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:

Demographic Data:

• 72 year old male
• Community dwelling
• Primary language: English
• Right Handed

Primary condition: Idiopathic Parkinson’s Disease

Diagnosis: 5 years prior

Nature of Condition: idiopathic, middle/moderate severity

• Due to loss of dopaminergic cells in the substantia nigra and a cascade of brain changes arising from it

Primary Concern:

• Increasing # and severity of impairments
• Increased tremor in resting, also noticed an increased tremor during eating and drinking
• Slowness in movements bilaterally (bradykinesia)
• Increasing challenge with ADLs (getting groceries, difficulty with eating, drinking due to tremor) due to slowness of movements
• Decreased mobility
• Increased risk of falls

Examination Findings:

Subjective/ Patient comments:

Social Hx

• Retired accountant
• Hobbies: playing bingo, walking his dog, playing bocce ball in his backyard, spending time with family
• Lives with wife that is able to support him; has additional support from adult children
• Lives in bungalow that has 3 steps to get into the front door, bilateral railing. Has no trouble navigating these stairs. He does have trouble navigating the 14 steps it takes to get to the second floor of his children's’ homes.
• Able to ambulate ~100 ft independently w/ single point cane Pt is independent in toileting and hygiene
• Wife takes care of grocery shopping because he feels unsteady walking long distances
• He is fearful of walking long distances within community due to fear of falling and difficulty initiating/stopping movements and walking at an appropriate speed. He finds it difficult crossing intersections with stop signs/ lights.
• Medications:
  • Levodopa-carbidopa- 100/25 mg 3x per day
    • Has been taking since diagnosis (5 years)

Observation:

• Slight facial masking
• Slight hypophonia
• Appears slightly anxious
• Posture shows slight tilt to right and stooped resting posture
• Bilat. resting tremors (predominantly in left LE and UE, progressing to R side)
• Bilat. Intentional tremors (predominantly in left LE and UE, progressing to R side)
• Sensory testing:
  • Somatosensation: intact
  • Smell: slightly decreased sense of smell
  • Taste: slightly decreased taste
• Motor:
  • Bradykinesia/ Akinesia:
    • AROM
      • Shoulder flexion: slow bilat, range within normal limits
      • Elbow extension: slow bilat, limited range into extension
      • Thoracic and cervical rotation: normal speed, range within normal limits
      • Axial rotation: normal speed, limited at half range
      • Hip and knee extension: slightly slow bilat, limited range bilat
    • Rapid alternating movements:
      • Upper extremities: slowness and irregular rhythm with finger tapping and finger to nose
      • Lower extremities: slowness, irregular rhythm and decreased amplitude with toe tapping
  • Strength: not assessed due to bradykinesia and fatigue
  • Rigidity:
    • Muscle tone:
      • Increased tone through range of passive elbow extension bilat. Not velocity dependent
  • Postural instability:
    • Quiet standing: intact
    • Romberg: Able to hold with narrow BOS and eyes closed with slight sway
    • Tandem stance: able to maintain tandem stance with slight sway
  • Gait:
    • Stooped posture, decreased arm swing, decreased step length, increased festination/ 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. Errors; some impossible.
• 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:

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 upper and lower extremities. A major change noticed during examination was impaired motor function and balance. This decline is due to freezing of gait and intentional tremors (1) (vervoort et al., 2016) as evidenced by low mini-BEST and TUG scores (cite physiopedia pages TUG, BEST). 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).

Intervention:

Patient-centred treatment goals (STG/LTG)

• STG
  • Increase patient’s knowledge of condition and ability to maintain functionality in one session
  • Progress patient to safe use of rollator walker and educate on proper use of in one session
  • Increase ability of patient to independently walk 150 ft with rollator walker after 2-3 weeks
  • Improve anticipatory postural correction strategies (i.e stepping strategy) in response to internal and external perturbations in 2-3 weeks

• LTG
  • Pt. able to independently ambulate minimum ~400 ft w/ rollator walker to navigate grocery store in 4 weeks
  • 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 pt. can be compliant with their exercises outside of treatment
  • Decrease TUG score to ~ 13 (4) (Dal Bello-Hass et al, 2011) in ~4-6 weeks to ensure safety with balance in the community.
  • Pt. 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)

• 75-90 minute classes including a warm up, work out, core workout, and cool down
• Positive boxing affects: optimal agility, speed, muscular endurance, accuracy, balance, hand- eye coordination, footwork and overall strength
  • Impacts of boxing: key ADLs (balancing, picking up objects, walking longer distances, transfers) became quicker and were more precise through progression of training. Changes in PD symptoms through boxing protocol as well as improved sense of self by thinking of themselves as a boxer rather than a victim of PD (5)
  • Improvement 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)
  • Mean decrease in UPDRS, improvements in TUG, 10MWT, BBS (7)
  • Improvement in PDQ-39, increase in QoL (8)

Independent treatment sessions

• Working on temporospatial qualities of gait
  • External/environmental cues- Using auditory rhythmic cueing to improve walking speed… questionable functional relevance (9),
  • Use internal and mental cueing to help with gait (including counting, rocking forward and backwards before sit-to-stand) (10)
• Working on balancing through a variety of balance exercises
  • Internal perturbations
  • External perturbations
• Education on using a rollator walker
• Findings strategies to manage tremors: holding objects

Forced cycling: Improve aerobic fitness, improve bradykinesia, dexterity, cadence

• Shifts feedback motor control to a feedforward process
• UPDRS motor scores improved 35% more than voluntary exercise
• Gains in UE’s function were maintained 4 weeks after cessation of forced
  • Exercise: 3x 1hr sessions/week (11)

Outcome:

Patient responded well to Rock Steady Boxing therapy as seen by improvements in balance (TUG, minibest). Pts 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 that were prescribed in therapy assisted in increasing patients’ postural stability, overall translating to increased independence with more functional tasks (ie. bocce ball). 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. However, according to the ABC Scale, he is below the normative data (15), so this is an area that can be improved. Bradykinesia has become less of an obstacle during ambulation and patients endurance with ambulation has increased, as seen by an increase in ambulation distance, due to the the use of cycling and boxing therapy. Overall patient reports feeling less anxious and feels that he is better able to manage his condition due to the education and boxing therapy.

Pt will be referred to a speech and language pathologist to address hypophonia, occupational therapist to address difficulties with ADLs (eating/ drinking). Pt. 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). Pt. 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.

Outcome measures:

• UPDRS Score (Part I, II, II): 61/199
  • Total score changed by 9 points, which is a significant change, as the minimally clinical important difference for this population is 8 points (12)
• Timed up and Go (TUG): 13 seconds
  • TUG Score decreased by 5 seconds, which is a significant change as the minimally clinical important difference for this population is ~5 (4)
• Will continue to monitor patient’s fall risk and address balance in treatment as the cut off is >13.5 second (13)
• Mini-Best: 23/28 did not achieve MDC for mini-BEST, but has shown improvement. (MDC = 5.5) (14)
• ABC score: 72/100
  • Patient has increased confidence, but is still below the normative data for this population (15)
• Touch on outcome measures that didn’t reach MCID score.
  • Mini-Best

Referrals:

Speech language pathologist to address hypophonia, occupational therapist to address difficulties with ADLs (eating/ drinking)

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