Industry and Advocacy Working Together to Raise ET Awareness

By Ramya Singh, Vice President – Americas
INSIGHTEC

March is National Essential Tremor Awareness (NETA) Month, a time specifically dedicated to educating the public on what living with the most common movement disorder really looks like. The team at INSIGHTEC focuses on this throughout the year as the innovator of focused ultrasound technology, an incisionless treatment option for certain people living with ET who do not respond to medications.

photo of Ramya Singh with Insightec

I just had a phone call from a woman desperate for information to help a friend of hers who is living with essential tremor, which is impacting his ability to live independently. We are inspired everyday by stories of courageous people sharing their experiences living with essential tremor. Our campaign this year is based on “Get a Grip on ET” and we are working alongside the International Essential Tremor Foundation with their efforts in “Raising the Curtain on Essential Tremor” so their voices are heard far and wide.

We share the stories of patients like Gregg. When Gregg’s essential tremor worsened, his livelihood as an electronics technician was threatened as he lost ability to use tools like a screwdriver. Determined not to let his hand tremor get in the way of his career, Gregg had the focused ultrasound treatment. Ever since, Gregg has been able to get back to performing everyday tasks with ease and can continue doing the job he loves.

There is not just one story, but thousands: Karen who went to the beach the day after focused ultrasound treatment . . . Haya who was able to get back to baking . . . Alexandra who is still amazed by her steady hand . . . Gary who was able to write a hand-written letter to his sister . . . Beverly who is back engaged with her photography . . . Bob who has been sharing his experience on Facebook.

By amplifying individual stories in awareness campaigns, we strive to increase understanding of essential tremor. We support the goal of “Raising the Curtain” to educate the public so they do not think that a person with tremor is nervous or drunk. We want people to recognize essential tremor is a challenging condition, but we also want to emphasize it is not the only thing that defines a person.  

Do you or someone you love live with essential tremor? We invite you to share your passion and what is essential to you in order to help more people understand that ET does not have to be the central part of one’s identity.

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Steadiwear is Raising the Curtain on Essential Tremor

Steadiwear has a personal interest in raising the curtain on essential tremor and helping those who have it live a better life.

Photo of Emile and Mark with Steadiwear
(From left) Mark Elias and Emile Maamary, the Steadiwear team.

While studying structural engineering at the University of Toronto, co-founder and CEO of Steadiwear Mark Elias visited his family over the winter holidays. As he was having coffee with his grandmother and discussing what his next steps were after graduation, he noticed a slight shake in her wrist. As she took her first sips of coffee, her tremors dramatically started to flare up. Her hands shook uncontrollably making her spill the coffee on herself. Mark rushed to her aid, only to find burns; it was shocking to see how difficult daily activities could become with hand tremors.

Mark decided to consult his aunt, a doctor who treats essential tremor, to discuss treatments and solutions. The only viable solutions at the time were medication, invasive surgery, and Botox injections. His structural engineering background began to kick in and he started brainstorming an alternative solution.

After countless nights of research and lengthy discussions with his aunt, Mark arrived at the ideation of the Steadi-One, the world’s first battery-free glove designed for hand tremors. A team was formed with his co-founder, Emile Maamary, whose family also suffered from tremors.

The team attended several support groups across Ontario and surveyed a lengthy list of stakeholders, including over 1,200 tremor sufferers, with high hopes of improving the lives of anyone with hand tremors and developing a worthy solution. Steadiwear’s first attempt of “raising the curtain on essential tremor” lead to starting a blog to address daily living with hand tremors. The recent launch of an online community support group on Facebook aims to build a stronger relationship with end users.

SteadiOne glove photo
Steadi-One

After significant testing, completing the regulatory requirements and multiple design iterations, the Steadiwear team launched pre-orders for the Steadi-One shortly after securing a third-party clinical trial. The Steadi-One is now available for purchase. In recognition of March National Essential Tremor Awareness Month, it is being offered at a discount price. The end goal is to help people with ET live better lives.

Learn more at the Steadiwear website or email info@steadiwear.com.

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Feline Friend Helps Owner Cope with Essential Tremor

Sheralyn Nicholson got much more than a pet when she adopted her cat, Willow. She got a caregiver and friend.

Sheralyn has essential tremor (ET). Her mom told her she first noticed Sheralyn’s tremor when she was in the first grade. But Sheralyn doesn’t remember life without it; she has never known anything different.

Nine years ago, she adopted a rescue cat through an ad on Kajiji (an online classified ad service popular in Canada). Her cat not only understands Sheralyn’s ET, but also tries to help her when her tremors are bad.

“She is patient with me,” said Sheralyn, who lives in Ontario, Canada. “When she sees my hand shaking, she puts her paw on it to steady it. She seems to know I’m struggling.”

But it’s not just Sheralyn’s shaking hands that Willow sees.

“When she sees my legs are shaking when I’m laying down, she lays across them to help calm them,” Sheralyn said. “It’s like having a weighted blanket. When I fall asleep she gets down.”

Studies show that animals can have a number of positive effects on humans. Human-animal interactions (HAI) have been known to increase oxytocin levels in people, according to the study Psychosocial and Psychophysiological Effects of Human-Animal Interactions: The Possible Role of Oxytocin (Beetz, Uvnas-Moberg, Julius and Kotrschal, 2012).  Oxytocin has been linked to anti-stress-like effects such as reduction of blood pressure and cortisol levels.

Sheralyn’s ET, like most, is familial. Both of her grandmothers had it, but much later in their lives. She’s thankful for the love and support Willow provides.

“Animals are amazing,” Sheralyn said. “They have a calming effect.”

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Instead of Thinking About My Tremors, I’m Focusing on the Warmth From Helping Others

By Barb Cole Smith
Support Group Leader,
Kalamazoo, MI ET Support Group

Holiday time is fast approaching. As I sit here contemplating the stress of the added responsibilities and work involved with Christmas time, and how that will increase my tremor level, I realize how much more productive I could be if I planned ahead. This leaves me more time to enjoy my family and friends, and the pleasure we could all have by being together, and less time to think about myself.

I could start by acknowledging that I brought some of this on myself and then think about how I can deal with things less stressfully. Rather than buying numerous gifts for all, buying just one gift, with a gift card attached might even be more appreciated. How much time could be saved!

Barb with her husband (far left) at her 8Oth birthday celebration. The couple is shown here with their son and daughter and their spouses; four of their grandsons; three of their great grandchildren; and a great granddaughter-in-law.

Perhaps even a theme, with a different restaurant gift card for everyone. My hubby and I could enjoy dining out at the selected restaurants, after a busy day, to avoid meal preparation that evening. Meal preparation and eating brings up so many unpleasant things. I have discovered that since I need so much help with preparation, selecting one-dish meals or things that could be heated easily have seemed to be the best answer. Using bowls with rounded edges instead of plates, and eating with heavy soup spoons help a lot. What should I do when I get an invitation to dinner at a friend’s home and worry that something might be served that I simply can’t get to my mouth? I suggest that we meet at a local restaurant where I can select my meal. Always explaining why. ET is nothing to be ashamed of but merely my way of life.

In preparing for this date, I try and make sure I am well rested and am in a good frame of mind. Using relaxation techniques could be different for all of us. Mine seem to center around music, either listening to it or playing the piano. It’s amazing what a difference this makes.

In thinking about the next few weeks, I promise to not spend my time thinking about myself but thinking about those who mean so much to me and how I can show my appreciation to them. Most importantly, I hope to seek out and help some less fortunate than myself. I truly feel that I won’t be thinking so much about my tremors but soaking in the warmth I get from helping others.

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This Song’s For You

By Nathan Frye

I have been a member of IETF for many years. I was diagnosed with early onset essential tremor that began when I was 16 years old. Of course back then my doctors would just say, “We don’t know why people shake” or “You are just a nervous Nellie.”

Photo of Nathan Frye

As an adult, I finally was properly diagnosed and received a lot of great information from the International Essential Tremor Foundation (IETF) which has really helped me. In my professional life as a school counselor, IETF gave me ideas on what to say when kids asked, “Why do you shake all the time?” or when adults would pull me aside as an intervention to ask what kind of crisis I was experiencing. 

Thank you, IETF. 

I am now retired but am focusing on writing instrumental piano music. I find that I have to modify how I play as things progress but it has been very therapeutic for me. I wanted to share an instrumental song I wrote that is about going through life with a great attitude and confidence even though I have essential tremor. It is called, “Shaking My Way Through.” I hope it brings you joy. 

(Click here to listen)
SHAKING MY WAY THROUGH

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ET, Exercise and Longevity

The question about whether or not to exercise if you have essential tremor comes up often. This article was written several years ago by Dr. Jankovic, who serves on our medical advisory board. But the information is worth reprinting.

By Joseph Jankovic, M.D.
Director, Parkinson’s Disease Center and Movement Disorders Clinic, Department of Neurology, Baylor College of Medicine, Houston, Texas

Any discussion of the management of a chronic disease would not be complete without emphasizing the importance of physical activity. Exercise has been shown to lower blood pressure, reduce obesity and prevent cardiovascular disease, but there is little data on the role of exercise and essential tremor (ET).

In fact, many patients with ET observe that their tremor is markedly exacerbated after strenuous physical activity or exercise and understandably wonder if they should avoid such activity.

As long as there is no cardiac, orthopedic or other contraindication, patients with ET should remain physically active. Be reassured that worsening of tremor after exercise is expected due to the outpouring of adrenaline (or epinephrine and norepinephrine) during exercise. Adrenaline, released during any physical or psychological stress, stimulates beta adrenergic receptors in muscle spindles, leading to increased muscle activity, manifested as worsening of tremor. This effect, however, is temporary and the tremor usually returns to its previous state after a few minutes of rest.

Alcohol and propranolol, a beta adrenergic blocker, can reduce stress-induced exacerbation of ET, hence the two drugs are often used to “calm” the nervous system.  Even professional actors often use propranolol to minimize the tremor effects of anxiety associated with stage fright.

Many studies have shown that exercise benefits not only the body but also the brain. It has been shown to improve learning, memory, and depression; it also appears to protect the brain from neurodegeneration. [Cotman et al, 2007].

Although Parkinson’s disease is different from ET (despite the occasional overlap of the two disorders), studies on exercise in Parkinson’s disease may be relevant to patients with ET.

In a prospective study of 48,574 of men and 77,254 women, higher levels of physical activity was associated with lower risk of Parkinson disease [Chen et al, 2005].  Based on systematic literature review, the Practice Recommendations Development Group from The Netherlands concluded that there is sufficient evidence to recommend physical therapy and exercise to improve balance, and training of joint mobility and muscle power and to improve physical capacity of patients with Parkinson disease [Keus et al, 2007].

There are many other studies that provide evidence exercise may be helpful in improving motor function [Kwakkel et al, 2007], although firm evidence that exercise lowers the risk of Parkinson disease is still lacking [Logroscino et al, 2006].

Exercise may prolong life not only by preventing or reducing the risk of life-threatening disorders, but also by slowing the aging process. One of the most compelling arguments in favor of exercise as an important anti-aging factor is the recent finding that leukocyte telomere length, a biological indicator of human aging, correlates with exercise.

In a study of 2,401 twin volunteers, comprising 2152 women and 249 men, who were asked to complete detailed questionnaires about their level of physical activity, smoking status, and socioeconomic status, the leukocyte telomere length was 200 nucleotides longer in the most active subjects as compared to the least active subjects during their leisure time (P<.001), even when adjusted for age, sex, body mass index, smoking, socioeconomic status, and physical activity at work.

It has been postulated for a long time that patients with ET live longer than those without it. The Russian neurologist, Minor, suggested in 1935 “that a factor for longevity was also contained in the tremor gamete.”

In a study published in 1995 it was found that parents of ET patients who experienced tremor lived on the average 9.2 years longer than those parents who did not have tremor. Since the parents with tremor who lived longer probably had ET, we concluded that ET confers some anti-aging influence and significantly increases longevity.

  • While there is no obvious explanation for this striking observation, it is possible that: patients with ET have an underlying personality trait that encourages dietary, occupational, and physical habits that promote longevity.
  • Perhaps, the small amounts of alcohol to calm the tremor might prolong life.
  • Finally, the tremor itself might be viewed as a form of exercise that would have beneficial effects on general health and on longevity.

Further studies are needed on the potential anti-aging effects of ET, and whether exercise confers additional benefits by favorably modifying the course of the disease.

References

Cherkas LF, Hunkin JL, Kato BS, Richards JB, Gardner JP, Surdulescu GL, Kimura M, Lu X, Spector TD, Aviv A. The association between physical activity in leisure time and leukocyte telomere length. Arch Intern Med 2008;168:154-8.

Cotman CW, Berchtold NC, Christie LA. Exercise builds brain health: key roles of growth factor cascades and inflammation. Trends Neurosci 2007;30:464-72. Trends Neurosci 2007;30:489.

Chen H, Zhang SM, Schwarzschild MA, Hernan MA, Ascherio A. Physical activity and the risk of Parkinson disease. Neurology 2005;64:664-9.

Jankovic J, Beach J, Schwartz K, Contant C. Tremor and longevity in relatives of patients with Parkinson’s disease, essential tremor, and control subjects. Neurology 1995;45:645-8.

Keus SH, Bloem BR, Hendriks EJ, Bredero-Cohen AB, Munneke M; Practice Recommendations Development Group. Evidence-based analysis of physical therapy in Parkinson’s disease with recommendations for practice and research. Mov Disord 2007;22:451-60.

Kwakkel G, de Goede CJT, van Wegen EEH. Impact of physical therapy for Parkinson’s disease: A critical review of the literature.  Parkinsonism and Related Disorders 2007;13:S478-S487.

Logroscino G. The role of early life environmental risk factors in Parkinson disease: what is the evidence? Environ Health Perspect. 2005;113:1234-1238.

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Preparing for Your Doctor’s Visit

By Dr. Rodger Elble,
Department of Neurology
,
Southern Illinois University School of Medicine

Preparing for your visit with a movement disorder specialist will increase the odds of accurate diagnosis and appropriate treatment at an affordable cost. A complete and accurate medical history is crucial.

rodger elble photo

Here are some things you can do to facilitate a successful clinic visit.

1.  Prepare a written chronological history of your problem. What was your initial symptom (e.g., hand tremor) and when did this symptom begin? It is important to estimate the time or age of onset as accurately as possible. This may be long before the time when your tremor and other symptoms became disabling or really bothered you. Describe how the tremor started (e.g., suddenly or gradually) and how the tremor has progressed. Which areas of your body were affected initially and subsequently? Has there been a recent or rapid worsening? If so, was this associated with other events or medical problems (e.g., a new medication)? Note any changes in your balance, coordination, gait, and speech. Tell your doctor about any involuntary movements other than tremor (e.g., body jerks, twisting movement of the neck or limbs).

2.  Note any medications, substances or circumstances that make your tremor better or worse. Prepare a list of all treatments you have tried for your tremor.

3.  Prepare a family history. Document any relatives with tremor or other neurological conditions such as Parkinson’s disease, dementia, dystonia, ataxia, neuropathy, etc.

4.  Prepare a list of past medical problems and note whether they had any effect on your tremor. A recent medical summary from your primary care physician will be helpful. Bring a complete list of current medications and their dosages. Your pharmacist can help you with this.

5.  Be prepared to discuss how your tremor affects your daily life. Which activities are affected most? How has your handwriting changed? How does tremor affect your occupation and social life? Has your tremor affected you emotionally? Have you been depressed? You should be as accurate and candid as possible.

6.  Do not stop any medication unless requested by your doctor.

Your doctor will perform a thorough neurological examination to assess tremor severity and look for abnormalities other than tremor. Patients referred for essential tremor frequently have some other condition that is revealed by a careful neurological exam. There is no test for essential tremor.

At the end of your visit, make sure you understand your diagnosis and treatment options. Ask questions. Discuss your goals and expectations with regard to your tremor, but understand that available treatment is not always adequate. Consider participating in a research study if one is available and appropriate for your condition. Ongoing and recently completed research studies can be found online at ClinicalTrials.gov. 

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The Best Caregivers Practice Self-Care

“You cannot serve from an empty vessel” ~Eleanor Brownn  

Carla Cheatham PhotoBy Rev. Carla Cheatham, MA, MDiv, PhD, TR

When we care for a family member, taking time to care for ourselves can be especially hard, assuming the resources are even available to allow us to do so. We do not want them to think they are a burden. We might feel sad for what they are going through, wishing we could fix it and make it all better.

We may feel selfish about stepping away for a bit of respite because they do not get to take a break from their illness, so why should we? We often feel compelled to push ourselves harder and further than is healthy, mistakenly seeing self-care as a luxury or feeling guilty for taking time away.

Selfishness is when we take care of our own needs at another’s expense. Self-care is when we take good care of ourselves so we CAN show up well for others. Exquisite self-care is our first and greatest priority if we wish to be good caregivers.

When we do not put our own oxygen mask on first, we can help no one and are more likely to develop compassion fatigue, the emotional and physical state that occurs when the amount of care we are taking in isn’t enough to make up for the care we extend.

Setting too high of expectations for ourselves can leave us feeling something is wrong with us, but humans under stress can get impatient, short-tempered, and long for our situation to be different. That happens, but will be less likely if we take in what we need to maintain our internal resources.

National Family Caregivers Month logoWe may feel powerless to change our circumstances and get the full support we need and deserve, but we are not helpless to take action on our own behalf. Even with very little time to ourselves, we can find mini-moments throughout the day to lower our feelings of stress and increase calm in our bodies and brains.

4-square breathing—Using your heartbeat as a timer, breathe in for the count of 4, hold that breath for 4, breathe out for 4, and hold for 4. You can do 3-4 of those in about a minute a couple of times a day.

Hand washing ritual—As caregivers, we wash our hands often and experts recommend doing so for 25 seconds. Take that time to breathe, feel your feet on the floor, soften your belly and torso, and lower your shoulders away from your earlobes where they’ve crept up due to stress.

 Waterfall doorway—Pick a doorway you walk through often. Imagine a waterfall coming down through that doorway washing off the stress of the day collected to that point to keep from accumulating it all day long.

 Common cues—Pick a common object, like a penny or a certain type of bird. Each time you see one, pause for 5 seconds and check in with the committee in your head to see if negative or self-defeating messages are running through your brain. If so, change the narrative with a positive phrase, mantra, or prayer repeated over and over again for a few more seconds until you feel a positive shift.

Phone a friend—Call someone you trust to talk about anything else other than your struggles and stressors. Even 5 minutes with someone who reminds us we are part of a larger world beyond the circumstances of our current moment can help to center us.

Three Good Things—Research has shown if, within one or two hours before sleep, we write down three good things that happened during the day and what made those moments positive, we sleep better and our rates of burnout go down substantially. Do this for 14 days. It only takes a few moments and re-trains our brain to see the positive as well as the negative our brains can so easily focus upon.

ABC’s of Gratitude—When we most need to practice gratitude is often when we feel the least grateful. Name something that begins with each letter of the alphabet for which you are grateful.  Even if our list starts frustratedly with apples, bananas, cats, and dogs, by the time we get to wisdom, yogurt and zebras our perspective will have shifted and we can feel the difference inside.

Hopefully something in these words has given you a couple of tools and encouragement to help you walk this journey. You and your loved ones deserve all the support and moments of peace you can access along the way.

*  *  *  *  *

Carla Cheatham is the principal and lead trainer for Carla Cheatham Consulting Group, LLC and serves as a national keynote speaker and educator teaching in the areas of clinical presence and attunement, compassion fatigue and resilience, ethical spiritual and existential care, grief support, ethical boundaries and healthy teams, and more. She publishes two blogs through CarlaCheatham.com and HospiceWhispers.com. She is the author of Hospice Whispers: Stories of Life and its companion piece, Sharing Our Stories: A Hospice Whispers Grief Support Workbook.

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Being ‘Mindful’ May Help in Managing Essential Tremor

By Dr. Michael Braitsch, PT, DPT
Tribe Wellness, LLC

Photo of Michael Braitsch, Tribe WellnessIf you’re like me, you’ve heard over and over again the value of mindfulness. It’s become quite a popular buzzword in a variety of manners of marketing. As we enter the next frontier of neuroscience and brain health, it seems like you can’t go anywhere without hearing about mindfulness. But what does mindfulness really mean and how can it be useful in daily life or in managing life with a tremor?

As a physical therapist, I have seen time and again the role of increased stress ramping up the severity of a patient’s symptoms (whether it be chronic pain in someone’s lower back, the amplitude or frequency of a tremor, the incidence of freezing gait in someone with Parkinson’s disease – the  list goes on).

I’ve met many people though with an essential tremor who usually say something like, “If I really focus on it, I can kind of calm my tremor down.” This is mindfulness!

The even better news is that practicing mindfulness can have far reaching benefits to improve quality of life with or without a tremor. It makes good sense. When we are calmer, we learn better, we perform better, we are less distracted, and we can even tap into a level of subconscious skill to make life easier.

While this all sounds great, I’m also here to warn you that it takes some effort and consistency; however, we all know that most worthwhile things in life take some effort. The intention of this blog post is to clarify what mindfulness practice is and how it could be helpful.

What is Mindfulness?
Many people consider the practice of mindfulness as simply, being aware of the present moment and the task-at-hand. Merriam-Webster’s dictionary defines mindfulness as:

“1 : the quality or state of being mindful

2 : the practice of maintaining a nonjudgmental state of heightened or complete awareness of one’s thoughts, emotions, or experiences on a moment-to-moment basis “

So “mindfulness” is really a practice. It’s NOT a destination. It has a lot of similarities with meditation or directed thinking which is common in all religious beliefs, to quiet the mind you don’t have to run off to the mountains or join a monastery. Rather, mindfulness provides a method of intentionally directing one’s focus to the task-at-hand, while avoiding judgment (both good and bad).

Let’s break each of these down further.

Focus on the Present
An increased focus on the present moment is a heightened commitment to directing one’s attention to the task-at-hand. Even though the mind may wander, coming back to the present is the key for mindfulness. We are all human beings and have a natural tendency to consciously or unconsciously drift into other thoughts, but coming back to “right now” is the goal of this practice. Oddly enough, in a world where multi-tasking is everywhere, mindfulness practices teach us that we are more effective and more efficient when we slow down and focus on what we are doing.

Be Non-Judgmental
Each day we make thousands of decisions. For the sake of survival of the species, we have an evolutionary drive to constantly judge things as good or bad, helpful or harmful, useful or a waste of time. Using our “fight or flight” response has served us tremendously for thousands of years. This is often the hardest part of mindfulness. Reinforcement of use of the “fight or flight” hardwires us to rush ahead to the next moment. However, when we lose sight of the present and constantly let the mind race, neuroscience tells us that we strengthen our brains’ stress responses to everyday tasks. On an extreme level, a heightened stress-response can have far-reaching negative effects. While it’s helped humanity to survive, we’ve become hardwired to get bogged down by incessant mental chatter. Mindfulness shows us that we can remain focused on the task at hand without judgment, and on a very practical level, rewiring our brains from training a ”stress-response,” to instead, training a “relaxation response.”

As we strive to increase our focus and to quiet the mind, we can find an abundance of benefits from improved awareness. We can even gain insight into why we feel a certain way or perhaps a deeper level of relaxation. This training has a powerful effect on our autonomic nervous system. By choosing presence and mindfulness, a hyperactive brain or a hyperactive nervous system can be slowed down, leading to a wealth of benefits including improved cardiovascular health, improved cognition, and more!

But What About My Tremor?
Managing stress is great for everyone. For someone with a tremor, it can be even more helpful. Most people I’ve met who are dealing with essential tremor say something like, “my tremor gets worse when I’m stressed out.” Stress and depression can even create a negative cycle that increases the tremor currently, and because of embarrassment about worsening of the tremor, causes more stress and depression. While there have not yet been studies on practicing mindfulness as a means of managing essential tremor, there have been many anecdotal reports of it helping. It stands to reason that even if mindfulness did nothing for the tremor itself, the already established far-reaching benefits make it worth the effort until a study can show what so many people have already reported. Why not give yourself a chance to reduce stress and feel good, right?

Can I Practice Mindfulness While Exercising?
Now for my favorite topic. . .there are forms of exercise that harness and foster a mindful approach while also striving to calm the mind and strengthen the body. As a physical therapist, my life’s mission is to help people move better and feel better. The research on the role of exercise in managing stress is abundant to say the least. As a long-time martial artist, I’ve seen first-hand the changes that can occur with dedicated practice of martial arts and the increased sense of well-being that students develop. Tai Chi is easily the most common form of martial art with emphasis on mindful practice because it is low-impact, easy to modify, and because it focuses on breath with movement. Alternatively, yoga has provided an avenue for mindful training for centuries and pilates also employs a mindful approach to movement, capturing the benefits of mindfulness and exercise.

What Else Can I Look at to Learn More?
Mindfulness resources are everywhere! There is no shortage of resources when it comes to mindfulness. The best practice though, like the best exercise, is the one that you can do consistently.

Here are a few to start with:

 

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