SYNOPSIS

In Partial Fulfilment of Requirements For The Award of Degree of

Doctor of Physical Therapy

Department of Physical Therapy,

Superior University Lahore-
Pakistan
 COMPARISON OF PROPRIOCEPTIVE
NEUROMUSCULAR FACILITATION Vs BALANCE
EXERCISE ALONG WITH CONVENTIONAL
THERAPY FOR BALANCE AND GAIT IN
CHRONIC PARKINSON’S PATIENTS
A Synopsis Submitted by
HAFIZA HADIQA SHAFIQ DPTM-S19-049
AMNA MAHMOOD DPTM-F17-017
MUBASHRA DPTM-F17-059
SARA AFZAL DPTM-F19-195

DOCTOR OF PHYSICAL THERAPY

SUPERVISOR: Dr. Syed Ali Behram Subazwari
(MSPT, DPT)

Department of Physical Therapy

Faculty of Allied Health Sciences

SUPERIOR UNIVERSITY
2017-2022
CONTENTS
1- INTRODUCTION………………………………………………………. 01

2- LITERATURE REVIEW…...……………………………………………04

3- OBJECTIVE …...…………...……………………………………………07

4- HYPOTHESIS……………………………………………………………08

5-RATIONALE….………………………………………………………….09

6-OPERATIONAL DEFINITION ………………………………………….10

7- MATERIAL AND METHODS ………………………………………….11

7.1. STUDY DESIGN……………………………………………………….11

7.2. STUDY POPULATION SETTING………………………………....….11

7.3. SETTING…………………………………………………………….….11

7.4. DURATION OF STUDY……………………………………………….11

7.5. SAMPLE SIZE………………………………………………………….11

7.6. SAMPLING TECHNIQUE…………………………………………….12

7.7. ELIGIBILITY CRITERIA…………………………………………...….13

7.7.1. INCLUSION CRITERIA…………………………………………...…13

7.7.2. EXCLUSION CRITERIA…………………………………………..…13

7.8. DATA COLLECTION PROCEDURE…………………………….……13

7.9. ETHICAL CONSIDERATION………………………………………….15

7.10. STATISTICAL PROCEDURE ………………………………………..16

8- REFERENCES…….……………………………….……………….…….17

9- APPENDIX ……………………………….…………………………..….2
INTRODUCTION:

In general, the incidence of Parkinson’s disease in adults under the age of 60 ranges from
0.13% to 1.6%, but as people get older, the incidence of Parkinson’s disease can rise to as
high as 9% in those aged 80 to 84.(1) In the 26 years since 1990, the global burden of
Parkinson's disease has more than doubled, from 25.5 million people (95 percent
uncertainty interval 0–30) to 61.1 million patients (50–73) in 2016.(2) According to
estimates, one million persons in Pakistan have Parkinson's disease, with the number rising
to 1,200,000 by 2030. Both non-modifiable (age, gender) and modifiable (occupation,
pesticide exposure, and depression) risk factors have been linked to Parkinson’s disease.(3)
By 2040, aging alone is expected to cause 700,000 cases of Parkinson's disease. After
accounting for the decreased smoking prevalence, 770,000 cases are projected,
representing a 10% rise over the prediction without smoking.(4)

Parkinson's disease is caused by degenerative changes in the nervous system that cause the
cerebral basal ganglia to malfunction. Patients frequently suffer from posture control and
mobility issues, which harm their quality of life.(5) During daily activities, people with
idiopathic Parkinson's disease frequently demonstrate postural instability. Balance
impairment caused by Parkinson's disease is linked to a loss of mobility and an increased
risk of falling, and it can result in significant disability.(6) Motor symptoms such as
bradykinesia, dystonia, tremor, and postural balance problem, as well as non-motor
symptoms such as cognitive impairment and depression, are among the clinical
presentations. Drug therapy is currently the most common treatment for Parkinson's
disease, although it is only helpful for the first few years after onset, and some symptoms
do not respond to it at all.

Anti-Parkinson drugs, such as LEVODOPA, MADOPAR, and SIRELIN, are currently the
most common treatment options for Parkinson’s disease. The therapeutic effect of
dopaminergic treatments, on the other hand, has its own limits, the most prominent of
which is that the therapeutic benefit of dopaminergic treatments fades over time. Exercise
training can promote the plasticity of the cortical striatum and boost dopamine release as
an adjuvant treatment and supplemental therapy. In Parkinson's disease patients, exercise
training has been shown to effectively improve motor disorders (such as balance, gait, risk

1
of falling, and physical function) as well as nonmotor diseases (such as sleep impairments,
cognitive function, and quality of life). Various types of fitness training have been utilized
to treat Parkinson's disease in recent years.(7)

Interventions used to improve gait and balance in Parkinson’s disease include dance
therapy, music therapy, LSVT BIG Intervention, balance exercise, whole body vibration
and Proprioceptive neuromuscular facilitation that are effective in improving gait and
providing social well-being and quality of life in the patient. But We will compare the two
techniques from them that are Proprioceptive neuromuscular facilitation versus balance
exercise in Parkinson’s patients. Rehabilitation that focuses on balance in Parkinson's
disease patients may help with not only balance but also locomotion. Postural instability
causes walking difficulty in those with Parkinson's disease, which can be alleviated with
proper balance training. Exercise is the cornerstone of physical rehabilitation for people
with a variety of mobility problems. Its effect depends on the dosage and type of the
exercise which we guide our patient.(8) Specific types of cognition were linked to gait and
balance features. The unique links between gait or balance and cognitive functions show
that mobility and cognitive functions share cerebral cortical circuits.(9)

In this study, there are some variables use which are connected with each other. First is
independent variables which are Proprioceptive Neuromuscular Facilitation and Balanced
Exercises and the dependent variables which are gait and balance. Proprioceptive
Neuromuscular Facilitation is a type of physiotherapy treatment for Parkinson's disease. It
is defined as the activation of proprioceptors to promote the response of the neuromuscular
system. Facilitation, inhibition, strengthening, and relaxation of muscular groups are used
in this strategy to enhance functional movement. Concentric, eccentric, and static muscular
contractions are used on diagonal motions, together with incremental resistance and
appropriate facilitator methods, all of which are tailored to the demands of each
individual.(10) The main techniques which we use from PNF are D1 flexion and D1
extension of the lower limb and also the PNF pelvic patterns to improve balance and if the
balance is improve automatically gait will improve.(11) As its clear from name of balance
training exercises that they use to improve balance and also the function. Other than these
two factors balance training exercises decreases the chance of falling. These are the one of

2
type of exercises which are used to improve motor functioning and performance.(12)
Participants in balance training do exercises like static vs. dynamic stability postures,
reducing the base of support (bipedal vs. tandem vs. one-leg stance), changing the height
of the center of gravity, changing the standing surface (such as the floor, wobble boards,
wobble cushions, foam, or perturbation platforms), and reducing the source of visual
information, all while attempting to simulate perturbations that lead to falls during daily
activities (e.g., eyes open vs. closed).(13)

For the assessment of balance of Parkinson patient, a gold standard tool present which is
Berg Balance Scale.(14) The Berg Balance Scale is a scale that assesses many aspects of
balance required for daily activities. A chronometer, a ruler, and an 18-centimeter-high
stool were utilized for this scale. There are 14 things in the Berg Balance Scale, each item
is graded from 0 to 4. A complete score of 56 = good balance, whereas 0 = significant
balance impairment.(15) For the assessment of the gait of Parkinson patient, in this study
we use Functional gait assessment scale. The Functional Gait Assessment evaluates
postural stability while doing ten different walking exercises. The PT administered this
scale, which has 10 functional items. Each item is graded on a 4-point scale, with 0 = severe
impairment and 3 = typical ambulation. In a community-dwelling population of older
individuals and Parkinson’s disease, the FGA was found to have strong predictive and
discriminative validity. Individuals with Parkinson’s disease had high test-retest and
inter/intrarater reliability.(16)

There are a lot of researches that shows the use of combination of different therapies is
really effective in physiotherapy rehabilitation.(17) but there is insufficient literature that
shows which combination of therapies is more effective among other approaches that are
available worldwide.(18) Especially there is no clear evidence that which approach is better
than the other for the improvement of lower limb gait in chronic Parkinson’s patients from
approaches which is described above.(19) So, basically the aim of this study is to compare
the effect of Proprioceptive Neuromuscular Facilitation Vs Balance Exercise along with
Conventional Therapy for balance and gait in Chronic Parkinson’s patients..

3
LITERATURE REVIEW:

Aayush Vaidyaet al. in 2020 conducted an experimental study to determine

comparison between Proprioceptive Neuromuscular Facilitation versus Mirror Therapy
enhance gait and balance in paretic lower limb after acute stroke 30 participants were
taken and then randomly divided into 2 groups. Group A 15 Patients were received
Proprioceptive Neuromuscular Facilitation along with conventional therapy or group
B patients were received Mirror Therapy along with conventional treatment. The
inclusion criteria of this study were that stroke with the onset of 6 months age 45-65
years, first ever stroke exclusion criteria of this study were any neurological disorder,
musculoskeletal disorders. According to the analysis this study shows that both
interventions were effective in improving gait and balance but Neuromuscular
Facilitation is more effective in improving gait and balance.(20)

Arva Khuzema et al. 2020 conducted an experimental study to determine the effect of
home-based Tai Chi, Yoga or Conventional Balance Exercise on functional balance
and mobility among persons with idiopathic Parkinson’s disease 27 patients with
idiopathic Parkinson’s disease were randomly taken into Tai Chi Yoga or conventional
exercise group. The inclusion criteria were both male and female patients with age 60-
85 years, patients who were physically independent, patient with some postural
instability, and the exclusion criteria were patient with life threatening diseases,
patients with history of osteoporosis, fracture and postural instability. The result of
study shows that both Tai Chi Yoga or conventional exercise were beneficial for
improving balance and functional mobility in patients with idiopathic Parkinson’s
disease in this study long term follow up or large scale were also required to gain better
understanding.(21)

Dr.Shilpa Khatri et al. 2018 conducted a randomized controlled trials to determine

the effect of chest Proprioceptive Neuromuscular Facilitation Vs Thoracic Maitland
Mobilization on respiratory parameters in Parkinson’s patients 54 patients were taken
and then divided into 3 groups according to inclusion or exclusion criteria group A
Patients received chest PNF And breathing exercise group B received Thoracic
Maitland Mobilization and Breathing Exercise and Group C received Breathing

4
Exercises. The inclusion criteria were as follows patients with age 50 - 60 years,
medically diagnosed with Parkinson’s and the exclusion criteria of this study were
patient with cognitive impairment, hoehn and yahr disability classification grades 4 and
5. The result of this study shows that the chest PNF technique were highly beneficial
for Parkinson’s patients in pre and post values of PEFR AND OTT’S SIGN as
compared to thoracic Maitland Mobilization.(22)

David Conradsson et al. 2015 conducted a randomized controlled trials to determine

the effects of highly challenging balance training in elderly with Parkinson’s disease
100 patients with Parkinson’s disease were taken and then randomly divided into 2
groups of balance program for 10 weeks (no of patients = 51) and other one control
group (no of patients = 49) observe the patients before and after interventions. The
study included anti Parkinson medication of greater than 3 weeks and exclusion criteria
were conditions that influence the Balance Performance, Mini Mental State
Examination score of greater than 24. The result of this study shows that balance
training improved gait and balance when compared with usual care in elderly
individuals this training develop physical activity and daily activities.(23)

Elzbieta Mirek et al. 2015 conducted a pilot study to determine the effects of
physiotherapy on gait and balance of patients with Huntington’s disease 30 patients
with Huntington’s disease were taken age group 21 - 60 patients followed 3 week long
Proprioceptive Neuromuscular Facilitation based physiotherapy programme evaluated
twice gait and balance in each participant. The inclusion criteria were that Huntington’s
disease (HD) motor manifestation, patient informed consent and the exclusion criteria
were psychiatric symptoms or cognitive dysfunction according to the analysis this
study shows that in Huntington’s disease patients gait and balance improved after PNF
therapy concept of PNF is based on brain stimulation and neuronal plasticity to restore
the lost function this concept should be used as complementary method in Huntington’s
disease to pharmacotherapy because it is safe or efficient.(24)

Chengqi He et al. 2014 conducted a randomized controlled trials to determine the

effects of Tai Chi on balance and fall prevention in Parkinson’s disease 80 patient were
taken and then randomly divided into 2 group one was Tai Chi group (no of patient =

5
40) and other group were control group (no of patients = 40) who received no
intervention. The inclusion criteria were as follows 40 years old patients, patients were
diagnosed as idiopathic Parkinson’s disease, patient could walk independently and the
exclusion criteria were patient with severe medical issues such that hypertension and
heart failure, patient had mini mental state examination score <24. The results of study
shows that Tai Chi training should be more beneficial for improving balance in
Parkinson’s patients this study also shows the effect of fall prevention of Tai Chi
exercise in the Parkinson’s disease patients ratio of average times of fall in patients
with 6 months of follow up were lower in the Tai Chi group.(25)

S Kumar et al. 2012 conducted a randomized controlled trials to determine the effect
of PNF technique on gait parameters and functional mobility in hemiparetic patients 30
patients were taken and then divided into 2 groups control group and experimental
group. The inclusion criteria as follow patient with age between 50-70 years, MCA
ischemic infarction patient or onset of less than 6 month post stroke duration and the
exclusion criteria of this study were that severe disabling arthritis patient, cardiac
disease like Myocardial Infarction (MI) Patients, cognitive dysfunction patients
according to the statistical analysis this study shows that PNF technique is very useful
technique for stroke patient for the development of functional independence but
improvement quantify for specific area like locomotion and for other gait it is used as
adjunct for the purpose of improving gait.(26)

6
OBJECTIVE:

To determine the effect of Proprioceptive Neuromuscular Facilitation Vs Balance Exercise

along with Conventional Therapy for balance and gait in Chronic Parkinson’s patients.

7
HYPOTHESIS

➢ Null Hypothesis:

There is no difference in the effects of Proprioceptive Neuromuscular Facilitation Vs

Balance Exercise along with Conventional Therapy for balance and gait in Chronic
Parkinson’s patients.

➢ Alternative Hypothesis:

There is a significant difference between effects of Proprioceptive Neuromuscular

Facilitation Vs Balance Exercise along with Conventional Therapy for balance and gait in
Chronic Parkinson’s patients.

8
RATIONALE:

There is scarcity of evidence in the clinical outcomes of Proprioceptive Neuromuscular

Facilitation and Balance Exercise Techniques.(10) Some studies compare the effect of
Proprioceptive Neuromuscular Facilitation and Balance Exercise in combination with the
other techniques like Ballet Exercise and Mirror Therapy.(20, 27) The current study will
have a very important significance for upcoming researchers and therapists it will give a
pathway to the physiotherapist for selecting the technique which will provide the most
efficient results for the treatment of chronic Parkinson’s patients. Upcoming studies can
emphasize on selecting the better approaches to treat Balance and Gait of lower limb.
Therefore, the purpose of this study is to determine the effects of Proprioceptive
Neuromuscular Facilitation Vs Balance Exercise along with Conventional Therapy for
balance and gait in Chronic Parkinson’s patients.

9
OPERATIONAL DEFINITION

Balance:

Balance is the integration of static and dynamic balance training to maintain or improve
Activities of Daily Living and Quality of Life.(28) Berg Balance Scale is used for the
assessment of balance and it is a gold standard scale.(14) The maximum score of this scale
is 56 which indicates the functional balance. History of fall in patients with score <42 is
higher as compared to the patients with a score of >51.(29)

➢ History of fall and BBS <51 or no

➢ History of fall and BBS <42 predictive
➢ Score of <40 on BBS associated with almost 100% fall risk

Gait:

When the body is moving forward, one limb acting as a support and the other limb make
the new support site. Then the limbs reverse their actions. This rhythm is repeated by each
limb with mutual timing until the person is reached to his destination.(30)

Functional Gait Assessment scale is used for asses the gait. It is a 10-item gait assessment
based on dynamic gait index. The maximum possible score is 30. A score less than 19
shows that the patients are at a high risk of fall. Reliability of Functional Gait Assessment
0.91.(31)

Functional gait assessment scale:

• 0 =severe impairment

• 1=moderate impairment

• 2=mild impairment

• 3=normal ambulation

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MATERIAL AND METHODS

Study design:

The study design will be A Randomized Control Trial (RCT).

Study population:

Chronic Parkinson’s disease patients.

Setting:

As per permission of the head of the department of physiotherapy from a superior

university, I will be collecting data from:

• General hospital
• Jinnah hospital
• Mayo hospital
• Chaudhry Muhammad Akram Teaching and research hospital
• Services hospital Lahore (SHL)

Duration of study:

The duration of the study will be 6 months after the approval of synopsis.

Sample size:

The calculated sample size using Berg Balance Scale as the outcome measure in each group
is 28. After adding 10% dropout the sample size will be 28+2= 30 in each group so the
total sample size of the study is 60.(32)

11
Z1-α/2 Level of significance=95%
µ1 Expected mean change in Motor Functioning in Group A= 53.4.(32)

µ2 Expected mean change in Motor Functioning in Group B= 50.7.(32)

δ1 Expected standard deviation in group A= 3.3.(32)

δ2 Expected standard deviation in group B= 3.85.(32)

Z1-β power of the study= 80%
n Expected sample size in a group= 56.(32)
After adding 10% drop out in each group 28+2 = 30 in each group so the total sample size
of both groups will be 30+30= 60.(32)

Sampling technique:

The sampling technique will be Non – Probability purposive sampling technique.(33)

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Eligibility criteria:

8.7.1. Inclusion criteria:

Following people will be included in this study:

❖ Chronic Parkinson’s patients.(34)

❖ Patients from both gender around the age of 45-65.(35)
❖ Patient with a score of 42 above on the Berg Balance Scale.(29)
❖ Patient with good cognitive function minimum score of 20 or more on Mini-mental
Status Examination Scale (MMSE).(36)

8.7.2. Exclusion criteria:

Following people will not be included in this study.

❖ Patients with a history of recurrent stroke.(37)

❖ Patient with peripheral vascular disease.(38)
❖ Patient with fracture or dislocation of lower limb.(39)
❖ Patient with peripheral nerve injury.(40)
❖ Patient with skin discoloration, skin ulcers, and skin allergy.(41)

DATA COLLECTION PROCEDURE

Ethical Approval and Screening:

After giving informed signed consent participants will have a detailed neurological
examination and assessed for eligibility as defined in the inclusion/exclusion criteria. For
assessing the eligibility, participants will undergo screening and examination. After this
pre test will be performed on eligible participants then we will apply Berg balance scale to
assess the balance and Functional gait assessment to assess the gait.

13
After the baseline assessment, the eligible participants will be randomly assigned to (in 1:1
ration) both groups group A and group B. Group A will receive the Routine Physical
Therapy treatment with Proprioceptive Neuromuscular Facilitation and Group B will
receive the Routine Physical Therapy treatment with Balance Exercises.

Randomization:

Computer generated randomization assignments will be designed by an independent

statistician and randomization will be done by one of the research team members who will
not involve in patient recruitment or assessment or data analysis. Randomization
assignments will be kept in opaque, sealed envelopes and unsealed by a researcher after
baseline testing. Outcome assessors will be unaware of group assignment. The experiment
will be started on the day after randomization. For both groups, the intervention progressed
during the regularly scheduled therapy session and all other routine interdisciplinary
rehabilitation proceeded as usual. After randomization, study participants will be only
informed about the content of their allocated program by their therapist, remaining unaware
of the intervention in the other group.

Blinding:

Patient information will state that the study purpose is to determine the effects of
Proprioceptive Neuromuscular Facilitation in addition to routine physical therapy in
comparison to Balance exercise, without specifying the details of both programs except for
similarities across both groups. Both programs will be personalized to the patient’s abilities
to ensure all eligible patients could complete the program. Researchers who will assess
outcomes or do data analyses will be masked to group allocation. Patients will be instructed
not to talk about the content of their exercise program during the post intervention visit and
could contact their therapist in case of any problems during trial participation.

14
Intervention:

Group A

Group A will be given Proprioceptive Neuromuscular Facilitation with routine Physical

Therapy for 45 minutes on lower limb. The intervention will be conducted 3 times a week
for a period of 12 weeks.

Proprioceptive Neuromuscular Facilitation exercises include D1 flexion and D1 extension

of lower limb, D2 flexion and D2 extension of lower limb, Rhythmic Initiation, Hold
Relax, Pelvic Patterns and Contract Relax.

Group B

Group B will receive Balance Exercise with routine Physical therapy for 45 minutes on
lower limb, 3 times a week for a period of 12 weeks. The interventions will be performed
by a trained physiotherapist.

Balance exercises include Static and dynamic stability patterns, Tandem, weight shifting
exercise in order to improve center of gravity, Wobble board and Open eyes and closed
eye exercises.

ETHICAL CONSIDERATION

The rules and regulations set by the ethical committee of Superior University will be
followed while conducting the research and the rights of the research participants will be
respected.

➢ Written informed consent will be taken from all the participants.

➢ All information and data collection will be kept confidential.
➢ Participants will remain anonymous throughout the study.
➢ The subjects will be informed that there are no disadvantages or risks on the
procedure of the study.

15
 ➢ They will also be informed that they will be free to withdraw at any time during the
process of the study.
➢ Data will be kept under key and lock. In laptop it will be kept under password

STATISTICAL ANALYSIS

The data will be entered and analyzed using SPSS Version 24. The numerical data like age
will be presented in the form of mean ±SD. Categorical Data like gender group will be
presented in the form of frequency (Percentage) Independent sample t test will be used to
determine mean difference of Berg Balance Scale and Functional Gait Assessment between
groups at baseline week 6 and week 12. After checking normality of data repeated measures
ANOVA will be used to compare the outcome variables at different follow-ups within the
groups. If data will not be normally distributed then alternate non-parametric tests Mann
Whitney U test and Friedman test will be used for between group and within group
comparisons, p- value < 0.05 will be considered significant.

16
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Parkinson’s disease. Journal of Neurology, Neurosurgery & Psychiatry. 2007;78(5):470-5.
35. Amara AW, Wood KH, Joop A, Memon RA, Pilkington J, Tuggle SC, et al.
Randomized, controlled trial of exercise on objective and subjective sleep in Parkinson's
disease. Movement Disorders. 2020;35(6):947-58.
36. Galea M, Woodward M. Mini-mental state examination (MMSE). Australian
Journal of Physiotherapy. 2005;51(3):198.
37. Hankey GJ, Jamrozik K, Broadhurst RJ, Forbes S, Burvill PW, Anderson CS, et al.
Long-term risk of first recurrent stroke in the Perth Community Stroke Study. Stroke.
1998;29(12):2491-500.
38. Jones JD, Jacobson C, Murphy M, Price C, Okun MS, Bowers D. Influence of
hypertension on neurocognitive domains in nondemented Parkinson’s disease patients.
Parkinson’s Disease. 2014;2014.
39. Fischer SM. MACHINE LEARNING & DATA ANALYTICS: FAU Erlangen-
Nürnberg; 2019.
40. Agliardi C, Meloni M, Guerini FR, Zanzottera M, Bolognesi E, Baglio F, et al.
Oligomeric α-Syn and SNARE complex proteins in peripheral extracellular vesicles of
neural origin are biomarkers for Parkinson's disease. Neurobiology of Disease.
2021;148:105185.
41. Bose A, Petsko GA, Eliezer D. Parkinson’s disease and melanoma: co-occurrence
and mechanisms. Journal of Parkinson's disease. 2018;8(3):385-98.

20
APPENDIX

I. CONSENT FORM
You are invited to participate in a research study conducted by Hafiza Hadiqa Shafiq,
Amna Mahmood, Mubashra Khan and Sara Afzal. The purpose of this research is to
evaluate the “effectiveness of Proprioceptive Neuromuscular Facilitation (PNF) versus
Balance Exercise along with Conventional Therapy in improving balance and gait in
Chronic Parkinson’s patients”.

Risks and Discomforts:

No risks are associated with the study

Potential Benefits:
All the participants will be able to get their Balance and Gait checked as well as get it
treated for 12 weeks in order for the improvement to be assessed.

Protection of Confidentiality:
We will do everything we can to protect your privacy. Your identity will not be revealed
in any publication resulting from this study.

Voluntary Participation:
Your participation in this research study is voluntary. You may choose not to participate
and you may withdraw your consent to participate any time. You will not be penalized in
any way should you decide not you participate or to withdraw from this study.

CONSENT

I have read this consent form and have been given the opportunity to ask
questions. I give my consent to participate in this study.

Participant’s Signature __________________ Date: ____________________

A copy of this consent form should be given to the participant.

21
I. QUESTIONNAIRE

DATE:
NAME OF THE PATIENT:
AGE:
GENDER:
ADDRESS:
PHONE NUMBER:
PRE- TREATMENT:
POST TREATMENT :
FILE NUMBER:

22
BERG BALANCE TESTS AND RATING SCALE
PatientName
___________________________________________________________________
Date
_____________________________________________________________________
Location
__________________________________________________________________
Rater
____________________________________________________________________
ITEM DESCRIPTION SCORE (0-4)
Sitting to standing _____ Standing unsupported _____ Sitting
unsupported _____ Standing to sitting _____ Transfers _____ Standing with eyes closed
_____
Standing with feet together _____ Reaching forward with outstretched arm _____
Retrieving object
from floor _____ Turning to look behind _____ Turning 360 degrees _____ Placing
alternate foot
on stool _____ Standing with one foot in front _____ Standing on one foot _____ TOTAL
____

GENERAL INSTRUCTIONS
Please demonstrate each task and/or give instructions as written. When scoring, please
record the lowest response category that applies for each item. In most items, the subject
is asked to maintain a given position for a specific time. Progressively more points are
deducted if the time or distance requirements are not met, if the subject's performance
warrants supervision, or if the subject touches an external support or receives assistance
from the examiner. Subjects should understand that they must maintain their balance while
attempting the tasks. The choices of which leg to stand on or how far to reach are left to
the subject. Poor judgment will adversely influence the performance and the scoring.
Equipment required for testing are a stopwatch or watch with a second hand, and a ruler or
other indicator of 2, 5 and 10 inches (5, 12 and 25 cm). Chairs used during testing should

23
be of reasonable height. Either a step or a stool (of average step height) may be used for
item #12.

1. SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hands for support.
( ) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hands
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or to stabilize
( ) 0 needs moderate or maximal assist to stand

2. STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding.
( ) 4 able to stand safely 2 minutes
( ) 3 able to stand 2 minutes with supervision
( ) 2 able to stand 30 seconds unsupported
( ) 1 needs several tries to stand 30 seconds unsupported
( ) 0 unable to stand 30 seconds unassisted
Page 2
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported.
Proceed to item #4.

3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED

ON FLOOR OR ON ASTOOL
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
( ) 4 able to sit safely and securely 2 minutes
( ) 3 able to sit 2 minutes under supervision
( ) 2 able to sit 30 seconds
( ) 1 able to sit 10 seconds
( ) 0 unable to sit without support 10 seconds

24
4. STANDING TO SITTING
INSTRUCTIONS: Please sit down.
( ) 4 sits safely with minimal use of hands
( ) 3 controls descent by using hands
( ) 2 uses back of legs against chair to control descent
( ) 1 sits independently but has uncontrolled descent
( ) 0 needs assistance to sit

5. TRANSFERS
INSTRUCTIONS: Arrange chairs(s) for a pivot transfer. Ask subject to transfer one way
toward a
seat with armrests and one way toward a seat without armrests. You may use two chairs
(one with
and one without armrests) or a bed and a chair.
( ) 4 able to transfer safely with minor use of hands
( ) 3 able to transfer safely definite need of hands
( ) 2 able to transfer with verbal cueing and/or supervision
( ) 1 needs one person to assist
( ) 0 needs two people to assist or supervise to be safe

6. STANDING UNSUPPORTED WITH EYES CLOSED

INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
( ) 4 able to stand 10 seconds safely
( ) 3 able to stand 10 seconds with supervision
( ) 2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays steady
( ) 0 needs help to keep from falling

25
7. STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding.
( ) 4 able to place feet together independently and stand 1 minute safely
( ) 3 able to place feet together independently and stand for 1 minute with supervision
( ) 2 able to place feet together independently but unable to hold for 30 seconds
( ) 1 needs help to attain position but able to stand 15 seconds with feet together
( ) 0 needs help to attain position and unable to hold for 15 seconds

8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE

STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as
far as you
can. (Examiner places a ruler at end of fingertips when arm is at 90 degrees. Fingers should
not
touch the ruler while reaching forward. The recorded measure is the distance forward that
the
finger reaches while the subject is in the most forward lean position. When possible, ask
subject to
use both arms when reaching to avoid rotation of the trunk.)
( ) 4 can reach forward confidently >25 cm (10 inches)
( ) 3 can reach forward >12 cm safely (5 inches)
( ) 2 can reach forward >5 cm safely (2 inches)
( ) 1 reaches forward but needs supervision
( ) 0 loses balance while trying/requires external support

9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING

POSITION
INSTRUCTIONS: Pick up the shoe/slipper which is placed in front of your feet.
( ) 4 able to pick up slipper safely and easily
( ) 3 able to pick up slipper but needs supervision

26
( ) 2 unable to pick up but reaches 2-5cm (1-2 inches) from slipper and keeps balance
independently
( ) 1 unable to pick up and needs supervision while trying
( ) 0 unable to try/needs assist to keep from losing balance or falling

10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT

SHOULDERS WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward left shoulder. Repeat to
the right.
Examiner may pick an object to look at directly behind the subject to encourage a better
twist turn.
( ) 4 looks behind from both sides and weight shifts well
( ) 3 looks behind one side only other side shows less weight shift
( ) 2 turns sideways only but maintains balance
( ) 1 needs supervision when turning
( ) 0 needs assist to keep from losing balance or falling

11. TURN 360 DEGREES

INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in
the other
direction.
( ) 4 able to turn 360 degrees safely in 4 seconds or less
( ) 3 able to turn 360 degrees safely one side only in 4 seconds or less
( ) 2 able to turn 360 degrees safely but slowly
( ) 1 needs close supervision or verbal cueing
( ) 0 needs assistance while turning

27
12. PLACING ALTERNATE FOOT ON STEP OR STOOL WHILE
STANDING UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot
has
touched the step/stool four times.
( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
( ) 3 able to stand independently and complete 8 steps in >20 seconds
( ) 2 able to complete 4 steps without aid with supervision
( ) 1 able to complete >2 steps needs minimal assist
( ) 0 needs assistance to keep from falling/unable to try

13. STANDING UNSUPPORTED ONE FOOT IN FRONT

INSTRUCTIONS: (DEMONSTRATE TO SUBJECT) Place one foot directly in front of
the other. If
you feel that you cannot place your foot directly in front, try to step far enough ahead that
the heel
of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of
the step
should exceed the length of the other foot and the width of the stance should approximate
the
subject's normal stride width)
( ) 4 able to place foot tandem independently and hold 30 seconds
( ) 3 able to place foot ahead of other independently and hold 30 seconds
( ) 2 able to take small step independently and hold 30 seconds
( ) 1 needs help to step but can hold 15 seconds
( ) 0 loses balance while stepping or standing

14. STANDING ON ONE LEG

INSTRUCTIONS: Stand on one leg as long as you can without holding.
( ) 4 able to lift leg independently and hold >10 seconds

28
( ) 3 able to lift leg independently and hold 5-10 seconds
( ) 2 able to lift leg independently and hold = or >3 seconds
( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently
( ) 0 unable to try or needs assist to prevent fall

TOTAL SCORE (Maximum = 56: _______

29
 ➢ FUNCTIONAL GAIT ASSESSMENT TOOL:

1. GAIT LEVEL SURFACE

Instructions: Walk at your normal speed from here to the next mark (6 m
[20 ft]).
Grading: Mark the highest category that applies.
(3) Normal—Walks 6 m (20 ft) in less than 5.5 seconds, no assistive
devices, good speed, no evidence for imbalance, normal gait
pattern, deviates no more than 15.24 cm (6 in) outside of the
30.48-cm (12-in) walkway width.
(2) Mild impairment—Walks 6 m (20 ft) in less than 7 seconds but
greater than 5.5 seconds, uses assistive device, slower speed,
mild gait deviations, or deviates 15.24 –25.4 cm (6 –10 in)
outside of the 30.48-cm (12-in) walkway width.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern,
evidence for imbalance, or deviates 25.4 –
38.1 cm (10 –15 in) outside of the 30.48-cm (12-in) walkway
width. Requires more than 7 seconds to ambulate 6 m (20 ft).
(0) Severe impairment—Cannot walk 6 m (20 ft) without assistance,
severe gait deviations or imbalance, deviates greater than 38.1
cm (15 in) outside of the 30.48-cm (12-in) walkway width or
reaches and touches the wall.

2. CHANGE IN GAIT SPEED

Instructions: Begin walking at your normal pace (for 1.5 m [5 ft]). When
I tell you “go,” walk as fast as you can (for 1.5 m [5 ft]). When I tell you
“slow,” walk as slowly as you can (for 1.5 m [5 ft]).
Grading: Mark the highest category that applies.
(3) Normal—Able to smoothly change walking speed without loss of
balance or gait deviation. Shows a significant difference in

30
walking speeds between normal, fast, and slow speeds. Deviates no more than 15.24 cm (6
in) outside of the 30.48-cm
(12-in) walkway width.
(2) Mild impairment—Is able to change speed but demonstrates
mild gait deviations, deviates 15.24 –25.4 cm (6 –10 in) outside
of the 30.48-cm (12-in) walkway width, or no gait deviations but
unable to achieve a significant change in velocity, or uses an
assistive device.
(1) Moderate impairment—Makes only minor adjustments to walking speed, or
accomplishes a change in speed with significant
gait deviations, deviates 25.4 –38.1 cm (10 –15 in) outside the
30.48-cm (12-in) walkway width, or changes speed but loses
balance but is able to recover and continue walking.
(0) Severe impairment—Cannot change speeds, deviates greater
than 38.1 cm (15 in) outside 30.48-cm (12-in) walkway width,
or loses balance and has to reach for wall or be caught.

3. GAIT WITH HORIZONTAL HEAD TURNS

Instructions: Walk from here to the next mark 6 m (20 ft) away. Begin
walking at your normal pace. Keep walking straight; after 3 steps, turn
your head to the right and keep walking straight while looking to the
right. After 3 more steps, turn your head to the left and keep walking
straight while looking left. Continue alternating looking right and left
every 3 steps until you have completed 2 repetitions in each direction.
Grading: Mark the highest category that applies.
(3) Normal—Performs head turns smoothly with no change in gait.
Deviates no more than 15.24 cm (6 in) outside 30.48-cm (12-in)
walkway width.
(2) Mild impairment—Performs head turns smoothly with slight
change in gait velocity (eg, minor disruption to smooth gait
path), deviates 15.24 –25.4 cm (6 –10 in) outside 30.48-cm

31
(12-in) walkway width, or uses an assistive device.
(1) Moderate impairment—Performs head turns with moderate
change in gait velocity, slows down, deviates 25.4 –38.1 cm
(10 –15 in) outside 30.48-cm (12-in) walkway width but recovers, can continue to walk.
(0) Severe impairment—Performs task with severe disruption of gait
(eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway
width, loses balance, stops, or reaches for wall).

4. GAIT WITH VERTICAL HEAD TURNS

Instructions: Walk from here to the next mark (6 m [20 ft]). Begin walking
at your normal pace. Keep walking straight; after 3 steps, tip your head
up and keep walking straight while looking up. After 3 more steps, tip
your head down, keep walking straight while looking down. Continue
alternating looking up and down every 3 steps until you have completed
2 repetitions in each direction.
Grading: Mark the highest category that applies.
(3) Normal—Performs head turns with no change in gait. Deviates
no more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway
width.
(2) Mild impairment—Performs task with slight change in gait
velocity (eg, minor disruption to smooth gait path), deviates
15.24 –25.4 cm (6 –10 in) outside 30.48-cm (12-in) walkway
width or uses assistive device.
(1) Moderate impairment—Performs task with moderate change in
gait velocity, slows down, deviates 25.4 –38.1 cm (10 –15 in)
outside 30.48-cm (12-in) walkway width but recovers, can
continue to walk.
(0) Severe impairment—Performs task with severe disruption of gait
(eg, staggers 38.1 cm [15 in] outside 30.48-cm (12-in) walkway
width, loses balance, stops, reaches for wall).

32
5. GAIT AND PIVOT TURN
Instructions: Begin with walking at your normal pace. When I tell you,
“turn and stop,” turn as quickly as you can to face the opposite direction
and stop.
Grading: Mark the highest category that applies.
(3) Normal—Pivot turns safely within 3 seconds and stops quickly
with no loss of balance.
(2) Mild impairment—Pivot turns safely in !3 seconds and stops
with no loss of balance, or pivot turns safely within 3 seconds
and stops with mild imbalance, requires small steps to catch
balance.
(1) Moderate impairment—Turns slowly, requires verbal cueing, or
requires several small steps to catch balance following turn and
stop.
(0) Severe impairment—Cannot turn safely, requires assistance to
turn and stop.

6. STEP OVER OBSTACLE

Instructions: Begin walking at your normal speed. When you come to the
shoe box, step over it, not around it, and keep walking.
Grading: Mark the highest category that applies.
(3) Normal—Is able to step over 2 stacked shoe boxes taped
together (22.86 cm [9 in] total height) without changing gait
speed; no evidence of imbalance.
(2) Mild impairment—Is able to step over one shoe box (11.43 cm
[4.5 in] total height) without changing gait speed; no evidence
of imbalance.
(1) Moderate impairment—Is able to step over one shoe box (11.43
cm [4.5 in] total height) but must slow down and adjust steps to
clear box safely. May require verbal cueing.
(0) Severe impairment—Cannot perform without assistance.

33
7. GAIT WITH NARROW BASE OF SUPPORT
Instructions: Walk on the floor with arms folded across the chest, feet
aligned heel to toe in tandem for a distance of 3.6 m [12 ft]. The number
of steps taken in a straight line are counted for a maximum of 10 steps.
Grading: Mark the highest category that applies.
(3) Normal—Is able to ambulate for 10 steps heel to toe with no
staggering.
(2) Mild impairment—Ambulates 7–9 steps.
(1) Moderate impairment—Ambulates 4 –7 steps.
(0) Severe impairment—Ambulates less than 4 steps heel to toe or
cannot perform without assistance.

8. GAIT WITH EYES CLOSED

Instructions: Walk at your normal speed from here to the next mark (6 m
[20 ft]) with your eyes closed.
Grading: Mark the highest category that applies.
(3) Normal—Walks 6 m (20 ft), no assistive devices, good speed,
no evidence of imbalance, normal gait pattern, deviates no more
than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway width.
Ambulates 6 m (20 ft) in less than 7 seconds.
(2) Mild impairment—Walks 6 m (20 ft), uses assistive device,
slower speed, mild gait deviations, deviates 15.24 –25.4 cm
(6 –10 in) outside 30.48-cm (12-in) walkway width. Ambulates
6 m (20 ft) in less than 9 seconds but greater than 7 seconds.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern,
evidence for imbalance, deviates 25.4 –38.1
cm (10 –15 in) outside 30.48-cm (12-in) walkway width.
Requires more than 9 seconds to ambulate 6 m (20 ft).
(0) Severe impairment—Cannot walk 6 m (20 ft) without assistance,
severe gait deviations or imbalance, deviates greater than 38.1

34
cm (15 in) outside 30.48-cm (12-in) walkway width or will not
attempt task.

9. AMBULATING BACKWARDS
Instructions: Walk backwards until I tell you to stop.
Grading: Mark the highest category that applies.
(3) Normal—Walks 6 m (20 ft), no assistive devices, good speed,
no evidence for imbalance, normal gait pattern, deviates no
more than 15.24 cm (6 in) outside 30.48-cm (12-in) walkway
width.
(2) Mild impairment—Walks 6 m (20 ft), uses assistive device,
slower speed, mild gait deviations, deviates 15.24 –25.4 cm
(6 –10 in) outside 30.48-cm (12-in) walkway width.
(1) Moderate impairment—Walks 6 m (20 ft), slow speed, abnormal gait pattern,
evidence for imbalance, deviates 25.4 –38.1
cm (10 –15 in) outside 30.48-cm (12-in) walkway width.
(0) Severe impairment—Cannot walk 6 m (20 ft) without assistance,
severe gait deviations or imbalance, deviates greater than 38.1
cm (15 in) outside 30.48-cm (12-in) walkway width or will not
attempt task.

10. STEPS
Instructions: Walk up these stairs as you would at home (ie, using the rail
if necessary). At the top turn around and walk down.
Grading: Mark the highest category that applies.
(3) Normal—Alternating feet, no rail.
(2) Mild impairment—Alternating feet, must use rail.
(1) Moderate impairment—Two feet to a stair; must use rail.
(0) Severe impairment—Cannot do safely.

TOTAL SCORE: ______ MAXIMUM SCORE 30

35
➢ MINIMENTAL STATUS EXAMINATION TOOL

36
II. OUTCOMEMEASUREMENT TOOL

1- Berg Balance Scale

2- Functional Gait Assessment Tool

3- Mini Mental Status Examination

37