Sarah Wahlstrom Helgren: Hello and welcome to this edition of MDS Community Conversations. I'm your host, Dr. Sarah Walstrom Helgren. Today I have the pleasure of chatting with Dr. Natalie Allen, Ms. Allyson Flynn and Dr. Victor Fung. We will be chatting about exercises for PD patients during COVID times.
Let's start with introductions so our audience knows who each of you are. Briefly, where are you working? And what are you studying? We'll start with Dr. Natalie Allen.
Natalie Allen: So I'm a senior lecturer in Physiotherapy at the University of Sydney. I'm doing some work with Alison, which she'll tell you about herself in a minute and as well as that I'm, mostly researching broadly speaking sort of physiotherapy and occupational therapy based interventions to help people with Parkinson's disease to live better with the disease. And one of my key areas of research is looking at how we can improve safe mobility and reduce falls in people with Parkinson's, and with a heavy sort of home-based exercise, focus to that.
Sarah Wahlstrom Helgren: All right. Miss Allyson Flynn.
Allyson Flynn: Yes. So I'm a Physiotherapist at the University of Canberra. And I guess, because this is an international audience, when I used the word physio-therapist, this is exactly the same as physical therapists. We just use different terms in different parts of the world. So if you hear physio or physiotherapists, throughout this talk or recording to see, physical therapist, And I run a clinic for people with Parkinson's disease and we, usually provide grid-based face-to-face therapy, but during COVID we've transitioned to providing telehealth and home-based exercise and my area of research is looking at models of physiotherapy service delivery. And I'm also looking at home-based exercise supported by telehealth. And this is done, under the supervision of Natalie at the University of Sydney and with the team there at the University.
Sarah Wahlstrom Helgren: And Dr. Victor Fung.
Victor Fung: Hi, my name is Victor Fung. I'm director of the movement disorder unit at Westmead hospital in Sydney, Australia. I've got a broad interest in Parkinson's disease and movement disorders and together with Natalie and also, professor Colleen Canning from the University of Sydney, we performed one of the first randomized controlled trials of exercise therapy for falls prevention in Parkinson's disease. So we've had a long-standing interest in both medical and nonmedical treatment for Parkinson's disease.
Sarah Wahlstrom Helgren: Excellent. All right, so let's dive right in. Can you tell us about the importance of exercise for people with PD and the role of exercise in the context of holistic care?
Allyson Flynn: So I'm happy to chat a little bit about this. I think it's very fair to say that there's really good evidence to show that exercise is beneficial for people with Parkinson's disease. We know that it improves mobility, balance, muscle strength. It can reduce falls and it might even slow the disease progression. If we look specifically at sort of home-based exercise, which is really what the focus of today's conversation is about, we also know that there's increasing evidence, that home-based exercise is effective. We've recently completed a feasibility study that showed that home-based exercise was feasible and acceptable from a person with Parkinson's disease perspective and also from a physiotherapy perspective was a really efficient way to deliver care. The other thing I think that's come up about home-based exercises is recently been a systematic review published, which shows that in people with mild to moderate Parkinson's disease home-based exercise, which was prescribed, monitored, and progressed was able to improve both balance and walking speed. And the other really interesting thing about this systematic review was that it also looked at location. So it compared home-based exercise compared to center vast exercise. And when the exercise was equivalent, in terms of type and dose, the location of the exercise didn't matter. So the results were similar for both groups.
So I think that's a real positive in the sense that it's not really the location of the exercise, which is important. It's probably more around the prescription and the monitoring of the exercise. And Natalie, I think you were going to talk a bit more about that side of things.
Natalie Allen: Yeah. So I'll talk a bit more about how we can think about exercise as being like medicine, I think. So when we think about using exercise as a treatment for people with Parkinson's, I think it is really helpful to sort of liken it to how we think about medications for people with Parkinson's. So we know that with medication, while there's general principles that guide the prescription of the medication, there's actually no standard one size fits all medication prescription for people with Parkinson's. And in the same way, there's guidelines of that exercise, but there's no standard one size fits all exercise prescription either. So while an optimal medication regime, may be prescribed in the appropriate combination at the appropriate time and the appropriate dose for the individual, in the same way an optimal exercise program also needs to be prescribed with the appropriate combination of exercises at the appropriate time, the appropriate duration and intensity and so forth. And we know that these prescriptions aren't steady. So just like medication, exercise needs to be undertaken for the long term. And the appropriate prescription is going to change over time. So for some people with mild Parkinson's, especially people who are already accustomed to exercising, this exercise prescription will be pretty straightforward and these people can often safely follow generic exercise advice, such as that found on the resources that are going to go along with this recording. But for people with more moderate to advanced disease or people who are having problems with falls or increasing levels of disability, or even people with mild disease who don't have a history of exercising regularly, and don't really know how to get started, these people really benefit from the input of a physiotherapist so that exercise can really be tailored to their needs.
So what we find is that for lots of people with Parkinson's a good model for exercise service provision is actually to provide a program that people can learn under the supervision of physiotherapists so they come for a number of sessions with the physiotherapists, whether that be face-to-face in person or through telehealth, then they can continue to exercise on their own. And by on their own, we mean that could be with the help of a care partner or a family member or something like that. Or it could even be through a community group depending on what's available and appropriate at that time. Then the person with Parkinson's can regularly check in with the physiotherapist as needed.
And for some people they might need to do that monthly or every few months and other people that might be annually or something like that, just depending on how their disease is progressing and what their particular difficulties might be. So that tends to work quite well.
Victor Fung: So, as a clinician, as a neurologist working with Parkinson's disease, I think the points that Natalie makes really important because, I don't think neurologists are really taught to think about exercise as a prescription. And for physiotherapists as, as guides, as experts who can guide patients rather than simply someone that you send someone to, to see, you know, once a week for three months and then that's done with. So I think for neurologists, it's really important to work closely with, a physical therapist, who has the same model of care so that, the patients can continue to benefit as their disease sort of changes and as their circumstances change. And I think the other thing is the concept of home based exercise. I think many patients will, if they're offered referral to the physical therapist will say, Oh, I don't think so, it's too difficult to get there. Or they feel that they can't do things at home. And so I think the programs that are being, and the research that is being done into home based therapy is really important as well.
Natalie Allen: That's right because it really needs, COVID aside, all this needs to be sustainable for the long-term in the context of this long-term degenerative disease.
Sarah Wahlstrom Helgren: So I'm sure that home-based therapies have now become right in the spotlight. And that leads me to my next question, which is how has COVID impacted the ability of people with Parkinson's disease to undertake regular exercise and what sort of strategies can be used to facilitate, exercise in these people during COVID times?
Natalie Allen: Yeah. So obviously COVID-19 has been devastating in many, many parts of the world. And part of that has meant that people have less access to physiotherapy clinics and to exercise programs, less access to those things than they usually would. But a lot of services have been able to adapt and continue to adapt, to provide as good a service as possible with these changing restrictions. So physiotherapy and exercise options haven't completely disappeared, but things have changed. Just to sort of touch on one of the big problems that many people with Parkinson's disease experience around exercise is a lot of difficulty getting motivated and engaged with an exercise program. So we all know that just telling someone that they should exercise is not enough, even under normal circumstances. And then you add to that the apathy and the depression that often comes with Parkinson's and the extra stress from the pandemic. And it really is quite difficult for people, to establish a regular exercise routine. So working through exercise self-management skills, as well as providing accountability and encouragement can really help. So this could mean doing things like helping people to set goals, helping people to develop new routines, that factor in their home exercise program. And technology certainly plays a role in that as well. So using things like step counters and pedometers, different exercise apps, exercise video games. There's been a few online exercise routines that different organizations have put out specific for people with Parkinson's disease. And we've got examples of all of these in the resources that'll go along with this recording.
And then there's also telehealth. So obviously, telehealth is another way that technology is being used to help people to exercise through COVID-19. And I'm sure now we all have a better understanding of what telehealth is, but just to define it, it's where the provision of healthcare is provided remotely using telecommunication tools. So that could be using phone calls, something as simple as that. Or it can be things like video conferencing software so you can actually see each other. And using telehealth, then, therapists can teach and intermittently monitor exercises that way. and then can also conduct virtual home visits that way as well, to help with specific problems like freezing of gait or falls in the home. And as Allyson mentioned in the introduction, she's been using telehealth in her clinics so I'll, let her have a chat about that to give us a bit more of her insights into the use of telehealth.
Allyson Flynn: Yeah. Thanks Natalie. So yeah, we have to change our entire clinic so normally, we sort of had clients coming into the clinic, and we're trying to switch telehealth model. So we developed home exercise programs for all of the clients and then we followed them up with a regular weekly phone call and we started with weekly phone calls. And then as our skills developed, we also moved into doing some video calls with clients as well. And so I guess from my clinical perspective, and also from talking with the people who come through the clinic, there's probably some really key things, that, they've given us feedback on and that we know about. So. We know that they really like the regular phone calls. So knowing that someone was going to call them each week at a similar time was really helpful. It made them feel supported in a stressful time of COVID already. And lots of people said it made them feel accountable because they knew that, you know, they were going to get a phone call from someone in the clinic saying, "where are you up to and what have you done?" We also try to encourage people to record their exercise and their physical activity. So, even if they hadn't had a chance to do their exercise, maybe they go for a walk or maybe they've done some gardening or things like that. And, there were really two groups of people here: Some people really liked recording their exercise and they'd check from week to week, how much they did. And some people just found it a complete hassle and another stress, so they didn't bother. So I think that's a really individual thing as to whether recording the exercise is helpful for some people.
Look, there was agreement across the participants and the people that come to the clinic that exercising at home is not the same as being in the clinic, but it doesn't mean that it's worse. It's just different. and people found it different in a few different ways. They found it different because they didn't get immediate feedback on their performance, they didn't have access to the same equipment, but we were able to often adjust and modify and come up with other ideas to the things they could use.
And I miss the social interaction of being able to meet with other people. And a lot of our therapy is group based so they really missing seeing their friends, really, that they developed over time. But despite all of this, everyone agreed that in this time of COVID, given the circumstances, that these home-based telehealth was a really good option and it really did help them to stay connected and we're quite fortunate in Australia, in Canberra, at the moment where people can actually return back to our classes. So, the people felt that they were still connected and were happy to come back. And we've managed to maintain all our clients back into the clinic, which has been really positive, transitions through COVID.
So I guess from the health perspective side, if I was talking about sort of my experience and giving advice to other health professionals, I think there's probably some really key features of helping people with Parkinson's to exercise at home. Make sure you've got regular contact with the client, can be as simple as a telephone call. If you can try to incorporate video calls so you can give immediate and specific feedback. And if you can't do this, maybe there's some other options. Maybe the person themselves could take a video and send it to you. Or maybe you could consider using the environment, so setting up a mirror or some markers to actually give the person some feedback as they're doing the exercise and I guess you need to adapt it as well so we were sort of routinely updating the home exercise programs every sort of three weeks, depending on how the clients are going with things were getting too lazy or too difficult. So making sure that you are sort of monitoring and progressing the program. And I think with that sort of a model, we were really effective in being able to deliver our service, but also be support people with Parkinson's to exercise at home.
Victor Fung: I think one of the bewildering things, but actually sort of very useful things, is the wide variety of exercise interventions which have been shown to be helpful. And so I think, for neurologists and for patients, you know, they'll read or hear about all these different, things that can be done. So would you like to comment on how you sort of utilize and tailor particular sort of forms of therapy to particular patients?
Allyson Flynn: Yeah, so I would say that first of all, that we were always doing assessment. And even when we were providing telehealth, we would do a video assessment. So we would sort of assess the client and we would look at sort of key areas. So we would look at their mobility. So how are they walking? We would look at how they coped under jewel task conditions. We would have a look at their balance and do some screening, some basic screening for their strengths. So really trying to work out what were the underlying impairments or issues that this person had and also from their perspective, what were maybe the activities or, you know, everyday things that they were having trouble with as well. So really trying to, work out what their, underlying needs were and then based off that, really writing a program that was sort of individualized to each person and really trying to encompass, I guess, some key features. So making sure that they meet ideally the physical activity guidelines, so 150 minutes a week. If there were any balanced based components, some general strengthening, and then if there were any specific issues like phrasing or any sort of motor skills that we thought they needed specific training on, then we would try and incorporate that as well. And Natalie, you've probably got some more advice or ideas about that as well.
Natalie Allen: Yeah. So, you know, we know from the research that lots and lots and lots of different modes of exercise are all effective. Which I think is good because it means that there's lots and lots of different options for people to do and to be exercising. And I think the thing is to try and make sure that, the exercise meets the person's needs in terms of addressing their impairments, like Allyson mentioned, and addressing their goals of what they want to achieve. And also that it's something that the person is going to enjoy doing, or at least doesn't mind doing, because people are going to be needing to do these exercises for the long haul. So I think that, you know, trying to sort of put those things together is important. So in terms of general exercise prescription, I think what we need to be thinking about for people with Parkinson's disease is similar to what we need to be thinking about for the general older population and the World Health Organization actually has some guidelines around what exercise for the general older population should look like.
So as Allyson mentioned, that does involve aerobic exercise, balance exercise, and then resistance exercises. And that's all stuff that people can do at home. So aerobic exercise, like Allyson mentioned, at least 150 minutes of moderate aerobic activities. So things like brisk walking or 75 minutes of vigorous aerobic activity. So things like fast cycling on an exercise bike every week is part of the guidelines and they say that can be accrued in bouts of about 10 minutes at a time. Then, for balance exercises, it's recommended that people do that on three or more days of the week. And that could be general balance exercises, or it could be things like Tai Chi or dance, depending on what the person would like to do and enjoys, and people can change what they do over time as well to keep it fresh and interesting.
Then for the strength exercises, it's recommended that they try and do exercises that strengthen the major muscle groups at least twice per week. And people often think strength exercises - "I've got to go to the gym and use the machine and all of that." And that's actually not true. You can do strength exercises at home. People can use their own body weight for resistance or simple things like dumbbells, cans of food, or getting plastic milk bottles, putting water in plastic milk bottles and things like that to make improvised weights that people can use at home to do resistance exercise as well. So for a lot of people with mild disease, this type of general prescription will suit them quite well. And you can see there's a really broad scope of what they can do and be meeting the guidelines. So people have a lot of choice around that. But I think the key thing is, is as the disease progresses, people start to then really need prescriptions that are much more specific for their own impairments and movement difficulties, and goals.
And that's where if possible it's really good to have a physiotherapist prescribe and monitor the program. She's sort of really honing in on, is this person specifically got a balance problem? Is this person starting to have falls and we need to address their falling? Is this person having problems with freezing of gait or other issues where they need some extra gait retraining practice and that kind of thing.
So that's where it starts to get really quite important that they're assessed by a physiotherapist. And as we've talked about before, this can be done by telehealth and we thought it might be fun for Allyson to actually show us an example of an exercise and how she might set that up over telehealth.
Allyson Flynn: So I'm going to set this up. A couple of things to think about: First is the environment and the safety, and the second one is actually making sure that you set up the computer so you can see as much of the person as possible. But it's really important that you see the thing that you're trying to train. So in this case, I'm going to do an example using a step. So it's really important that we can see my feet and my body. And if I cut off my head in the video camera, that's probably not so important. So it takes a little bit to set up. It's worthwhile investing the time, because the better you can get the camera position, the better you can give feedback. So just bear with me one minute.
Yep. That's good. I can just see the step there. Yep, yep. Yep. I can see you if we're going to lose your head when you step up, but we know what you look like, so that's okay.
So what I'm going to do is sort of demonstrate really a range of possible exercises that you could do using a very simple piece of equipment, which is a step, which most people have at home. And as we've already mentioned, you can really make things as easy or as complex as you like, based on the person with Parkinson's disease. So, in terms of safety, it's something near a wall, often a step at home would have a rail or maybe you'd set it up near a kitchen table or something sturdy. And it's always useful just to have a chair nearby just in case you need to have a rest and things like that. So you can just start with a really easy balance exercise of just lifting the foot up onto the step and then back down. And you can alternate between legs or you can keep doing the same leg.
And then to add, if you want to sort of make the task more challenging, I'd always start by holding on first and then you can ask the person to just step up onto the step. And this is also good for not only balance, but improving, lower limb strength as well. If you want to add complexity take the upper limb support away and again, you can keep stepping up and again, you can alternate between legs, or you can do the same leg 10 times and then change. If you wanted to add more of a balance component, I'd then think about adding some sort of a hole once I get onto the step. So as I step up and then keeping my other leg of the step balancing and then putting it down and again, I can do that the other side as well, the stepping up bending a time balancing and single leg stance, and then putting my foot down.
It is going really well and you want to make it even more challenging, I'd add an amplitude component to the exercise session and get the person maybe to step up and bring their opposite knee up to hip height and then balance. And also the longer I stand in this position, the more challenging the exercise is going to be.
And again, you can alternate that, do that on the other side, it's a knee up to hip height and then balance. If this is all going really well, and you're looking for even more complexity or challenge, then I would start to do things like incorporate the upper limbs and also be starting to think about maybe some group passing side, some cognitive impairment. So here I'm going to add the opposite arm. So I'm going to be my knee up to hip height and balance, and then bring my arm up towards the ceiling. And even just getting those opposite movements can sometimes be a bit of a challenge. The other thing you could do is potentially, bring up both arms, or change the position of the arms once you're in standing.
The other way you can progress all of these exercises is to increase the speed at which you do them. And I'm not going to go too fast today, or to increase the height of the step. If that's an option, if someone's got one, but got a different, height of a step at home. We're going to come back and then I'm just gonna talk a little bit more about safety in terms of setting up the exercise.
So that's sort of just a really quick range of examples of exercises that you could do. It is important to consider safety. We know that people can exercise at home safely, but we do want to be careful of falls and injuries and this was some really key things you can do to reduce the risk.
So the first one is to make sure that people have got appropriate footwear. So one of the things we've found is, is that you're calling people at their home. So they often just sitting there in their slippers or with no shoes. So, make sure that they've got appropriate clothing and footwear, like they would wear if they were going out of the house or if they were going to exercise.
Make sure you set up the space, not to bump into anything. So we've got a nice space, around to do the exercise and people with balance problems may well require, or will require, a stable object nearby. So a chair, the kitchen bench, and potentially even a partner or carer, just to be present, to give them a bit of confidence, to be able to exercise.
As I mentioned in the recording, having a chair so you can rest if you get tired, is always useful. And the last thing that I'd say, and we learned this from doing lots of video calls, is if someone's watching a video, so they're watching you do an exercise and they're trying to keep up, or they're trying to mirror you be really mindful that this is actually a dual task and it adds a level of complexity so you might need to bring your complexity of your exercise down so you're not overwhelming the person. So they're probably the hints and tips that I would give someone in terms of trying to do telehealth and prescribe exercise via telehealth. Does anyone have any questions?
Victor Fung: Can I ask either of you to comment on, so one of the things that I say to my patients is informing them, that there is a range of things they can do and, basically the, the exercise that's effective is the exercise you do, you know, not, not, not what's theoretically best and you've touched on that already. The other thing I've read about, in lay press rather than, in anything medical is how long it takes to form a habit, you know, so, and it's doing something I forget it's four weeks or six weeks. And so I often asked the patients, I suggest to patients to keep a regular timing and, and, routine and then it should take, but they have to keep doing it for four or six weeks. Do you guys know what the actual, sort of, proven sort of scientific or psychologically sort of validated time that you have to keep at a task for is before it becomes a habit?
Natalie Allen: I think it depends on how often you do the thing that you're trying to make a habit, is one of the factors. And I think there's also personal variability with that. So if it was something, for example, you were doing on the hour, every hour, you would probably establish that habit in fewer weeks than if it was something you were doing once a week. So I don't think there's really a simple answer as to how long it takes to establish a habit. And I think it also depends on now how attractive the activity is, how much you do or don't enjoy it and all these sorts of factors as well. So I think, I think there's no clear cut answer for how long it takes to establish a habit. I think we need to expect that different people will have take different lengths of time to establish habits, because it's also going to pend on whether they have any cognitive impairment or mental health issues and things like that, which might influence that as well, but I think, you know, trying to work with the person to establish routines where they can regularly try and fit their home exercise into their routine. So if their routine looks quite different now because of COVID and they're staying at home all the time, you know, things get very blurry in what you don't even know what day it is sometimes. So trying to have a daily routine where there's a certain time to do the exercise can really help people with forming that habit as well, as well as, you know, just talking to people about, you know, what are the things that you think will get in the way of you doing the exercise and then trying to work out, okay, well, if they've said what these barriers are talking with them to see if they can come up with some solutions to how they might get past those barriers to doing the exercise. So if they might forget to do the exercise, maybe they can set a time to do it at 10:00 AM every day and put a timer on or, you know, something like that. Or if, you know, depending on what their barrier is trying to come up with some solutions. Do you have any other thoughts about that, Allyson?
Allyson Flynn: Yeah. So I think we really talked to people about, like what, what do they like doing? So for example, I'm not a morning person. So, to asking me to get up out of bed and exercise would just be a file, like it just wouldn't work. So thinking about, well, what, what are the times that I do like exercise? Where, where might it fit in and actually having those types of conversations. We also, at times, people felt overwhelmed by having to set aside an hour of time to do their exercise. So we looked at strategies for breaking it up during the day, you know, maybe they could do a little bit, a bit like going to take their medication. Can they do a little bit in the morning, middle of the day, end of the day and getting them to think about, you know, how do they like to exercise? Do they like to exercise with others? Do they like to exercise alone? Those types of things such a really trying to meet their needs. And I think having a goal to work towards, even if it's a short goal that I told the physio that I was going to do the exercises twice before they called me next week, or, you know, hopefully a longer term goal about, an activity that they want to do or something they want to participate in, is really helpful so that they can, they can see the benefits of it. And hopefully internally drive it, rather than externally drive it.
Victor Fung: I think that does answer it. I mean, I think sometimes we assume patients will think of things that are instinctive to us because we talk about it with sort of a patient after patient or person after person. And I think informing them of, of sort of, of a, of a plan of turning the exercise regime into a regular, into a habit, you know, I think even that can be useful, you know, so that, so that they know that if they persist, it's likely to then start being ingrained.
Natalie Allen: Yeah. I agree. And also talking to them about, you know, in the longer term, because things will happen. People will get, illnesses or life events will happen that will interrupt their new exercise habit. And then they've got to get back onto the habit. It'd be like, it's, it's incredibly easy to lose these sorts of habits. So making sure people are aware of that as well. And then if they do need help reestablishing their habit after something has stopped them from exercising for awhile, then knowing where they can go and get help with that too, can be useful.
Allyson Flynn: I said one of the other things that I think that we really recognized was that COVID is a really stressful time for people and so they might not be able to do everything they were doing before, but maybe they can do something and then they should really celebrate and acknowledge the success of doing something because it is extremely stressful. And so, something's better than nothing to, you know, be kind to themselves when they have done it rather than the, Oh, you know, I didn't do an hour. I only did 15 minutes. Well, that 15 minutes is worthwhile.
Sarah Wahlstrom Helgren: Well, I'm going to take us to our last question here, which is, can you talk a little bit about the role of the physical therapist as a part of the allied health team?
Natalie Allen: Yeah, I'll take, I'll take that one if you will like Alison. Okay. So in terms of the physiotherapist or physical therapist and the allied health team, obviously we all know that Parkinson's is a really complex condition. So it is best managed by a rehabilitation team. So including people like the neurologist or the movement disorder specialist, as well as the Parkinson's nurse, the IT, speech therapist, et cetera, et cetera. And in that team, the physiotherapist obviously has a really big role in prescribing exercise, but they also have a role in teaching people with Parkinson's disease about motor skills as well. And also looking at movement, strategy, training and things like helping people with, motor skills around upper limb activities also.
And with that, the physios often work really closely with the occupational therapist. So OTs also look at motor skill training and movement strategies, as well as looking at things like environmental modifications and cognitive strategies to try and help people with their everyday activities, whether that be self-care activities or activities related to paid work or leisure activities.
I think, if you haven't looked in the resources, there's a link there to some exercise videos provided by the European Physiotherapy Association. And they're actually a really good example of activities that go across allied health disciplines. Where they go across physio, OT and speech therapy, because they have activities there that provide combined challenge to movement with the exercise, as well as cognitive challenge, as well as challenges to voice with getting people, to make loud vocalizations while they're doing different activities as well.
So there are any really interesting thing to have a look at. If you're interested. Just keep in mind that while they're excellent exercise sessions, they are relatively fast paced and challenging with lots of Juul and multitasking activities. So they're really best suited to people with milder Parkinson's disease, but if you are looking for some exercise videos for people with, you know, across the spectrum of disease, there's also links in the resources to videos made by the American Parkinson's Disease Association and by Parkinson's UK, where there really is something there for, for most ability levels. So there's something there for most people with Parkinson's. So I think that with all the complexities that Parkinson's brings, teamwork amongst the rehab team is really important to help optimize people's quality of life. And hopefully today we've persuaded everyone that suitably prescribed, monitored and progressed exercise is a really important part of that. And that for most people, exercise can be done safely at home, even when there's a pandemic. Did you have anything you wanted to add to that, Allyson?
Allyson Flynn: No, I think that's a really good summary.
Sarah Wahlstrom Helgren: Well, this was a joy to chat with you all today. Thank you so much for your time. In addition to your time today, I know that, Dr. Allen and Ms. Flynn have put together a whole host of resources that they've mentioned and those I'm going to post when I post this video, so they will be in the text. They'll also be a transcript of our conversation here today. I'm Dr. Sarah Walstrom Helgren, and this is MDS Community Conversations.