What Is Exercise Therapy and How Can It Ward Off Dementia? (Interview)

An interview with William Smith, an exercise therapist and author of several books about brain health

Today SevenPonds speaks with William Smith, an exercise therapist and account manager at Atlantic Corporate Health, a nationally recognized health care system based in New Jersey. Educated in exercise science, today Mr. Smith works with employers, fitness professionals, and healthcare organizations to develop targeted exercise programs for various patient populations, including those suffering from or at risk for dementia and other neurocognitive disorders such as Parkinson’s disease. He is also an accomplished author, whose books include “Exercises for Better Balance,” “Exercises for Stroke,” and “Exercises for Brain Health.”

Editor’s note: This interview has been edited for length and clarity.

Kathleen Clohessy: Hi, Will. Thanks for speaking with me today. Can I start by asking you to explain a little bit about what exercise therapy is? It’s different from physical therapy, correct?

William Smith: That’s right. Physical therapy is used for rehabilitation — treating or managing an illness or injury after it occurs. For instance, PT might be prescribed for a patient after a stroke or a fractured hip. The focus of exercise therapy is the prevention of injuries and maintenance of optimal function. You might call it “prehab.” 

Kathleen: That’s something of a novel concept, isn’t it?

William: Here in the United States it is, although it is becoming far less so over the past eight to 10 years. Unlike European countries, the U.S. for many decades has employed a “sick model” of healthcare that focused on treating illnesses and injuries after they occur. Now we are seeing a greater emphasis on prevention, with a focus on community-based care such as the programs I manage at Atlantic Corporate Health.

Kathleen: I may be showing my ignorance here, but what is Atlantic Corporate Health?

William: Atlantic Health System is the largest healthcare system in New Jersey, and one of the largest in the Northeastern United States. It has a huge network of hospitals and specialty clinics, including one of the largest departments of cardiovascular surgery in the northeast at Morristown Medical Center in Morristown, New Jersey.

Atlantic Corporate Health is a part of Atlantic Health System that focuses on working with employers to reduce healthcare costs by promoting healthy living initiatives such as diet, exercise and smoking cessation programs. We work with employers to identify target populations — for example, people with Type 2 diabetes or arthritis — and design programs to help them develop healthier habits, including more nutritious eating and targeted exercise. These, in turn, help reduce the employer’s health insurance costs.

Kathleen: Speaking of insurance: Does health insurance typically cover exercise therapy? I know a lot of insurers pay for some aspects of integrative therapy, like acupuncture and chiropractic. But I haven’t heard of them covering exercise therapy before. 

William: I’m glad you asked that. Some insurers will actually approve exercise therapy if it is prescribed by the person’s primary care physician to manage a specific health condition. The doctor needs to write a letter to the insurer specifying what the condition is and how exercise therapy can be of benefit. Then it’s up to the insurer whether to approve it or not.

Exercise therapy may also be considered a qualified medical expense under an employer’s “cafeteria” plan (also known as IRS code 125.) Again, the patient would need to get a letter from his or her primary care physician specifying their underlying condition and how exercise therapy can be of benefit and submit it to the insurer. 

Lastly, if a person has a high-deductible health plan and a health savings account, they may be able to use their HSA dollars to pay for exercise therapy. But, again, it needs to be ordered by a physician to treat a specific health condition and approved by an insurer as a qualified medical expense. 

Kathleen: What sort of conditions might exercise therapy be used to treat? 

William: Exercise is beneficial for everyone! But exercise therapy is a more targeted approach that is tailored to each individual’s needs. So, for someone with knee arthritis, we would design a program to strengthen the muscles in the leg that support the joint. Someone with gait issues due to Parkinson’s disease would have a different set of exercises to help them with balance and fall prevention. It’s a very individualized approach with specific therapeutic goals.

Kathleen: And it also promotes brain health and helps prevent neurocognitive decline? 

William: Yes, absolutely. Exercise improves blood flow and oxygen and nutrient delivery to the brain, which promotes healthy brain function. It also enhances neuroplasticity, actually rewiring the brain and encouraging the development of new neural pathways. The more targeted the approach, the better the results.

Kathleen: Your background is in exercise science, and you’re a Certified Strength and Conditioning Specialist — a specialty that focuses on athletic performance for the most part. How did you become interested in working with people with neurocognitive challenges like Alzheimer’s, dementia and Parkinson’s disease?

William: I have actually been interested in this aspect of health and wellness since I was an undergrad at Western Michigan University. Part of the impetus was my experience with my Aunt Peg, who had Alzheimer’s disease. She started developing symptoms when she was quite young — in her late 50s or early 60s. So by the time she was in her 70s she was pretty much out of touch with her surroundings and hallucinating quite a bit. She kept telling us she saw John Gotti (the Mafia guy) in the room with her! I wanted to help but there was nothing I could do.

Then, some of my earliest clients were people who had neurocognitive disorders. There was one in particular that I recall, a man in his 70s named Ken who had Parkinson’s disease. He had all of the hallmark symptoms — tremors, an abnormal gait, a mask-like facial expression. Yet he benefited so much from a targeted exercise program that his grandson could not stop thanking me. That was gratifying, to say the least.

Kathleen: I’m sure! Is that what got you started writing books? 

William: To some extent, yes. I have always loved writing, and I have always wanted to help people to be their best selves. Being an author allowed me to do what I love to do and use my knowledge and expertise to help a lot of people at once. So it’s a great side gig for me.

Kathleen Clohessy: Can we talk specifically about improving brain health now? How does exercise help keep our brains functioning at “full capacity” so to speak? 

William Smith: Let me start by saying that if there’s a “silver bullet” that can help keep our bodies functioning and our minds sharp as we age, it’s exercise. Exercise not only improves blood flow and oxygen delivery to the tissues, but it can also help mitigate the damage caused by unhealthy behaviors, chemicals and inflammation. 

I’ll also add to that the fact that cognitive decline and dementia are not a “normal” part of aging. Some people are predisposed to it as a result of genetics and family history. But the real culprit is cell death and the failure of the brain to make new connections when brain cells die off. That’s what neuroplasticity is about, really. Creating new connections or new neural pathways within the brain. And exercise can definitely help with that. 

Kathleen: Is there a particular kind of exercise that improves brain health? Or is exercise itself the silver bullet regardless of what kind of exercise it is? 

William: The type of exercise a person engages in really doesn’t matter as long as it achieves the desired effect. For a healthy adult, walking at a leisurely pace on a flat surface probably isn’t going to accomplish all that much physiologically, although it’s still better than sitting in front of the TV.

What this means is that exercise needs to be challenging to have a positive effect. I use the FITT principles from the American College of Sports Medicine to design workouts for my clients. That’s an acronym for frequency, intensity, time and type. 

Kathleen: Can you expand on that a bit? 

William: Sure. Let me break it down.

Frequency is how often you exercise. The ACSM recommends a minimum of 150 minutes per week for a healthy adult, which translates to about 30 minutes 5 days a week. I actually recommend more than that. I believe everyone should engage in some form of physical activity every day. 

Intensity can be measured by heart rate or the “talk test.” For adults, a moderate intensity workout should get the heart rate up to about 100 to 110. But that varies by age and fitness level, so you might want to use the “talk test” instead. To do that, just gauge for yourself how hard it is to talk or sing while you’re exercising. If you can easily carry on a conversation, you are probably working at low to moderate intensity. If you can talk but not sing, you’re working moderately hard. If you can only gasp out a few words, you’re working hard. [Editor’s note: Check out this target heart rate chart for some guidelines on where your heart rate should be during exercise based on your age.]

Time, obviously, is how long you exercise. For aerobic exercise, that’s usually a minimum of 30 minutes. Strength training typically takes a bit longer.

Type refers to the kind of exercise you engage in. To be really effective, an exercise program should include aerobic activity such as walking, jogging or swimming; strength training; and exercises for flexibility and balance. It should also involve the three primary joints in the body: the shoulders, hips and the ankles.

Kathleen: That’s very helpful! Do you have any other lifestyle suggestions to help people maintain brain health as they age? 

William: I do! Here are the top three:

#1. I already mentioned this, but it’s important, so I’ll say it again. Be consistent! Make exercise a daily habit, and engage in some kind of targeted activity every day. 

#2. Limit stress. Stress leads to inflammation, which has a negative impact on brain health. That means you need to know what your triggers are and develop strategies to avoid them. For example, if you know you feel stressed (either mentally or physically) when you don’t eat well or don’t get at least 8 hours of sleep every night, take steps to eat more nutritiously and make sure you get enough rest. 

#3. Create a social support system. Isolation and loneliness are big problems in our society, especially for the elderly. They can lead to depression, anxiety and cognitive decline. Join a book club. Take an exercise class. Volunteer at a local hospital. Social support is the glue that can hold us together as we age. 

Kathleen: Those are great suggestions! Do you have any pointers for people who already have symptoms of dementia, or is your advice pretty much the same? 

William: As I mentioned earlier, it’s very important to work with a qualified exercise therapist who can develop a targeted exercise program that addresses specific symptoms. For example, people with Parkinson’s disease tend to develop plantar flexion (a problem with the feet) which puts them at greater risk for falls. So I work with them on a program to mitigate that risk.

That said, anyone can benefit from a program of regular exercise, even if a short walk is all they can tolerate. Again, just do something every day! 

Kathleen: Thank you so much, Will, for all the wonderful advice and for sharing your time and expertise. 

William: You’re very welcome. Thanks for the opportunity!