Boxing-Based Training to Improve Balance and Mobility in Parkinson's Disease

Background and Rationale Balance control is a complex function managed by a distributed neural network within the central nervous system, where the basal ganglia serve as a central node operating in coordination with the cerebral cortex, brainstem, and cerebellum. This network spans multiple neurochemical systems, including dopaminergic, cholinergic, and serotonergic pathways. In Parkinson's Disease (PD), this multi-level system is compromised early on, leading to symptoms like axial rigidity and progressive postural instability.

Current standard treatments, such as Levodopa and Deep Brain Stimulation (DBS), often fail to address global balance dysfunction. While Levodopa may improve gait speed, it can paradoxically worsen postural sway and fails to significantly improve dynamic balance or dual-tasking. Therefore, there is a clinical need for interventions that target the balance network globally rather than in isolation.

Study Hypothesis The core hypothesis of this trial is that physical exercise that extensively and simultaneously challenges the distributed neural network of balance control is significantly more effective at improving multiple domains of balance in people with mild-to-moderate PD than simple exercise programs. Researchers propose that to achieve global improvement, the intervention must mimic the simultaneous demands of functional mobility in daily life. In this study, the Boxing-Based Balance and Agility Training (EBA-B) is utilized as a specific tool to operationalize this high-intensity, multidomain neural challenge.

Study Design This study is a randomized, crossover, controlled clinical trial. Participants are randomized into two groups (EF and EDU) which differ only in the order of the interventions received. The total study duration per participant is approximately 19 weeks, consisting of:

• Phase 1: 8 weeks of intervention (EBA-B or AC).
• Washout Period: 3 weeks of no study-related exercise to minimize carry-over effects.
• Phase 2: 8 weeks of the opposite intervention.

Intervention Protocols

• Boxing-Based Training (EBA-B): The EBA-B program combines functional exercise with non-contact boxing techniques.

• Structure: 24 sessions (50 minutes each, 3 times per week).
• Progression: Organized into a Learning Block (Weeks 1-4) for habit formation and technical acquisition, and an Integration Block (Weeks 5-8) where exercises increase in volume, complexity, and intensity.
• Session Layout: Each session includes a warm-up, three successive 12-minute work stations, and a cool-down. Stations focus on asymmetric postures, trunk mobility, coordination of punch sequences, and reaction to stimuli.
• Intensity: Monitored via heart rate (pulse oximetry) and Rated Perceived Exertion (RPE), with a planned progression from 40% to 75% of maximum heart rate.
• Active Control (AC): The AC intervention is designed to match the total weekly volume of 150 minutes but with lower physical demand.

• Education: Weekly 50-minute in-person talks regarding PD pathology and quality of life to maintain group socialization.
• Mobility: A 20-minute video workout of simple, seated (chair-based) mobility exercises to be performed at home 5 times per week.

Monitoring and Safety Clinical evaluations are performed in the "ON" medication state at three time points: Baseline (0M), Mid-point/Washout (2M), and Study Completion (4M). Participants are instructed to maintain stable medication and daily activity levels throughout the study. Adverse events, such as falls or musculoskeletal injuries, are recorded via participant diaries and direct reporting during sessions.

Inclusion criteria

• Age 25 years or older
• Confirmed diagnosis of idiopathic Parkinson's Disease by a specialist physician
• Parkinson's Disease severity stage between I and III on the Hoehn and Yahr scale
• Current use of stable doses of anti-parkinsonian medication
• Ability to stand upright without assistance
• Ability to walk independently at home for at least two minutes, with or without a walking aid
• Not currently participating in any other specialized exercise program (such as non-contact boxing, Tai Chi, tango, or aquatic therapy)
• Availability and means to attend in-person group sessions three times per week for eight weeks

Exclusion criteria

• Currently undergoing the process of Parkinson's Disease diagnostic confirmation
• Diagnosis of atypical parkinsonism
• Other neurological conditions besides Parkinson's Disease
• History of Deep Brain Stimulation (DBS) or other brain surgeries
• Severe bone or muscle problems that prevent safe exercise
• Uncontrolled heart or metabolic conditions that make exercise unsafe
• Severe respiratory conditions or current COVID-19 (SARS-COV2) infection