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 Table of Contents  
Year : 2017  |  Volume : 4  |  Issue : 1  |  Page : 54-57

Effectiveness of square stepping exercise among subjects with Parkinson's disease: A pilot Randomised Controlled Trial

1 Department of Physiotherapy, Global Hospitals and Health City; Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
2 Department of Physiotherapy, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
3 Department of Physiotherapy, Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu, India
4 Department of Physiotherapy, School of Medicine, College of Health Sciences, and Ayder Comprehansive Specialized Hospital, Mekelle University, North Ethiopia

Date of Web Publication20-Jun-2017

Correspondence Address:
Hariharasudhan Ravichandran
Sree Balaji College of Physiotherapy, Chennai, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jgmh.jgmh_1_17

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Background: Parkinson's disease is a movement disorder that seriously affects body balance and gait; therefore, increases the risk of fall and related complications. Freezing of gait and postural instability are disabling symptoms, which compromises motor independence among Parkinson's disease patients. Aims and Objectives: The purpose of this study analyses the effects of square-stepping exercise (SSE) among Parkinson's disease patients in terms of improving balance and reducing fall risk. Materials and Methods: This is a pilot randomized controlled study, in which thirty male and female Parkinson's disease patients between 60 and 70 years of age were selected by simple random sampling method and randomly divided into SSE group (N-15) and conventional physiotherapy (CPT) group (N-15). Interventions were provided for 4 weeks. Baseline and posttest outcomes were measured using the Berg balance scale (BBS) and timed up and go test (TUG). Results: Statistical measures of mean, standard deviation, and t-test were performed using SPSS 21. SSE exhibited statistical significant improvement in BBS (P < 0.05) and TUG (P < 0.0001) compared to CPT group. Conclusion: SSE is more effective in improving balance and gait in Parkinson's disease. Although further studies with larger samples are required, the result of this study implies that SSE could be used as a mean of rehabilitation in Parkinson's disease.

Keywords: Berg balance score, freezing of gait, Parkinson's disease, timed up and go test

How to cite this article:
Ravichandran H, Janakiraman B, Yitayeh A, Sundaram S, Fisseha B. Effectiveness of square stepping exercise among subjects with Parkinson's disease: A pilot Randomised Controlled Trial. J Geriatr Ment Health 2017;4:54-7

How to cite this URL:
Ravichandran H, Janakiraman B, Yitayeh A, Sundaram S, Fisseha B. Effectiveness of square stepping exercise among subjects with Parkinson's disease: A pilot Randomised Controlled Trial. J Geriatr Ment Health [serial online] 2017 [cited 2023 Jun 7];4:54-7. Available from:

  Introduction Top

Parkinson's disease is a common neurodegenerative disorder affecting people in large numbers throughout the world. It is estimated that 6.3 million people suffer from Parkinson's disease worldwide. The World Health Organization gives an “estimated crude prevalence” (the total number of existent cases each year, old, and new) of 160/100,000, and an estimated incidence (the number of new cases each year) of 16–19/100,000.[1] Epidemiology of Parkinson's disease has been better studied than other disorders in India. Population-based surveys (excluding Parsis) have shown a crude prevalence rate of Parkinson's disease varying from 6 to 53/100,000.[2] Subjects with Parkinson's disease typically show prominent mobility problems such as shuffling gait, stooped posture, impaired balance, and freezing of gait (FOG).[3] FOG remains one of the most common debilitating aspects of Parkinson's disease and has been linked to injuries, falls, and reduced quality of life. Gait and balance disturbance in Parkinson's disease is a major contributor to increased disability and decreased health-related quality of life and survival.[4]

Improving gait and balance and thus preventing falls are notoriously difficult to treat [4] and responds poorly to pharmacological or surgical treatment, and is, therefore, a major therapeutic challenge in Parkinson's disease.[5] Patients with Parkinson's disease who participated in balance training have shown improvements in gait and ambulation.[6] In a clinical randomized controlled trial, patients who undergone physical therapy consisting of strength exercises, balance, and gait training in addition to medication therapy show short- and long-term increases in quality of life, mobility, walking speed, and activities of daily living compared to patients who only receive medication.[2] Physical exercises that include a balance component can reduce the risk of fall and improve gait among patients with Parkinson's disease. To be effective, it has been suggested that balance exercise should be undertaken with reduced base of support, minimized upper limb support, and include weight shifting components such as stepping.[7]

Most rehabilitation studies in Parkinson's disease address the treatment of bradykinesia and effect of balance rehabilitation. Recent systematic reviews concluded that evidence available was insufficient to support or refute the efficacy of physiotherapy in Parkinson's disease or to support the use of one form of physiotherapy over another.[8] Therefore, the development of rehabilitation approaches that work in conjunction with current treatment is important to manage these problems.

Shigematsu and Okura developed the square-stepping exercise (SSE) concept in 2006, an exercise method for preventing risk of falls and improving balance among elderly population.[9] SSE involves sensorimotor stimulation [10],[11] and tasks that require the integration of cognitive and motor information during the exercise program. Research articles support the use of SSE among the elderly population in view of reducing the risk of fall and improving balance. However, to the best of our knowledge, there are no papers reporting the influence of SSE exercise on improving gait and balance among patients with Parkinson's disease. This study aims to compare the effects of SSE and conventional physiotherapy (CPT) exercise program among patients with Parkinson's disease.

  Materials and Methods Top


A total of 37 participants were screened initially, out of which 3 had cardiac complications, and 4 were not willing to participate. Hence, a total of thirty participants were randomly assigned to one of two groups: SSE (N-15) or CPT group (N-15). All participants (recruited through a database from Global Hospitals and Health City, Chennai, India) were diagnosed with Parkinson's disease and then randomized and matched for overall demographics. Participants were recruited according to the following inclusion criteria: Mild–moderate disease severity, with a Stage of II and III of the Hoehn and Yahr scale;[12] ability to walk without any physical assistance, visual and hearing capacity sufficient to perceive the cues, mini-mental state examination score >26, all participants were tested in their “ON” phase, which was approximately 1 h following their usual medication. Patients were excluded if they had any neurological condition other than Parkinson's disease, musculoskeletal, or cardiopulmonary conditions that would affect the ability to walk, need of assistive device to walk. Before the recruitment of the participants, approval for the study protocol was obtained from the Institutional Ethical Committee of Sree Balaji College of Physiotherapy, Chennai, India. All participants provided written informed consent.


The study is a pilot, randomized clinical trial, conducted in the Physiotherapy Department of Global Hospitals and Health City, Chennai, India, during January 2016 to February 2016. A set of neurologists and physicians helped the investigators in medical and safety monitoring, medical stableness, and diagnostic featuring of the Parkinson's disease. Randomization scheme was generated by custom-made software by an independent statistician. The randomization list was not known to anyone in the study. A sealed envelope containing specific treatment was given to the patient on inclusion, and the treating physiotherapist opens the envelopes at the start of the treatment. Baseline and posttest assessment was recorded by a therapist who was unaware of the patient's intervention. Nonprobability sampling design was used, and convenience method was used for assigning participants in two groups. The study duration was 4 weeks.

Outcome measures

Berg balance scale (BBS)[13] utilizes a scale of 14 common tasks involving static and dynamic balance, such as reaching, spinning, standing on 1 foot, and getting up. Each task is given four points on ordinal scale, ranging from 0 (unable to perform the task) to 4 (performs the task independently). The scores of the 14 are summed to yield a total score ranging from 0 to 56 points. Higher scores indicate better performance while scores of <45 are predictive of falls.

Timed up and go test (TUG)[14] assess the level of mobility of the individual by measuring the time in seconds required to stand up from a chair. At the beginning of the test, the participant's backs must touch the chair, and at the end of the test, the participants return to this position. The test was performed once for familiarization before the timed trial.


Intervention is divided into three parts. Warm up, group intervention, and cool down. Warm up and cool down are common for both groups.

Warm up: Participants started with muscle stretches for the upper limb (biceps, triceps, flexors of forearm, wrist, and fingers) and lower limb (hamstrings, quadriceps, and gastrosoleus) followed by joint movements being performed in all planes.

SSE group intervention: This exercise training is based on the usage of a “mat” (2.5 m × 1.0 m), partitioned into 40 small squares of 25 cm each. Elementary pattern 1 and 2 were used in this study. Participants were instructed to walk (step) from one end of the mat to the other according to the step pattern provided. When the participant reached the end of the mat, they were instructed to return to their starting position by walking normally off the mat and start next stepping. Each participant repeated each sequence three times and then started a new one. Sequences were created with forward, backward, lateral, and oblique steps, and for each sequence, the complexity of the steps combination was higher. This intervention was applied five times a week, for 4 weeks.

CPT group intervention: Patients were trained to do backward walking, sideways walking, forward walking, and walking on high knees with emphasis on taking long steps and arm swinging. Appropriate verbal cues were provided. Step turning and pivot turning exercises are taught. All these exercises are performed five times a week, for 4 weeks.

Cool down: The execution rhythm becomes progressively slower. Slow walking, swinging legs in standing, stretching lower limbs and trunk, and relaxation exercises are done.

Statistical analysis

Data were coded and entered using Epi Info version 3.5.1 (Centers for Disease Control and Prevention, USA) and exported to Statistical package for the social sciences 21 (SPSS; Norusis/SPSS Inc., Chicago, IL, USA). Various statistical measures such as mean, standard deviation (SD), and test of significance such as Student's t-test were analyzed for this study. Student's t-test (two-tailed, independent) for paired comparison was utilized. P < 0.05 was considered statistically significant, and P < 0.001 was considered highly significant.

  Results Top


Participant's age range was maintained between 60 and 70. The mean age of the participants in SSE group was 68.8, and the mean age of the participants in CPT group was 69.1. SSE group had 8 males and 7 females, whereas CPT group had 11 males and 4 females. There was no statistically significant difference between the mean age, height, and weight of participants in both groups [Table 1].
Table 1: Descriptive statistics

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Berg balance scale

The mean value of pretest score of BBS in SSE group was 41.70 ± 4.80 which showed significant improvement in posttreatment mean value of 45.80 ± 0.40. P value was 0.0027, which is considered to be significant. It depicts that SSE is effective in improving balance in Parkinson's disease patients. The mean value of baseline and posttreatment BBS score in CPT group was 40.50 ± 3.40 and 41.00 ± 3.50, respectively, with P value of 0.6945 [Table 2]. It depicts that CPT is not significant in improving balance. On comparing post- and pre-intervention mean values between groups, statistical significant difference was achieved with P value of 0.005 [Table 3].
Table 2: Within-group comparison of the Berg balance scale and timed up and go test

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Table 3: Comparison of pre- and post-test score difference of the Berg balance scale and timed up and go test

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Timed up and go test

Baseline mean and SD of SSE group were 23.30 ± 2.50 which was reduced in postintervention as 19.70 ± 1.50. This change is considered to be highly significant with a P value of 0.0000. SSE is effective in improving TUG score among Parkinson's disease patients. Pre- and post-test mean value of TUG in CPT group was 23.80 ± 3.30 and 23.90 ± 4.30, respectively. P value of TUG test in CPT group was 0.9435 which is not significant [Table 2]. It depicts that CPT failed to achieve significance in TUG score among Parkinson's disease patients. Between-group comparison of post- and pre-test mean score resulted in highly significant P value of 0.0000.

  Discussion Top

This pilot study was conducted to evaluate changes in functions of balance and gait in people with Parkinson's disease who underwent SSE program to a matched CPT program. In this study, preintervention mean score of BBS and TUG for SSE and CPT group had no statistical significant difference, suggesting that participants were homogenous based on their balance performance. After the 4 weeks regimen, SSE group demonstrated significant improvements in BBS and TUG performance similar to those studies reported previously for elderly population without Parkinson's disease.[10],[15] In this study, we implement SSE strategy for elderly with Parkinson's disease.

In this study, both groups performed multidirectional steps (forward, backward, and sideways) whereas in SSE group, multidirectional steps in elementary and intermediate level mats lead to better results than conventional groups, this may be due to the fact that SSE improved better activation of synergist and agonist leg muscles. According to the reports by Shigematsu et al., SSE regimen reduces fall risk among healthy older adults.[10] This is due to improvement in functional fitness of the lower extremities, which is a fall risk factor. The Previous studies by Smania et al. and Rochester et al. utilized conventional balance training program among Parkinson's disease patients and reported that balance exercises are effective in improving gait and preventing falls.[16],[17] When comparing our study result with those studies, it proves that SSE program incorporates more complex activity than conventional balance exercises in improving balance and reducing falls. Moreover, posttest mean value of BBS in SSE group is 45.80 which indicate good performance and risk of fall is predicted to be low.

A study by Teixeira et al. in 2013 revealed that SSE intervention improves balance and cognitive function among elderly.[18] Parkinson's disease is also associated with decline of cognitive function. SSE is a training program that stimulates physical function, cognitive function, concentrated attention, memory, and executive functions. In Parkinson's disease, SSE increases attentional engagement, thus promoting improvement in performance. SSE promotes sensory-motor integration which therefore stimulates thalamic activation of subcortical structures from internal globus pallidus and cerebellum. In addition, SSE facilitates previously learned movements; this stimulates internal signals from the basal nucleus.[19] SSE has more advantages: It can be performed within a small indoor space, feasible, and inexpensive. SSE is ideal in group therapy programs which utilizes fewer staffs, and six subjects shall undergo the training at the same time in a mat; hence, they will be motivated, enthusiastic, and competitive while performing the task.

Although no studies in the literature have utilized SSE to evaluate balance in patients with Parkinson's disease. Our study provides new evidence that SSE is a useful exercise program in Parkinson's disease and also it serves as a new form of exercise to prevent fall. This is a pilot study and has few limitations such as small sample size, lesser duration, and limited outcome measures.

  Conclusion Top

This study shows that SSE is more effective as compared to CPT program in improving balance and gait in Parkinson's disease patients. This study recommends that SSE has a good potential to be applied in Parkinson's disease patients, which improves their dynamic balance and reduces the risk of fall. In addition, SSE method could be a safe, low-cost, and feasible alternative to practice physical activity with good impact on improvement of functional mobility.


We would like to express our gratitude to Sree Balaji College of Physiotherapy and all the staffs of Global Hospitals and Health City, Chennai, India for their support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Incidence, Prevalence and Cost of Parkinson's Disease; 2011. Available from: Parkinsons-disease/. [Last accessed on 2012 Jul 16].  Back to cited text no. 1
Ellis T, de Goede CJ, Feldman RG, Wolters EC, Kwakkel G, Wagenaar RC. Efficacy of a physical therapy program in patients with Parkinson's disease: A randomized controlled trial. Arch Phys Med Rehabil 2005;86:626-32.  Back to cited text no. 2
Heremans E, Nieuwboer A, Spildooren J, Vandenbossche J, Deroost N, Soetens E, et al. Cognitive aspects of freezing of gait in Parkinson's disease: A challenge for rehabilitation. J Neural Transm (Vienna) 2013;120:543-57.  Back to cited text no. 3
van der Kolk NM, King LA. Effects of exercise on mobility in people with Parkinson's disease. Mov Disord 2013;28:1587-96.  Back to cited text no. 4
Özgönenel L, Çagirici S, Çabalar M, Durmusoglu G. Use of game console for rehabilitation of Parkinson's disease. Balkan Med J 2016;33:396-400.  Back to cited text no. 5
Toole T, Hirsch MA, Forkink A, Lehman DA, Maitland CG. The effects of a balance and strength training program on equilibrium in Parkinsonism: A preliminary study. NeuroRehabilitation 2000;14:165-74.  Back to cited text no. 6
Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JC. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc 2008;56:2234-43.  Back to cited text no. 7
Nieuwboer A, Kwakkel G, Rochester L, Jones D, van Wegen E, Willems AM, et al. Cueing training in the home improves gait-related mobility in Parkinson's disease: The RESCUE trial. J Neurol Neurosurg Psychiatry 2007;78:134-40.  Back to cited text no. 8
Shigematsu R, Okura T. A novel exercise for improving lower-extremity functional fitness in the elderly. Aging Clin Exp Res 2006;18:242-8.  Back to cited text no. 9
Shigematsu R, Okura T, Nakagaichi M, Tanaka K, Sakai T, Kitazumi S, et al. Square-stepping exercise and fall risk factors in older adults: A single-blind, randomized controlled trial. J Gerontol A Biol Sci Med Sci 2008;63:76-82.  Back to cited text no. 10
Shigematsu R, Okura T, Sakai T, Rantanen T. Square-stepping exercise versus strength and balance training for fall risk factors. Aging Clin Exp Res 2008;20:19-24.  Back to cited text no. 11
Hoehn MM, Yahr MD. Parkinsonism: Onset, progression and mortality. Neurology 1967;17:427-42.  Back to cited text no. 12
Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: Validation of an instrument. Can J Public Health 1992;83 Suppl 2:S7-11.  Back to cited text no. 13
Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.  Back to cited text no. 14
Harshika B, Vishnu V, Tushar P, Shilpa K. Comparative study on the effect of square stepping exercises versus balance training exercises on fear of fall and balance in elderly population. Int J Physiother Res 2016;4:1352-9.  Back to cited text no. 15
Smania N, Corato E, Tinazzi M, Stanzani C, Fiaschi A, Girardi P, et al. Effect of balance training on postural instability in patients with idiopathic Parkinson's disease. Neurorehabil Neural Repair 2010;24:826-34.  Back to cited text no. 16
Rochester L, Baker K, Hetherington V, Jones D, Willems AM, Kwakkel G, et al. Evidence for motor learning in Parkinson's disease: Acquisition, automaticity and retention of cued gait performance after training with external rhythmical cues. Brain Res 2010;1319:103-11.  Back to cited text no. 17
Teixeira CV, Gobbi S, Pereira JR, Vital TM, Hernandéz SS, Shigematsu R, et al. Effects of square-stepping exercise on cognitive functions of older people. Psychogeriatrics 2013;13:148-56.  Back to cited text no. 18
Wu T, Hallett M. The cerebellum in Parkinson's disease. Brain 2013;136(Pt 3):696-709.  Back to cited text no. 19


  [Table 1], [Table 2], [Table 3]

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