August 17, 2017

By TOM BELOTTI (Physiotherapist)

Lack of activity destroys the good condition of every human being, while movement and methodical physical exercise save it and preserve it – Plato (cited in H. Dawes, p.867)


The “Exercise is Medicine” program was initiated by the American Medical Association due to the well studied, documented and widely recognised positive effects exercise has on the cardiovascular, metabolic and musculoskeletal systems [4]. Of particular importance are the exercise induced benefits on brain health, relating to blood flow, trophic factors and immune system changes, which create an optimal environment for neuroplasticity [4].  Neuroplasticity refers to the various structural and physiological mechanisms such as synaptogenesis, neurogenesis, neuronal sprouting and potentiating synaptic strength, which leads to the strengthening, repair and formation of neuronal circuitry, particularly beneficial for driving improvements in the injured brain [4].


Parkinson’s Disease (PD), is one of the most prevalent neurodegenerative conditions, characterised by specific decreases in motor function associated with progressive degeneration of nigrostriatal dopaminergic (DA) neurons [5]. This leads to a reduction in overall neural activity of the motor cortex resulting in symptoms of bradykinesia [2], hypokinesia [2], rigidity [5], tremor [5], gait dysfunction [2], postural instability [5] and difficulty dual tasking [1].  DA neurons are preferentially lost within the basal ganglia hence resulting in diminished automatic control of movement and subsequently increasing cognitive (frontal cortex) load when executing motor or cognitive tasks [5].


Literature reviews by The American Academy of Neurology and joint task force of the European Federation of Neurological Societies and European Movement Disorders Society suggest exercise based physiotherapy is a catalyst for positive neuroplasticity, which relates to improvements in movement, functional capacity and cognitive symptoms of those diagnosed with PD [5], this being especially true for those with mild to moderate presentations [4]. However, despite the above evidence, studies suggest that those diagnosed with PD are likely to reduce their levels of physical activity [4].


Four specific exercise based PD treatments backed by level 2 evidence have been recommended [4]:

·         Cuing strategies to improve gait

·         Cognitive movement strategies to improve transfers

·         Exercises to improve balance

·         Mobility and strength exercises to improve physical capacity


Laboratory studies have investigated the specific effects exercise has on the brain health of those diagnosed with PD. Effects include neuroprotection (slow, negate or reverse the neurodegenerative process) and neurorestoration (adaption of compromised neural pathways) [5].


In terms of neuro-protection and restoration, studies have shown regular exercise both triggers and maintains the production of glial cell line-derived neurotrophic factor (GDNF) producing cells in the substantial nigra where DA neurons are located and subsequently leading to an increase in dopamine release [4]. This is particularly important finding from a pharmacological treatment stand point, especially for those with early PD, as can lead to a reduced reliance on levodopa going forwards [3]. Levodopa is the most effective drug in reducing PD symptoms, however unwanted effects such as levodopa-induced dyskinesias can potentially be minimized or postponed with exercise intervention [3].


In terms of exercise intervention it is suggested that a combination of skilled and aerobic training is best to trigger and maintain multiple mechanisms of neurogenesis [5]; especially that which is forced (rate beyond what the participant would self-select) [3] and progressive in terms of intensity, duration, repetition and specific skill demand [2].  The prefrontal cortex plays an important role in the early phases of motor development; hence to maximize motor learning, cognitive engagement is also necessary via verbal or proprioceptive feedback, cueing, dual tasking and motivation [5]. Exercise and avoidance of a sedentary lifestyle also helps alleviate common secondary symptoms such as depression and constipation [3].


There are four important components of effective exercise based PD treatments:

·         Forced high intensity exercise with low variability and increased amplitude to increase cortical excitability and subsequent motor cortex output, improving symptoms of bradykinesia, hypokinesia and executive cognitive impairment [2]

·         Goal directed motor skill training to recruit cognitive circuitry important in skill acquisition [5]

·         Cognitive engagement with practice and learning of movements to enable volitional access to previously automatic motor patterns [5]


Further to the above, research shows that inactivity and/or stress can reverse the positive neuroplastic changes brought about through exercise (negative neuroplasticity). It can be said that a decrease in physical activity levels and an increase in stress is prodegenerative, thus increasing the rate of PD pathogenesis and associated symptoms [4].


Of all motor impairments affecting those with PD, balance impairments are of heightened concern as they lead to increased falls risk and subsequent morbidity [5]. Exercise/movement practices reflective of Tai Chi, Dance and Boxing are backed by current evidence as being useful for PD patients due to their focus on multi-directional weight shift and postural control (balance) [5].  Interestingly the combination of skilled movements and cognitive engagement native to these varied movement practices has seen participants show transferrable improvements [5] in maximum exertion (eg. cardiovascular fitness and musculoskeletal strength) [5], movement amplitude (eg. stride length and speed) [2], postural control (balance) [5], dual tasking capability (eg. mobility plus cognitive-auditory attention) [1] and cognition (eg. visuospatial problem solving) [1]. Randomised controlled trial paper discussions also bring to our attention the need to individualise training variables of cognitive movement modalities; if the difficulty level is too high or not high enough opportunities for improvements (positive neuroplasticity) are either limited or missed [6].


It can therefore be reasoned that regular exercise addressing multiple movement and cognitive elements specific to an individual’s PD presentation will be most effective, especially for those early in disease progression. At Inner Focus Physiotherapy we utilise a variety of cognitive movement practices, tailored to an individual’s needs to maximize physical capacity and quality of life for those with PD.









[1]       Brauer, S.G., Morris, M.E. (2009). Can people with Parkinson’s disease improve dual tasking when walking? Gait & Posture. 31: 229-233.


[2]       Farley, B.G., Koshland, G.F. (2005). Training BIG to move faster: the application of the speed-amplitude relation as a rehabilitation strategy for people with Parkinson’s disease. Experimental Brain Research.


[3]       Frazzitta, M.D., et al. (2015). Intensive rehabilitation treatment in early Parkinson’s disease: A randomized pilot study with 2-year follow up. Neurorehabilitation and Neural Repair. 29(2): 123-131.


[4]       Hirsch, M.A., Farley, B.G. (2009). Exercise and neuroplasticity in persons living with Parkinson’s disease. European Journal of Physical and Rehabilitation Medicine. 45: 215-229


[5]       Petzinger, G.M., et al. (2013). Exercise-enhanced neuroplasticity targeting motor and cognitive circuitry in Parkinson’s Disease. Lancet Neurology. 12(7): 716-726.


[6]       Ridgel, A.L., et al. (2009). Forced, not voluntary, exercise improves motor function in Parkinson’s disease patients. Neurorehabilitation and Neural Repair. 23 (6): 600-608.



Yoga Therapy

June 22, 2017

Case study and evidence

Clinical yoga can be practiced at any age, and also applied as a pain management treatment at any age. Here is Penny practicing at age 79. Several years ago, as a result of persistent shoulder pain, Penny was advised by one surgeon (rather stridently) that she needed bilateral shoulder replacements, and another "more conservative" physician recommended bilateral arthroscopy. 

However, through multifactorial treatment, including education, and a graded yoga program, she i...

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Yoga in Clinical Practice

February 5, 2017
The Science of Nocebo, Placebo, Iatrogenesis and Evidence Based Yoga

Clinical Yoga

Clinical yoga is essentially physiotherapist instructed yoga, designed with an evidence based framework, taught individually, with a biopsychosocial focus and neuroscientific understanding.

This approach to treatment is founded on an understanding of the neuroscience behind the patient-therapist relationship:

There are certain behaviours and brain mechanisms that are initiated by an individual who experiences pain ...

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Old Yoga and Modern Bodies

November 30, 2016

There are several movement patterns present in modern day yoga sequences that are reflective of the cultural context in which yoga originated.



A posture like Ardha Matsyendrasana is an example of this. Effectively there is the requirement for a deep squat, a comfortable cross legged sitting position, and a twist. The effect of this posture traditionally is to stimulate the abdominal organs; to create a seal, or bandha around the abdomen. 


However, due to the lifestyle of individu...

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Back Bending Technique

August 13, 2016


An area of concern for many novice practitioners is correctly progressing with the more advanced back bending postures. While there are specific technique cues to be cognisant of, adequate preparatory work is also crucial to ensure correct technique in advanced practice. There are a number of ways to safely progress into advanced postures.

Individualised teaching

The most efficient way of teaching involves an individualised approach, with inst...

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Consensus: Exercise First For Fibromyalgia

July 25, 2016

Nonpharmacological therapies take centre stage


1.    Note that this consensus statement from the European League Against Rheumatism (EULAR) notes that exercise should be a mainstay of therapy for the treatment of fibromyalgia.

  1. Broadly, the group did not endorse most pharmaceutical interventions, especially drugs with a high potential for abuse.

Updated recommendations on the management of fibromyalgia by the European League Against Rheumatism (EULAR) emphasize exercis...

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Discectomy vs conservative management of sciatica

June 29, 2016

One large randomised trial (
n = 283) with a low risk of bias compared early surgery to prolonged conservative treatment followed by surgery if needed in patients with severe sciatica for 6–12 weeks. At 1 year of follow-up, 95% of patients in both treatment groups had experienced satisfactory recovery, and no subsequent differences were found. This lack of a difference between groups was maintained for the following year [1].


One small trial (n = 56) compared microdiscectomy with conserv...

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Yoga for Pain: Personal experience and Evidence

June 22, 2016

·         P   

This picture above is me practicing at my teacher’s (Kales) house today. In the context of writing about pain experience, evidence and yoga, I should point out that when I first met Kale, in 2009, I could barely move. 2 years of chronic pain, and what I now recognise as sensitisation, fear avoidance and textbook chronicity markers, I could barely even sit on the ground (hip and knee pain), my squatting ability was non existent (too stiff, too sore). Additionally, I was too ...

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Tailoring Yoga to the Western Body

March 29, 2016

Eka Pada Viparita Dandasana II.

In Light on Yoga, Iyengar ranks the poses according to difficulty. 1 being the easiest and 60 being the hardest. This pose is given a 29. (Though the heel should be grabbed in the final posture).

When analysed, the ranking reveals stark differences between traditional eastern body types and western body types. For example, Supta Virasana is given a 2, Malasana a 2, Baddha Konasana is given a 3 and Padmasana a 4. 

For the average person who grew up sitting on chair...

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Supervised Yoga for COPD: Proven, but Underutilized

November 19, 2015

Summary Points:

• Nonpharmacologic interventions, such as pulmonary rehabilitation are proven treatments for COPD.
• Recent studies have demonstrated that a supervised yoga program matches conventional COPD rehab (spirometry, function, QOL outcomes all similar).
• Unfortunately, patients aren’t using these therapies to their fullest extent.
• It’s important to overcome barriers so that patients can experience the potential benefits of these interventions.

Pulmonary rehabilitation has b...

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Yoga, Strength and Physical Fitness

November 3, 2015

The primary goal of most traditional yoga is to quiet the mind through focused concentration an attention; however, of all the yoga traditions, the importance of physical fitness is emphasized most in hatha yoga. [1-4]

Studies have shown that hatha yoga practice can lead to improvements in:

- Hand-grip strength [5]
- Muscular endurance [6]
- Flexibility [7]
- Maximal oxygen uptake [8]
- Decreases in percent body fat [9, 10]
- Increased forced vital capacity (FVC) and forced expiratory volume in 1 se...

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Yoga to Prevent Cardiovascular Disease

October 18, 2015

It is widely accepted that both stress and physical inactivity are important risk factors for cardiovascular disease (CVD) [1].

Strategies which promote a healthy lifestyle, including exercise and stress management, have been shown to be beneficial in terms of reducing CVD risk factors [1]. Yoga has been demonstrated to reduce stress [2] and the holding of poses that is involved provides surprising robust exercise [3]and so, theoretically, yoga could be effective as a primary prevention interv...

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Yoga therapy recommendations for Ankylosing Spondylitis: An evidence based review

October 18, 2015

The below recommendations are based on a new consensus statement published in Rheumatology, which provides the first comprehensive exercise recommendations to guide practitioners treating AS patients:

1) Assessment: Individual yoga prescriptions should be informed by a thorough and reproducible assessment that includes musculoskeletal and psychosocial factors, and AS-specific measures, including objective axial mobility and chest expansion.

2) Monitoring: Sufficient monitoring and feedback shou...

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Yoga may be the missing link to stroke survivors' rehabilitation

October 18, 2015

One in six Australians will have a stroke in their lifetime [1].

That’s about 51,000 strokes per year, or one every ten minutes. 
Worldwide, stroke is the second most common cause of premature death, after heart disease, and is the leading cause of disability among adults [2].

During a stroke, the blood supply to the brain is interrupted by a blocked or ruptured blood vessel. Cells in the brain are deprived of oxygen and nutrients, causing them to die. Damage is localised to the area of brain ...

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Determining Hatha Yoga's Stress-Reduction Benefits

October 18, 2015

Journal of Physiology and Behavior


►We compared adiponectin and leptin data from novice and expert yoga practitioners.
►Leptin plays a proinflammatory role, adiponectin has anti-inflammatory properties. 
►Leptin was 36% higher among novices compared to experts.
►Experts' average adiponectin to leptin ratio was nearly twice that of novices. 
►Intensive yoga practice may benefit health by altering leptin and adiponectin production.


Kiecolt-Glaser, J. K., Christian, L. M.,...

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Exercise Directly Causes an Increase in the Number of Neural Stem Cells in the Brain

October 18, 2015

Neuroscientists have, for the first time, been able to demonstrate that moderate exercise significantly increases the number of neural stem cells in the ageing brain.

In research published in Stem Cells, Dr Daniel Blackmore and his colleagues at the Queensland Brain Institute (QBI) have shown that moderate exercise directly increases the number of stem cells in the ageing brain.

Despite the conventional wisdom that we only have a set number of neurons or brain cells, neuroscientists have known ...

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Exerpt from the 1934 textbook The Yoga Makaranda. Mayurasana:

October 18, 2015

This asana must be done before eating (on an empty stomach). Wait a minimum of four hours after eating before practising this asana. This asana should be held from 1 minute up to [a long time] according to the practitioner’s capability. It is good to practise this regularly and to remain in this asana for longer periods during the winter or colder months rather than in the summer.If we make it a habit to practise this asana every day for at least fifteen minutes, we will attain tremendous b...
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Jump From Downward Dog to Handstand: A Review of Motor Learning Principles.

October 18, 2015

Below are some general guidlines on motor skill learning and performance. These factors are relevant when learning any new complex motor pattern, and are incidently the cornerstone of neurorehabilitation.

Observation of others, particularly when it is combined with physical practice, can make important contributions to learning. This includes dyad practice (i.e. practice in pairs), where the novice practitioner can observe the experienced practitioners technique, can ...

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Evidence for Exercise and Mindfulness in Cold and Flu Prevention

October 18, 2015

1. Exercise May Block Colds

Being fit -- or at least a perception of being fit -- appears to be associated with a reduction in upper respiratory tract infections, researchers found.

During a 12-week period, individuals who said they exercised at least five days a week had 43% fewer days with an upper respiratory tract infection than those who exercised no more than one day a week (P<0.05), according to David Nieman, DrPH, of Appalachian State University in Kannapolis, N.C., and colleagues.

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First-person experience and yoga research: studying neural correlates of an intentional practice

June 6, 2015


Recent years have seen a dramatic increase in the scientific study of contemplative practices. While seated meditation practices have historically been at the center of inquiry in contemplative sciences, movement-based practices, such as yoga, t'ai chi, qigong, and others, are currently coming to the forefront of this discourse. In her introduction to the present Research Topic, Schmalzl et al. (2014) introduce movement-based contemplative practices (MBCP) and present their essent...

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Exercise and stress: Get moving to manage stress

June 4, 2015

Exercise in almost any form can act as a stress reliever. Being active can boost your feel-good endorphins and distract you from daily worries.

You know that exercise does your body good, but you're too busy and stressed to fit it into your routine. Hold on a second — there's good news when it comes to exercise and stress.

Virtually any form of exercise, from aerobics to yoga, can act as a stress reliever. If you're not an athlete or even if you're out of shape, you can still make a little ex...

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Yoga and Overcoming Pain. An Evidence Based Approach.

May 18, 2015

ovement, and exercise generally, are crucial aspects of effective pain management in the case of long standing pain conditions.


Pain is a vital aspect of the body’s defence mechanism. However, when pain responses occur beyond normal physiological healing times, this type of pain is counterproductive [1].

A rapidly expanding body of research is demonstrating that mind-body exercise, specifically yoga, can be immensely beneficial for managing persistent pain [2-8].


Improving function (e....

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ADOLESCENT IDIOPATHIC SCOLIOSIS - a summary of the latest evidence.

April 23, 2015

By Tom Belotti (Bsc Physiotherapy)

Adolescent Idiopathic Scoliosis (AIS) is the most common form of scoliosis, widely thought of as a lateral curvature of the spine, it is actually a three dimensional structural deformity of the spine and trunk, which occurs in otherwise healthy children during puberty, cause unknown. The Cobb angle is the conventional measurement of scoliosis as taken from x-ray images in the coronal plane, curvatures <10deg are viewed as normal as they have little potential ...

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Knee OA: Corticosteroid Shot Does Not Boost Exercise Benefit

April 2, 2015

Adding an intra-articular injection of 40 mg corticosteroid before exercise in patients with painful knee osteoarthritis (OA) provided no extra benefit, results from a new randomized trial show.

Exercise has been shown to provide relief of knee OA symptoms, as have intra-articular injections, but no studies to date have evaluated the two treatments in combination.

Therefore, Marius Henriksen, PT, PhD, from Parker Institute, Department of Rheumatology, Copenhagen University Hospital at Bispebjer...

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**Yoga and Self Inquiry; Health Outcomes of Introspection**

March 2, 2015

Mindful exercise is defined as physical exercise executed with a profound inwardly directed mental focus.

This focus allows postures to be performed with a meditative, proprioceptive, sensory awareness component.

The term mindful may be best described in several ways as: Self inquiry to gain knowledge to answer questions on self- control and understanding, or maintaining moment-to-moment awareness.

The inwardly directed attention in mindful exercise is performed with specific attention to breath...

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*Yoga May Benefit Heart as Much as Aerobic Exercise*

March 2, 2015

New research reveals that the ancient mind-body practice of yoga may provide the same benefits for your heart as traditional types of aerobic exercise, such as biking or brisk walking.

The similarity of yoga and exercise’s effect on cardiovascular risk factors, according to the researchers, “suggest that there could be comparable working mechanisms, with some possible physiological aerobic benefits occurring with yoga practice, and some stress-reducing, relaxation effect occurring with aer...

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Fibromyalgia Bends To Yoga

March 2, 2015

Key Points from the article below:

1. Clinicians should explain to interested patients that yoga may take away some of the debilitating symptoms of fibromyalgia.

2.Women who practiced yoga had greater improvements in symptoms and functioning, including: pain, fatigue, mood, pain catastrophizing, acceptance, and other coping strategies.


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Yoga Mindfulness Explained:

March 2, 2015

Hatha Yoga is a form of Yoga that employs a number of different body positions. These postures are held in place for a period of time before moving to the next while utilizing a specific breathing technique.

Movement is slow, and focus is placed on the body and how the body reacts to different postures. Practitioners scan their bodies to become aware of stiff muscles, which they can then loosen until the posture is correctly attained. The abdominal breathing technique and focus of awareness on...

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Yoga and High Level Balance: Children and Adults

March 2, 2015


Muscle weakness and impaired balance are risk factors underlying many falls and fall related injuries experienced by older people [1]. Recent studies have demonstrated the capacity for individualised yoga to reduce age-related balance decline and reduce fall-related injuries.

A 2014 systematic review found that yoga practice can:

>Enhance balance and postural control, based on objective assessment

> Reduce the incidence of balance-related falls

> Reduce fear of falling

This supports other r...

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**Treatment and Prevention of Headaches**

March 2, 2015

Nonpharmologic Management:

Educating patients about headache and its management, identifying and managing triggers (via diaries), modifying lifestyles, and understanding the importance of adopting and adhering to interventions are relevant to all persons with headache.

Strong candidates for nonpharmacologic treatment include individuals with significant headache-related disability, comorbid mood or anxiety disorders, difficulty managing stress or other triggers, medication overuse, and patients...

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