Parkinson's patient Lori Katz, 60, is whipping a jump rope around her head as she calls out words beginning with the letter B.
At the ready nearby: a heavy weight bag that Katz will attack later in her workout - before donning boxing gloves to match mitts with her physical therapist, Joellyn Fox.
"Go, go, go!" Fox screams as Katz nimbly steps from one set of colored circles to the next, landing punches against her therapist's gloved hands. "Orange! Green! Red!" Fox is a whirling dervish of energy and encouragement. "All we need," she rhythmically chants, "all we need is . . . dopamine!"
At Pennsylvania Hospital's Parkinson's rehabilitation center, the latest novel therapy is known as Rock Steady Boxing. Despite the name, a metaphor for fighting the disease, it's a noncontact, intensive exercise routine that can help improve flexibility, range of motion, gait, posture, and activities of daily living - all serious issues for patients with Parkinson's disease.
Developed in 2006 by retired Indianapolis district attorney Scott C. Newman, who found that boxing eased his early-onset Parkinson's symptoms, the therapeutic workout is done mainly in group classes. Rock Steady Boxing, which uses all the training elements of the sport, helps push patients to simultaneously work on gross motor movement, rhythm, core strength, balance, and hand-eye coordination.
The nonprofit program, housed in an Indianapolis gym that specializes in Parkinson's and that is now affiliated with the University of Indianapolis, has trained more than 100 coaches across the country - two physical therapists at the Philadelphia rehab center are the first in this region - and has 24 affiliates in 12 states as well as in Italy, Canada, and Australia.
The key to Rock Steady Boxing is intense exercise that pushes participants just beyond "where they think they've had enough," said Jessica Fithen, the program's affiliate services director. Medical studies have shown this type of high-exertion activity may be "neuroprotective for the brain, and may help reconnect parts of the brain that are being lost in the disease," she said.
Boxing - real and not - is also a bilateral exercise. This helps Parkinson's patients who often have forced, stiff movements on one side of their bodies. "By using the entire body at the same time, boxing can reverse and delay some of the symptoms of Parkinson's disease," Fithen said.
Though exercise may be good for everyone, Fithen said, this level of intensity for patients with neurodegenerative diseases has been studied only in Parkinson's, which is not a muscle-wasting disease but a condition that prevents signals from the brain from reaching the body.
In August, Fox and physical therapist Heather Cianci traveled to Fithen's facility from the Dan Aaron Parkinson's Rehabilitation Center, part of Good Shepherd Penn Partners, to become certified in the boxing program. After months of use with individual clients, a pilot program of Rock Steady Boxing group classes is scheduled to begin this week.
Recent research in the Journal of Applied Physiology showed that high-intensity training combined with interval training produced significant improvements in quality of life, mood, and motor function for older patients with Parkinson's disease. During 16 weeks of high-intensity training, participants improved their muscle-endurance capacity and showed much improvement in the function of muscle mitochondria, which help fuel muscle fibers and fight muscle fatigue.
Though this study did not address boxing, lead author Marcas Bamman, director of the University of Alabama Center for Exercise Medicine, said that "with boxing's high-intensity, rapid movements, you're likely to see improvements in Parkinson's patients."
Stephanie Combs-Miller, an associate professor at the Krannert School of Physical Therapy at the University of Indianapolis, has done several small studies on the safety and effectiveness of Rock Steady Boxing for Parkinson's patients. Her most recent presentation, at the World Parkinson Disease Congress in Montreal in October, described an ongoing, two-year study that compares 39 Rock Steady boxers to 26 other exercisers, all with Parkinson's. After one year, preliminary findings showed that although all participants benefited from exercise, "boxers demonstrated significantly greater comfortable 10-meter walking speed compared to non-boxers," the abstract indicated.
"We're really interested in slowing the progression of the disease," Combs-Miller said in an interview. "And so far, we didn't see any progression of symptoms in the boxers. "
The opportunity for group exercise also makes Rock Steady Boxing attractive for Parkinson's patients, she said. Research shows that people are likelier to follow exercise plans if they are part of a group and if the members share the same diagnosis and stage of disease.
"I think the whole concept of boxing is interesting and intriguing," Coombs-Miller said. "In general, we're learning that people with Parkinson's disease need to exercise - whether it's boxing, tango dancing, tai chi, or walking on a regular basis."
Parkinson's is caused by a decrease in dopamine, a hormone involved with internal rhythm and movement that normally happens without thought, like swinging your arms when you walk. Primary symptoms are trembling in hands, arms, legs, jaw, and face; rigidity, or stiffness, of the limbs and trunk; slowness of movement; and impaired balance and coordination. Patients may have difficulty walking, talking, or completing simple tasks.
As many as one million Americans live with Parkinson's, and about 60,000 are diagnosed each year, according to the Parkinson's Disease Foundation. It usually affects people over 50.
One of the hallmarks of the disease is a motor and sensory disconnect - people don't realize their voices and movements have become diminished, like the arm swinging.
"They need to see themselves in a mirror and recognize, 'Oh, I really do look like that' or hear themselves and say, 'I really do sound like that,' " said Joan Levicoff, the rehab center's site manager. So physical and speech therapy both work on improving amplitude, of movement and voice.
"Normally, we don't think about how we get up off a chair and answer a phone," said Fox. "But in Parkinson's, patients lose that automatic response. Instead of rising up, we might see rigidity and tremors. Hip flexors can become tight, posture can become stooped, and you don't take a long enough stride. Your balance can be affected, as well."
Rock Steady Boxing addresses many of these issues. "Shadowboxing and sparring helps you gain that high level of amplitude. Boxing forces you to maintain the bigness of movement," said Fox.
A lack of control over your own movements can be exasperating, and the exercises help there, as well. "There's a lot of frustration with Parkinson's," Fox said. "Patients wear their symptoms on their sleeves. It's not a disease you can hide. It's great to work out, hit a bag, and shout out loud."
Katz, the Parkinson's patient, who lives in Cherry Hill, calls herself a guinea pig for every new idea or type of treatment; she recently recovered from surgery to implant a small pacemakerlike device in her brain, for a therapy known as deep brain stimulation, to help decrease her symptoms.
Her twice-a-week boxing workouts are the "best hours of the day," Katz said. "Boxing energizes me." She recently received a pair of boxing gloves as a birthday present.
Rock Steady isn't the only kind of boxing around. Margaret Rohdy, a 66-year-old patient with multiple sclerosis, was sharing the workout room with Katz and sparring - with soft plastic "noodles" - with Cianci, her physical therapist.
"Everybody has something they want to hit," said Rohdy, who lives in Center City. "In real life I don't get to hit; all I get to do is try not to fall down."
Cianci seems to understand that need.
"People feel strength and speed," she said. "They're energized. After boxing, they're more animated and feel more confidence."
Perhaps, added Levicoff, the rehab center manager, it's also something else.
"It's something new, something that people don't think they can do. And when you do it -," Levicoff shook her head. "What a sense of empowerment."
Rock Steady Boxing is designed to be a lifelong program of exercise specifically for people with Parkinson's disease.
When: New group classes are planned once a week for an hour. Individual sessions vary.
What: Classes start with 20 to 30 minutes of a flexibility warm-up and deep-breathing exercises. Then balance and footwork drills for agility; punching a heavy bag and a speed bag for posture and rhythm; pushups, sit-ups, and squats for strength conditioning; and circuit weight and strength training for the core, back, and legs.
Who: For one-on-one physical therapy, patients must be referred by a physician. A referral is not required for group classes, but participants must be cleared by a doctor for physical activity.
Where: Dan Aaron Parkinson's Rehabilitation Center, part of Good Shepherd Penn Partners at Pennsylvania Hospital, offers individual sessions with a physical therapist. It plans to begin two group classes this week, for people with early-onset Parkinson's and for active seniors with more advanced disease who may need to do seated exercises.
Cost: Individual physical therapy sessions that incorporate elements of Rock Steady Boxing may be covered by Medicare or other health insurance. The cost of the new group classes has not yet been determined; it is not likely to be covered by insurance.
Information: Call 215-829-7275 or go to www.rocksteadyboxing.org.