Welcome back to the Healing Pain Podcast with Laverene Garner, PT, DPT

In today’s episode of Healing Pain Podcast, Dr. Joe Tatta is joined by Laverene Garner, PT, DPT, to discuss how to treat comorbid chronic pain, orthopedic conditions, and neurologic conditions. Dr. Gardner is a board certified neurologic clinical specialist, and currently works as an assistant professor in the Department of Physical Therapy at Winston-Salem State University. Prior to her role as professor, Dr. Gardner developed the vestibular therapy, mindfulness and integrated health components of a concussion recovery clinic at Camp Lajune, where she treated individuals with chronic neurologic conditions. On today’s episode, we discuss how Dr. Gardner’s passion for integrative healthcare shaped her early career and research interests, why exercise intensity matters in neurologic conditions, how to prescribe physical activity for individuals with neurologic problems, and a lot more.

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How To Treat Neurologic And Orthopedic Conditions With Laverene Garner, PT, DPT

Why Intensity Matters

We are discussing how to treat comorbid chronic pain, orthopedic conditions, and neurologic conditions with Dr. LaVerene Garner. She is a board-certified neurologic clinical specialist and works as an assistant professor in the Department of Physical Therapy at Winston-Salem State University. Prior to her role as a professor, Dr. Garner developed the vestibular therapy mindfulness and integrative health components of a concussion recovery clinic at Camp Lejeune, where she treated individuals with chronic neurologic conditions. Dr. Garner teaches Doctor of Physical Therapy students how to provide evidence-based care for those with pain as well as orthopedic and neurologic conditions.

In this episode, we discuss how Dr. Garner’s passion for integrative healthcare shaped her early career and research interests, why exercise intensity matters in neurologic conditions, how to prescribe physical activity for individuals with neurologic problems, what special interests or considerations should be made, how to promote neuroplasticity in Parkinson’s disease and multiple sclerosis through diet and nutrition, how lifestyle-based interventions can improve the function and health of the nervous system, and finally, how to empower people to take control of their health and long-term recovery.

Dr. Garner did write a chapter on neurology in the Integrative and Lifestyle Medicine in Physical Therapy textbook. If you are following along with that textbook and you would like to learn the keys to a healthy nervous system, make sure to check out Chapter 15. You can buy that text on Amazon or at OPTP.com. Without further ado, let’s begin and meet Dr. LaVerene Garner.

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LaVerene, welcome to this episode. It’s great to have you here.

Thanks, Joe.

I’m excited to speak with you about the intersection of this dual diagnosis of caring for, treating, and evaluating a person who has both orthopedic and neurologic problems. It speaks so well to what we do here on this show and what we do as pain professionals. Oftentimes, you even hear people say, “It’s a neuromusculoskeletal pain or a neuromusculoskeletal condition.” As a physical therapist and a neurologic-certified specialist, this is your bread and butter. Tell me a little bit about yourself and how your personal and professional experience as a PT brought you to where you are here.

I have been a PT for years now. I work as an assistant professor at Winston-Salem State University in their PT department. Interestingly, I started with high aspirations of wanting to be a manual therapist. I took a lot of manual therapy courses early in my career but never made it to be certified or anything. I spent the majority of my first seven years as a PT working in largely orthopedic clinics but occasionally, for short bursts of time, I worked with the neuro population.

I moved to Jacksonville, North Carolina, where Camp Lejeune is, and ended up being the only person in town that worked with people with vestibular problems. I ended because I had this neuro experience combined with orthopedic experience treating a lot of people post-concussion. That led me to appreciate the intersectionality of the way the brain impacts pain and vice versa.

Tell us about Camp Lejeune a little bit since you breezed over that but I’m curious about your experience there and what the camp attendees were like.

Camp Lejeune is a Marine Corps base. I ended up going to work on base after working in the civilian sector there for a long time. I helped start and develop an interdisciplinary concussion recovery program, particularly the vestibular and then the yoga and meditation components of the program as well. People that have had a lot of concussions tend to have a lot of chronic pain complaints as well. The military population is carrying a lot of gear. They often have a lot of low-back pain complaints that are chronic in nature with trauma histories. It’s a very complex population.

I had the opportunity there to co-treat and develop mindfulness and Cognitive Behavioral Therapy programs that combine yoga with mental health professionals and also chaplains. It was an actual, highly integrative place to provide care and to learn and grow as a clinician. It gave me a profound understanding of the complexity of human existence.

When we hear things like TBI, people may or may not be familiar that there are higher rates of vestibular problems in the TBI population but chronic pain is something new. We often don’t think that if you have a TBI, it’s a risk factor or the prevalence is higher for developing chronic pain. Can you make some of the connections for us? On this show, we hear that pain is a nervous system/brain problem but what is it about the TBI experience or the TBI injury that leads to that central sensitization that all of us are so familiar with?

One of the first things that happen is that TBI is a trauma. The brain stores it as trauma sometimes. I have a skewed lens when it comes to concussions because everyone that I see has chronic symptoms. Most people recover fine but the people that I have worked with did not. First of all, there’s trauma. I’m not the leading expert on chronic pain management but when you hear leading experts talk about it, they talk about the event. If it’s stored as trauma, it can contribute to chronic pain.

That is the first thing. The second problem that’s frequently associated with chronic pain is autonomic dysregulation. That’s common post-concussion. The ability to downregulate the nervous system doesn’t always return to normal. Sometimes there has to be specific attention paid to that. The head is attached to the neck. When you have a concussion, you often have cervical problems as well.

For orthopedic therapists, maybe they are at least familiar with the oculomotor system. When someone’s oculomotor system is not working well, it can lead to eyestrain and tension headaches in addition to cervical problems. It’s important that all of these things are treated well, that the person’s symptoms are not minimized, and are validated at the onset of injury if they are having symptoms. Otherwise, this cadre of issues is mixing together. It leads to real problems for people that are difficult to treat if they are not managed appropriately upfront.

I love the way you put all those pieces together. I can hear a piece of Polyvagal theory that even sits in there because you are talking about trauma, the autonomic nervous system, and chronic pain. There have been a couple of papers that applied the Polyvagal theory to the development or the persistence of chronic pain. All this experience that you had sounds like it was key to shaping this integrative biopsychosocial approach that you now have as a professional.

I frequently say that I owe a tremendous amount to the people, the military, the individuals, and the service members that I got to treat because they taught me so much. I feel like I didn’t necessarily deserve to learn but through their lived experiences, they gave me huge gifts as a therapist that I’m responsible now to pay forward.

The yoga came into your practice and to this approach at Camp Lejeune because it sounds like part of that was targeting that autonomic regulation or dysregulation that people were experiencing. Was that key in their rehab program?

One of my favorite approaches to yoga overall is understanding the koshas. Lots of the people that I worked with at Camp Lejeune also experienced an inability to connect meaningfully with family members and life again. They would have this spiritual wound or injury that happens. Yoga was a way for them to relax for a little while, learn to move again without experiencing pain, and understand that they have some control over their life. The behavioral health therapists, psychologists or social workers that would be there with me would be often doing additional coaching about specific things that people could do to connect from a joyful perspective in their lives as well. It was a holistic way to work with people.

Was the mindfulness component part of the yoga? Was it a separate class or session?

My meditation training has been primarily with iRest Yoga Nidra. I don’t know if you are familiar with that or not.

Tell us what that is.

iRest Yoga Nidra was developed by Richard Miller, who is a clinical psychologist. Yoga Nidra is a play on words. It’s waking up to the fact that we have been asleep. In iRest, the I is little. It’s putting the ego to sleep and becoming aware of things that are controlling our lives so that we can choose the most auspicious way to move forward. This is the meditation that I am most frequently taught. The military service members loved it because they could rest and find a place of peace to be in for a little while.

As you are talking, you are sitting in your office at the university. You teach in a DPT program. I’m going to veer for a moment off of the topic of ortho and neuro problems in our patients. Have you been able to implement some of that mindfulness into the curriculum with your students?

Interestingly, I am advising them through their comp exam that they have to pass to get through our curriculum. One of the things that I talk to them about now is how to self-regulate so that they can make the best choice possible on the test. This is low stakes in the grand scheme of life but I have them work with mantras oftentimes, develop something they can say over and over to themselves during the test, and then learn to self-regulate through their breath so that they can calm themselves down if they get anxious.

That’s great because it’s so important that those pieces are in the programming that early student physical therapists are exposed to both for their physical and mental health and then when they start to practice. This can be key for the different types of conditions and diagnoses that we are talking about. You like to talk a lot about intensity and why intensity matters. Why is that an important topic when we discuss people with both pain and comorbid neurologic conditions?

There has been a lot more research in relation to PT for people with neurologic problems and physical activity. If we talk about people with Parkinson’s disease, for example, a lot of the research now points to the benefit of moderate to high-intensity physical activity. Moderate to high-intensity physical activity can help slow down the progression of motor symptoms in people with Parkinson’s disease. It’s important that they do it.

If someone comes in with pain, it may be sometimes the tendency, especially of a young practitioner, to tell people to stop doing exercise. Instead, it’s important that even if someone has pain, we recognize that for people with neurologic problems, especially in this case, Parkinson’s disease, we need to find a way for them to still move. Even if it’s the arm bike, it doesn’t matter what the activity is. It’s the intensity that matters and vice versa with people with concussions also need to do physical activity in a small dose but it’s the opposite.

They may need to start with something at a lower intensity so they can be successful and then slowly scale up the intensity of the activity to improve the autonomic regulation of their heart rate when they are doing an activity. Those are two examples I can think of right off the top of my head of why intensity is important. It’s important with people with neurologic problems that we understand how not engaging in physical activity even though someone is experiencing pain can worsen their outcomes long-term if we tell them to stop moving.

It’s interesting because it speaks to using a prescriptive form of exercise. You gave two different examples there, one with a group of Parkinson’s patients where they need moderate to higher intensity. Most people might say it was the opposite, that people would need lower to moderate because, at times, people with Parkinson’s can be older and perceived as frailer but they don’t have to be doing jumping jacks or running. You can achieve a high-intensity exercise by using equipment or other means versus the traumatic brain injury population. You might have to start slower and build strength and resilience as they move along.

It’s a little bit of a paradox there because people see most people with a chronic health condition as, “They shouldn’t do too much. They shouldn’t do a level of intensity that might affect them in some adverse way.” Do we know the science behind why moderate to higher intensity helps Parkinson’s versus a lower intensity? Oftentimes, Parkinson’s patients wind up in a gentle yoga class, a gentle Pilates class or something like that, which tends to be a lower intensity but you and your researchers are saying something different.

It’s not my research. Margaret Schenkman did a great study on people doing treadmill walking. There’s another study that talks about high-intensity biking, which is commonly used in people with Parkinson’s disease. The rationale is still developing in the literature but it seems that possibly, it’s related to BDNF. The production of BDNF that happens promotes neuroplasticity within the nervous system but I thought you would like this because you are a nutrition guy.

There are growing bodies of literature that talk about the gut dysbiosis that happens in people with Parkinson’s disease. Some of that is purportedly also possibly linked to pain. Educating people on things like the Mediterranean diet and stuff like that may also help with managing pain in that population and help to control inflammation. The same can be true with people with MS. It’s important also that there’s this holistic approach to the way we are working with people. Integrative lifestyle medicine lends itself well to that overall.

That’s perfect because what you are saying is for us to optimize the nervous system. Many of these conditions may, research is still building, start in the gut. There’s some research that with Parkinson’s disease, there may be pesticides that are on plants that we are eating and ingesting. That’s how it’s entering through the gut track, up the vagus nerve, into our brain, and perhaps the portal circulation.

There’s an aspect of healing the gut that would come into play but there’s also this aspect of exercise where you can upregulate brain-derived neurotrophic factor, which is important for that neuroplasticity. We want to make sure that we can grow new synapses and connections and promote neuroplasticity. I always love tackling things from two different avenues because people are eating all day long. There’s an opportunity for us to help them there. People should be or hopefully are moving their bodies all day long for us to help them.

Movement is the way we connect with the world around us, whether we are moving in a wheelchair, on our feet or with a walker. It’s how we typically engage in relationships. One of the big things people with neurologic diseases face is immediate when they get the diagnosis. There’s a psychospiritual injury that happens right away because this ball is dropped on them that they have to carry or choose to carry. Maybe an insightful healthcare provider can help them put down and learn to navigate life with this health condition artfully. If movement is not a big part of their plan of care in a way that is targeted for their disease process, then it can make it harder for the person to live a good life for a long time.

You mentioned psychospiritual aspects. You mentioned it early in the episode too. I put a little tag on it and let it go, and then you brought it back up again. I want to touch on that for a moment. When we think about people with trauma, and it sounds like you’ve worked with veterans in the military who have had physical as well as psychoemotional traumas, why is it important for us to keep that into consideration? How does that begin to connect with what we do as healthcare professionals? People would say, “How do movement and exercise connect to my psychospiritual essence?”

I had the benefit of co-teaching with a chaplain at Camp Lejeune. One of the things he used to talk about was that spirituality is impacted by our ability to connect with the world around us in a meaningful way. When I talk to my students about why people come to physical therapy, it’s never to address impairment. No one cares that they have decreased shoulder range of motion.

Let’s stay on that for a second because we have a very impairment-focused profession. It sounds like you and I are on the same page with that. We have changed dramatically as a profession. The ICF still has somewhat of an impairment focus but what you are saying is that there are impairments, and we shouldn’t ignore those.

We should not ignore them.

People aren’t necessarily coming in saying, “I’m lacking 35 degrees of external rotation out of 45. This is a real problem in my life.” If they are not coming in with that in mind, what are they coming in with in mind?

The people that I work with come in with worry that they are not going to be able to participate in their life or fall, and they are scared they are not going to be safe to function in the community. They want to be able to go to church or play with their grandkids. It’s never about their foot drop, not necessarily. It may be about their foot dropping and tripping when they walk to the grocery store. We have to address the foot drop issue.

It’s not that impairments aren’t important but it’s not the driving factor. It’s not the salience that is sending someone to therapy and promotes neuroplasticity. When we think about the principles of neuroplasticity, salience is one of them because people pay attention better when they care about something. We can all get better outcomes in physical therapy if we are intentionally goal-setting with our patients in a way that is shaping their time in physical therapy toward meaningful activity instead of just addressing an impairment.

If I hear you right, there’s a piece in there about valued life activity domains, being a productive member of the community, being a part of a social system with friends and family, being able to engage in employment or potentially education in school. We, as professionals, PTs, and other health professionals, should keep those value life domains in the back of our minds and the room with us. In the container of that, we’re treating it with the patient. That’s how we set our goals. There’s another piece in there when you start talking about spirituality that starts to discuss or tap into the idea of identity and autonomy for people and how important that can be in someone’s recovery.

That’s important for motivation. Having the ability to make choices about one’s plan of care or goals was a big area of learning for me. I did a study on medical therapeutic yoga for people with MS several years ago. I let patients set their goals. I didn’t even look at them. That was a very novel thing for me to do. I was like, “I’m going to let go of control and let people do this,” but people could set goals that were salient and meaningful to them. We coached them through how to set SMART goals. They did a great job. That salience piece and letting people have the ability to choose and be solid partners in a plan of care helps internalize motivation. It also helps them build self-efficacy.

I wonder how much stress it took off you as a professional that they were allowed to develop that piece on their own. That’s a patient-centered way to look at things because they are guiding their care and their recovery process.

There’s this guideline or this clinical tool that we can use in stroke recovery called the Goal Attainment Scale. That’s how therapists coach people on how to set their goals through the scale. I’ve always thought it would be great if it were used in chronic pain because it makes sense to allow people to learn. One of the things that we do in neuro clinical practice or that I try to do is to set a big goal and then show patients how they are going to take the step-wise goals. They are going to walk up the staircase to get this bigger goal they want to achieve. That’s one of the things that the Goal Attainment Scale does. Goal-setting was one of the things when I was planning for this that I felt was important to talk about.

We talked a little bit about physical activity and the promotion of exercise. What are the barriers that sit in the way of the physical therapists from helping, promoting or counseling on effective physical activity promotion for this particular population?

Overall, physical therapists tend to have poor self-efficacy in prescribing physical activity for community-dwelling adults and older adults. That doesn’t include people with neurologic problems. There’s a lack of awareness on how to promote exercise or physical activity in this population, and the fear that they are going to hurt someone or going to fall. We need to do what we can and what we are comfortable with the individuals that we are working with and make sure in some way, within any orthopedic precautions they might have, that we are sending them onto some physical activity.

Another is biased. It’s interesting because you brought up earlier how the tendency would be to think a person with Parkinson’s disease should do low-intensity physical activity and a person with a concussion that’s an athlete should do high-intensity physical activity. The goal for the person with a concussion that’s an athlete is to get back to high-intensity physical activity but there are all these systems impeding their progress like the oculomotor system, cervical, and so forth.

We have to start them and walk them through that process. I talked about this in a lecture. I have to recognize my internal bias with physical activity, what is valuable and not valuable to me, and recognize that in the end, it’s about the patient being the best version of themselves that they can be. It’s my job to walk with them on that path. I have to recognize my bias and think about how I can best prescribe exercise to meet that person’s needs and what’s also in line with what the literature says.

Another thing that is a big problem is a lack of accessible equipment. Fitness facilities overall and communities are not set up well for people with neurologic problems to walk in the community. For people with MS, for example, it’s important that fitness facilities are climate-controlled because of their heat sensitivity. For people living life in a wheelchair, the built environment impacts their ability to access the community.

We have drilled down some of the details. If I wanted to choose a couple of general health-promoting activities that all of us should be aware of, those of us that are healthy and those of us with orthopedic problems, pain, and neurologic problems, what are the general lifestyle recommendations, and healthy habits and behaviors that we can begin to implement to keep our nervous system functioning in a way that is healthy for our lifestyle?

Getting healthy sleep is important. Engaging in habits that are healthy from a sleep hygiene perspective is valuable for many different people with neurologic populations but it’s also important as a preventative measure. Eating a plant-based diet is great because it helps control inflammation. That’s one. Physical activity is another one. It’s interesting because I don’t think any of these things necessarily prevent any one disease from happening or is a failproof thing for every single person but when you start putting all of these together, it can improve someone’s well-being.

Those would be three that I would say are important. Overall, it’s avoiding head injuries and spinal cord injuries, especially for young people. It’s educating younger individuals on what can happen if they are in a car accident so that they understand maybe a little bit more about the ramifications of catastrophic car accidents. We should have these conversations instead of shying away from them.

A lot of physical therapists are more involved in the TBI space and things like helmets and other protective equipment or even exercise programs to try to build up resilience should those things happen. Those are important components but probably not as important as the ones that you’ve mentioned. Early on, we spoke about mindfulness. Does mindfulness have a place in optimizing the normal health of our nervous system?

Being able to upregulate and downregulate your nervous system equally well is valuable. One of the things that I frequently tell my students is that they are all experts in upregulation. They spend all this time with their sympathetic nervous system on overload but then something happens, and they can’t move. You have an injury. The movement can’t be the way you deal with it.

Being able to practice mindfulness or meditation practice in general, having control of your breath, and being able to use that so that you can still navigate life from a place of peace is important. I’m glad you brought this up. For people with neurologic problems, it’s also very important that they gain this mindfulness piece because, at some point, there’s probably going to be a time when they have a fall that’s going to keep them from being able to move in the way they want to. Being able to still have a sense of self-worth and value and navigate that time artfully is challenging if you haven’t practiced it before you have the life experience.

In the military environment, maybe they are teaching these skills earlier on but for these young men and women that have served their country, teaching them after the fact when their nervous system is in a state of disarray is much more difficult than it is if they were taught on the front end how to practice mindfulness, breathwork or some meditative technique to help them self-regulate.

You are saying that we should be able to experience both ends of the spectrum of our nervous system function, both the downregulation or the more paused and relaxed aspect of our nervous system, and be able to access when we need to how to upregulate our nervous system activity, and then probably at some point, be able to find all the various points in between that we go through sometimes on a normal daily basis.

If you are going to work in the morning and you wind up in traffic, the nervous system gets upregulated, not as upregulated as when you might be in a car accident, let’s say. Being able to notice and observe each of those states as distinct and then having the tools to regulate your nervous system in and out of all those states is part of being a whole human.

It’s part of the messiness of being human and being able to embrace that. This is a very vulnerable activity for me to be on a show. I have to do both. I have to try to manage and ground myself. I practice breathing while I’m here and then also bring some energy and vibrancy to the conversation at the same time. There’s this duality that happens. It’s learning to hold both of those simultaneously. Can you hold the pain and still move forward at the same time? Does the pain have to be crippling? Those are some of the gifts of mindful practices.

One of the things as neuro PTs that we do is to help patients hold hope and despair simultaneously. Oftentimes, the people that we are seeing have had something terrible happen to them. They are in the worst circumstances they could ever be in their life. Maybe they are fortunate enough to have significant family resources but lots of times, that’s not the case.

We have to figure out how to help them hold hope while they are moving through this situation that is full of despair. Mindfulness is the way that I learn to do that. For me, it’s a priceless practice that is invaluable for anyone. It makes life easier, whether you are dealing with physical pain or a pain that’s more psychospiritual. It is a skill. You can’t put a price on it.

We have to psychoemotionally and spiritually hold the idea for our patients of hope as well as a little bit of despair that we are working through. That’s on a more cognitive level. At the same time, be mindful of our body and the body-fullness experience that we have and be able to move in and out of regulated, dysregulated, and downregulated states as part of that hope and despair experience.

It’s hard.

This is where the work comes in for us with patients.

It’s on ourselves. It’s hard to teach other people this if you haven’t had the experience of what it’s like.

As we start to wrap up, you have these three recommendations that you oftentimes share with both people who are living with pain and comorbid medical conditions. I wonder if you can share those with us and tell our community what they are.

Number one is to keep them moving. Even if it’s the arm bike, lots of times, it’s the intensity. Lately, I have been working a lot on step counts with people with MS. There’s a great study by Valerie Block that talks about how people with MS that walk on an average of more than 4,766 steps a day are less likely to experience a functional decline. We work a lot on stepping. They don’t have to necessarily do any intense physical activity. Getting in those step counts can give them a positive prognosis.

This leads well into the next one. Educate people. Tell them why you are having them do things. Pain neuroscience education does a great job of this because it explains to people why their behavior is important and how that’s driving changes in their brains. For people with MS or Parkinson’s disease, it’s not enough to tell them to do something. It’s important that we explain what neurobiology is and the impact that the activity is having on their disease. That helps shift motivation from being extrinsic, “You do this,” to, “I can have control over my disease if I do this.” That can then help the physical activity become more of an identity component.

The third is to work with patients to set achievable long-term goals and then follow the patient. There’s a big shift in neuro PT towards seeing people using more of a dental model. We follow people or see them for a large dose of therapy. Maybe we see them 2 times a week for 4 weeks for a little while but then we don’t necessarily discharge them. We have them come back in six months. When we see people in this way, 1) It lets us establish a strong connection with the patient, and 2) It also gives us the opportunity to follow them across the disease spectrum, know how to progress their activity, continue to set goals, and modify things so that they can be the best version of themselves for as long as possible.

I appreciate that. I always thought for so many of our patients that the idea of discharge is wrong. It’s created by the insurance companies, which we all know but we should have a long-term view as profession and see that we can be an important part of someone’s health and well-being, and should it be a disease process that we can be there with people all the way from the time when they are young throughout the lifespan to very late in life.

People should come back for check-ins and checkups, so we can be engaged in that resilience and positive growth that people are looking for throughout the spectrum. LaVerene, it has been great speaking with you. Everyone is going to share this with their friends and family on social media, Facebook, LinkedIn, and Twitter. On Instagram, you can tag me @DrJoeTatta. Where can people find you and learn more about the work that you are doing?

I have a Twitter account. It’s @LavaGPT and also Winston-Salem State. If you look me up at Winston-Salem State, you can find me here, get my email, and send me a message. I would love to hear from people.

The Winston-Salem Physical Therapy program is where you can find Dr. Garner. Thanks for joining us again. Make sure to share this episode with your friends and especially people who have comorbid orthopedic, neurologic, and chronic pain problems.

Important Links

• LaVerene Garner – LinkedIn
• Integrative and Lifestyle Medicine in Physical Therapy
• Amazon – Integrative and Lifestyle Medicine in Physical Therapy
• OPTP.com
• iRest Yoga Nidra
• @DrJoeTatta – Instagram
• @LavaGPT – Twitter

About Dr Garner

Dr Garner is an ABPTS Board Certified Neurologic Clinical Specialist and currently works as an assistant professor in the Dept of Physical Therapy at Winston-Salem State University. Prior to moving to Winston-Salem, NC, Dr Garner helped develop the vestibular therapy, mindfulness and integrative yoga components of a concussion recovery clinic at Camp LeJeune where she worked treating individuals with prolonged symptoms post concussion for over 5 years. Today, Dr Garner teaches her DPT students how to provide evidence-based care for individuals post-concussion. She also performs research related to balance and falls as well as the implementation of integrative physical activity promotion for individuals living with Multiple Sclerosis.