# Non-Contact Boxing Therapy for Depression, Anxiety, and PTSD: An Evidence-Based Mental Health Treatment Modality

Non-Contact Boxing Therapy for Depression, Anxiety, and PTSD: An Evidence-Based Mental Health Treatment Modality is a therapy approach developed by Dr. Barry Zabielinski.
Non-contact boxing therapy is currently not offered as a mental health treatment option for veterans within the U.S. Department of Veterans Affairs (VA) in Montana or within the VA healthcare system. The benefits of physical activity for the treatment of mental health issues are well established, and there is growing evidence for non-contact boxing therapy as a viable activity-based treatment modality for various mental health conditions. Below, is a proposal to pilot an outpatient non-contact boxing group for veterans diagnosed with depression, anxiety, and post-traumatic stress disorder (PTSD).
Please note: The focus of this proposal is individual non-contact boxing-based exercise. All exercises are performed using equipment only, and participants are never in physical contact with an opponent as part of the exercise. It is acknowledged that there are known health risks associated with contact boxing.

## Evidence
### Physical Activity and Mental Health

The mental health benefits of physical activity are well established. According to the VA, physical fitness is associated with reductions in depression, anxiety, stress, and the risk of relapse of depression (Veterans Health Library, 2024). Research has also shown that exercise can be as effective as antidepressants in the treatment of depression (Dinas et al., 2011) and that physical activity may even help to decrease suicidality among veterans (Davidson et al., 2013). Furthermore, exercise is associated with decreased PTSD symptoms and improved coping among combat veterans (Caddick & Smith, 2014; Whitworth & Ciccolo, 2016). In pursuit of a more holistic approach to mental health care, some have even called for a shift to a paradigm that views exercise as a medicine for veterans facing mental health challenges (Caddick & Smith, 2017).

### Non-Contact Boxing Therapy for Mental Health

Non-contact boxing as a form of activity-based therapy has steadily grown in popularity over the past decade. A review by Bozdarov et al. (2022) analyzed 16 studies, each examining some form of non-contact boxing with a mental health component, and found a common theme of a “significant reduction in symptoms of anxiety, depression, PTSD, and negative symptoms of schizophrenia” (Abstract, para. 3). Additional themes across the sources that were analyzed included the efficacy of non-contact boxing for (1) creating anxiolytic effects, (2) improving mood, (3) improving sleep, and (4) improving overall quality of life. One randomized controlled trial found that a combination of cognitive behavioral therapy (CBT) and non-contact boxing was more effective at reducing symptoms of major depressive disorder and schizophrenia than CBT combined with relaxation techniques (Oertel-Knöchel et al., 2014); similarly, a study by Gallenberg (2020) found that, of 24 men who participated in a 6-week boxing group, the majority experienced reduced psychological distress, improved health behavior, and increased self-esteem. Though most research has thus far focused on predominantly male cohorts, non-contact boxing-based groups have been found to be effective for both males and females (e.g., Gallenberg, 2020; Gammage et al., 2022).
Commonalities among non-contact boxing interventions also extend to the delivery format: most use a group setting, high-intensity interval training methodologies, and weekly session delivery (Bozdarov et al., 2022). However, not all interventions have used such formats, with one study finding that virtual group boxing—through the use of virtual reality goggles—was effective at reducing stress among adolescents (Cioffi & Lubetzky, 2023).
Though the current project focuses specifically on mental health, there is also research supporting non-contact boxing-based interventions for diagnoses such as Parkinson’s disease and other movement disorders (e.g., Larson et al., 2022). Indeed, a 2022 U.S. House of Representatives bill proposed by former New York representative Brian Higgins called on Congress to “direct the Secretary of Veterans Affairs to provide coverage for boxing-based exercise classes for veterans diagnosed with certain movement disorders” (Boxing Therapy for Parkinson’s Access Act, 2022). Should a pilot group prove successful in the current study, future efforts could expand to include other evidence-based applications of non-contact boxing therapy, such as for Parkinson’s disease and other movement disorders.

## Pilot Group Format

The pilot group will consist of a closed cohort of 6‒10 participants who will meet biweekly for 60-minute sessions for 4 weeks (eight sessions total). Each session after the first will have a focus that builds on the previous session (Table 1). Session 1 will focus primarily on orientation and fundamentals, while sessions 2‒8 will each follow a similar format (see Table 2).
Table 1. Session-Specific Content :
| Session | Content |
| 1 (week 1) | Introduction, orientation, and fundamentals: Ice breakers Participant and staff introductions Introduction and background to non-contact boxing therapy Group overview and expectations Introduction to mental health measures Participants complete Generalized Anxiety Disorder 7-item scale (GAD-7), Patient Health Questionnaire 9-item scale (PHQ-9), and/or PTSD checklist (PCL-5) as appropriate to their respective diagnoses from the Diagnostic and Statistical Manual of Mental Disorders 5‒Text Revision Orientation to space and equipment Information on health and safety and infection prevention Introduction to the Borg Rating of Perceived Exertion (RPE) scale and injury prevention Non-contact boxing fundamentals Hand wrapping |
| 2 (week 1) | Proper stance, correct fist placement for punching, and learning jabs |
| 3 (week 2) | Learning overhand cross punches and introduction to combinations (jabs, overhand crosses) |
| 4 (week 2) | Learning hooks and introduction to focus mitts and combination work |
| 5 (week 3) | Introduction to uppercuts, learning combinations (jabs/uppercuts, jabs/overhand crosses) Midpoint assessment: Midpoint evaluation and feedback using a paper survey Participants complete GAD-7, PHQ-9, and/or PCL-5, based on relevant diagnoses, as noted above |
| 6 (week 3) | Introduce speed bag and continue combinations and focus mitt work |
| 7 (week 4) | Continue speed bag and combination work |
| 8 (week 4) | Group wrap-up: Final evaluation and feedback using a survey Participants complete GAD-7, PHQ-9, and/or PCL-5, based on relevant diagnoses, as noted above |
Table 2. Sample Group Plan, Sessions 2‒8 :
| 10 minutes | Check-in: Explanation of session activities by therapy leaders Complete “pre-session” check-in section of print out (see Table 5) Walk around and verbally ask, “How are you doing? Where are you at today? What is your goal for today?” Hand wrapping and stretching |
| 10 minutes | Warm up (e.g., jumping rope) |
| 31 minutes | Non-contact boxing rounds (eight 3-minute rounds) Round 1, 3 minutes: Jabs 1 minute rest Round 2, 3 minutes: Overhand cross punches 1 minute rest Round 3, 3 minutes: Hooks 1 minute rest Round 4, 3 minutes: 90 seconds of uppercuts then 90 seconds of punching bursts (15 seconds of punching, 15 seconds of rest) 1 minute rest Round 5, 3 minutes: four-punch combinations every 5 seconds 1 minute rest Round 6, 3 minutes: four-punch combinations every 5 seconds 1 minute rest Round 7, 3 minutes: Alternating 15 seconds of combinations, 15 seconds of rest 1 minute rest Round 8, 3 minutes: Combinations of choice |
| 9 minutes | Cool down and debrief: Stretching Complete “post-session” check-in section of print out (see Table 5) Discussion: How did the session go? Did we meet our goals? What are our goals for the next session? |

## Participant Selection
### Participation Criteria

The following criteria will allow for the selection of a cohort who can safely and effectively participate in the pilot group; they are intentionally restrictive and may be expanded for future groups.
Veterans will be considered for pilot program participation if they meet all of the following criteria:
* Active mental health prescriber or therapist listed in the computerized patient record system (CPRS)
* One or more of the following diagnoses listed in the CPRS problem list: PTSD, depression, anxiety
* No active behavioral flags in the CPRS
* Medical clearance from their primary care practitioner (PCP)
* Signed participation waiver
Additionally, this group is intended for novice boxers (e.g., little to no experience). Veterans with prior boxing experience will be considered on a case-by-case basis.

### Adaptive Needs

Veterans with adaptive needs who feel that they may benefit from non-contact boxing therapy will be encouraged to participate in the pilot group. As with all participants, they must receive medical clearance through their PCP. Group leadership will try to adapt exercises to each veteran’s skills and abilities and may order adaptive equipment as needed.

### Group Size and Attrition

An anticipated challenge to measuring group outcomes is participation and group adherence, which is a known issue in group therapy (Yalom, 1966). For example, a study sought to assess participant perspectives at the onset and conclusion of a 6-week “Boxercise” group therapy program and found that only two of the ten participants completed both the pre- and post-program interviews (Hefferon et al., 2013). In another study, an estimated 36% of combat veterans who had served in Iraq and Afghanistan and were diagnosed with PTSD dropped out of outpatient PTSD interventions (Goetter et al., 2015).
To overcome this barrier, the proposed pilot group will be large enough to accommodate some attrition (e.g., 10 veterans, with the expectation that 3‒4 veterans will not complete the program) while being small enough to facilitate group cohesion and fit in the available space. The program will also be fully explained to any interested veterans, and prospective participants will be asked to verbalize a willingness to complete the entire program, if possible.

## Safety
### Medical Clearance

To reduce the risk of injury, pilot group participants will be required to obtain medical clearance from their PCP. The format of this clearance will be developed in collaboration with their PCP, with final approval from appropriate VA leadership.

### Waiver

In addition to medical screening, veterans who agree to participate in the pilot group will be required to sign a waiver that outlines the risks associated with this form of activity and releases the VA from liability in the case of injury. Final approval of the draft text of this waiver will be sought from appropriate VA leadership.

### Perceived Exertion

The participants will be asked to tailor their activity based on their “perceived effort or exertion,” with the goal of not overexerting so as to prevent injury while promoting activity. The group will use the Borg RPE scale, which is a widely used 15-point scale that allows participants to self-identify their level of exertion, as shown in Table 3 below (Borg, 1982). Once familiar with the scale, the participants will be encouraged to warm up at an RPE of 9‒11, to perform non-contact boxing rounds at an RPE of 11‒15, and to not go above an RPE of 15. The participants will also be encouraged to be aware of their bodies and muscles and to reduce their RPE or refrain from participation if they experience symptoms of injury (e.g., muscle strain).
Table 3. Borg RPE :
| Rating | Perceived Exertion |
| 6 | |
| 7 | Very, very light |
| 8 | |
| 9 | Very light |
| 10 | |
| 11 | Fairly light |
| 12 | |
| 13 | Somewhat hard |
| 14 | |
| 15 | Hard |
| 16 | |
| 17 | Very hard |
| 18 | |
| 19 | Very, very hard |
| 20 | |

### Infection Prevention

The group will adhere to an infection prevention protocol to prevent the spread of illness or infection:
* the group will practice good hand hygiene,
* each participant will have their own set of gloves and hand wraps, which will not be shared, and
* any communal equipment will be wiped down with Sani-Cloth wipes after each session, and between each use as needed.
Because this pilot study will take place at the Fort Harrison VA Medical Center, the space will be routinely cleaned by the center’s Environmental Services.

### Emergency Equipment

Within the space to be used by the group, emergency equipment, including an automated external defibrillator and a backboard, will be identified and made accessible in the event of an emergency. Because this pilot study will take place at Fort Harrison VA Medical Center, the participants will be taken to the 24-hour emergency room, should injury occur.

## Logistics
### Program Costs and Funding

The following equipment (or similar) will be necessary for the proposed pilot study. These items have been selected based on an initial assessment of a sound balance between cost and functionality. All items are available for order through Walmart. The center’s Volunteer Services has indicated interest in supporting this effort, and backup funding sources have also been identified.
Table 4. Necessary Equipment and Costs :
| Item | Proposed Purchase | Quantity | Cost/Each | Cost/Total |
| Freestanding punching bag | GIKPAL Freestanding Punching Bag with Stand 67″ 182 lbs. | 3 | $117.99 | $353.97 |
| Freestanding punching bag stand with speed bag | VEVOR Freestanding Punching Bag Stand with Speed Ball | 1 | $155.99 | $155.99 |
| Heavy ceiling-mounted bag kit | Everlast 70 lbs. Nevatear Heavy Bag Kit, 11″ L x 11″ W x 34″ H | 1 | $80.55 | $80.55 |
| Focus mitts | Essential Curved Boxing MMA Hand-Target Focus Mitts (Pair) | 2 | $28.99 | $57.98 |
| Individual hand wraps | Venum Kontact Elastic Cotton Boxing Wrap 180″– Black and White | 10 | $9.58 | $95.80 |
| Speed jump ropes | RDX Adjustable PVC Speed Jump Rope | 10 | $5.99 | $59.90 |
| 16 oz. boxing gloves | RDX F7 Leather Boxing Gloves, 16 oz, Blue | 6 | $34.99 | $209.94 |
| 14 oz. boxing gloves | RDX F7 Leather Boxing Gloves, 14 oz, Blue | 4 | $35.97 | $143.88 |
| Gym timer | Seesii USB LED Gym Timer with 11.5″ x 4″ Display | 1 | $35.99 | $35.99 |
| Total cost: | Total cost: | Total cost: | Total cost: | $1194.00 |

### Group Staffing

Session leadership for the proposed pilot group will comprise both therapy (Dr. Barry Zabielinski) and nursing (Russ Biddle, RN) leaders. Dr. Zabielinski is a licensed independent practitioner who is currently employed by the VA. He has extensive professional education, training, and supervised experience in multiple disciplines. He is also a USA Boxing certified coach and has served as a military officer in the U.S. Armed Forces. Russ Biddle, RN, graduated from nursing school in 1993 and has spent most of his career in mental health nursing. He has also been involved in boxing most of his life, both as a participant and as a spectator. Research has shown that having experienced group leaders is important for participant perceptions of trust and safety (Hefferon et al., 2013) and self-esteem (Richardson et al., 2005).
Carmen Thissen, RN, is a Post-Baccalaureate Registered Nurse Resident at the Montana VA, who will provide program and logistics support to the group.

## Time and Location

Based on a review of available options, after-hours use of the Madison Clinic waiting room has been identified as the most appropriate arrangement for this 4-week pilot study. The space has been recommended by VA Facilities Management for a number of reasons, including adequate lighting, egress doors, accessibility by VA police, proximity to the emergency room, proximity to equipment storage, and cleanable floors/surfaces. The area is not used by patients or staff after 5:00 p.m., which reduces privacy concerns associated with holding the sessions in a public area.
The space will be secured through a Light Electronic Action Framework request to use the space for two sessions per week (e.g., Tuesdays and Thursdays) for 60 minutes (e.g., 5:30 p.m. ‒ 6:30 p.m.) for the 4-week duration of the program. Final determination of dates and times will be made in collaboration with Facilities Management. Should any issues arise with using the Madison Clinic waiting room, the on-site Recreation Hall will serve as a backup location.

### Evaluation of Study Success

The goal of the proposed study is not to produce publishable research but rather to explore the possible value of providing non-contact boxing therapy to veterans receiving mental health services at the Montana VA. As such, we will measure and assess success in the following ways:
* Evaluation and Feedback During Sessions 5 and 8. At the midpoint (session 5) and conclusion (session 8) of the study, the participants will be asked to complete an evaluation of their experience, in which they can provide written feedback. In this evaluation, the participants will be asked questions such as whether they feel the group has helped them, whether they would recommend it to others, and whether they have specific feedback on how to improve the group.
* Mental Health Assessment During Sessions 1, 5, and 8. The participants will complete one or more of the following inventories at the beginning (session 1), middle (session 5), and end (session 8) of the 4-week study, based on their individual diagnoses: GAD-7 for anxiety, PHQ-9 for depression, and PCL-5 for PTSD. Any changes in the participants’ scores cannot be attributed solely to group participation and will instead be interpreted in combination with the evaluation and feedback received as well as the pre- and post-session check-in data.
* Pre- and Post-Session Check-Ins for All Sessions At the beginning of each session, the participants will be given paper versions of three scales for anxiety symptoms, depression symptoms, and PTSD symptoms (Table 5). They will be asked to circle the numbers representing their current mental state for the individual diagnoses that apply and then return the scales to the group leaders. This will be repeated at the end of each session.
Table 5. Printable Pre- and Post-Session Check-in Sheet :
* Name:
* DOB:
* PRE-SESSION: Please only complete the sections relevant to you (anxiety, depression, and/or PTSD).
* Please rate your anxiety symptoms at this moment from 0 to 10 (0 = no anxiety, 10 = the most anxiety you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10
* Please rate your depression symptoms at this moment from 0 to 10 (0 = no depression, 10 = the most depression you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10
* Please rate your PTSD symptoms at this moment from 0 to 10 (0 = no PTSD symptoms, 10 = the most PTSD symptoms you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10
* POST-SESSION: Please only complete the sections relevant to you (anxiety, depression, and/or PTSD).
* Please rate your anxiety symptoms at this moment from 0 to 10 (0 = no anxiety, 10 = the most anxiety you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10
* Please rate your depression symptoms at this moment from 0 to 10 (0 = no depression, 10 = the most depression you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10
* Please rate your PTSD symptoms at this moment from 0 to 10 (0 = no PTSD symptoms, 10 = the most PTSD symptoms you have ever experienced):
* 0 1 2 3 4 5 6   7 8 9 10