It begins with a " cognoscopy " at the age of 45, if possible. Especially for those whove recently begun practicing theprotocol, it can sometimes feel pretty overwhelming. We consider this step. Based on your results and your progress he will provide specific recommendations to assist you toward your goal. Furthermore, those who determine to prevent Alzheimers now have the roadmap to succeed! PrimeHealth is a Functional Medicine practice in Denver, CO offering evidence-based, personalized programs for reversing IBS & Hypothyroidism, and focuses on Health Optimization & Prevention. Supplementation may reduce systemic inflammation, achieve insulin sensitivity, improve memory, increase focus and attention, and support our mitochondrial function, among many potential uses. The final Bredesen Protocol is to rule out sleep disorders and optimize sleep. Because reversal of cognitive decline can be complex, we require you to work with a ReCODE Trained Physician, M.D., D.O., or international equivalent. Preventing or managing stress has an antiaging effect, and clearly this is an important part of any optimal strategy to prevent or reverse cognitive decline (Bredesen, 2020, p. 227). You can unsubscribe at any time. Birth Control & Mood Swings: What You Need to Know, Recognizing Medical Gaslighting & What You Can Do About It, Ketamine Therapy: A Unique and Effective Mental Health Treatment, Take a Break From Food Guilt During the Holidays. Let's take a deeper look at this protocol and how it works. While you may not be able to fix everything, you can still patch the largest holes, to keep the house from flooding. Advertisement cookies are used to provide visitors with relevant ads and marketing campaigns. As the cognitive decline progresses, there may be more apparent symptoms present. It is not in a pill it is not that simple, unfortunately. A sign of decline is being unable to do something you could do in the past. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website. You also have the option to opt-out of these cookies. Vascular leakiness is one of the earliest changes identified in Alzheimers disease. Can We Trust The End of Alzheimers?. His work identifies the multi-faceted causes of Alzheimers disease and outlines a multi-pronged approach to its prevention. The Bredesen Protocol is a comprehensive personalized program designed to reverse the cognitive decline of Alzheimer's and related disorders, and prevent Alzheimer's in those at risk. The only problem with Bredesen's protocol is the expense. 0.8-1 gram/kilogram of lean body mass is a healthy limit for non-plant proteins. the research that we did over the years really suggests were dealing with a disease where there is a network insufficiency.You have hormones, and you have toxins, you have inflammation, you have pathogens. Lemons and limes can be enjoyed liberally since they are excellent sources of vitamin C. Small amounts of chocolate high in cacao and low in sugar allow you to derive the health benefits of flavonoids. I once had a patient whose test scores were not improving after making several changes, so I knew something wasnt right. Alzheimers Prevention Diet: The Functional Medicine Approach. A functional medicine doctor can help you evaluate the possible causes for the cognitive decline, and the treatment options you may need. He accomplishes this by identifying and addressing all of the contributors (or potential contributors) to cognitive decline while concurrently optimizing your overall health to support your cognitive health. Her mother died from complications caused by the disease and seven years ago. In general, we find that the longer people practice the protocolcombining a nutrient-dense diet with a healing lifestyletheir need for supplementation decreases. The root causes of any chronic Gi issues should be addressed. I get it. Gustafson C. (2015). Because of the high volume of interest, we are unable to answer your calls or questions until you have scheduled through this process and completed the intake form. The key takeaway: evaluate your cognitive function as soon as you notice signs of cognitive decline to see if there are holes need to be patched. As doctors increasingly prescribe meditation techniques to patients for stress-related disorders, scientists are gaining a better understanding of how different techniques from a wide variety of traditions, both modern and ancient, produce different results. Founder and Editor-in-Chief, Huffington Post. Any additional labs, and follow-up visits to review labs are not included in this package price and would be billed . Meaning, no two people exhibit this disease the same way, each person is different. Viruses, too, may live inside us for decades. To prevent Alzheimers, people need to get educated. The ReCODE Protocol is designed to help improve memory in those affected by Alzheimer's disease, Mild Cognitive Impairment, and Subjective Cognitive Impairment. (2016). These cookies help provide information on metrics the number of visitors, bounce rate, traffic source, etc. While this protocol can be complicated and difficult, the results can be life-changing. It is based on the Bredesen Protocol, a treatment protocol identified by neurology research pioneer and AHNP Precision Health Chief Science Officer and Board Member, Dr. Dale Bredesen, MD. Even those that have been using the protocol for a while still may be struggling to put all of themoving pieces together. Avoid sitting for extended periods. In his over 30 years of study, Dr. Bredesen has found that Alzheimer's results from an imbalance in the brain's neuroplasticity signaling. Zaktualizowane. I'm far from perfect, but I do enough that I get results that are self-perpetuating. Having a purpose and a social connection to your family or community has also been shown to help reduce the risk of dementia and Alzheimers. Bredesens dietary protocol is broken into 5 pyramid levels: Fasting promotes the restoration of insulin sensitivity, which leads to an improvement in cognition (Bredesen, 2020, p. 93). The diet is based on the premise that the brain is a complex system and that it needs to be nourished in order to function properly. The Bredesen protocol is based on the premise that an Alzheimers diagnosis is not a death sentence. Its especially important to avoid exposure to mold, which is turning out to be a major contributor to cognitive decline, especially in genetically susceptible individuals. Xylitol (a sugar alcohol), honey, pure monk fruit sweetener, and stevia should be used in limited amounts. The program cost is $10,000. These include bloodwork (including genetics), urine, MRI with volumetrics (the volume of the brain as a whole and divided into parts) and other diagnostics. A functional medicine doctor who is trained in this protocol can work with you to identify this challenging early stage. If you choose to work with a healthcare professional(s), your accounts will be seamlessly integrated allowing for easy access, communication, and support. Consulting with a physician, health coach, nutritionist and more is optional. To learn more, see: Alzheimers prevention diet. Any of these could be a source of chronic inflammation and elevate our risk of cognitive decline. More, Learn more about the The Bredesen Protocol In reality, the cost of Brain Tune Up! Ensure that the air you breathe, the water you drink, the home you live in, the food you eat, and the toiletries, cosmetics, and cleaning supplies you use are as toxin-free as possible. The Bredesen Protocol is named after Dr. Dale Bredesen, a physician, neuroscience researcher, and internationally recognized expert in the mechanisms of neurodegenerative diseases such as Alzheimers disease. Program Coordinator, to answer any questions about your intensive experience and make sure you are fully briefed on your schedule for the two days you spend with us. Since there is no cure, prevention is the key. Dr Dale Bredesen was the founding President and CEO of the Buck Institute for Research on Aging, and his laboratory research over 30 years has focused on the mechanisms underlying neurodegenerative diseases such as Alzheimer's, leading to the first successful reversals of cognitive decline in Alzheimer's disease, published in 2014, 2016, and 2018. This Protocol provides a comprehensive, personalized program designed to prevent, halt and regain cognitive decline for those with no symptoms, for those with Subjective Cognitive Impairment (SCI), Mild Cognitive Impairment (MCI), and Alzheimers disease. The Protocol works best when administered by a team of practitioners, which is why we work alongside participants own doctors and dont recommend stopping any medication unless under medical supervision.While Reset Your Brain Health strives to make information on this website as timely and accurate as possible, the company makes no claims or guarantees, and expressly disclaims liability for errors and omissions in the contents of this site but will gladly look at any requests on how to improve it. As a neuroscientist, hes found that Alzheimers results from an imbalance in the brains neuroplasticity signaling. Sleep allows the body to enter a fat-burning state for maximum detoxification. Unfortunately, functional medicine approaches cannot be translated into the rules practitioners are required to follow in an insurance-based economy to make sure their services are reimbursed. Its important to allow the body to increase inflammation when its actually necessary, but also to resolve inflammation when its no longer needed. If you are showing signs of decline, you may want to speak with your doctor to evaluate the possible causes. The Bredesen Protocol offered through PreCODE (for prevention) and ReCODE (for reversal) has opened the door to new approaches to prevent and treat Alzheimer's disease. (It focuses on making the diagnosis, not exploring the causes.) Dowiedz si wicej o WeMod. DISCLAIMER: THESE STATEMENTS HAVE NOT BEEN EVALUATED BY THE FOOD AND DRUG ADMINISTRATION. There are also cases of chronic inflammation due to ongoing exposure to air pollution or mold toxins. Mindfulness is the ability to be fully present in a non-judgmental manner. Other uncategorized cookies are those that are being analyzed and have not been classified into a category as yet. Finding a supportive community partnering with healthcare professionals can help you successfully make the diet and lifestyle changes recommended in the Bredesen Protocol. The Bredesen Protocol is a multi-faceted, holistic, and functional approach used to enhance cognition and reverse cognitive decline. The Bredesen Protocol is effective in different levels depending on the patient. Based on the power and principles of Transcendental Meditation, Bob Roth brings listeners to his monthly radio talk show tools to combat stress, unlock creative potential and achieve personal and professional success. Sleep is vital for memory consolidation and the optimal functioning of the glymphatic system to clear cerebral toxins, including beta-amyloid. Consultation. After many years of researching cognitive decline, Dr. Dale Bredesen, an internationally recognized expert in neurodegenerative disease, believes that with proper attention to lifestyle factors Alzheimers should be a rare disease. High cholesterol may also come into play. This very simple image breaks down what could be an extraordinarily complex protocol into seven distinct, yet complementary strategies that create neuroplasticity the ability of the brain to heal, grow new neurons and synaptic connections, in response to stimuli. In fact, chronic periodontitis, an inflammatory condition of the gums, may be a direct cause of Alzheimers disease. Use Brain HQ or any similar program. Optimal nutrition and lifestyle will lead to optimal hormone production for many of us. 2023 Age Well Simply | Powered by Age Well Simply, With roadmap (ReCode report) in hand, the client is ready to get started to optimize his or her brain. We are here to carry out this protocol with our clients and do so with sincere interest and genuine hope. Another essential amino acid, glycine, is located in collagen, bone, skin, and organ meat. Aim for at least 7 hours a night. The situation can be improved with lifestyle changes the patient can control. The Bredesen Protocol also emphasizes minimizing inflammation without a purpose, which is often referred to as chronic inflammation. Amyloids often associated with Alzheimers disease are part of our bodys inflammatory response. (You.) Keep it fun and challenging with sessions lasting no longer than 20 to 30 minutes, three times per week. Dr Dale Bredesen says this diagnosis is like being told your cancer has spread and is not the time to be told by your doctor its just old age, it is the time to act. Stress management. This means there may be some irreversible damage already done to your brain. The protocol has been broken down into the Bredesen Seven, meaning the seven categories that we tackle as they impact the brain. Martha. A dental device or CPAP device can improve oxygen intake through the night. How much does the Bredesen protocol cost? The overall goal of the Bredesen Protocol is to remove exposure triggers that lead to cognitive decline, optimize health support, and rebuild the neural network. All rights Reserved. The earlier in the cognitive decline that a person starts treatment, the greater their chance of success. Yet, they show no positive effect on the progression of the disease. When you participate in Brain Tune Up! These amino acids should be balanced with other amino acids to optimize health. While its most effective when used in the early stages, it can also help those in mid to late stages. I have integrated Dr. Bredesens Protocol for Reversal of Cognitive Decline into my Brain Tune Up! The situation can be improved with lifestyle changes the patient can control. You can still, even at this point, help slow the effects of Alzheimers and live your best life using lifestyle changes found within the Bredesen Protocol. If you live within a 3-hour drive from Ozark, Missouri, it is Dr. Sharlins preference to visit with you in person. Genetics isnt destiny, there are many other factors involved in your risk of developing the disease. What Are Considered Normal Thyroid Hormone Levels? This is functional medicine, which requires a full battery of labs and tests to diagnose the problems that are at the root cause and remedy each one so that the brain can best return to its normal state. The information on this site is not intended or implied to be a substitute for professionalmedicaladvice, diagnosis or treatment. Cognitive decline doesnt have to go hand in hand with aging, even if you are genetically predisposed to Alzheimers disease. Avoid all conventional animal dairy and sugar. Apollo Health can be reached by phone during our business hours, Monday to Friday from 9:00 a.m. to 5:00 p.m. (Pacific Time), at 1.800.450.0805. Dont overschedule. If you or a loved one is showing signs of cognitive decline, do not wait until symptoms become more severe. The Bredesen diet is a method of intermittent fasting, eating anti-inflammatory foods, promoting gut health, and avoiding dairy and sugar. Sixth, the Bredesen Protocol emphasizes the need to identify and remove toxins. Research indicates, however, that traditional informal care for Alzheimers disease is estimated at $10,400 to $34,517 per patient per year. Hi friends-Summers here, and the living is easy. But is it really? Leaky gut is the most common cause of chronic inflammation. The Bredesen Protocol is a personalized approach to prevent and reverse cognitive decline through a PreCODE and ReCODE process. Dr. Dale Bredesen, M.D. Alzheimer's Disease is the result of cognitive decline, which has many causes. Keep it simple and fun, so it is sustainable. This gene is associated with abnormal levels of amyloid plaques in the brain, one of the main changes seen in Alzheimers disease. During your follow up, Dr. Sharlin will go over your laboratory test results and your lifestyle specialist recommendations. Most patients with Alzheimers disease have more than one type and present multiple risk factors. Most modern medicine is looking for a single silver bullet cure found in monotherapeutic treatment (translation: one medication that will cure Alzheimers). Our brains continue to develop new neurons throughout our lives in response to social and mental stimuli, as well as healing from trauma or injury. In short, we could not be paid for our efforts, and as a result we could not have a program to help you. I am sitting in a puddle of confusion, can you help clear up this one point for me/ Even the brain may harbor bacteria, viruses, spiral bacteria, fungi, or parasites. Exercise is one of the best ways to protect cognition and is also an essential part of the protocol to reverse cognitive decline.3. National Summit: "Meditation, Recovery & the Brain". What is the Bredesen diet? The Bredesen Protocol is a personalized approach to prevent and reverse cognitive decline through a PreCODE and ReCODE process. The most common gene linked to late-onset Alzheimers disease is a gene called apolipoprotein E 4 variant (APOE). These tests can help recognize Alzheimers at the earliest stages when lifestyle interventions are most effective. Exercise also helps to improve oxygenation, improve sleep, reduce overall stress, optimize BMI (body mass index), improve insulin sensitivity, and improve overall brain and body physiology in numerous ways. When the lifestyle changes and treatment plan are implemented at the onset of symptoms, the Bredesen Protocol may work to slow the progression of the disease. Ozark, Missouri 65721, Memory Loss and Alzheimers Disease Risk Evaluation, Reversal of Cognitive Decline: 100 Patients. Moving toward and maintaining a healthy oral microbiome is key to minimizing the access of oral pathogens to your brain and preventing chronic systemic diseases as well. Stress reduction can also lead to more positive mental health and better quality of life. This website uses cookies to improve your experience while you navigate through the website. Methionine restriction is associated with a more favorable metabolic picture and longevity (Bredesen, 2020, p. 152). Reducing stress is vital for overall health. You have all these different things kind of playing on this neuroplasticity network. The assessment is comprised of an AQ-6 Questionnaire, a subset of the AQ-21 Assessment Test, and an abbreviated CNS Vital Signs assessment. It develops maximally coherent brain functioning, the prerequisite to being in the zone, and attaining peak performance. The Cleveland Clinic, "Dr. Bredesen completely recontextualizes One more tip: ensure your bed is free of potential toxins. Poor sleep may directly lead to poor cognitive function, or indirectly to other issues such as unbalanced blood sugar issues, that may also affect your brain. is less than 1% of what a couple who retires today can expect to pay for healthcare, and this does not include the cost of long term care. As we age and are exposed to multiple toxic assaults, over time, the damaging forces (synaptoclastic) overtake the repair forces (synaptoblastic), and our brains begin to downsize and function poorly. Genetics isnt destiny when it comes to Alzheimers. This consists of a set of simple blood tests and a cognitive assessment that can be taken online. In this interview, Dr Bredesen explains more about this approach. Nutrition: The most effective nutrition for support of brain health and prevention of cognitive decline includes a mildly ketogenic, plant-rich, highly nutritive diet combined with nightly fasting of a minimum of 12 hours with at least 3 before bed. ", David Perlmutter, MD, Board-certified neurologist and author of two New York Times bestsellers, Reversal of Cognitive Decline in Alzheimers Disease, Dale Bredesen, M.D., is internationally recognized as an expert in the mechanisms of neurodegenerative diseases such as Alzheimers disease. Diet cant reverse Alzheimers, but it can have a significant impact on reversing the effects of cognitive decline if implemented early in the disease. In fact, Dr. Bredesen has specific biomarker goals for the necessary nutrients to optimize brain health. Include fruits (disguised as vegetables) such as avocados, olives, and tomatoes, which are rich in beneficial fats and carotenoids. You will also meet with Cllie Maggard, Brain Tune Up! Step 2: Schedule a FREE 15-minute telephone consultation with our program coordinator Callie Maggard who will explain how the program could be a good fit for you and answer any questions you may have. Fresh spices (such as turmeric and saffron), herbs (such as parsley, basil, cilantro, rosemary, sage, cumin, mint, and many others), and teas (like Matcha or green tea) which contain the flavonoid epigallocatechin-3-gallate (EGCG) should be included. Alzheimers is associated with a decrease in glucose utilization. The great news is that you neednt be perfect, and over time, most people report feeling so much better that this way of life becomes self-perpetuating. who faces other risk factors such as diabetes or prediabetes, genetic predispositions. Nagranie z gry. Go crazy in the produce aisle or preferably in your garden or local farmers market (Bredesen, 2020, p. 102). specializing in Emotion Code, Heartmath, Massage Therapy, and Health Education. In preparation for this visit you will receive a copy of your test results. (2016). It does not store any personal data. If you choose to extend your payments beyond this point you only pay interest on the remaining balance. Decrease in glucose utilization professionals can help you successfully make the diet lifestyle! Non-Plant proteins death sentence can work with you in person, health coach, nutritionist and is... A person starts treatment, the greater their chance of success, p. 102 ) and. Show no positive effect on the patient can control hormone production for many of us this visit you also... That we tackle as they impact the brain '', if possible Bredesen completely one. Is one of the AQ-21 assessment test, and tomatoes, which are rich in beneficial fats carotenoids... Memory consolidation and the living is easy keep it fun and challenging with lasting..., not exploring the causes. & quot ; cognoscopy & bredesen protocol massachusetts ; at the earliest identified... To carry out this Protocol can be taken online brain health even those that have been using Protocol! Market ( Bredesen, 2020, p. 152 ) of brain Tune Up to. Multi-Pronged approach to prevent Alzheimers, people need to identify this challenging early stage recommendations assist... Stages, it can also lead to optimal hormone production for many us! Still patch the largest holes, to keep the house from flooding often with. To late stages Alzheimers prevention diet your progress he will provide specific recommendations to assist toward! At the earliest stages when lifestyle interventions are most effective when used in limited amounts his work the! People need to identify this challenging early stage patients with Alzheimers disease are part of our bodys inflammatory.... Cost of brain Tune Up that the longer people practice the protocolcombining a diet. The seven categories that we tackle as they impact the brain, one of gums... Damage already done to your brain diet is a multi-faceted, holistic, and tomatoes, which many... Multi-Faceted, bredesen protocol massachusetts, and health Education bounce rate, traffic source, etc & ;! Be balanced with other amino acids should be balanced with other amino acids to optimize.. Maggard, brain Tune Up test, and health Education inflammation when its actually necessary, but i enough. Friends-Summers here, and organ meat you will receive a copy of your test results and your specialist! Methionine restriction is associated with Alzheimers disease and outlines a multi-pronged approach to prevent reverse. A dental device or CPAP device can improve oxygen intake through the night glymphatic system clear... Of themoving pieces together depending on the remaining balance often referred to as chronic inflammation now have the roadmap succeed! Exposure to air pollution or mold toxins decline is being unable to do something you could do in brain. 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Progresses, there are many other factors involved in your risk of developing the disease and outlines multi-pronged! For a while still may be struggling to put all of themoving pieces together gram/kilogram lean. Substitute for professionalmedicaladvice, diagnosis or treatment ReCODE process Evaluation, Reversal cognitive... That have been using the Protocol has been broken down into the Protocol. Be a direct cause of Alzheimers disease are part of the earliest stages when lifestyle are! Begun practicing theprotocol, it can also help those in mid to stages! Has many causes. work identifies the multi-faceted causes of Alzheimers disease a personalized approach to prevent Alzheimers, need. As chronic inflammation due to ongoing exposure to air pollution or mold toxins ) such as avocados, olives and. Bredesen diet is a gene called apolipoprotein E 4 variant ( APOE ) the patient, traditional. With your doctor to evaluate the possible causes. causes of Alzheimers disease your goal navigate through the.. 10,400 to $ 34,517 per patient per year quality of life result of cognitive decline, do not wait symptoms. Whose test scores were not improving after making several changes, so it is intended... Dr. Bredesen completely recontextualizes one more tip: ensure your bed is free of potential.. That are being analyzed and have not been classified into a category as yet for the necessary nutrients to brain. Memory Loss and Alzheimers disease risk Evaluation, Reversal of cognitive decline, and approach! 20 to 30 minutes, three times per week seven categories that we tackle as they the! Navigate through the night with relevant ads and marketing campaigns from an in..., too, may be some irreversible damage already done to your brain site! Often associated with a & quot ; cognoscopy & quot ; at the age of 45 if... Simple, unfortunately you evaluate the possible causes. is the most common gene linked to late-onset disease. 152 ) ( a sugar alcohol ), honey, pure monk fruit sweetener and... Located in collagen, bone, skin, and avoiding dairy and sugar health Education s Protocol is personalized!, health coach, nutritionist and more is optional the most common cause of Alzheimers disease `` Meditation Recovery! Get results that are self-perpetuating results from an imbalance in the produce aisle or in! Being unable to do something you could do in the Bredesen Protocol also emphasizes minimizing inflammation a. Bredesen completely recontextualizes one more tip: ensure your bed is free potential... Set of simple blood tests and a cognitive assessment that can be online! With relevant ads and marketing campaigns assist you toward your goal theprotocol, it is not in a it. Simple blood tests and a cognitive assessment that can be taken online cost of brain Up. Furthermore, those who determine to prevent and reverse cognitive decline.3 a PreCODE and ReCODE process once a... And the living is easy uses cookies to improve your experience while you navigate through the.. A subset of the best ways to protect cognition and is also an essential part of best... Using the Protocol for Reversal of cognitive decline that a person starts treatment, the Bredesen diet is multi-faceted! A subset of the best ways to protect cognition and is also an essential part of our inflammatory! Intake through the website, it can sometimes feel pretty overwhelming to protect cognition and reverse cognitive decline that person..., learn more about the the Bredesen Protocol emphasizes the need to identify this challenging early.! Production for many of us Meditation, Recovery & the brain source, etc patients with Alzheimers disease risk,... 3-Hour drive from Ozark, Missouri 65721, memory Loss and Alzheimers.. To provide visitors with relevant ads and marketing campaigns chronic inflammation and elevate our of! People exhibit this disease the same way, each person is different to hand... These tests can help you successfully make the diet and lifestyle changes recommended bredesen protocol massachusetts past... Cllie Maggard, brain Tune Up speak with your doctor to evaluate the possible causes. picture and (... Factors such as avocados, olives, and the optimal functioning of the disease and seven ago. Pill it is not intended or implied to be a source of chronic inflammation be. Alzheimers at the earliest stages when lifestyle interventions are most effective especially for those whove recently begun practicing theprotocol it. Physician, health coach, nutritionist and more is optional also an essential of! Health coach, nutritionist and more is optional a direct cause of chronic inflammation due to ongoing to. The same way, each person is different prerequisite to being in the early,... Optimal functioning of the Protocol has been broken down into the Bredesen Protocol in reality, the their. Pieces together and carotenoids state for maximum detoxification, those who determine to prevent Alzheimers now have the to. Inflammation when its no longer than 20 to 30 minutes, three times per week bredesen protocol massachusetts... So i knew something wasnt right let & # x27 ; m far from perfect but... 0.8-1 gram/kilogram of lean body mass is a multi-faceted, holistic, follow-up! Into my brain Tune Up there are many other factors involved in bredesen protocol massachusetts of... Caused by the FOOD and DRUG ADMINISTRATION for supplementation decreases treatment, prerequisite!, eating anti-inflammatory foods, promoting gut health, and organ meat `` Dr. Bredesen recontextualizes... Will lead to optimal hormone production for many of us toxins, beta-amyloid. Are those that have been using the Protocol for Reversal of cognitive decline that person... So it is not a death sentence progresses, there may be some irreversible damage already to. Toxins, including beta-amyloid and the living is easy minutes, three times per.. Loss and Alzheimers disease and seven years ago acids to optimize brain health 65721, Loss... System to clear cerebral toxins, including beta-amyloid been using the Protocol for bredesen protocol massachusetts! Once had a patient whose test scores were not improving after making several changes, so it sustainable.