Anytime you're making something harder, more challenging, whether it's through balance, whether it's through weight change, through dynamic balance, working harder with dynamic bounce, speed, you get the speed up, you have to make them more accurate, all those sorts of things is going to make it harder for you. So the idea would be getting out of your comfort zone, problem-solving how to get more accurate, how to get that speed up, how to become more dynamic on that task. And as I said, that can be done even with a physical therapist working on gait and balance, right? That itself is going to be more skillful over time.

[Rhonda]: So the skillful exercise that you're describing, it seems really independent of talking about something else which would be the intensity of your exercise, the vigorousness, like that's another aspect. What you're talking about specifically has to do...I mean, you're getting some physical activity, but it's a very specific type of activity where you're focusing on something, you're getting that feedback of learning, and, you know, you're basically engaging your brain a lot more than just like...

[Giselle]: Right. And I think fundamentally, you're sort of getting at the two kind of discussions that are going on with exercise. Actually, there's other discussions with muscle resistance and those sorts of things. But I think fundamentally, some of the questions that are coming up are intensity in the context of learning. Someone is learning. More about motor learning, right? Which definitely requires lots of practice and challenge to get good, right? Like tennis as an example, right? And the other type of intensity was the heart rate, getting your heart rate up, feeling your heart pounding in your chest, and sweating. That's also intense. So they can both be very intense, but for different reasons, right? So one more from the aspect of learning and practice and problem-solving to get better at something from a physical point of view. So things can be very physically challenging to learn, you know, like skateboarding, or tai chi, or yoga.

And Parkinson's disease, the bottom line is their gait isn't normal. The balance is not normal. We're starting all over again. So this is not normal walking, right? And this is not normal dynamic balance. They have impairments in that. So we can start at that level where we're concentrating on getting their balance better, the walking stride better, the posture better. All those things are what we call more normal, automatic gait. That's practice to them, to get it good and to make it harder.

[Rhonda]: And as the disease progresses, those things are dysfunctional or you're saying like from the beginning?

[Giselle]: Even from the beginning. Right. We're already working on it and making it harder. We can make it harder yet. I mean, we can make it, you know, have you be more accurate with it, make you go through an obstacle course. So we can make it harder yet to get you even better for balance, as an example.

[Rhonda]: No. What I was saying is when someone is diagnosed, like does their balance, like, for example, if they were just diagnosed, you know, are they going to be having problems with their balance or is that as the disease progresses or is it at very...

[Giselle]: No. It is as the disease progresses in general, but gait is very common. I mean, not normal gait. So they'll have the slowness in the gait, for example.

[Rhonda]: And by gait you mean like how they're walking?

[Giselle]: Walking. Exactly. Yeah. So, I mean, we tend to target, and that's why you see many of the exercise programs really target gait and balance because many times...I mean, so people definitely can have slowness in their hand and stiffness in their trunk, but targeting gait and balance is huge because that's really ultimately probably where the biggest deficits are. And many times in targeting gait and balance, you're really engaging different parts of the body as well, arm swing, posture, and these sorts of things. So it's a good place to start, if you will. Now, obviously, you can add more with things in your arms, boxing is an example that you can add more and make it more complicated tasks.

[Rhonda]: And if people that are doing this rock steady boxing, as it's called, the non-contact, or they just like doing like a bag or is it like...is that...

[Giselle]: Yeah. So I have to tell you, I've never gone to a rock steady boxing class, but the idea would be that yeah, they're learning different types of patterns of movements, for example. So it may not just be pure moving of the arm, but it may be a pattern that they have to replicate, for example. So that would make it more skillful.

[Rhonda]: So the cognitive skill that you were talking about.

[Giselle]: Exactly. Right. And I don't think anybody thinks that one type of exercise necessarily negates the other. There's no...you know, no one thinks that one is necessarily better. They're just different. You know what I'm saying? And I think fundamentally, the reason we care is we think that the mechanisms which underlie, they may be different. And that's why I think in terms of the work that we're doing, we're very interested in that idea. And some of the work that a colleague, Dr. Holschneider at USC has shown is certainly in the animal models that we've been doing, looking or trying to separate out or tease apart these different mechanisms where one group of rodents with Parkinson's have gone through a type of exercise practice more skillful, meaning they're on a motorized wheel with spokes removed, animals definitely need to pay more attention versus a group of animals Parkinsonian where there aren't spokes removed, so it's nice and smooth. They don't have to think as much about what they're doing, same match for speed, the animals that have the spokes removed have blood flow in top-down circuit cognitive domains much more so than animals that don't. So kind of the proof of concept that, "Okay if exercise is just exercise is exercise, we shouldn't be seeing differences in blood flow to different circuits."

[Rhonda]: Wow. Yeah. So they were doing the same intensity?

[Giselle]: Yeah. Right. And so, again, why do we care? I think the biggest thing, honestly, is that it's just beginning to say, "Hey, guess what? The brain is not passive. This is not a passive effect of exercise. The brain is engaged very much in this reparative mechanism and is driving this effect." So it's not just take blood and dump it onto the brain, it's like, no, the brain is an important signal of this effect. And that's huge to think about.