  131. 131. Endurance Training<br />Safely make it more PD-Specific?<br />Involve more balance<br />Elliptical, treadmill vs: recumbent bike<br />Changes in direction, environment, surface, tasks<br />Go BIG! – try trekking poles<br />Mix it up, variety<br />Renewable Fitness . . .imagine the possibilities<br />
  132. 132. Community Programs<br />Pilates<br />Tai Chi<br />Yoga<br />Aerobics<br />Dance<br />Martial Arts<br />Others (Zumba Gold is Big, quick, imaginative & fun)<br />Renewable Fitness . . .imagine the possibilities<br />
  133. 133. As PD Progresses . . .make changes<br />All stages: Flexibility, postural alignment, <br />BIG movements, deep breathing, kinesthesia, mind body connections<br />Early: Sports—physical & mental agility, stamina, strength (neuroprotective)<br />Later: Walking, transitions, useful tricks, external cues, fall prevention<br />Renewable Fitness & ABLE Bodies<br />
  134. 134. Safety Considerations for Exercise with PD<br /><ul><li>Fall Risks</li></ul> Backwards<br /> Obstacles, hazards<br /> Low vision<br /> Dual tasks<br /><ul><li>Light Headedness: Quick postural changes
  135. 135. Musculoskeletal Injuries: Rigidity, difficulty initiating movement</li></ul>Renewable Fitness & ABLE Bodies<br />
  136. 136. BIG, Flexible, Reciprocal, Sequential<br />Self initiated, Self paced<br />Upright & Supple Posture <br />Mind-Body Connections<br />Sensory Integration<br />Arm and leg coordination <br />Quickness<br />Endurance <br />Renewable Fitness & ABLE Bodies<br />Strategies for basal ganglia and neuroplasticity<br />
  137. 137. Sensori-motor Activities:Benefits & Mechanisms<br />Preserve/protect/enhance function & behavior<br /><ul><li>Adapt, behave, function
  138. 138. Increase neuro –transmitters
  139. 139. Neuro-plasticity
  140. 140. Increase number of synapses
  141. 141. Cell proliferation?</li></ul>Prevent falls<br />Reduce cardiovascular events<br />Improve, motor function<br />Maintain quality of life, social ties, independence, connections to community, <br />Renewable Fitness & ABLE Bodies<br />. . . Imagine the Possibilities<br />
  142. 142. What’s the Best Exercise?<br />The one they’ll do!<br />Renewable Fitness & ABLE Bodies<br />
  143. 143. Sue Scott<br />email<br />RenewableFitness@comcast.net<br />Ph: 503-720-9161<br />Physical Therapy<br />April 2009; v89:4<br />Active Aging Today <br />January 2010<br />I think my work here is done<br />Thank You!<br />
  144. 144. Parkinson's<br />Disease<br />Upright posture requires good kinesthesia<br />Stooped posture reduces stability <br />Upright<br />Control<br />Strengthen<br />Extensors<br />Lengthen<br />Flexors<br />Hip <br />Extensors<br />(back/hip)<br />Hip Flexor<br />(Abs)<br />Knee <br />Extensor<br />(Quad)<br />Knee <br />Flexor<br />(Hamstring)<br />Ankle<br /> Flexor<br />(Tib)<br />Ankle<br />Extensors<br />(Calf)<br />
  145. 145. Strength & Endurance w/ Dual Task<br />Renewable Fitness & ABLE Bodies<br />
  146. 146. Exercise preserves neural function<br /> Neuroprotective . . . Can exercise slow progression?<br />More<br />Function/<br />Neurons<br />Improved function!<br />NoExercise<br />Less<br />Years after Diagnosis<br />Renewable Fitness & ABLE Bodies<br />
  147. 147. Spinal Rotation<br />Gentle, lithe rotation along <br />long axisof spine<br />Renewable Fitness & ABLE Bodies<br />
  148. 148. Renewable Fitness & ABLE Bodies<br />Exercise is especially importantbecause it works!<br /><ul><li>Prevents anticipated problems
  149. 149. Reduces depression and apathy
  150. 150. May slow disease progression . . . ? </li></li></ul><li>Mind/Body Connections<br />Kinesthesia <br />Breath tied to movement<br />Self awareness<br />Dual Tasks<br />Useful tricks<br />Renewable Fitness & ABLE Bodies<br />
  151. 151. Unknowns about Exercise for PD<br /><ul><li> What is the best kind?
  152. 152. How intense and often?
  153. 153. How long does it last when you stop?
  154. 154. Does it reduce the rate of decline?
  155. 155. Who would benefit the most?</li></ul> Both young and older benefit<br /> Start: The earlier the better<br />Renewable Fitness & ABLE Bodies<br />
  156. 156. Renewable Fitness & ABLE Bodies<br />

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