Rock Steady Boxing Therapy to treat the effects of Parkinson’s Disease; a case-study

Abstract:

This case presentation is an elderly man with Parkinson’s Disease. The case study highlights the initial assessment, main problems encountered by the patient, the goals, the rehabilitation program and the outcome.

Introduction:

Parkinson’s disease (PD) is one of the most common age-related neurodegenerative disorders, and is estimated to affect 1% of the population above the age of 60 years. (https://www.ncbi.nlm.nih.gov/pubmed/28150045) Its prevalence is estimated to continue to increase with the rising demographic of older adults. https://www.bcmj.org/articles/epidemiology-parkinson%E2%80%99s-disease The cause is unknown for most cases, with genetic link being shown in only 5-10% of patients. The pathophysiology is not well understood, but the disease is known to stem from the loss of dopaminergic neurons in the substantia nigra pars compacta. https://bestpractice.bmj.com/topics/en-gb/147/aetiology The cardinal signs of the disease are presence of tremor, rigidity, and bradykinesia, which has significant impact to quality of life of patients. (repeated citation: NCBI) Pharmacological interventions are generally intended to provide supplementary dopamine, with carbidopa-levodopa being one of the most commonly prescribed medications. (https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062). Physical therapy is also widely used and intended to increase function; for gait and balance training; and stretching and strengthening exercises. https://bestpractice.bmj.com/topics/en-gb/147/management-approach Physical therapy is also intended to promote self-management of the disease. https://www.nhs.uk/conditions/parkinsons-disease/treatment/ Possible physical interventions for Parkinson’s include forced cycling and rock steady boxing. Forced cycling has been shown to improve aerobic fitness, bradykinesia, dexterity, and cadence, which has transferability for gait training. It also promotes shifting feedback motor control to a feedforward process to help with anticipatory movements. Rock Steady Boxing is another physical intervention that has been shown to improve agility, speed, muscular endurance, accuracy, balance, hand-eye coordination, footwork, and overall strength.

Client Characteristics:

Patient is a 72 year old community dwelling male presenting with middle/moderate severity Idiopathic Parkinson's Disease (diagnosed approx. 5 years ago). Patient's primary language is English and patient is right-handed. Patient primarily sought help from physiotherapy because of his concerns surrounding balance and his fear of falling. Additionally, patient is concerned with completing certain ADL's, specifically groceries, eating and drinking due to tremors and bradykinesia. Patient has no additional co-morbidities.

Examination Findings:

Subjective assessment:

Social History

The patient is a retired accountant that current resides with his partner in a single-storey house. He has no difficulty navigating the three steps outside his front door (using the railing), however he has difficulty going up and down the 13 stairs to the basement in his house. He currently receives support with instrumental activities of daily living (grocery shopping) from his partner and his adult children that live nearby.  His hobbies include playing bingo at a community centre, walking his dog, playing bocce ball in his backyard, and spending time with his family. The patient is able to ambulate 100 ft independently with a single point cane, and is independent for toileting and hygiene functions. At present, he does not feel confident to do grocery shopping and relies on the assistance of his partner. He also reports that he does not walk far distances due to his fear of falling; and that his difficulty with initiating movements and slower walking speed makes navigating crosswalks challenging. Patient has been taking Levodopa-carbidopa (100/25mg) three times per day to assist with modulating his symptoms since his diagnosis 5 years ago.

Objective assessment

Physical Observation

Patient appears slightly anxious at the time of initial assessment. Patient presents with slight facial masking, and a stooped resting posture with a tilt to the right. Patient has bilateral resting tremors, in addition to intentional tremors. Both tremors exist predominantly in the left upper and lower extremities and are progressing to the right side. Upon sensation testing it was noted that the patient's somatosensation is intact, however patient has slight decrease in both taste and smell.

Upon assessment of active range of motion, bradykinesia was noted during shoulder flexion, elbow extension and hip and knee extension bilaterally. Patient was limited halfway through range into left elbow extension and axial rotation, and slightly limited into hip and knee extension bilaterally. During assessment of ability to perform rapid alternating movements, patient exhibited a slow and irregular rhythm with finger tapping and finger to nose, as well as toe tapping. This presented bilaterally, but was more severe on the left upper and lower extremities. Muscle strength was not assessed due to patient's bradykinesia and fatigue. Upon assessment of rigidity, patient displayed increased tone through range of passive elbow extension that was not velocity dependent. Upon assessment of postural instability, patient's ability to stand quietly was intact. In rhomberg and tandem stance patient displays a slight sway. During gait assessment, patient ambulates with a stooped posture, decreased arm swing and step length, and an increase in festination and freezing of gait.

Outcome measures:

UPDRS Score: 70/199

• V: Modified Hoehn and Yahr - Stage 3: Mild to moderate bilateral disease; some postural instability; physically independent

• VI: Schwab and England Activities of Daily Living Scale: 60%. Some dependency. Can do most chores, but exceedingly slowly and with much effort.

Timed up and Go (TUG): 18 seconds, at risk of falling

Mini-Best: 19/28

Cognition exam: Montreal Cognitive Assessment: 23/30

PDQ-39 Summary Index: 35

ABC score: 65 / 100

Clinical Impression/ Hypothesis:

Medical diagnosis: Idiopathic Parkinson’s disease, Middle/Moderate’ stage (with unilateral onset, positive response to Levodopa).

Physiotherapy Diagnosis: The patient presents with progression of Parkinson symptoms bilaterally demonstrated by presence of tremors and rigidity bilaterally in both upper and lower extremities. A major change noticed during examination was impaired motor function and balance as evidenced by low mini-BEST and TUG scores. This decline is due to freezing of gait and intentional tremors (1) (vervoort et al., 2016) .The presence of freezing of gait decreases the patient’s independence with functional mobility and puts him at an increased risk for falls (https://onlinelibrary.wiley.com/doi/full/10.1002/mds.20115), also indicated by a low ABC less than 69% (Mak & Pang, 2009; (3) https://www.ncbi.nlm.nih.gov/pubmed/19240961).

Problem List: Patient experiences anxiety regarding the degenerative nature of his disease. Patient is at high fall risk due to balance difficulties and postural instability. Patient has difficulty ambulating long distances and navigating the community, especially with grocery shopping, due to bradykinesia and festination associated with his gait. Additionally, eating, drinking, and writing are challenging due to the intentional tremors experienced by the patient. Patient experiences fatigue and difficulty manipulating more than 10 steps.

Intervention:

Patient-centred Treatment Goals:

Short-term Goals (STG):

In one session, the patient will increase their knowledge about the condition and his ability to maintain functionality. Also, the patient will gather the necessary education to safely progress to safely using a rollator walker. Within the first 2-3 weeks, the patient will increase his ability to independently walk ~200 ft with a rollator walker, as well as improve anticipatory postural correction strategies (i.e. stepping strategy) in response to internal and external perturbations.

Long- term Goals (LTG):

Patient will be able to independently ambulate a minimum of ~400 ft with a rollator walker (to navigate a grocery store) in 4 weeks. Patient will increase self- reported confidence on the ABC to a score of ~ 76 in 4-6 weeks as MDC is 11 points (4) (Dal Bello-Hass et al, 2011 - https://www.ncbi.nlm.nih.gov/pubmed/22210979 ) to ensure that patient can be compliant with their exercises outside of treatment. Patient's TUG score will decrease by ~ 13seconds (4) (Dal Bello-Hass et al, 2011) in ~4-6 weeks to ensure safety in the community. Patient will be able to respond appropriately to perturbations via anticipatory stepping strategies during functional tasks (ie bocce ball) in 4-6 weeks.

Management program

Boxing protocol (Rock Steady Boxing aka RSB)

Rock steady boxing is typically a 75-90 minute boxing class that includes warm up, work out, core workout, and cool down portions of the session. Overall, these boxing sessions aim to emphasize: optimal agility, speed, muscular endurance, accuracy, balance, hand- eye coordination, footwork and overall strength.

It has been found that RSB has positively influenced patient's with Parkinson's Disease through ADLs (balancing, picking up objects, walking longer distances, transfers) becoming quicker and more precise through progression of training. Additionally to changes in Parkinson's Disease symptoms becoming more manageable, patients participating in RSB benefitted from an improved sense of self by thinking of themselves as a boxer rather than a victim of PD (5).

It has been shown that RSB resulted in improvements in spatiotemporal gait parameters (increased gait velocity and cadence, increased single leg support, increased stride length, improved step length ratios) in protocol with emphasis on footwork skills (6).

One study that implemented a RSB protocol for patients with Parkinson's Disease demonstrated a decrease in UPDRS scoring, improvements in TUG, 10- minute walk test, and Berg Balance Scale (7).

Another study indicated improvements in PDQ-39 and QoL after performing RSB (8).

Independent treatment sessions

Independent treatment sessions will emphasize working on temporospatial qualities of gait.

This will be addressed via external/ environmental cueing such as auditory rhythmic cueing. Although this method has been shown to be effective in improving walking speed, there is questionable functional relevance (9). Internal and mental cueing to help with gait (including counting, rocking backwards and forwards before transferring) (10) will be implemented throughout treatment sessions.

Another focus of the treatment sessions will be on balance training. This is done via various exercises emphasizing internal and external perturbations to challenge the patient.

The safe use of a rollator walker will be taught in independent treatment sessions so that the patient is able to safely navigate his community while using an appropriate gait aid.

Part of the treatment sessions will emphasize finding strategies to manage tremors, for example, holding onto something to prevent/ attenuate/ limit the tremor.

Forced cycling exercise intervention

Sessions of forced cycling have been shown to improve aerobic fitness, improve bradykinesia, dexterity, cadence in participants with Parkinson's Disease. The protocol of this intervention consisted of 1- hour sessions 3 times a week for 8 weeks. One study indicated that forced cycling protocols were able to shift motor control feedback to a feedforward process. Also, UPDRS motor scores improved 35% when compared to voluntary exercise. Finally, this protocol showed gains in upper extremity functioning that was maintained 4 weeks after cessation of the exercise intervention (11).

Outcome:

Patient responded well to Rock Steady Boxing therapy as seen by improvements in balance. Patient's TUG score on reassessment is 13 seconds, and has decreased by 5 seconds, which is a significant difference for this population (4). Patient will continue to be monitored as he is still at risk for falls (cut-off for risk of falls is 13.5 seconds) (13). Activities surrounding internal and external perturbations assisted in increasing patients’ postural stability, overall translating to increased independence with more functional tasks (ie. bocce ball). However, according to the ABC Scale, he is below the normative data regarding confidence in his ability to maintain balance while completing activities (15), so this is an area that can be improved. Boxing therapy as well as rhythmic cueing in the clinic and mental cueing in community has helped improve his gait mechanics, specifically gait speed and cadence. Patient reports feeling more confident navigating in the community with the use of a rollator walker, and is able to ambulate for longer distances. Bradykinesia has become less of an obstacle during ambulation and his endurance has increased, as seen by an increase in ambulation distance. This may be attributed to the use of cycling and boxing therapy. Patient is making excellent progress overall, as his UPDRS Score for Parts I, II, and III decreased by 9 points, which is a significant change, as the MCID for this population is 8 points (12). In addition, patient reports feeling less anxious and feels that he is better able to manage his condition due to the education and boxing therapy.

Patient will be referred to a speech and language pathologist to address hypophonia, occupational therapist to address difficulties with ADLs (eating/ drinking). Patient will be discharged upon completion of his therapy goals in regards to balance, as during reassessment his results in the Mini-Best test is improving, but is not yet clinically detectable (14). Patient is encouraged to continue to participate in boxing therapy and incorporate cueing into his routine as this is showing significant improvements in regards to his balance and gait.

Summary of outcome measures on re-assessment: UPDRS Score (Part I, II, II): 61/199, TUG: 13 seconds, Mini-Best: 23/28, ABC score: 72/100

Discussion:

As there are no set standard criteria for diagnosing Parkinson’s disease and an etiology being hypothesized as both genetic and environmental, diagnosis and treatment are worked around clinical findings. Parkinson’s disease, as a chronic disorder, in particular can be profoundly frustrating as it can greatly impede on one’s quality of life, often associated with comorbidities… Thus, PD management must stem at the center of an interdisciplinary team. As there is increasing evidence to support that exercise can cause possible short-term reversal and slowing the rate of disability long-term (INSERT EVIDENCE). With a life-long disease like Parkinson’s, education on the trajectory of the condition and current evidence is imperative; there is no cure but it can be managed. This element with unable patient’s involvement and motivation to As treatment goals vary for each person, physiotherapy treatment for Parkinson’s disease, alongside prescribed medication, targets maintaining quality of life and mental status, reduce tremor, rigidity, improve posture/balance/speech, and improve mobility and function.

Self- study questions

1. Rock steady boxing protocol positively impacts outcome measures such as
   1. Spatiotemporal gait parameters
   2. Sense of self
   3. Balance- BBS and TUG
   4. All of the above
2. What value of the ABC indicates a Parkinson’s Disease patient is at risk of falling
   1. > 69 seconds
   2. < 69 seconds
   3. > 82 seconds
   4. < 82 seconds
3. Levodopa-carbidopa is a medication used to treat Parkinson’s Disease
   1. True
   2. False