Bob Knight's left hand shakes.
It has for a couple of years.
The shake was one of several Parkinson's disease symptoms that alerted his wife and children that Knight could have the disease.
Other symptoms were manifesting. He was beginning to hunch over. Family members had trouble hearing him.
"I'd say something at the dinner table, and they didn't respond," the 68-year-old said. "I don't think they could hear me."
He went to a specialist to be evaluated.
"They made me walk. A lot of people with Parkinson's drag their toes when they walk," Knight explained. "They hunch over and have a soft voice."
Knight is one of six Parkinson's patients enrolled in a Rock Steady Boxing program that started early this month at Sam B. Cook Healthplex.
Rock Steady was developed in Indianapolis in 2006.
Organizers of the program said it slows - and in some cases reverses - some symptoms of Parkinson's disease.
Rock Steady uses boxing training techniques to improve patients' balance, hand-eye coordination, speed of movement, agility, muscle power, mental focus and rhythm.
Under the program, Parkinson's patients perform stretches for fitness, footwork for balance and punching techniques to steady tremors. They also spar to improve coordination and shout to counter their "soft voice syndrome," which is caused by weakened muscles.
Cases of Parkinson's have been associated with boxing, but there is no contact in the training.
It's counter-intuitive, but it works, organizers said.
The different effects Parkinson's has on individuals is evident in the Rock Steady class. Some participants have difficulty raising their hands over their heads. Others walk with a shuffling gait or have difficulty moving their feet laterally. Balance is an issue for several.
Time to begin
When the large red numerals on a clock opposite the entrance to the workout room in the Healthplex turned to "10:00," Wesley Lochhead, an exercise specialist, began setting up an agility ladder. After the rope-and-ribbon had been laid along the floor, athletes stepped in and out of its openings to perfect their footwork, develop coordination or simply warm up before a workout.
The ladder was challenging for Lonnie Schneider, a 68-year-old man who was diagnosed with the condition about two years ago.
"My Parkinson's disease is more balance than anything else. I was, maybe, falling a little more than I should have," Schneider said.
Schneider had polio when he was 2, which affected his right side. That may have had a residual effect, he surmises.
In Parkinson's disease, neurons (nerve cells) in the brain break down or die. Doctors believe the condition begins in the part of the brain where neurons create dopamine, which tells parts of the brain when to move body parts.
Affecting movement, Parkinson's disease is a progressive nervous system disorder that typically starts with a slight tremor in one hand, according to the Mayo Clinic. Along with tremors, the disorder commonly causes stiffness or slowing of movement. Patients' faces may show little or no expression, or their arms may not swing when they walk in early stages.
Symptoms worsen over time.
There is no cure for the disease, but medications may improve symptoms, according to the clinic.
In Missouri, 15,900 people have Parkinson's, according to a Parkinson's Foundation Study. About 930,000 people nationwide are expected to have the condition by 2020.
Sharmila Suri, a neurologist with an office at Capital Region Medical Center, said physical therapy has been an important part of treatment for patients with Parkinson's disease.
For some people, she said, the disease remains stable. The disease continues to progress, Suri said. How fast, nobody knows.
"We do prescribe physical therapy to help with symptoms," Suri said. "Our goal is to keep (patients) as functional as possible."
She's excited to see the use of Rock Steady because it is a new type of therapy that can help patients.
"People all over the country have seen improvements," Suri said.
The foundation, which strives to improve care and advance research toward a cure for Parkinson's, estimates the cost of treatment, Social Security payments and lost income associated with the condition for Americans is $25 billion annually. Medications for people suffering with the condition can cost $2,500 per year. And therapeutic surgery (deep brain stimulation), which involves insertion of electrodes in targeted areas of the brain stimulated by an impulse generator battery, can cost up to $100,000. The battery provides an impulse to a part of the brain involved in motor function, according to the foundation.
Men are 1.5 times more likely to have Parkinson's than women, according to studies. Two women are participants in the Jefferson City class.
Suri said stem cell treatments and other research are in early stages. Within the past few years, some research has looked into using a dopamine pump, which constantly stimulates the brain's dopamine receptors.
Patients said they feel better after undergoing physical therapy, Suri said.
Besides Rock Steady, the Healthplex has two other programs to help Parkinson's patients, said Derek Parker, a supervisor at the center.
One is LSVT Big Therapy, an exercise treatment program based on the principle the brain can learn and change. It evolved from a speech program for people with Parkinson's disease called Lee Silverman Voice Treatment. LSVT uses a series of vocal exercises to strengthen a patient's voice. Big Therapy uses rapid, intense movements to reverse some Parkinson's movement symptoms.
A third program involves intense, one-on-one physical therapy.
"We're pretty stoked that (Capital) Region has options and people have choices," Parker said. "Rock Steady is the perfect opportunity for them to fight back."
Putting on the gloves
After about 20 minutes spent stretching, running and working on sideways shuffles, the patients stopped for a water break and to pull on their black boxing gloves.
Lochhead instructed them to begin work on the heavy bag. The large stuffed black bags often seen in boxing gyms are used for practicing power punches and coordinating footwork with punches. Three hang from the ceiling in one corner of the workout room. The cylindrical bags may be raised out of the the way using electric winches.
He began by teaching them a simple punch combination - a jab and cross. Each took a 30-second turn performing the combination as quickly as possible while another patient steadied the bag.
Connie Nussbaum threw herself into the effort. The 58-year-old began hitting the bag so hard that her partner, Judi Jecmen, could hardly hold it.
Nussbaum received her diagnosis about two years ago, when she was recovering from foot surgery. The condition affects her right side, she said. It's the same side on which she had surgery.
"I had a lot of trouble with stiffness and balance. It seems like I was less stiff after doing some boxing," she said on the third day of class.
Sitting still is Parkinson's disease's best friend, Nussbaum said.
So she doesn't.
She throws herself into every stretch, exercise and activity. And she's made her grandson proud.
"My grandson is going around telling everybody that his grandmother is a boxer," she said.
Boxing isn't the only activity recommended to ease symptoms of Parkinson's disease.
Jecmen, who is 68 and was diagnosed in 1999, said in addition to boxing three days a week, she attends a tai chi class twice a week.
"Boxing is the newest thing when it comes to Parkinson's disease," Jecmen said. "They demonstrated it at the last world congress."
Since her diagnosis, she's attended four world congresses on the condition. At these gatherings, experts from around the world share their approaches to Parkinson's disease and related movement disorders to encourage discussion of original research and clinical management solutions to a wide range of problems associated with the conditions.
She takes medications to help with symptoms, but "some of the side effects are not fun," Jecmen said.
Getting into shape
After participants each had opportunities to master the jab-cross, Lochhead taught them other combinations.
They moved on to a jab-uppercut, then left and right uppercuts in combination, and finished with a three-punch combination of jab-cross-uppercut.
Sweat streamed down not only the participants' cheeks but also Lochhead's as he led them through the routines. Leading the class is difficult, he said. But it has given him a chance to see how much he and another instructor can handle in each session. They may be able to expand the class to about 10, he said.
That's good news for about 20 people who are on a waiting list to enter the program.
Lochhead said he'll be curious to see how each participant's body mass index changes after about nine weeks of the class.
Jerry Kemple, a 77-year-old U.S. Air Force veteran, said he was diagnosed about 18 months ago. The workout takes him back to his youth, he said.
"It's like being in basic training in the military," Kemple said.
Parker had evaluated each of the patients before placing them in the class to see what might be best for them. Their progress will be checked periodically.
It's too soon to tell if the program is having an effect on his tremors, Knight said, explaining just talking about the condition makes his hand shake more.
"It gets a little worse when I'm nervous."