Can boxing relieve symptoms of Parkinson’s disease and improve quality of life? A qualitative study of the experiences of participants attending the Danish Parkinson boxing concept

Abstract

Purpose

To explore how people with Parkinson’s (PwP) experience the impact of attending Parkinson Boxing (PB) on their symptoms and quality of life.

Methods

The authors NMAY and PeB conducted participant observations of four PB sessions and eight semi-structured interviews with PwP who participated in PB in Denmark. The empirical material was systematically analyzed using thematic analysis.

Results

Four main themes arose. The participants experience a sense of community from being part of a group where they share the same diagnosis. They described various bodily experiences related to their physical and cognitive functioning and well-being, as well as emotional experiences including feelings of joy, gratitude, and mental well-being. They are motivated to participate in the training sessions, and participation further motivates them to retain their exercise practice.

Conclusions

The experienced impact of participating in PB relates to physical relief of symptoms and improved functioning in everyday life, as well as a mental lift, energy, and joy during and after training sessions. Participants described being motivated to attend PB and to continue their training practice. Thus, PB entails experiences of relief of symptoms and presumably improved quality of life for the participants.

IMPLICATIONS FOR REHABILITATION

• Physical activity is an effective complementary treatment to experience improvement in health and well-being for people affected by Parkinson’s disease.

• The Danish concept, Parkinson Boxing, inspired by the concept Rock Steady Boxing from USA, shows promise to relieve symptoms, improve mental and physical well-being and create social relationships.

• The motivation to engage in physical activity increases when exercising in a diagnosis-specific group as Parkinson Boxing where participants have a shared understanding of each other’s challenges and simultaneously achieve social relationships.

• We recommend that rehabilitation professionals use diagnosis-specific group-based interventions which in addition to physical benefits creates basis for a sense of community, mental well-being and motivation to maintain physical activity among participants.

Keywords:

• Semi-structured interviews
• Parkinson’s disease
• Parkinson boxing
• symptoms
• quality of life
• bodily experience
• motivation
• sense of community

Background

Parkinson’s disease is a neurological disorder characterized by motor and nonmotor symptoms. Medical treatment cannot stop the progression of the disease. The aim of the treatment is to relieve symptoms, delay progression, and maintain a good quality of life for as long as possible. It is therefore relevant to find the most suitable methods for preventing and delaying symptoms and improving quality of life [1–3].

The prevalence of Parkinson’s rises worldwide with age in both women and men. In the age group 40–49 years, the prevalence was found to be 41/100.000 persons. This rises to 1903/100.000 persons in the age group 80+. Also, men are more often diagnosed with Parkinson’s than women. Numbers for North America, Europa, and Australia show that 1535/100.000 men are diagnosed with Parkinson’s compared to 1267/100.000 women [4,5]. The Parkinson’s Association in Denmark estimates that the prevalence of people with Parkinson’s (PwP) in Denmark will rise from approximately 12.000 in 2022 to 20.000 in 2040 due to increased life expectancy [6,7].

Physical activity is increasingly recognized as an important treatment for motor and nonmotor symptoms of Parkinson’s. Physical activity has shown a positive effect on physical symptoms in the form of increased strength, improved balance and walking, and at the same time, it has been shown to improve quality of life [8–10]. However, by the course of the disease and with increased levels of disability, levels of physical active decline in PwP [11,12]. Apart from progressed motor symptoms, PwP face several barriers for being physically active, including feeling chronically tired, feeling apathy, fear of falling, lack of social support, poor accessibility to exercise location, lack of transportation opportunities, not being motivated by existing offers, and lack of belief in and knowledge about the impact of exercise on their symptoms [3,13–15].

In recent years, several forms of exercise targeted PwP have been developed and evaluated. These include for instance dance, table tennis, football, and boxing. Studies of these targeted exercise concepts indicate that dance can facilitate the handling of “freezing of gait” incidents and support training of a variety of cognitive skills promoting the ability to carry out everyday activities, facilitate communication with other people, and develop social relations [16,17]. Table tennis has been found to provide social relations, and improve balance, physical functioning, and mental well-being [18]. There is no evidence for the use of football.

Internationally, boxing as complementary treatment for Parkinson’s has been widely implemented. The idea of boxing for PwP originates from the USA and is mainly based on the boxing concept Rock Steady Boxing (RSB) [19]. RSB and other group-based boxing interventions for PwP have shown impact on both motor and nonmotor symptoms. Participants in the studies experienced improved muscle strength, balance, and flexibility, and reduced stiffness. This, for example, enabled the participants to get up from a chair faster and generally improved their ability to perform daily activities. Also, a reduced risk of fall was found [20–26]. Improvement in nonmotor symptoms included reduced fatigue, reduced anxiety and depression, improved mood, and the experience of better sleep [20,21,26,27]. Group-based boxing interventions have shown to improve motivation to attend boxing classes [3,22,28]. Also, they have shown to provide the participants with life-affirming friendships, enable knowledge sharing among the participants, and give hope and a sense of security within the group [3,21–23,27]. Furthermore, participants in the studies gained a sense of competence, a sense of pride, and increased self-confidence. Altogether it increased the participants’ quality of life [3,21,23,27].

Research on RSB in the USA has provided inspiration for and knowledge on boxing as a possible complementary treatment to Parkinson’s in Denmark. In 2020 the Parkinson’s Association in Denmark started the project Parkinson Boxing (PB) after receiving funds from the Danish Health Authority. The Danish Boxing Association trained boxing trainers in the PB concept and implemented the concept within existing boxing clubs. The aim was to offer PwP boxing classes targeting relief of symptoms specific for Parkinson’s. The exercise was aimed at the nervous system and included exercises training cognitive functions, mobility, and general physical strength and fitness [6]. The Parkinson’s Association aimed to attract young PwP to this intensive form of exercise [7]. The PB project ran over 3 years ended by the end of 2023. At the time of this study (spring 2023) around 200 PwP attended PB in Denmark.

While the Danish concept of PB is inspired by RSB, several contextual conditions differ between Denmark and USA, including the healthcare system and the organization and culture of sports clubs. No studies have been made concerning the Danish concept of PB. To be able to guide PwP in Denmark on possible complementary treatments and to inform the Parkinson’s Association in Denmark in the decision regarding the continuation of PB, it was necessary to investigate the Danish concept from the perspectives of the participants. Therefore, the purpose of this study was to explore how PwP experience the impact of participating in PB on their symptoms and quality of life. Hereby, the study contributes to the research evidence on complementary treatment of Parkinson’s in a Northern European context.

Methods

Seeking to gain an in-depth insight into the experiences of the participants attending PB, this study used a qualitative methodology including participant observations of boxing classes and semi-structured interviews with participants [29,30]. Data were collected between March and April 2023 by NMAY and PeB. Both authors are experienced health practitioners (nursing and radiology) and hold a master’s degree in public health. SKW supervised the study and has expertise in qualitative phenomenological research on movement and health. None of the authors knew the participants and the trainers beforehand.

Data collection and participants

Participant observations were conducted to gain insight into the specific training sessions. The aim was to explore participants’ engagement, interactions with each other and the coaches, and establish contact with the participants for the subsequent interviews. Additionally, the researchers PeB and NMAY immersed themselves physically in the training, gaining a firsthand experience of the sessions [29,30].

The study took place in a boxing club in a major Danish city. PeB and NMAY participated in four PB classes, three times before the first interview and once during the interviews. Each training session was attended by approximately 15 participants, one physiotherapist, one boxing coach, and occasionally a speech therapist. The classes took place at the boxing club in a training hall with the use of boxing pads, boxing gloves, ropes, balls, rubber bands, weights, buckets, drumsticks, and foam swords. Each session had a duration of 90 min and took place once a week. Music adapted to the pace of the exercises was played during the training sessions.

Boxing classes in PB took place as individual exercises and without physical contact. There were physical exercises for cardio training, balance exercises, breathing instructions, and strength training. The training also included voice training with a speech therapist and during the boxing exercises, where the participants cheered each other on and made a sound simultaneously with their boxing punches. The training also included dancing as a method to prevent falls. Much of the training took place as a competition, where the participants fenced against each other or hit a boxing pad from different angles.

The participants all have different experiences of what it is like to live with Parkinson’s, and therefore probably also different experiences of PB. To gain an insight into and knowledge of the participants’ lives and subjective experiences, empirical material was produced through individual semi-structured interviews [29,31]. Eight individual semi-structured interviews lasting between 30 and 60 minutes were conducted by the authors PeB and NMAY before data saturation was reached [31,32]. Some of the participants were challenged in finding words and lost their focus and concentration during the interview. It was therefore necessary to ask many clarifying questions in order to elicit statements and experiences [31].

In the group of participants volunteering for interviews, a convenience sample strategy was used including both women and men [29]. Apart from gender, no selection criteria were applied, as all the participants’ experiences would be unique.

The interviews were guided by an interview guide which was structured according to predefined themes with subsequent open-ended questions (Table 1). The development of the interview guide was based on the participant observations combined with theoretical knowledge about the disease and interventions. Statements were verified with clarifying questions throughout all interviews [31]. NMAY and PeB ensured that interviews were conducted in the same format by choosing PeB to perform all interviews while NMAY took notes and asked supplementary questions. Participants were given the opportunity to choose the location of the interview. Four participants chose to be interviewed in their own homes, while the other four participants chose to be interviewed in the boxing club before or after training.

Table 1. Main themes and questions in the interview guide.

Background: Age, employment status, time since diagnosis, symptoms How does Parkinson’s affect your everyday life? Motivation: Why did you start attending PB? How do you experience the PB training? What is it that makes you keep attending the PB sessions? Has your motivation for physical training changed since you started PB? How? Symptoms: Have you experienced a change in your symptoms? How? Mental well-being/quality of life: Have you experienced that PB affects your mood? How? Have you experienced changes in your general quality of life? How? Comparing with other forms of training: Have you tried other forms of training? Which differences have you experienced between these forms and PB?

Analysis strategy

The interviews were transcribed verbatim and analyzed using thematic analysis as described by Virginia Braun and Victoria Clarke [33]. The analysis process was initially guided by an inductive approach. The empirical material was read through, after which a search was made for patterns and subject words. The subject words that had the same meaning were collected and made into codes. The codes were organized into separate documents, which ended up with 21 codes. The 21 codes were grouped into potential themes. To become a theme, it had to be found as a pattern or meaning in the interviews and have significance for the aim of the study [33]. Several themes could be placed together, and themes that were not relevant to the study’s purpose were excluded. The final themes were “sense of community”, “bodily experiences”, “emotional experiences”, and “motivation”.

Ethics

The study protocol was approved by the Research and Innovation Organization at University of Southern Denmark. Before the interviews, the participants were introduced to the study and were given written material about the purpose of the study. The participants were informed about anonymity, and that the material was treated confidentially. In addition, the participants were informed that their participation was voluntary, and that they had the opportunity to withdraw their consent at any time. Written informed consent was obtained from all participants.

Results

Four men and four women aged between 60 and 76 years participated in the interviews. All of them lived in or near the larger Danish city, where the study was conducted. Four participants were retired, while the other four participants were still employed. The time since diagnosis (TSD) differed between 2–10 years and the mean TSD within the group of participants was 6 years. They had participated in PB for 9 months-2 years. The observations revealed that the participants were in different stages of the disease with some having no visible symptoms and others having many visible symptoms. Participants reported widely varying disease progressions, but all had received their diagnosis due to an impact on daily functioning. Symptoms leading to diagnosis included reduced function in one side of the body, in the arm and/or leg, tremors, slow movements, joint stiffness, lack of fine motor skills, fatigue, and falls. All participants had received medication during their course of treatment. In addition to PB, they all engaged in other forms of exercise.

Sense of community

The participants described experiencing a sense of community from being part of a group where they share the same diagnosis. The opportunity to attend a weekly boxing class with other persons sharing the situation of being affected by a central life circumstance as Parkinson’s, was described by some participants as valuable to them. One participant described it the following way:

“It’s strange, after I got the diagnosis, I became happy. How can it be so?… It’s not the diagnosis I am happy about. I think it’s the fact that we are some people who have something together. That’s what I think this (boxing) is … we have a common understanding.” (Participant 3, employed, TSD under mean)

Some participants described that they find it difficult to be ‘someone who is affected by Parkinson’s’. In everyday life, they do not always tell others that they are ill, and they do not want to show off the illness. Being in a forum for PwP can therefore initially feel difficult. However, the participants described that they had realized it as a relief to exercise with others with the same illness. One participant described: “I didn’t want to be a person with Parkinson’s. It shouldn’t be the label in my forehead… but in a way I think it’s relieving to be in a place where people know what you’re affected by.” (Participant 2, employed, TSD under mean).

The participants find that during boxing classes they do not need to explain themselves, because they have a common frame of reference where they know what the others are challenged by, and what the others are going through. For example, one participant expressed: “We all have coordination problems in one way or another, and some more than others. Somehow, it’s just a good feeling that we’re in the same situation - and we can help each other." (Participant 3, employed, TSD under mean). This understanding of each other provides the participants a sense of security and supports a sense of community where they experience it as pleasant to exercise and where there is room for everyone.

The participants’ descriptions of experiencing a sense of community and "team spirit" as making a positive difference for them resonates with the researchers’ experiences during participant observations. The way the participants and the coaches acted towards each other, for example by cheering on each other or supporting each other in difficult exercises, seemed to support the creation of a strong team spirit, which further motivated the participants to perform during the exercises.

The PB concept holds a particular focus on that everyone should feel welcome and should be able to participate at any level of illness. The participants described that they indeed felt welcome through being greeted and included with great friendliness and hospitality at their first appearance. This also made them aware of making the same effort when welcoming new participants. The careful attention is also shown by the participants and coaches during exercise. One participant described: “People are very caring here. Also, if there is someone who feels unwell and needs to sit down - someone will ask if the person is ok. I think that means a lot.” (Participant 2, employed, TSD under mean). According to the participants, this careful attention means that they also feel safe to participate on the days when they have many symptoms.

The participants described that within the boxing community they had obtained social relationships, some going beyond the boxing classes. Usually, the participants meet in a cafe before or after boxing classes and they also described succeeding in getting everyone to join in on a Christmas party. Also, the participants join each other for other events outside the boxing club. For example, one participant had signed up for an event organized by the Parkinson’s Association, after which 6-7 others from the boxing class also signed up. This indicates that the community from PB extends beyond the exercise sessions and encourages the participants to take part in other activities.

The participants also described a careful attention in the community, where they through a common email thread keep in touch with each other in everyday life and for example are noticed if one of the participants reports sick.

Some of the participants described how they in the community have found closeness and care of great significance. For example, one participant mentioned having found a "little family here”.

As part of the description of close social relations, the participants mentioned how they have gained great confidentiality with each other. They experience being able to ask the other participants about subjects they would never ask about in other forums. The confidentiality and trust mean that the limits of what they allow themselves to ask about have moved to very personal matters: “When you know that the others have the same diagnosis you can allow yourself to ask about subjects that you wouldn’t have done otherwise.” (Participant 8, retired, TSD over mean). For example, they would share experiences and questions regarding symptoms and side effects of medication. Hereby, the community offers them an opportunity for gaining further knowledge about the disease, which is not available outside the group.

In contrast to the positive experiences of the boxing community, some participants described experiencing a downside to the community. At boxing classes, they are confronted with the fact that some of the other participants are more severely affected by Parkinson’s than themselves. This cause them worries about the future, which they find difficult.

Summing up, the participants’ and coaches’ effort to create a strong team spirit as well as the participants’ positive experiences of being in a common situation, which enables a safe and supportive exercise environment, contributes positively to their experience of sense of community and joy during PB classes. In addition, participants have obtained social relations extending beyond the training sessions and with a confidentiality enabling them to talk about personal matters such as symptoms and side effects.

Bodily experiences

Participants described various kinds of bodily experiences related to their boxing exercise. These experiences included inner bodily sensations, appearance experiences, and experiences related to cognitive bodily aspects.

First, according to the participants’ descriptions, the intensive 90 minutes of exercise reaches around all their challenges and has a positive impact on many of their symptoms. They experience improvements related to endurance, strength, balance and rotation, flexibility, and fitness. For example, one participant described an experienced improvement in flexibility and rotation:

"It has occurred to me that the exercises we do with rotations have a ‘side effect’. I have had problems for a long time when I ride my bike and must turn and look back when I have to turn left. This has improved a lot.” (Participant 3, employed, TSD under mean)

Among these descriptions, some participants described effects, which are invisible for others but sensed very evidently by the participants. For example, one participant described experiencing an inner shiver which disappears when the participant has attended PB. Another participant often feels stiffness in the body, but after exercise the body feels less stiff:

“At least I feel that my arms, shoulders and back have been activated…. And they are exposed to a load of different kinds… Which means that when I leave here, I am not as stiff in my body as when I came here.” (Participant 1, retired, TSD over mean)

Hence, the participants experience positive changes in inner bodily sensations during and after the 90-minute training session. They described varying duration of these effects from a few hours to days, or as a long-term effect. One participant even described experiencing that the development of symptoms had stopped. The experienced effects of boxing on inner bodily symptoms such as shivering and stiffness, thus, seem to depend on individual circumstances and symptoms.

From the observations, it was evident that the participants also had visible bodily experiences such as sweating and being short of breath during the exercise. These experiences seemed to vary between the participants depending on how much they were able to participate in the exercise and how the class was arranged on the specific day. In addition, several participants described bodily experiences related to a change in their appearance. For example, their relatives would comment on how they appeared with much more energy after returning from boxing classes: “And my spouse can see, when picking me up from training, that I appear with a completely different surplus and energy. It is both here and now it gives me something. But it also gives me some strength.” (Participant 4, employed, TSD over mean). The participant had also experienced a neighbor commenting on improved running style: “I am also told that I walk more nicely and run better. There was actually someone, my neighbor, who called out to me, ‘Wow, how well and nicely you run!’”. The participant expressed pride in having achieved an improved running style and it probably affects the participant’s self-image positively.

Finally, the participants described how they experience the boxing exercise to improve cognitive bodily functions such as coordination. These effects imply experiences of the body being able to do more or better in functions, which are important to manage everyday life. One participant described an experience of improved coordination:

“My spouse and I thought we would play a game of table tennis. There I could simply feel that I could play in a completely different way than I used to. That was before I started boxing training. So, I have gained some more strength and some more coordination in my right hand to hit the (swearing) ball.” (Participant 4, employed, TSD over mean)

The participants generally described being challenged by coordination problems during the exercises in boxing classes. One participant explained that the first time introduced to an exercise, it was impossible to do the exercise. The next time the participant suddenly succeeded in doing the exercise. The participant described a thought of the brain working in the period between boxing classes:

"Coordination has never been my strong point…, but the fact that we practice it so much, I feel that it improves, nevertheless. After all, the brain also works while you are not there, so even if some exercises have been difficult one time and you think no, no, no, I will never learn it. Then the next time, I can suddenly do it.” (Participant 7, employed, TSD under mean)

Another participant described experiencing improvement in ability to react, i.e., reflexes had become faster. Reduced ability to react among the participants was evident in the observations of the boxing classes. Especially if several directions had to be coordinated into an exercise, it presented challenges for several participants.

The participants, hence, described experienced effects of boxing on general bodily strength and fitness, as well as bodily symptoms such as shivering and stiffness, on change in their physical appearance including more energy and improved movement styles, and on cognitive bodily functions such as coordination and faster reflexes.

Emotional experiences

In general, the participants described joy as an immediate effect of PB. For example, one participant described how boxing made such a difference to the person’s feeling of joy that a relative noticed and commented on this. Furthermore, the participants described the mental effect boxing has on them, specifically related to gaining energy during boxing exercise, which reduce their feelings of fatigue and apathy and enables them to overcome more after training. One participant said: “I can get down there and be insanely tired, it was especially before I got medicine that I almost had to drag myself there. But then afterwards, wow, I was able to do anything. It lifts up the energy.” (Participant 3, employed, TSD under mean). This is an important finding since fatigue and apathy are dominant symptoms among PwP.

PB also contributes to positive expectations in the participants’ lives. Some described that they daily looked forward to going to boxing.

In addition to feelings of joy and a mental lift, the participants described a sense of gratitude for being part of PB. This sense is related to the great efforts and thoughts put into each training session by the coaches as well as the careful attitude among coaches and participants creating an atmosphere where the participants experience there is room for everyone. One participant describes a sense of gratitude: “The fact that someone takes responsibility, that someone actually cares about you, someone actually puts together a training program, which is good for me. That means a lot! Wow, they are so good.” (Participant 3, employed, TSD under mean). Moreover, some participants described the sense of gratitude as related to the opportunity for meeting new people, which would not have been possible without the disease: "On the positive side, I have met a lot of nice people that I wouldn’t have met otherwise." (Participant 8, retired, TSD over mean).

PB therefore contributes positive elements to the participants’ mental well-being both during and outside training sessions in the form of feelings of joy, extra energy, positive expectations, and a sense of gratitude.

Motivation for training—also outside boxing classes

All participants described being highly motivated to attend PB, and to keep coming. PwP are challenged by fatigue and inactivity, which can be a barrier for being physically active. The participants in the study were all aware of the importance of keeping themselves active. Several of them had tried other forms of physical activity, which they did not find inspiring and quit. The participants therefore expressed that it is important for them to find a form of physical exercise that they like to attend.

One of the things that motivates the participants to attend PB, is the specific approach of the coaches including the message that participants can participate at their possible level and the acceptance that everyone has different limits—also from time to time, as well as a supportive and cheering attitude. This approach gives the participants a feeling of security.

Another motivating element described by the participants is the variation in the content of the training as well as a deliberate action point of the PB concept, namely the “fun factor”: “Well, I just think it was fun training and some fantastic coaches. You can just see how we fool around with buckets and drumsticks, right? I think it’s fantastic!” (Participant 2, employed, TSD under mean). They never experience the training as boring, and the good laughs and atmosphere have a positive impact on their mood. They also like to tell other people outside the boxing community about the good experiences they have during training.

Some of the participants described how they use some of the exercises in their daily lives, which indicates that the motivation from the boxing classes extends outside classes. For example, one participant describes:

“When I stand up ironing or something, I can do some exercises at the same time. If I do this, it’s like the basic position in boxing. I stand and sway from one foot to the other. So, I become more aware of strengthening my balance and strengthening my body in general.” (Participant 2, employed, TSD under mean)

The participants thus have become aware that small daily exercises can train some of the challenges they experience. They use their knowledge and the inspiration from the exercises to find motivation for daily input that can improve or maintain their everyday functions.

Finally, the strong sense of community seemed to be a highly motivating factor for the participants. They mentioned, for example, how “cancelation is not an option”, and how they end up attending PB even on days where they lack energy because they know “the others are there” and they do not want to let them down by not attending.

Hence, the participants described being highly motivated to attend PB classes. Apart from motivation related to their experiences of a strong sense of community, improvement in bodily sensations and functions, and a general mental lift and energy, their motivation is related to the specific approach and content of the training sessions and the fact that they can use some of the exercises in their daily living.

Discussion

The aim of this study was to explore how PwP experience the impact of PB on their symptoms and quality of life.

The impact of boxing on symptoms

The participants in this study all participated in PB classes offered in a major Danish city. They had been attending PB classes for 9 months to 2 years. 9 months is long enough for the participants to assess whether the exercise has an impact on their symptoms. Evidence for this claim is found in a systematic review and meta-analysis by Shu et al. investigating 18 randomized controlled trials, which in total included 901 patients participating in aerobic exercise interventions spanning from 3 weeks to 16 months [10]. The review found evidence for improvement in motor action, balance, and gait right after starting the exercise intervention.

The participants had very different symptoms of Parkinson’s, and thus also very different bodily experiences of the disease and the changes that the symptoms brought. In addition, their symptoms varied greatly from day to day. Some participants experienced effects on symptoms from PB for a few hours, some for days and others reported that they experienced more long-term effects from the exercise. It depended on their individual symptoms, and how much they were able to participate. One of the participants described having experienced that the symptoms increased in the time after the diagnosis. When the participant started PB, the exercise relieved the symptoms, increased strength, and kept the disease from developing. That physical exercise can relieve symptoms or delay development in Parkinson’s disease has also been found in other studies [3,20–27].

The participants in this study all practiced several different forms of exercise such as yoga, dance, tennis, table tennis, running or exercise with a physiotherapist. They reported that exercise had a positive impact on their symptoms, regardless of the kind of exercise they did. However, a PB session lasts 90 minutes, which is longer than most forms of physical activity, which are often 45-50 minutes. The participants described that the intensive exercise during the 90 minutes reached around all their challenges and thus affected many symptoms. They reported improvements in endurance, strength, rotation, fitness, and cognitive functions. This agrees well with the findings in a qualitative study conducted by MacCosham et al. [24], who found that the participants found the form of exercise in RSB to be a perfect fit for their symptoms. The participants reported gaining more muscle strength, better balance, more flexibility, and they reported improvement in handling daily functions.

The review by Shu et al. highlights the insufficient evidence for long-term effects of physical exercise on motor symptoms due to few follow-up studies [10]. A study by Sangarapillai et al. including 40 participants randomized to a 10-week intervention program of either boxing exercise or sensory training followed by a 20-week wash-out period found that the effects of boxing exercise on symptoms were not sustained after cessation of the program, which was the case for sensory training [34]. The study also assessed quality of life, which was improved and sustained in both groups. Based on other studies, the authors suggest that “The fun, enjoyable nature of boxing allows participants to feel as though they are part of a community”. Hence, while there might be a clinical interest in studying the long-term effects after program cessation, the evidence for immediate effects as well as the significance of actual participation on quality of life seems just as important to focus on and study further.

While motor symptoms can be relieved by medication, medication does not influence non-motor or social challenges experienced by PwP [24]. This is another reason why exercise in the sense of participating in a training community as PB is important as a complementary treatment for symptoms. In the interviews, PeB and NMAY gained insight into the fact that the participants in PB meet like-minded people with whom they feel safe and can spar on very personal and difficult topics, including handling non-motor symptoms. The fact that the participants share the diagnosis, means that they have an understanding of each other and the symptoms they experience to struggle with. It is therefore possible for the participants to gain new knowledge about symptoms, treatments, and side effects in the PB community.

One of the challenges for PwP is dropping out of exercise due to apathy, fatigue, and lack of motivation [3,13–15]. The participants in this study emphasized the importance of motivation in relation to training. Several of them had experienced losing interest and dropped out of exercise that was boring, at too high a level or where it was entirely up to themselves to carry out an exercise session. The challenge is therefore that exercise must be inspiring, so the participants keep showing up. The participants in this study were highly motivated to attend PB. They described looking forward to attending PB and they seldomly cancelled training. The sense of community at PB means that even if they lack energy or desire, they end up attending because of their fellow participants. This agrees well with the finding in the systematic literature review by Morris et al. [28] which found that RSB keeps PwP attending classes and staying physically active. The study found that boxing has the advantage that it is based on a sense of community, that it can be found in the local environment, and that it is a social form of intensive and continuous exercise.

Several participants described that it makes a significant difference to have the assurance that at PB there is someone who takes care of you if you become unwell during exercise. This means that they also participate on the days when they have many symptoms. The high motivation for attending PB and retaining the training practice is an important finding of this study. Fatigue and apathy will increase as the disease progresses, and thus the prevention and relief of symptoms will depend on the participants’ willingness to attend.

Quality of life

When a person cannot be cured, the person’s focus is shifted towards improving his/her conditions and making sense in life as it is now. One of the participants described this existential challenge following the Parkinson’s diagnosis: “When you have Parkinson’s, you are to find things in life that makes life worth living. Life will never be as it used to be.” (Participant 8, retired, TSD over mean). Thus, after being diagnosed with Parkinson’s disease, what constitutes quality of life may change fundamentally along with experiences of a “changing self” [35]. The interviewed participants described experiences of moments where the body shortly is relieved from enervating symptoms, which momentarily creates greater bodily well-being. They also described experiences of being able to manage everyday tasks better due to improved balance and coordination assumingly causing feelings of empowerment. Expressions of joy, positive expectations, and gratitude as well as motivation to attend training despite lack of energy and challenging symptoms are all expressions illustrating how PB seems to be a very meaningful and valuable activity for the participants in several and more profound ways. These are important findings as the main aim of treatment for Parkinson’s patients is to reduce or delay the progression of symptoms and to improve the quality of life. Similar findings are shown in studies on RSB that show increased self-confidence, self-respect and a sense of pride when the participants experience “being able to” [3,21,24].

Participants described that they in the PB classes formed social relations with the other participants, also relations going beyond the training sessions. The strong sense of community enabling a common understanding of the challenges caused by the disease, also in a bodily sense, was important for the PB participants’ experience of safety and security, and for their supportive approach to each other both during and outside training sessions. This corresponds to findings in several other studies, which showed that the participants in RSB achieved life-affirming social ties with others with Parkinson’s [3,18–21,24].

Implications for practice

This study underlines that many of the benefits of PB are due to the fact that the training is done in a group of people sharing the same diagnosis. It seems important that PB remains a training concept specifically targeted people diagnosed with Parkinson’s, as the common situation supports a shared understanding and opens up a safe space for targeted physical training as well as a free space for the participants to talk about very personal and intimate topics related to the specific diagnosis. While some of the physical benefits could be achieved in a training session with just one therapist and one person with Parkinson’s, based on this study we may assume that the person would miss out on the social and mental benefits and the motivation for maintaining the practice. Some of the participants described in the interviews how they struggled to keep up the motivation for attending single training sessions with their physiotherapist.

Participants in PB also expressed that it is of great importance and provides reassurance that they are met by equals with great kindness and friendliness during the exercise. This was something they were very conscious of passing on to new participants. Several studies on RSB also found that meeting equal people the moment one entered the boxing training door provided hope [3, 21, 24]. The culture surrounding PB therefore seems to be important. If PB is offered in larger contexts, it will be important to keep a focus on preserving this culture which ensures that the participants feel included in the group.

Being able to prevent and relieve symptoms of Parkinsons requires motivation and persistent training. Four out of the eight participants in this study were still employed at the time of the study, and they were motivated to participate in PB, but they were also challenged logistically since the training took place during working hours. PwP in Denmark can take time off with pay to participate in training. However, the participants in this study did not make use of this opportunity until late in the course of their illness. In the interviews, they did not describe why they chose not to take time off with pay, but they described how they rearranged their working hours to be able to participate. This must be a focus point for the Parkinson’s Association in Denmark in the future implementation of PB, as the retirement age in Denmark is increasing and the challenge of participating during working hours will affect more people in the future.

Limitations

Although only eight participants were interviewed in this study, PeB and NMAY experienced data saturation after 6-7 interviews and therefore assessed findings to be valid. Also, the participant observations enabling a third-person perspective on the participants’ participation during training sessions was a strength of the study. The participants volunteering to participate in interviews were benevolent and positive towards the PB project. The results were very positive and may have reflected that this group of interviewees had a particular positive opinion of PB. In addition, the coaches were also very positive and dedicated which adds to the assumption that the study was done in a particular successful context. The participants in the study are all physically active outside PB, which may reflect that the included group takes a particular responsibility for their own health and well-being and have good access to exercise locations. This may not necessarily be the case for all persons affected by Parkinson’s. Although not possible in this study, extending the data collection to other training sites would have strengthened the generalizability of the findings. However, the findings were in line with other similar studies (i.e., RSB).

Conclusion

This qualitative study explored the subjective experiences of participants attending the Danish Parkinson Boxing concept. Eliciting these experiences in-depth is important to get a nuanced understanding of the possible benefits of PB, some of which are hard to capture through more measurable methods. Also, giving voice and listening carefully to PwP experiencing a life world very different from other people, is important to understand how to support them in the best ways.

Participants in PB consistently emphasized their experience of a strong sense of community within the program. They described feeling welcomed, quickly integrated into the community, and experiencing a strong team spirit during training. This sense of community was a driving force behind their persistent attendance in PB sessions and it seemed to enable a safe a supportive training atmosphere. Regarding physical effects, participants noted that the impact of PB on their bodies varied depending on their individual symptoms. Some experienced short-term relief of symptoms, while others reported longer-term improvements. Overall, they felt that the exercise positively influenced their bodily functioning. Additionally, participants commonly described a mental boost, increased joy, and greater energy levels after participating in PB. PB acted as a strong motivator for participants to engage in regular exercise, both within and beyond the boxing sessions. This motivation extended to their daily routines, contributing to the prevention of symptom development. PB presumably has a positive impact on the participants’ overall quality of life. They experienced an improved ability to engage in activities they enjoyed, felt better physically, and reported enhanced well-being. PB not only brought joy and anticipation before each session but also provided a mental lift afterwards, adding a sense of contentment to their lives. These positive experiences in PB also spilled over into their social lives, as they could share their uplifting stories and contribute positively to other aspects of their daily routines.

Acknowledgments

The authors wish to acknowledge all the participants, without whom this study would not have been possible.

Disclosure statement

No potential conflict of interest was reported by the author(s).