BRIEF RESEARCH REPORT

published: 30 March 2020

doi: 10.3389/fpsyg.2020.00581

Boccia as a Rehabilitation
Intervention for Adults With Severe
Mobility Limitations Due to
Neuromuscular and Other
Neurological Disorders: Feasibility
and Effects on Upper Limb
Impairments
David Suárez-Iglesias 1* , Carlos Ayán Perez 2 , Nuria Mendoza-Laiz 3 and
José Gerardo Villa-Vicente 1
Edited by: 1
Department of Physical Education and Sport, VALFIS Research Group, Institute of Biomedicine (IBIOMED), University
Sergio Machado,
of León, León, Spain, 2 Well-Move Research Group, Faculty of Education and Sport Science, Department of Special
Salgado de Oliveira University, Brazil
Didactics, University of Vigo, Vigo, Spain, 3 Department of Sport Science, University of Francisco de Vitoria, Madrid, Spain
Reviewed by:
Luis Mochizuki,
University of São Paulo, Brazil Purpose: Scant research exists regarding the effects of playing Boccia as a
Carla Silva-Batista, rehabilitation strategy for people with severe mobility limitations due to neuromuscular
University of São Paulo, Brazil
and other neurological disorders. This study is aimed at identifying the feasibility and
*Correspondence:
David Suárez-Iglesias
effects of playing Boccia on the upper limb impairments of people with severe mobility
dsuai@unileon.es limitations due to neuromuscular and other neurological disorders.

Specialty section: Materials and Methods: Seven people played Boccia three times per week for
This article was submitted to 20 weeks as part of the rehabilitation process, while other seven kept up with their
Movement Science and Sport
Psychology,
usual rehabilitation schedule. Attrition, adherence, adverse effects, participation and
a section of the journal completion rate were registered to assess feasibility. The effects of the program on grip,
Frontiers in Psychology pinch strength and upper-limb active range of motion were assessed by means of a
Received: 26 November 2019 dynamometer and a goniometer.
Accepted: 11 March 2020
Published: 30 March 2020 Results and Conclusions: The program was feasible, although no effects were
Citation: observed after its completion on variables assessed, except for hand flexion and
Suárez-Iglesias D, Ayán Perez C,
Mendoza-Laiz N and Villa-Vicente JG
ulnar deviation active range of motion. In a group of people with severe disability
(2020) Boccia as a Rehabilitation due to neuromuscular and other neurological disorders, playing Boccia as part of a
Intervention for Adults With Severe
multidisciplinary rehabilitation program was shown to be a feasible therapy. However,
Mobility Limitations Due
to Neuromuscular and Other practicing this game did not lead to significant improvements in upper limb impairments,
Neurological Disorders: Feasibility except for wrist flexion and ulnar deviation active range of motion.
and Effects on Upper Limb
Impairments. Front. Psychol. 11:581. Keywords: neuromuscular disorders, neurological impairment, severe mobility limitations, upper limb
doi: 10.3389/fpsyg.2020.00581 impairments, grip strength, range of motion, Boccia, paralympic

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

INTRODUCTION to identify the feasibility of incorporating Boccia as part

of a multidisciplinary rehabilitation program for people
People with neuromuscular and other neurological disorders with severe mobility limitations due to NNMDs. A second
(NNMDs), including central nervous system disorders such as goal is to describe changes in hand grip and pinch strength
cerebral palsy (CP) or multiple sclerosis, generally have an and upper limb range of motion in this population due
unfavorable physical behavior profile characterized by a low to the implementation of a Boccia program to their usual
level of physical activity, which, in turn, leads to functional rehabilitation program.
deterioration (Slaman et al., 2015; Streber et al., 2016). Practicing
adapted sports is considered a beneficial therapeutic approach
for this population because it contributes to the development MATERIALS AND METHODS
and maintenance of physical function (Shapiro and Malone,
2016). For any adapted sport regimen to be beneficial, it is
Participants
important to select one that a patient can practice successfully.
Participants were recruited from a Spanish State Referral Centre
To this end, there are a number of important person-level
(SRC) for severely disabled people by a Ph.D. student who
characteristics to consider when choosing an adapted sport
was carrying out research on the impact of adapted sports in
exercise suitable for people with NNMDs. These factors include
populations with severe disabilities. The study participants were
degree of disability, economic resources, and motor skill level.
receiving individual level, multidisciplinary, rehabilitation (i.e.,
In addition, performance of the selected exercise should include
psychological and speech therapies and voluntary therapeutic
sport-specific movements that stimulate and improve conditional
exercise). At the moment of the study, two occupational therapy
aspects that are important not only for sport, but also for daily
and two physiotherapy sessions were administered per week,
functioning of the individual.
60 and 30 min each, respectively. While the usual course
Boccia is a Paralympic sport originally designed for individuals
of rehabilitation treatment was received without interruption,
with CP. The sport, however, is accessible to individuals
participants were offered the opportunity to practice Boccia as
with other clinical presentations of neurological impairment
an additional therapy (a leisure time physical activity, LTPA).
and other physical impairments. To be eligible to play an
Those who agreed to participate in a scheduled Boccia program
individual must experience a disability and use a wheelchair
formed the Boccia plus usual rehabilitation program group
(BISFed, 2018). Boccia’s accessibility presents an interesting
(BG), and those who did not show interest in participating in
option for people with NNMDs for several reasons. Firstly, it
regular Boccia sessions formed the usual rehabilitation program
is a low-cost, adapted sport modality that is easy to organize,
group (UG).
and is accessible to individuals with a very wide range of
All participants with a physical disability affecting all four
ability and disability levels (Rimmer, 2012). Given that playing
limbs due to a NNMD or another musculoskeletal disorder,
Boccia can be perceived as a recreational form of therapy
and who used a manual or power wheelchair, were invited to
by those who practice it (Molik et al., 2010), and given
take part in the study. The exclusion criteria were as follows:
that this sport provides a means of control, achievement and
(a) acute cardiac or respiratory episode in the past 2 months;
identity (Cunningham et al., 2012), adherence to its practice is
(b) upper limbs treated with surgery in the past 5 years; (c)
expected to be high. Therefore, playing Boccia can be regarded
engagement in a regular sporting activity (including Boccia)
as a useful physical rehabilitation strategy for people with
during the previous 4 months; and (d) inability to release the
severe mobility limitations (CP or related NNMDs involving a
ball. None of the participants exhibited cognitive impairment
wheelchair). Secondly, because Boccia is a precision ball sport,
(Mini-Mental State Examination >26), and all of them were
it allows individuals with significant functional limitation to
on stable drug therapy for at least three months before and
strengthen impaired or weakened muscles and improve their
for the period of study participation. A total of 20 participants,
motor skills (Lapresa et al., 2017). Indeed, given that the
with a mean age of 44.2 ± 11.0 years and mean Barthel Index
aim of Boccia is to throw balls closer to a target than an
(BI) score of 64.8 ± 29.0, initially volunteered and met the
opponent, players that throw the ball with the hand are required
inclusion criteria for the study. Half of them were interested
to perform a range of motor skills with the upper limb as
in the Boccia program while the other half were not. The
it involves grabbing, gripping and releasing hand movements
research design was approved by the ethics committees of the
(Huang et al., 2014). Therefore, playing Boccia could represent
University of León and the SRC, and all subjects gave their written
an effective stimulus for improving hand muscular strength
informed consent.
and upper extremity range of motion, both of which are
conditional aspects that are strongly related to the functional
autonomy of people with NNMDs (Yozbatıran et al., 2006; Measurements
Braendvik et al., 2010). Baseline Demographic and Clinical Characteristics of
However, Boccia research has focused mainly on Participants
biomechanical, learning and motivational aspects (Barak The participants’ age, height, sex, type of disability, functional
et al., 2016), while scientific evidence regarding the effects of status (according to the BI), cognitive status (according to the
playing Boccia on upper limb impairments in this population Mini-Mental State Examination) and medication status were
is scarce. This study has a two-fold objective. Firstly, it aims obtained from the records of the institution’s medical staff.

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

Feasibility of the Program Pinchmeter test. After a 10-min break, pinch strength
A number of variables were collected by the same researcher measurements for the key (lateral), three jaw (tripod) and
who administered the program to assess the feasibility of the tip to tip positions were performed. The assessment followed
program. The variables include: recruitment rate (number of the standard procedure and used the recommended three-trial
participants recruited from those that fulfilled the inclusion method (Mathiowetz, 1990). For this assessment, participants
criteria), attrition rate (number of drop-outs), completion rate exert their maximum strength for 3–5 s. The software
(number of participants who completed each outcome measure), automatically calculated the average pinch measurement.
adherence (proportion of participants with participation rates
exceeding 80%), participation (total number of session hours Range of motion
completed divided by the total number of possible hours), and Active range of motion (AROM) of the upper limb was assessed
safety and tolerability (number of participants who experienced using an electrogoniometer (Biometrics E-Link R500 Range
Boccia-related adverse effects). of Motion Kit), consisting of a small and a large goniometer
(Biometrics Ltd, 2018). Specifically, AROM in shoulder (flexion,
Effects of the Boccia Intervention on Upper-Limb extension, abduction, medial rotation and lateral rotation), elbow
Impairments (flexion and extension), forearm (pronation and supination) and
wrist (flexion, extension, radial deviation and ulnar deviation)
Maximum grip and pinch strength
were measured. Test–retest reliability of measuring upper limb
Data were collected using Biometrics E-Link H500 Hand Kit
ROM in patients with CP has been reported as good (ICCs
that consisted of a G200 Dynamometer with precision load
0.81–0.94), although it may vary based on the experience of
cell and a P200 Pinchmeter for determining grip and pinch
the tester, joint measured, position of the participant and
strength. Both devices were linked to the E-LINK software
stabilization of the proximal segments (McWhirk and Glanzman,
(Biometrics Ltd., Gwent, United Kingdom). This system allows
2006; Mutlu et al., 2007). To control for these factors, standard
accurate measurement on very weak subjects by providing
procedures and positions were followed (Norkin and White,
grip and pinch strength measurements to the closest 0.1
2016). One experienced examiner took all measurements. For
increments (kg) (Biometrics Ltd, 2017). The test–retest reliability
each measurement, the examiner aligned the goniometer and
of grip strength and pinch assessments with the latter has
an assistant recorded all data and provided stabilization to
been shown to be good-to-excellent (ICCs 0.83–0.99) in a
participants when required. Three AROM measurements of each
similar sample of participants as the present study (Hutzler
motion were taken.
et al., 2013). Calibration accuracy of both G200 Dynamometer
Evaluations took place twice, at baseline (Pre-test) and after a
and P200 Pinchmeter was verified before and after the test
20-week period (Post-test). All measurements focused on the arm
period. Before starting the actual tests, participants were
involved in the throwing action and were taken with participants
provided with ample opportunity to familiarize themselves with
in supine and sitting positions, with a consistent position
the protocols. An experienced examiner provided consistent
between tests. The tests were performed under controlled
encouragement for pre- and post-test, using standardized verbal
laboratory conditions at the same time of the day and were
instructions plus equal feedback for each test and participant
conducted by the same person who supervised the intervention.
(Mathiowetz et al., 1984).
The evaluations were performed on two non-consecutive days.
Dynamometer test. Participants were tested in their own Muscular strength measurements were performed on the first day
wheelchairs in accordance with ASHT recommendations and electrogoniometry was carried out on the second day.
(Shechtman and Sindhu, 2015), with shoulder adducted and
neutrally rotated, elbow flexed at 90◦ , and the forearm and wrist Procedures
in neutral position, while the examiner lightly supported the base Participants in the BG were asked to attend three Boccia sessions
of the dynamometer. Participants grasped the dynamometer’s per week for 20 weeks. Fifty-seven sessions were held in a sports
handle that ran parallel to the knuckles with the entire palmar room, with two 90-min sessions on Mondays and Wednesdays,
surface of the hand (Mathiowetz et al., 1985). Dynamometer and one 60-min session on Thursdays (in total 4 h per week). The
readings present on the Biometrics E-Link’s computer screen sessions included warming-up and cooling-off activities as well
were not visible to participants. Standard peak force grip as friendly Boccia matches (Table 1). Official Boccia balls were
was registered. Participants were instructed to apply as much used (weight of 285 ± 12 gr; circumference of 270 mm ± 8 mm).
grip pressure as possible on the dynamometer for 3–5 s. The The dimensions and setup of the sports rooms mimic those of a
evaluation system is valid and reliable when used for measuring Boccia court (12.5 × 6 m with 2 m of empty space around it),
grip strength with the second handle position (Allen and with six rectangular throwing boxes (1 × 2.5 m) in which the
Barnett, 2011). Thus, the readings of three successive trials players must stay completely within during play. The progression
were recorded in kilograms using the second handle position of of the Boccia program was based upon participant’s functional
the dynamometer. The three-trial method is recommended in ability to play Boccia, performing all activities in their own
rehabilitation patients with neurologic disorders (Mathiowetz, wheelchairs. To ensure each individual received the required
1990). A 60-s intertrial rest was established to avoid fatigue. attention and comprehensive instruction tailored to their needs,
The average result of the three trials was registered for further the following aspects were observed during the first two weeks of
statistical analysis. the Boccia program by the Boccia coach: a) ability to maintain

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

TABLE 1 | Activities involved in a typical Boccia group session. the ball, such as underarm throwing and overarm throwing
(Fong et al., 2012), which require wrist, elbow, and shoulder
Activity Duration Description
(min) control (Huang et al., 2014). The Boccia program not only
promoted skill, but also tactical development. Throughout the
Warm-up 10–15 20 weeks, all sessions included games to develop teamwork and
Static stretching 3–5 Two sets of isometric holds for 15 s. the ability to make tactical and strategic decisions. Subjects in
Dynamic stretching 3–5 Two sets of repeated upper limb both groups were able to throw the ball with their hand, and
flexion/extension swinging movements for
had never undergone classification evaluation in a sanctioned
15 s (i.e., arm circles).
Boccia-specific 4–5 Practicing various ways to propel the ball.
competition. Participants in the UG group kept up their
activities usual daily activities as part of the specialized multidisciplinary
Force control 15–20 rehabilitation program at the SRC, but did not attend any
“Drawing Each player gets six balls which are thrown Boccia sessions.
lines” to form horizontal lines. This activity is
repeated six times, aiming for different Statistical Analysis
distances (short, middle, and long distance)
of the boccia court.
Results are presented as mean ± SD. Normality was checked
Throwing 15–20
using the Shapiro-Wilk test. All variables were converted to
accuracy a log-scale, with the corresponding values shown in original
“The Cross Three pairs of cones are placed at the 3 m units for display purposes. The chi-square test and independent
Hall” mark. Each pair of cones is separated by a t-test were used to compare clinical characteristics of the two
distance equal to the width of two balls. groups. Data from the pre-test-post-test design were compared
A pair of cones is placed on the right,
using two-way repeated measures ANOVA (group × time).
another in the center and another on the
left. The aim is to throw six balls through
The post hoc analysis for significant F-values was performed
each pair of cones, making it pass between with the Bonferroni correction. The assumption of sphericity
them without touching. was evaluated using Mauchly’s test. When this assumption was
Competition 15–25 not met, the level of significance was adjusted by means of
simulation the Greenhouse-Geisser epsilon. Additionally, an independent
1 vs. 1, 2 vs. 2 or 3 vs. 3 situations. t-test was used to compare the measures of maximum grip and
Cool-down 5–10 pinch strength and range of motion between the two groups
Static stretching 2–3 Two sets of isometric holds for 15 s. at pre- and post-test. Partial eta squared (ηp 2 ) values were
Relaxation 3–7 Variations of Jacobson’s progressive calculated as indicators of effect size, and values of 0.01, 0.06,
relaxation exercises.
and 0.14 were considered small, moderate, and large effect
sizes, respectively (Cohen, 1988). Magnitude-based inferences
were used for analysis of clinical significance using a published
proper position and balance in the wheelchair (the stability spreadsheet (Hopkins, 2006). The threshold for a change to
forward, rearward and sideways); static and dynamic postural be considered clinically important (smallest worthwhile change,
control before and during the throw, ways of grasping the ball SWC) was set as 0.2 × observed between participant SD, based on
properly (cylindrical, spherical or three-finger grasp), accuracy Cohen’s d effect size principle (Batterham and Hopkins, 2006).
and coordination in ball-throwing movements (underarm -with The magnitude of difference was expressed as the standardized
or without pendulum movement- and overarm action). From mean difference. The probability that the magnitude of change
this point on, fundamental movements skills were incorporated was greater than the SWC was rated as: <0.5% almost certainly
into the Boccia sessions as necessary. Moreover, the focus was not; 0.6–5% very unlikely; 6–25% unlikely; 26–75% possibly;
on the introduction and development of a variety of Boccia- 76–95% likely; 96–99.5% very likely; >99.5% most likely. For
specific skills. This foundation consisted of three phases, that a clinical inference, the effect was indicated as “unclear”
were initiated with simple activities and progressed to more if its chance of benefit is promising but its risk of harm
complex activities as the participants advanced their proficiency is unacceptable; the effect was otherwise characterized by a
level in terms of force control, throwing direction and throwing statement about the chance that it is “trivial”, “beneficial” or
accuracy. The Boccia coach emphasized the improvement of: (a) “harmful” (% chances: beneficial/trivial/harmful%) (Hopkins,
force control (weeks 3–10), where the learning intention was to 2006). The statistical significance was set at p < 0.05. All analyses
be able to deliver a ball with the appropriate speed to achieve the were performed using SPSS v. 22.0 for Windows.
intended outcome; (b) throwing direction (weeks 11–15), where
the learning intention was to apply the principles that underpin
delivery of a ball in the right direction toward the intended target, RESULTS
covering different frontal and diagonal throwing lines; and (c)
throwing accuracy (weeks 16–20), where the learning intention Out of the 20 people who initially met the inclusion criteria, two
was to refine shot placement and trajectory of shots at targets dropped out. One participant included in the BG moved away
from different distances, promoting strength and speed of ball- from the SRC, and the other, included in the NG, dropped out
throw accuracy. Participants used different styles of propelling due to family reasons. Therefore, the recruitment rate for the BG

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

was 90% (9/10). Four subjects (two from the BC and two from ηp 2 = 0.11; F = 2.51; 83/15/2%), wrist flexion (90% CI of
the UG) were omitted from further analysis due to missing data, difference 16.0 ± 11.0; p = 0.01; ηp 2 = 0.27; F = 7.44; 97/3/0%)
as they were unable to perform the baseline tests as requested. and ulnar deviation (90% CI of difference 25.0 ± 11.0; p < 0.001;
Thus, a completion rate of 77.7% (7/9) was obtained for the ηp 2 = 0.43; F = 14.96; 100/0/0%), which were classified as likely
BG. Two participants attended less than 80% of the scheduled to be beneficial, very likely to be beneficial and most likely to be
sessions (71.9% and 78.9%, respectively). Therefore, adherence to beneficial, respectively.
the program in the BG stood at 71.4% (5/7). All scheduled Boccia
practice hours were completed, and no injuries or adverse effects
were registered. The duration of the sessions did not affect the DISCUSSION
observed adherence values.
The final study sample was made up of 14 people (mean age Knowledge of the feasibility and effects of exercise programs
of 44.1 ± 10.8 years; mean BI score of 64.3 ± 16.2; 64% women) in NNMDs is required in order to provide evidence-based
(Table 2). The BG (mean age of 44.1 ± 12.6 years; mean BI score recommendations. In this study, Boccia was shown to be a
of 72.9 ± 14.7) included five women (CP, n = 2; Friedreich’s ataxia, feasible physical therapy for people with severe disability due to
n = 1; poliomyelitis, n = 1; Charcot-Marie-Tooth disease, n = 1) NNMDs. Indeed, although a few drop outs were registered, none
and two men (ataxia, n = 1; Steiner’ myotonic dystrophy, n = 1). of them were related to the proposed activities. Moreover, no
The UG group (mean age of 44.1 ± 9.8 years; mean BI score of adverse events were registered and adherence to the intervention
55.7 ± 13.4) included four women (CP, n = 3; traumatic brain was acceptable, and similar to those observed in other exercise
injury, n = 1) and three men (CP, n = 2; neurofibromatosis, n = 1). interventions performed on this population (Kierkegaard et al.,
All participants presented an impairment that belongs to at least 2011). This is a finding worth of mentioning, since adherence and
one of the six Boccia eligible impairment types identified in the drop-outs are possible threats to the validity and outcome of any
Boccia Classification Rulebook (BISFed, 2018). intervention study, but especially those carried out in people with
The groups were comparable at baseline on the relevant NNMDs (Aldehag et al., 2013).
baseline characteristics (except for BI score, p = 0.041), and on The feasibility and adherence observed in the present study
all tested variables except for pinch strength values: key position can be explained on the bases of institutional, interpersonal and
(p = 0.035), three jaw position (p = 0.025), and tip to tip position intrapersonal factors. Concerning institutional factors, research
(p = 0.046). The intragroup analysis indicated that neither group suggests that a health professional’s skill and knowledge in
experienced significant changes in the variables assessed after the terms of exercise guidance, building/facility accessibility, lack
intervention, except for wrist flexion and ulnar deviation, which of transportation and low and limited financial resources, are
significantly improved in the BG (Table 3). aspects that strongly affect participation in people with physical
The clinical inference analysis showed that the observed disabilities (Martin Ginis et al., 2016). In the present study,
changes were mostly unclear or trivial, except for shoulder and in accordance with suggestions to increase participation in
medial rotation (90% CI of difference 11.0 ± 12.0; p = 0.13; this kind of interventions (Shirazipour et al., 2018), an exercise

TABLE 2 | Baseline participant characteristics and adherence to Boccia program.

Participant Age Gender Diagnosis Time since Barthel Wheelchair Presence (no Absence (no Reasons for Adherence (%)
diagnosis Index type of sessions) of sessions) absence

Boccia plus usual rehabilitation program

1 42 Female FA 17 90 Manual 57 0 100.0
2 54 Female CP 54 50 Power 55 2 (2) visit family 96.5
3 21 Female CP 21 85 Power 55 2 (3) 96.8
4 56 Female Polio 50 65 Power 53 4 (4) illness: flu 93.0
5 35 Male FA 11 80 Manual 50 7 (6) health issues 87.7
6 48 Female CMT 14 60 Power 45 12 (10) health issues 78.9
7 53 Male DM1 9 80 Power 41 16 (12) health issues 71.9
Usual rehabilitation program
8 62 Male CP 62 60 Power
9 33 Female CP 33 65 Power
10 52 Male NF1 52 60 Manual
11 40 Male CP 40 75 Manual
12 39 Female CP 39 50 Power
13 44 Female TBI 4 35 Power
14 39 Female CP 39 45 Power

Abbreviation: FA, Friedreich’s ataxia; CP, cerebral palsy; Polio, poliomyelitis; CMT, Charcot-Marie-Tooth disease; DM1, myotonic dystrophy type 1; NF1, neurofibromatosis
type I; TBI, traumatic brain injury.

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 TABLE 3 | Between-group analysis.

Variables Boccia plus usual rehabilitation program Usual rehabilitation program

1 2 3 4 5 6 7 M ± SD 8 9 10 11 12 13 14 M ± SD p
Suárez-Iglesias et al.

Grip strength (N) Pre-test 196.1 84.3 88.3 117.7 313.8 147.1 84.3 157.9 ± 86.9 176.5 137.3 186.3 156.9 186.3 156.9 186.3 158.9 ± 35.1 0.221
Post-test 211.8 81.4 81.4 109.8 360.9 166.7 80.4 168.7 ± 107.2 188.3 166.7 147.1 166.7 127.5 225.6 221.6 165.5 ± 48.3 0.272
Change 15.7 −2.9 −6.9 −7.8 47.1 19.6 −3.9 8.7 ± 20.2 11.8 29.4 −39.2 9.8 −58.8 68.6 35.3 8.1 ± 43.9 0.976
Pinch strength (N)
Key Pre-test 31.4 30.4 23.5 14.7 16.7 40.2 19.6 26.1 ± 9.7 22.6 32.4 58.8 34.3 30.4 41.2 52.0 25.3 ± 5.2 0.035
Post-test 26.5 22.6 16.7 25.5 30.4 30.4 23.5 36.4 ± 13.6 46.1 46.1 51.0 61.8 19.6 38.2 30.4 39.6 ± 14.4 0.014

Frontiers in Psychology | www.frontiersin.org

Change −4.9 −7.8 −6.9 10.8 13.7 −9.8 3.9 −0.1 ± 9.6 23.5 13.7 −7.8 27.5 −10.8 −2.9 −21.6 3.1 ± 18.6 0.690
Three jaw Pre-test 11.8 30.4 17.7 15.7 14.7 47.1 13.7 22.9 ± 13.5 16.7 31.4 58.8 28.4 36.3 48.1 59.8 36.6 ± 17.6 0.025
Post-test 12.7 33.3 16.7 24.5 25.5 40.2 11.8 25.5 ± 10.2 42.2 34.3 56.9 46.1 22.6 43.2 38.2 36.9 ± 14.1 0.014
Change 1.0 2.9 −1.0 8.8 10.8 −6.9 −2.0 1.9 ± 6.2 25.5 2.9 −2.0 17.7 −13.7 −4.9 −21.6 0.6 ± 19.6 0.861
Tip to tip Pre-test 10.8 28.4 14.7 13.7 28.4 37.3 13.7 22.2 ± 10.6 28.4 17.7 41.2 26.5 38.2 29.4 41.2 29.5 ± 10.3 0.046
Post-test 8.8 25.5 18.6 14.7 25.5 37.3 7.8 21.7 ± 10.0 30.4 26.5 35.3 39.2 11.8 35.3 38.2 28.1 ± 12.0 0.078
Change −2.0 −2.9 3.9 1.0 −2.9 0.0 −5.9 −1.3 ± 3.2 2.0 8.8 −5.9 12.7 −26.5 5.9 −2.9 −0.8 ± 13.0 0.936
Shoulder AROM (◦ )
Flexion Pre-test 138 120 119 152 60 69 144 114.6 ± 36.3 65 144 163 132 113 142 63 88.9 ± 57.1 0.928
Post-test 139 140 143 155 141 138 37 127.6 ± 40.3 74 145 135 160 86 136 69 117.4 ± 39.4 0.763

6
Change 1 20 24 3 81 69 −107 13.0 ± 61.3 9 1 −28 28 −27 −6 6 −2.4 ± 20.0 0.539
Extension Pre-test 14 9 23 13 30 14 28 18.7 ± 8.2 −12 48 23 10 5 11 16 14.4 ± 18.4 0.646
Post-test 17 18 29 40 30 30 17 25.9 ± 8.8 8 16 −2 26 15 −15 9 8.1 ± 13.3 0.029
Change 3 9 6 27 0 16 −11 7.1 ± 12.1 20 −32 −25 16 10 −26 −7 −6.3 ± 21.8 0.180
Abduction Pre-test 75 50 47 80 79 37 74 63.1 ± 17.8 45 84 77 76 68 68 39 65.3 ± 16.9 0.816
Post-test 73 62 76 92 110 65 39 73.9 ± 22.6 91 18 53 84 80 32 33 55.9 ± 29.3 0.174
Change −2 12 29 12 31 28 −35 10.7 ± 23.5 46 −66 −24 8 12 −36 −6 −9.4 ± 36.4 0.242
Medial rotation Pre-test 28 18 3 19 65 50 27 30.0 ± 20.9 1 50 17 31 59 30 18 29.4 ± 20.0 0.811
Post-test 53 40 20 18 70 56 27 40.6 ± 19.9 15 25 29 27 36 67 32 33.0 ± 16.4 0.504
Change 25 22 17 −1 5 6 0 9.0 ± 8.8 14 −25 12 −4 −23 37 14 0.7 ± 22.0 0.374
Lateral rotation Pre-test 127 63 41 122 77 78 20 75.4 ± 39.3 61 65 83 62 75 73 76 70.7 ± 8.2 0.749
Post-test 99 54 86 117 104 73 90 89.0 ± 20.8 70 97 76 131 102 62 29 81.0 ± 32.7 0.469
Change −28 −9 45 −5 27 −5 70 13.6 ± 34.8 9 32 −7 69 27 −11 −47 10.3 ± 37.0 0.867
Elbow AROM (◦ )
Flexion Pre-test 160 143 108 118 124 122 53 118.3 ± 33.6 67 109 138 88 127 96 114 105.6 ± 24.1 0.587
Post-test 115 139 120 115 137 93 89 115.4 ± 19.3 151 78 112 148 95 89 107 111.4 ± 28.3 0.672
Change −45 −4 12 −3 13 −29 36 −2.9 ± 27.2 84 −31 −26 60 −32 −7 −7 5.9 ± 46.9 0.678
Extension Pre-test −44 −33 −58 −14 1 −21 −25 −27.7 ± 19.5 4 −4 −3 −25 −23 −5 −29 −12.1 ± 13.1 0.105
Post-test −43 −10 −29 −37 −41 −41 −34 −33.6 ± 11.5 −14 2 −21 −10 −14 −17 −42 −16.6 ± 13.3 0.025
Change 1 23 29 −23 −42 −20 −9 −5.9 ± 25.5 −18 6 −18 15 9 −12 −13 −4.4 ± 13.9 0.899

(Continued)

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 Suárez-Iglesias et al.

TABLE 3 | Continued

Variables Boccia plus usual rehabilitation program Usual rehabilitation program

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1 2 3 4 5 6 7 M ± SD 8 9 10 11 12 13 14 M ± SD p

Forearm AROM (◦ )
Pronation Pre-test 75 75 55 75 75 75 54 69.1 ± 10.0 77 64 72 62 66 75 56 67.4 ± 7.6 0.782
Post-test 75 75 70 71 75 75 34 67.9 ± 15.1 75 75 75 64 65 75 29 65.4 ± 16.8 0.784
Change 0 0 15 −4 0 0 −20 −1.3 ± 10.2 −2 11 3 2 −1 0 −27 −2.0 ± 11.8 0.906
Supination Pre-test 60 72 70 79 71 77 77 72.3 ± 6.4 72 70 75 70 76 79 65 72.4 ± 4.6 0.931
Post-test 62 75 76 75 75 75 75 73.3 ± 5.0 70 75 73 75 73 75 66 72.4 ± 3.4 0.754
Change 2 3 6 −4 4 −2 −2 1.0 ± 3.7 −2 5 −2 5 −3 −4 1 0.0 ± 3.7 0.624
Wrist AROM (◦ )

7
Flexion Pre-test 42 51 22 44 73 32 33 42.4 ± 16.5 64 34 58 62 57 56 45 53.7 ± 10.6 0.122
Post-test 52 48 67 50 74 46 73 58.6 ± 12.3 70 30 62 73 57 55 63 58.6 ± 14.2 0.918
Change 10 −3 45 6 1 14 40 16.1 ± 18.9 6 −4 4 11 0 −1 18 4.9 ± 7.6 0.169
Extension Pre-test 38 18 24 53 76 42 13 37.7 ± 22.0 48 85 76 85 38 28 83 63.3 ± 24.5 0.064
Post-test 47 15 31 74 70 20 66 46.1 ± 24.6 47 63 20 44 56 77 63 52.9 ± 18.2 0.465
Change 9 −3 7 21 −6 −22 53 −3.7 ± 24.0 −1 −22 −56 −41 18 49 −20 0.9 ± 24.7 0.731
Radial deviation Pre-test 30 24 16 30 30 30 9 24.1 ± 8.5 28 30 30 18 9 29 38 26.0 ± 9.5 0.794
Post-test 13 24 18 18 30 31 44 25.4 ± 10.5 30 35 20 12 17 19 37 24.3 ± 9.7 0.841
Change −17 0 2 −12 0 1 35 1.3 ± 16.6 2 5 −10 −6 8 −10 −1 −1.7 ± 7.2 0.668
Ulnar deviation Pre-test 11 18 3 3 16 2 31 12.0 ± 10.6 31 6 27 17 28 36 23 24.0 ± 9.9 0.052
Post-test 35 31 36 47 50 31 32 37.4 ± 7.8 24 17 32 22 10 45 24 24.9 ± 11.2 0.029
Change 24 13 33 44 34 29 1 25.4 ± 14.4 −7 11 5 5 −18 9 1 0.9 ± 10.2 0.003

AROM: Active Range of Motion. In bold, significant changes where, p < 0.05.

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

specialist with strong physical activity and disability-specific games (Wii training) on the hand grip muscular strength of
knowledge monitored the sessions. Moreover, the building people with upper limb impairments. It should be noted that
and the facilities in which the intervention took place were the proposed intervention also included strengthening exercises
completely accessible to people with mobility limitations. It is and activities aimed at improving hand skills (El-Shamy and
also important to note that transportation was provided for those El-Banna, 2018). In the light of all this, it seems that in order
participants who needed this service, and the Boccia activity to achieve improvements in hand muscular strength, people
was free of charge. Thus, transportation and cost barriers were with NNMDs should take part in muscular training programs
properly addressed, so adherence in the program could have specifically designed for this purpose.
consequently improved due to this strategy. For instance, in In people with NNMDs, upper limb impairment results in
people with severe multiple sclerosis who participated in an reduced manual dexterity, which interferes with the execution
exercise program free of charge and in which transportation of daily life activities. As tripod pinch strength and thumb
was arranged and paid for, a high adherence rate was observed opposition are major determinants of manual dexterity, it
(van der Linden et al., 2014). Regarding interpersonal factors seems important to develop rehabilitation strategies aimed at
(i.e., self-perceived support and attitudes) the fact that the increasing their functionality (Videler et al., 2010). However, few
Boccia group was exclusively comprised of participants with investigations have been carried out in this regard, specifically
similar functional limitations could have improved adherence in people with severe disability. In the present study, playing
to the program, since the opportunity for participants to Boccia did not lead to changes in pinch strength, implying that
meet and exercise with others with similar disability levels this game does not have a positive impact on this variable in
has been acknowledged as an important point to consider people with NMD. Improvements on the pinch strength level
in this regard (Kierkegaard et al., 2011). Indeed, it has been of this population have been found after the performance of
suggested that in patients with NNMDs, social and behavioral exercise programs specifically designed for this purpose (Hutzler
aspects improve markedly when training programs are held in et al., 2013; Regardt et al., 2014; El-Shamy and El-Banna, 2018).
groups where people with the same condition (i.e., sclerosis Therefore, one can assume that when it comes to improving
multiple) share experiences and make friends (Sánchez-Lastra pinch strength for people with NNMDs, performing targeted
et al., 2019), as in the case of this study. Fatigue, lack of exercise of specific muscles may be a more effective rehabilitation
motivation and apathy are intrapersonal factors that influence approach. However, Aldehag et al. (2013) did not find any
exercise adherence for people with NNMDs (Aldehag et al., significant changes in the pinch grip force of a group of people
2013). Other barriers to exercise for this population include with myotonic dystrophy, even after completing a 12-weeks
exercise complexity (Phillips et al., 2009) and activity related hand training program specifically designed for people with this
embarrassment (Martin Ginis et al., 2016). Therefore, because disability. Together, these results suggest that although pinch
of the fact that Boccia sessions included friendly matches, easy strength can be improved by means of specific muscular training
to perform tasks, and were conducted in a recreational, relaxed programs, not all people with NNMDs will benefit from them.
atmosphere; it could have had a positive impact on the adherence Thus, the existing heterogeneity in NNMDs should be taken into
to the program. The lack of adverse effects observed could account when designing this type of rehabilitation strategy.
also be due to this reason, as few harmful effects related to Rehabilitation strategies for NNMDs should include therapies
Boccia have been observed in those who play at a competitive aimed at improving AROM, however, scientific evidence is
level (Fong et al., 2012). Finally, it should not be overlooked scarce (Johnson et al., 2012). The findings of this study provide
that participants in the Boccia group wanted to practice this preliminary evidence regarding the effects of playing Boccia on
sport, thus, they were probably motivated to undertake the AROM for people with severe upper limb functional limitation.
intervention and inclined to persevere. Taken together, these After the intervention, some positive changes were observed in
findings suggest that the degree of disability showed by the hand wrist flexion and ulnar deviation. The MBI method showed
participants in this study may not have caused significant that both changes were considered very likely or most likely to
barriers to their desire and ability to practice Boccia as a be beneficial. Interestingly, a strong association between ulnar
rehabilitation strategy. deviation and wrist flexion range of motion has been observed (Li
Nevertheless, we acknowledge the effects of the Boccia et al., 2005), suggesting that changes in one movement influences
program on the participants’ hand muscular strength and upper the range of motion in the other. Given that wrist flexion and
limb range of motion are anecdotal at best. This is because ulnar deviation are related to spasticity (de Bruin et al., 2014),
this was not a randomized controlled research and the groups it could be hypothesized that playing Boccia could be a useful
were not fully comparable at baseline. Both facts constitute a strategy to ameliorate this symptom. In this regard, further
potential source of bias, therefore we are cautious about making research is needed.
inferences from this study. Our findings suggest that playing Patients with NNMDs have reported that they would like to
Boccia did not improve hand grip muscular strength. We believe see more research into movement and physical training (Jerath
the lack of effect could be due to the nature of the performed et al., 2017). Although no major improvements or detrimental
activity, as research suggests, improvements in muscular hand effects in the upper limb impairments tested in this study were
strength have been observed in people with NNMDs who carried observed (hand strength, shoulder, elbow and hand range of
out specific and individualized strengthening exercise programs motion), the findings add to the scientific body of knowledge.
have been observed (Anziska and Sternberg, 2013; Hutzler et al., Moreover, very limited information has been reported to date on
2013). Other researchers have reported positive effects of playing the impact of a training program on the upper limb impairments

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Suárez-Iglesias et al. Boccia as a Rehabilitation Intervention

in people with severe disability due to NNMDs. Similarly, limited DATA AVAILABILITY STATEMENT
research has been carried out on the effects of playing Boccia
as a physical therapy rehabilitation strategy. Therefore, the main All datasets generated for this study are included in the
strength of this study lies in its originality, on which future article/supplementary material.
randomized trials aimed at increasing the existing scientific
evidence in the field of physical rehabilitation for people with
severe upper limb impairments can be based. However, we ETHICS STATEMENT
acknowledge that a small number of participants took part in
this non-randomized, and they were not randomly distributed The studies involving human participants were reviewed and
between groups. Both factors increase the risk of bias and approved by Comité de Ética de la Universidad de León. The
the probability of making a type II error. Therefore, future patients/participants provided their written informed consent to
randomized trials with larger samples are needed to confirm the participate in this study.
results showed here. It should also be noted that the evaluation
was not blind. In addition, although all participants showed
similar upper limb impairments, the origin of their disability was AUTHOR CONTRIBUTIONS
equally varied, implying the existence of certain heterogeneity in
the BG and UG groups. In this regard, we evaluated the effects NM-L and JV-V contributed to the conception and design of the
of the Boccia program on the participants’ muscular strength and study. All authors were taken part in the acquisition, analysis,
range of motion, however, we did not identify the impact that and interpretation of data, contributed to drafting the article and
the program had on their functional independence level. Finally, critically revised the article for important intellectual content, and
we did not apply a progression in training load and variation DS-I and CA approved the last version to be published.
in stimulus regarding size and weight of the Boccia balls. These
limitations should be taken into account when interpreting the
findings of this study.
FUNDING
This work was supported by the Ministry of Education, Culture
and Sports, Government of Spain (FPU12/05828).
CONCLUSION
In a group of people with severe disability due to NNMDs, ACKNOWLEDGMENTS
playing Boccia as part of a multidisciplinary rehabilitation
program was shown to be a feasible therapy. However, practicing The authors would like to acknowledge the considerable
this game did not lead to significant improvements in upper contributions of Maria Rubiera Hidalgo to this study, and the
limb impairments, except for wrist flexion and ulnar deviation institutional support from the CRE Discapacidad y Dependencia
active range of motion. Future randomized controlled trials with (San Andrés del Rabanedo), Institute for Older Persons and
a larger sample size are needed to confirm these findings. Social Services (IMSERSO).

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CR323–CR329. Copyright © 2020 Suárez-Iglesias, Ayán Perez, Mendoza-Laiz and Villa-Vicente.
Norkin, C. C., and White, D. J. (2016). Measurement of Joint Motion: A Guide to This is an open-access article distributed under the terms of the Creative Commons
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