Boxing Helps Knock Out Nonmotor
Parkinson's Symptoms

Pauline Anderson

March 04, 2020

TORONTO — Boxing may help improve common nonmotor symptoms of Parkinson's disease (PD), new research suggests.

In the study, patients with PD who participated in a noncontact boxing program experienced improvement in nonmotor symptoms such as fatigue, depression, and anxiety, and had significantly better quality of life compared with their counterparts who did not engage in this type of exercise.

Dr Danielle Larson

"We know we should be prescribing exercise for our Parkinson's disease patients because more and more research shows it can delay the progression of the disease, but it can be overwhelming to know what type of exercise to prescribe to patients," study investigator Danielle Larson, MD, a neurologist and movement disorders fellow at Northwestern University, Chicago, Illinois, told Medscape Medical News.

On a daily basis, patients at Larson's clinic who have taken Rock Steady Boxing (RSB) classes "really endorse" this exercise, she said.

The full findings will be presented at the upcoming American Academy of Neurology (AAN) 2020 Annual Meeting in April.

Global Program

A form of noncontact boxing, RSB was created in 2006 for patients with PD. A typical 90-minute class starts with stretching and cardiovascular exercises, then foot movements and stepping over obstacles.

"PD patients are slowed down and have difficulty navigating around obstacles," Larson noted.

The class also includes "speed training," such as fast walking or running. In the boxing part of the class, participants use suspended punching bags.

Eric Johnson hits the punching bag at a Rock Steady Boxing class. There are more than 43,000 participants at 871 RSB sites worldwide.

Larson said the RSB program caters to all patients with PD, "even those who need a walker for assistance." Most RSB sites require a release from a physician to ensure patient safety, she said.

There are now about 43,500 participants at 871 RSB sites around the world.

Adults with PD who were aware of RSB completed a 20-minute anonymous survey, distributed via email and social media by RSB Inc and the Parkinson Foundation.

Of 2054 survey respondents, 1709 were eligible for analysis. Of these, 1333 were currently participating in RSB, 166 had previously participated, and 210 had never participated in the program.

For all three groups, researchers gathered demographic information, such as age, gender, and income, and asked respondents how long they had the condition, who takes care of their illness, etc.

Current and previous RSB participants were asked about the exercise. For example, they were asked how many classes on average they would take per week and whether specific symptoms had improved or not changed with their participation.

RSB participants had a mean age of 69 years, 59% were male, and 96% were white. Demographics were similar for the other groups, although Larson noted that the group that had never participated was relatively small.

There was no difference between the groups in terms of years since PD diagnosis or use of a movement disorders specialist.

Less Fatigue

Compared to nonparticipants, a higher percentage of participants were retired (76% vs 65%, P < .01) and married/had a partner (85% vs 80%, P = .03).

The symptoms for which participants reported at least a 50% improvement were mostly nonmotor symptoms. For example, participants had improvements in social life (70%), fatigue (63%), fear of falling (62%), depression (60%), and anxiety (59%).

Over 50% of respondents in the previous participant group also reported improvement in these symptoms, "just not to the same degree as the current participants," Larson said.

"Those symptoms are difficult to treat in Parkinson's disease," she noted. "We really don't have any good medications for those symptoms; so to report, for example, a 63% improvement in fatigue is pretty substantial."

The survey included the Parkinson's Disease Questionnaire-39 (PDQ-39). The questionnaire assesses factors associated with daily living, including relationships and the impact of PD on functioning and well-being.

Compared with nonparticipants, current participants had better mean scores on the PDQ-39 (25 vs 32, P < .01), which indicates better quality of life, Larson said. Previous participants had a higher (or worse) score than current participants, she added.

Largest Study To Date

Researchers also examined likelihood of exercising even with certain barriers, such as distance to the gym, bad weather, or fatigue using the Self Efficacy for Exercise (SEE) Scale. Current participants had better SEE scores compared with nonparticipants (54 vs 48, P < .01).

"We can't prove causality. We can't say it was the RSB that improved their quality of life or their exercise self-efficacy, but at least there's a correlation," Larson said.

For the SEE, again, the previous participants had lower scores than current participants, she noted.

"An interpretation of this is that individuals who previously participated but stopped did so because they had lower exercise self-efficacy — which is the ability to self-motivate and stick with an exercise — to begin with," she said.

As for PD-related motor symptoms, the survey found some improvements. "People did report between 20% and 40% improvement on various motor symptoms," but not more than 50% of respondents.

Larson noted that some motor symptoms such as tremor would not be expected to improve with exercise.

This study, the largest to date of RSB in PD patients, illustrates the benefits of this type of exercise intervention for these patients, she said.

"It's a step in the right direction in showing that RSB, or noncontact boxing classes, can be a really good option for patients who have previously not been motivated to exercise, or maybe haven't stuck with an exercise class, or maybe fatigue or anxiety or depression is a barrier for them to exercise."

Patients who have experienced RSB praise its unique approach, in addition to generating friendships and promoting a sense of camaraderie and team spirit, Larson said.

"It's almost like a support group inside an exercise class," she noted. "We also see that people are really committed to the classes, whereas with other exercises it can be hard to get people to be motivated."

Some 99% of current and 94% of previous participants indicated they would recommend RSB to others with PD.

Interpret With Caution

Commenting for Medscape Medical News, Michael S. Okun, MD, professor and chair of neurology, University of Florida Health, Gainesville, and medical director at the Parkinson's Foundation, said many patients with PD attend RSB classes and report that the regimen has a beneficial effect on symptoms and quality of life.

"The data from this study support these types of observations," he said.

But Okun noted that caution is in order. "We should be careful not to overinterpret the results given that the methodology was survey-based," he said.

To some extent, the results aren't surprising, as multiple studies have already shown that exercise improves PD symptoms and quality of life, Okun said. "We have no reason to believe that Rock Steady Boxing would not result in similar improvements."

He stressed that a follow-up study will be necessary to better understand the potential benefits, both nonmotor and motor.

Also commenting for Medscape Medical News, movement disorders specialist Anna DePold Hohler, MD, professor of neurology at Tufts University School of Medicine, Boston, and chair of neurology at St. Elizabeth's Medical Center in Brighton, Massachusetts, said the new results "provide an added incentive" for patients to participate in RSB programs.

Such programs "should be started early and maintained," Hohler added.

The study received no outside funding. The study authors have disclosed no relevant financial relationships. Okun and Hohler have disclosed no relevant financial relationships.

American Academy of Neurology (AAN) 2020 Annual Meeting: Abstract 1210. To be presented April 2020.

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