For Cheryl Karian, a 72-year-old retired physician assistant, boxing is medicine. Karian, whose Parkinson’s disease was diagnosed in 2020, doesn’t compete or spar, but every Tuesday and Thursday, she trains for an hour at Main Street Boxing and Muay Thai in downtown Houston.

Before her diagnosis, Karian ran, played tennis and worked a demanding job caring for patients at MD Anderson Cancer Center. This all changed in the years leading up to her diagnosis in 2020, as she started experiencing cognitive difficulties and frequent falls. “I can’t do what I used to do,” Karian said one day after a boxing class.

Along with two other class participants, Karian was shadowboxing, or punching into thin air, under the direction of the professional boxer Austin Trout, known as No Doubt Trout. It was part of a program called Rock Steady Boxing, which specializes in no-contact boxing training for Parkinson’s patients.

As Trout called out instructions — “One, two! One, two, slip!” — Karian threw different punches, dodging and rolling her head, all while maintaining a boxer’s wide-legged stance.

No-contact boxing training has grown more popular over the past decade or so, with 4,000 new gyms popping up before the pandemic hit and more than 5 million Americans strapping on gloves in 2020. Boxing’s varied and high-intensity workouts offer a blend of strength and cardiovascular conditioning that improves agility, coordination and balance, and which may be especially beneficial for people with neurological disorders such as Parkinson’s disease.

Parkinson’s is caused by a chronic deficiency in dopamine, which triggers increasing muscle stiffness, tremors, difficulties with speaking, fatigue, dizziness and a loss of coordination and balance. Patients’ movements often get very slow and small. Falling is a big problem, especially as symptoms progress. And while there is no cure, or even a way to halt the symptoms, no-contact boxing training seems to offer a way to slow the effects and improve confidence.

“If you train for boxing, you’ll see that your coordination is better, your agility is better, your balance is better,” said Trout, a former light middleweight world champion who has been teaching Rock Steady classes for four years. “This is a way to physically fight back against Parkinson’s.”

Counterintuitive idea

Rock Steady Boxing was founded in 2006 by Scott Newman, a prosecutor in Marion County, Ind., who discovered that boxing workouts helped him manage his symptoms of early-onset Parkinson’s disease. In the beginning, it was just he and five other patients training with a former professional boxer, Kristy Follmar.

The strangeness of boxing therapy was not lost on them — the sport has among the highest rates of concussion and brain injury. While it’s not clear that a lifetime of concussions can cause Parkinson’s, it can increase the risk. Muhammad Ali, one of the sport’s most iconic figures, developed the condition after a professional career in which he famously wore out the hardest-hitting heavyweights of his time by taking punch after punch.

In Rock Steady’s classes, participants don’t take punches; they only throw them. Ryan Cotton, the chief scientific officer at Rock Steady Boxing, said that in the early days Newman and Follmar were working on a hunch. At the time, Parkinson’s experts recommended focusing on mobility and balance while avoiding overexertion. The wide-legged stance of a boxer and the shifting center of gravity when throwing a punch seemed perfect for training balance and posture.

“There was theory this should work, but there was no scientific evidence,” Cotton said. “Really, science has caught up to us and now supports a lot of the things we were integrating.”

In the years since, research has shown that many forms of high-intensity exercise, and particularly boxing, may slow the progression of Parkinson’s symptoms. Boxing also seems to help with other neurological disorders, such as multiple sclerosis and stroke.

Rock Steady has grown to more than 850 affiliate programs in 17 countries, with training and certification programs for coaches like Trout, who want to offer training specifically for people with Parkinson’s disease with varying severity of symptoms.

When Karian learned of her illness, she knew what her future could look like if she wasn’t proactive. She watched her mother, who also had Parkinson’s disease, for years as her quality of life declined. But she has found that boxing helps her balance, coordination and mental functioning. “I’m going to do as much as I can, for as long as I can,” she said.

Finding balance

Around half of all Parkinson’s patients will fall in a given year, most more than once. Trout, like many boxing coaches, drills his students on maintaining a stable stance while keeping their hands by their faces and their arms tucked to protect the body and face.

“This is exceptional training for fall prevention,” said Ben Fung, a physical therapist based in San Diego who specializes in helping patients, including those with Parkinson’s, avoid falling. Fung also has a background in mixed martial arts.

Many falls happen when a person is either reaching for something or changing direction or velocity. Learning a boxer’s stance can help with maintaining balance, while keeping the hands up can protect the body and face from injuries in the event of a fall.

Participants practice falling as part of the Rock Steady curriculum. “Ending up on the floor is more common than not with people with Parkinson’s,” said Cotton, whose father received a diagnosis of Parkinson’s disease a few years after he started working with Rock Steady. “Our boxers still fall; they’re just not paralyzed by fear.”

Less fear may mean fewer falls. “One of the biggest factors in whether or not someone is at risk for falling is if they’re fearful of falling,” said Rebecca Martin, a professor of physical therapy at Hanover College in Indiana. Martin is not affiliated with Rock Steady Boxing, but seeing its effectiveness has led her to incorporate boxing techniques into her work, which includes leading weekly exercise classes for people with Parkinson’s disease.

A recent study of boxing therapy found that Parkinson’s patients who underwent twice-weekly training reported fewer falls, with the number of falls going up during COVID-19 lockdowns and going back down once the restrictions were lifted and they were able to resume training. This is something Trout saw firsthand, as many of his participants — or “fighters,” as he calls them — came back from lockdowns stiffer and shakier than before.

Outside the ring

Parkinson’s disease also has psychological effects. As patients lose coordination and balance, many start to second-guess their abilities and pull into a shell, withdrawing from friends and family and limiting trips outside the home, because of fears about falling.

“Parkinson’s takes away your confidence,” Karian said. “You have to work at it to keep it up.”

In a recent survey of more than 1,700 people with Parkinson’s disease, nearly three-quarters of Rock Steady Boxing participants reported that the program improved their social lives, and more than half said it helped with fatigue, fear of falling, depression and anxiety.

“Parkinson’s disease is not just a condition that affects motor symptoms, such as how you move, walk and talk. Parkinson’s can also affect people’s moods, making them feel lonely or isolated,” said Danielle Larson, a neurologist at Northwestern University in Illinois and one of the researchers to conduct the survey. She is not affiliated with Rock Steady but said she now often recommends boxing to her patients.

For some of Trout’s fighters, boxing class is often the only time they get out of the house each week. Kathy Smith, a retired schoolteacher, said she often felt self-conscious about her abilities in exercise classes. In Rock Steady Boxing, “they understand, and they help us adjust to our different abilities,” she said.

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