Topics in Geriatric Rehabilitation • Volume 36, Number 3, 140-145 • Copyright © 2020 Wolters Kluwer Health, Inc.
All rights reserved.
DOI: 10.1097/TGR.0000000000000272
Diagnostic Accuracy of the 3-Meter Backward
Walk Test in Persons With Parkinson Disease
Valerie A. Carter, DPT, PT, NCS, GCS; Becky G. Farley, PhD, MS, PT; Kay Wing, DPT, PT, NCS;
Hendrik “Dirk” de Heer, PhD, MPH; Tarang K. Jain, PhD, PT
Purpose:  To test diagnostic accuracy of the 3-Meter
Backward Walk (3MBW) test for falls among 175 persons
with Parkinson disease (PwP).
Methods:  Retrospective data analysis was performed on time
for 3MBW test, forward walk tests (Timed Up and Go, TUG
cognitive, and 10-Meter Walk), and the 5 times Sit-to-Stand
test. A receiver operating characteristic curve analysis was
completed to determine fall cutoff scores, and the optimal
area under the curve (AUC) with sensitivity/specificity values
was defined.
Results:  The 3MBW test at 4.2 seconds had the highest
AUC (AUC = 0.699). Persons with Parkinson disease with
advanced disease were slower for each test; the 3MBW was
the only test that was significantly different across disease
severity.
Conclusion:  The 3MBW test had the highest overall accuracy
for retrospective falls and should be considered as part of
battery of tests among persons with Parkinson disease.
Key words:  balance, fall risk, Parkinson, sensitivity, specificity,
3-Meter Backward Walk, Timed Up and Go
A pproximately 50% of persons with Parkinson dis-
ease (PwP) who fall require medical care.1 Per-
sons with Parkinson disease who fall have
increased morbidity and mortality, caregiver burden, utili-
zation and cost of health care, and have a reduce quality of
life.2-8 Developing and optimizing therapeutic strategies to
prevent falls require identifying PwP at risk for falling. It is
critical to develop outcome tools that can effectively iden-
tify PwP who are at risk of falling earlier in the Parkinson
disease (PD) continuum.
Author Affiliations: Departments of Physical Therapy and Athletic Training
(Drs Carter and Jain) and Health Sciences (Dr de Heer), Northern Arizona
University, Flagstaff; NeuroFit Networks Inc DBA: Parkinson Wellness Re-
covery | PWR, Tucson, Arizona (Dr Farley); and Southwest Advanced Neu-
rological Rehabilitation (SWAN Rehab), Phoenix, Arizona (Dr Wing).
Becky G. Farley is founder and chief scientific officer and an employee of
NeuroFit Networks, Inc DBA Parkinson Wellness Recovery, a 501(c)(3)
nonprofit organization that manages both the physical therapy clinic and
neurofitness and wellness center where these data were collected.
The authors have disclosed that they have no significant relationships with,
or financial interest in, any commercial companies pertaining to this article.
Correspondence: Valerie A. Carter, DPT, PT, NCS, GCS/Tarang K. Jain,
PhD, PT, Department of Physical Therapy and Athletic Training, Northern
Arizona University, 208 Pine Knoll Dr, Bldg 66, PO Box 15105, Flagstaff,
AZ 86011 (Valerie.Carter@nau.edu/Tarang.Jain@nau.edu).
140 www.topicsingeriatricrehabilitation.com
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Over the years, many risk factors for falls have been
identified such as age, levodopa treatment, and motor
fluctuations.9 However, these risk factors are common
with most PwP and may not contribute to predicting which
subgroup of PwP is at greatest risk of falls. Recent research
indicates that backward walking might be a more challeng-
ing measure that is better at indicating level of impairment
in gait than forward walking and forward walking with dual
task.10 Persons with Parkinson disease have an increased
axial stiffness and more limited sense of proprioception
and verticality, resulting in falls in backward and lateral
directions.11-13
Recently, Carter et al14 introduced a novel clinical mea-
sure for fall risk using the 3-Meter Backward Walk (3MBW)
test in a sample of community-dwelling older adults. The
authors proposed that a low risk of falls score of 3.0 seconds
and a high risk of falls score of 4.5 seconds were more pre-
dictive of retrospective falls in the elderly than other popu-
lar fall-predictive tests such as the Five Times Sit to Stand
(5×STS) and the Timed Up and Go (TUG) and may be a
valuable addition to the current battery of clinical tools.14
However, fall risk cutoff values for the 3MBW have not
been determined in neurologically impaired populations
such as PwP. In addition, no study has documented the
extent to whether the 3MBW times increase with disease
progression. Therefore, the following retrospective study
aimed to
1. compare scores in time (seconds) on the 3MBW
test with other existing measures of fall risk related
to forward walking (TUG regular, TUG cognitive,
and 10-Meter Walk) and the 5×STS tests between
PwP who reported falls versus who did not;
2. compare 3MBW and forward walking tests across
disease severity in PwP; and
3. define optimal cutoffs for diagnostic accuracy for
3MBW and forward walking tests as well as the
5×STS in PwP who reported falling.
METHODS
Design and participants
This study looked at data collected from an ongoing medi-
cal record data set of clients with PD who attended a PD-
specific clinic (see the Table). The retrospective data pre-
sented here represent clients who received an initial
July–September 2020
 TABLE Demographics and Outcome Results
TUG Regular TUG Cognitive 5×STS 10MW 3MBW
Variable (Mean ± SD) (Mean ± SD) (Mean ± SD) (Mean ± SD) (Mean ± SD)
Sex
  Male (N = 123) 7.8 ± 2.5 10.1 ± 4.0 12.7 ± 4.2 7.0 ± 1.8 4.5 ± 2.2
n = 112 n = 109 n = 68 n = 120 n = 116
  Female (N = 52) 7.6 ± 2.4 10.1 ± 4.3 11.7 ± 4.3 6.9 ± 1.8 4.7 ± 2.0
n = 46 n = 45 n = 32 n = 48 n = 47
Age (decade)
  5.00 5.9 ± 1.2 6.8 ± 1.6 9.7 ± 2.3 6.0 ± 1.2 3.3 ± 1.5
n = 13 n = 13 n=9 n = 13 n = 13
  6.00 6.8 ± 1.8 9.4 ± 4.0 11.5 ± 4.1 6.7 ± 1.7 4 ± 1.6
n = 42 n = 42 n = 25 n = 45 n = 44
  7.00 8.0 ± 2.4 10.3 ± 4.0 12.2 ± 4 7.1 ± 1.8 4.6 ± 2.1
n = 77 n = 75 n = 47 n = 83 n = 80
  8.00 9.3 ± 3 12.3 ± 4.1 15.3 ± 4.3 7.5 ± 1.8 6.1 ± 2.6
n = 26 n = 24 n = 19 n = 27 n = 26
Hoehn and Yahr Stage
  1.00 6.7 ± 2.2 8.3 ± 3.6 10.6 ± 3.8 6.2 ± 1.2 3.4 ± 1.4
n = 60 n = 60 n = 42 n = 60 n = 60
  2.00 7.6 ± 1.8 10.1 ± 3.2 12.8 ± 3.8 6.7 ± 1.3 4.6 ± 1.8
n = 66 n = 66 n = 38 n = 67 n = 67
  3.00 9.0 ± 2.4 13.5 ± 4.6 14.9 ± 4.3 7.9 ± 2.2 5.9 ± 2.5
n = 22 n = 21 n = 16 n = 26 n = 25
  4.00 11.7 ± 2.9 14.3 ± 5.2 16.8 ± 3.1 9.4 ± 1.9 7.5 ± 2.3
n = 10 n=7 n=4 n = 15 n = 11
Abbreviations: 5xSTS, Five Times Sit to Stand; 10MW, 10-Meter Walk; 3MBW, 3-Meter Backward Walk; TUG, Timed Up and Go.

evaluation by PD-specialized physical therapists from July
2013 through July 2018 (n = 175) as part of a larger ongo-
ing medical record review. Study procedures were reviewed
and approved by the Northern Arizona University Institu-
tional Review Board.
Measures
The following demographic characteristics were included
for analysis: age, gender, years with PD, disease severity as
defined by Hoehn and Yahr (HY) stage of PD,15 and fall his-
tory within the past 6 months (yes/no). In addition to the
3MBW, the following tests and measures commonly used to
determine risk of falls in PwP were also included:
Timed Up and Go regular (TUG regular) aims to assess
mobility, balance, walking ability, and fall risk in older adults
and PwP. The test begins with individuals seated in an arm-
chair with their back against the back of the chair. When
the clinician says “go,” the person stands up, walks 3 m,
turns around, walks back, and sits down again. This test has
been well established with fall cutoff time for PwP ranging
from 8 to 12 seconds.16,17
Timed Up and Go cognitive (TUG cognitive) aims to
assess walking mobility, balance, and fall risk under dual
task conditions in older adults and PwP. Participants
complete the same procedure as in the TUG regular but
counted backward by threes from a randomly selected
number between 20 and 100. This test has been well
established with a fall cutoff time range of more than 15
seconds in the elderly with a history of falls and 21.5 sec-
onds in PwP with a history of falls.18
Five Times Sit to Stand (5×STS) aims to assess lower
extremity strength as well as fall risk.19 The test starts in
seated position with arms folded across the chest and the
individual is instructed to stand up and sit down 5 times
as quickly as possible while reaching full standing position
between repetitions. A fall cutoff score for a community-
dwelling older adult is 12 seconds whereas a cutoff of more
than 15 seconds is indicative of recurrent fall risk. For PwP,
a fall risk cutoff score of 12 seconds for a single fall and 15
seconds for multiple falls has been indicated.20
10-Meter Walk (10MW) aims to assess forward gait
speed, which can predict morbidity and mortality as well

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as functional ability. The time to complete a 10-m distance
(with 5 m on either side) was recorded in seconds. Partici-
pants completed two trials for each normal and fast 10MW
tests, as 10MW tests administered at both comfortable and
“fast and safe” walking speeds have demonstrated excel-
lent test-retest reliability in PwP (intraclass correlation coef-
ficient, ICC > 0.96).21
3-Meter Backward Walk (3MBW) aims to assess back-
ward walking mobility, balance, and fall risk. The test starts
with participants standing straight facing backward on a
marked line on a smooth surface such as tile or wood.
They are then instructed to walk backward as quickly
but safely as possible and stop after 3 m (marked on the
floor). Participants were permitted to look behind them-
selves if they desired and the examiner walked with the
participant to ensure safety. A fall cutoff range of 3.0 sec-
onds (low risk of falls) and 4.5 seconds (high risk of falls)
for the normal elderly community has been previously
recommended.14
Fall history is a strong predictor for future falls in the
elderly.22 The primary dependent variable for the current
study was whether a participant reported falling (dichot-
omized yes or no) when asked to answer the question
(“Have you fallen in the past 6 months?”). For this study, a
fall was defined as an event that resulted in a person com-
ing to rest unintentionally on the ground or other level.23,24
For a fall to count toward the fall status categorization, the
participant had to recall at least an approximate date and
specific circumstances surrounding the fall.
Analyses
Data were analyzed using the SPSS software package, ver-
sion 26 (SPSS, IBM Corp, Armonk, New York) and MedCalc
19.1.7 (MedCalc Software, Ostend, Belgium). For each vari-
able, extreme outliers (more than 2.0 standard deviations
away from the mean) as assessed by boxplot were excluded
from the analysis. Demographic characteristics of partici-
pants were summarized with descriptive statistics, includ-
ing mean ± SD and frequency distributions. The forward
and backward walking times were compared for age (50-80
years) by decade (5-8 retrospectively), disease severity (HY
stages 1-4), and reported falls using a 1-way analysis of vari-
ance. Post hoc tests were performed with Bonferroni cor-
rections to account for multiple comparisons. Sensitivity
was calculated as the proportion of PwP with a fall history
who were correctly identified by a fall risk assessment tool
as having fall risk. Specificity was calculated as the propor-
tion of PwP who did not have a fall history and were cor-
rectly identified by a fall risk assessment tool as not having
fall risk. Receiver operating characteristic (ROC) curves for
different tests and measures were examined, and optimal
cut points were determined from the shortest distance
from the upper left of the ROC plot. Overall accuracy was
assessed by defining the optimal area under the curve
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(AUC). In all statistical comparisons, P < .05 was used as
the criterion for statistical significance.
RESULTS
Demographics and baseline values
A total of 175 PwP participated, most of whom were males
(70.8%) in their 60s and 70s (75.3%). Although not all par-
ticipants completed all outcome measures, at least 153 of
175 participants completed each of the functional tests
performed in this study. Only 100 people completed the
5×STS as this test was added later in the process of data
collection. The number of extreme outliers excluded from
analysis for each variable (TUG regular, n = 15; TUG cogni-
tive, n = 13; 5×STS, n = 12; 3MBW, n = 7; 10MW, n = 2)
were most representative of people with advanced PD (ie,
8/10 reported falls and freezing of gait and represented
nearly 39% HY stage 4). Overall, males and females had
similar walking speeds on all the functional tests. For exam-
ple, males averaged 4.5 ± 2.2 seconds on the 3MBW and
females 4.7 ± 2.0 seconds; males averaged 7.8 ± 2.5 sec-
onds on the TUG and 7.0 ± 1.8 on the 10MW and females
averaged 7.6 ± 2.4 and 6.9 ± 1.8 seconds (Table).
Aim 1: Comparison of PwP who reported falling
versus those who did not
People who reported falling in the past 6 months were
compared with people who did not report falling. Age (P =
.168) and gender (P = .490) were not significantly different
between people who fell and people who did not fall. How-
ever, disease severity was significantly different between
people who fell and people who did not fall (P = .000). In
total, 67 people reported falling in the past year and these
data are summarized in Figure 1 for each measure. People
who fell had a significantly slower 3MBW of 5.5 seconds on
average, compared with 4.0 seconds for people who did
not fall (P < .001). People who fell also had a significantly
slower TUG regular (8.6 vs 7.3 seconds, P = .001), TUG
cognitive (11.5 vs 9.3 seconds, P = .002), 5×STS (13.8 vs
11.8 seconds, P = .025), and 10MWT (7.6 vs 6.6 seconds,
P < .001) (see Figure 1).
Aim 2: Comparison of forward and backward walk
tests across disease severity
We tested the difference in times during forward and back-
ward walking across disease severity using 1-way analysis of
variance. The test times were statistically significantly dif-
ferent for all forward and backward walking tests across
disease severity (3MBW: F3,159= 21.249; P < .001; TUG reg-
ular: F3,154= 19.223; P < .001; TUG cognitive: F3,150= 13.553;
P < .001; 5×STS: F3,96= 7.016; P < .001; 10MW: F3,164=
21.732; P < .001). The post hoc analysis showed that
3MBW was able to detect significant differences between
stages 1, 2, 3, and 4, whereas forward walking tests and the
5×STS were able to detect significant differences between
July–September 2020
Figure 1. Fall risk values (in seconds) for different fall risk
assessment measures in fallers vs non-fallers. “a” indicates
statistical significance at P < .05; 3MBW, 3-Meter Backward
Walk; TUG, Timed Up and Go; 5×STS, Five Times Sit to
Stand; 10MWT, 10-Meter Walk Test.
stage 1 and stages 3 and 4 only. For example, people in
stage 1 walked 6.7 ± 2.2 seconds on the TUG, which
increased to 7.6 ± 1.8 (stage 2), 9.0 ± 2.4, and 11.7 ± 2.9
seconds in stage 4, or a 74% increase in time from stage 1
to stage 4. For the 3MBW, the times were 3.4 seconds (stage
1), 4.6 ± 1.8, 5.9 ± 2.5, and 7.5 ± 2.3 seconds, respectively,
or a 120% increase in time from stage 1 to stage 4.
Aim 3: Define optimal cutoffs for diagnostic
accuracy
Using ROC curves, optimal cutoffs were evaluated for the
forward and backward walk tests and fall history (yes or no)
(Figure 2). The diagnostic accuracy, as determined by the
AUC of forward and backward walking tests for detection
of falls, in the descending order was 3MBW: 0.699 (Sensitiv-
ity 71.4%/Specificity 64%), 5×STS: 0.674 (Sensitivity 64%/
Specificity 69.1%), TUG cognitive: 0.666 (Sensitivity 64.2%/
Specificity 61.7%), 10MWT: 0.656 (Sensitivity 32.8%/Speci-
ficity 92.7%), and TUG regular: 0.647 (Sensitivity 67.9%/
Specificity 58.5%). The optimal cutoff points in terms of
sensitivity and specificity for falls in PwP for different tests
and measures were determined to be TUG: 7.3 seconds,
TUG cognitive: 9.2 seconds, 5×STS: 12.4 seconds, 10MWT:
6.6 seconds, and 3MBW: 4.2 seconds.
DISCUSSION
In the context of prior research reporting that 3MBW is
more sensitive at evaluating risk of falls in the healthy
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Figure 2. Receiver operating characteristic (ROC) curves
for fall risk assessment measures. 5×STS indicates Five
Times Sit to Stand; 3MBW, 3-Meter Backward Walk; TMWT_
FS, 10-Meter Walk Test-fast and safe speed; TMWT_RS,
10-Meter Walk Testregular speed; TUG_C, Timed Up and
Go-cognitive; TUG_R, Timed Up and Go-regular.
community-dwelling elderly,14 this study aimed to assess the
ability of the 3MBW to identify PwP who reported fall in the
previous 6 months and to determine an appropriate fall cut-
off score for PwP. Clinically, sensitivity is an important meas-
ures to assess fall risk. High sensitivity is preferred because
it corresponds to more true positives and fewer false nega-
tives, whereas the opposite is true for low sensitivity. It is
important that PwP who have fall risk be identified as such
(true positives) and that no PwP who have fall risk be identi-
fied as not having fall risk (false negative) so that appropri-
ate fall risk measures can be taken.
To our knowledge, this is the first study to identify the
diagnostic accuracy of the 3MBW test as a fall risk assess-
ment tool in PwP. In this study, 3MBW cutoff of 4.2 seconds
was identified to be the most optimal for identifying falls in
PwP, having the highest overall AUC of 0.699. A cutoff at 4.2
seconds would correctly identify almost 71% of PwP who
reported falling, while correctly identifying 64% of PwP
who did not. These were much higher than the 10MWT
at 6.6 seconds, which missed almost 67% of the PwP who
reported falling, although correctly capturing most of the
PwP (93%) who did not fall. 5×STS and TUG cognitive
were closest in overall accuracy to the 3MBW and not sig-
nificantly different in overall AUC. This corresponds to pos-
sible proposed fall cutoffs times on the 3MBW test for PwP
of 4.0 seconds for low risk and of 5.5 seconds for high risk
of previous falls.
www.topicsingeriatricrehabilitation.com 143
 The 3MBW test is designed to give insight to the abil-
ity of a person to initiate and sustain walking in the back-
ward direction. For the elderly and PwP, walking backward
is more difficult than walking forward.11,12,22,25-27 Persons
with Parkinson disease are most unstable during backward
movement and have difficulty with initiating movement in
the backward direction, take more steps to regain balance
after a backward perturbation, and demonstrate more
pronounced changes during backward walking than age-
matched controls.11,12,26,27 Recently, Kwon et al10 showed
backward walking variability in de novo PwP to be more
variable than forward walking, as well as forward walking
with dual task conditions. They determined that backward
walking, as the earliest indicator of gait variability, may be
strongly associated with the risk of falling and disease pro-
gression.10 This is consistent with the data in this study.
Only the 3MBW test was able to detect differences across
all HY stages (1-2-3-4) and the only test that was sensitive
enough to detect a difference between early stages (HY1
and 2) when compared with the TUG regular, TUG cogni-
tive, 5×STS, and 10MWT. Therefore, along with the capac-
ity of fall predictability, the 3MBW test could be used as an
additional functional outcome measure to detect changes
in PwP disease severity.
Limitations and future directions
Limitations of this study include the retrospective falls
assessment (fall history), which is not as strong as a pro-
spective analysis. Although retrospective fall assessment
studies are not uncommon, a prospective assessment
would allow validation of the utility of 3MBW test for pre-
diction of falls and its ability to detect disease severity in
PwP. We included PwP with advanced PD in the analysis
because this is representative of individuals who attend
physical therapy for assessment and fall intervention pro-
gramming. However, as our data showed, this poses unique
problems in the interpretation of cutoffs because of outli-
ers (>2 SD). While these extremes may be truly represent-
ative of the off medication periods and freezing of gait epi-
sodes experienced in daily life, the scores are hard to
interpret. For example, 8 of 10 of our outliers experienced
falls and freezing of gait (FOG) in real life, but during the
data collection process, there is no standardized process
for adapting the data collection process (ie, how long do
you wait for them to move before ending the trial; what is
the amount of cueing or assistance needed to complete
the trial). While they may all be high fall risks, future studies
need to determine what measures (and adaptations) are
most meaningful for identifying change in those individu-
als with advance PD who have the most potential to
improve.
Second, the incidence of falls was self-reported and
some participants’ recall of falls may be inaccurate. How-
ever, in this study, a 6-month period, instead of a 12-month
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period, was used to assess history of falls and may have
helped with recall.28 Future studies are needed to com-
pare the accuracy of recall at different time points and to
develop a more standardized set of questions for eliciting
recall that controls for cueing or bias.
Third, the categorical distinction between people who
fell only once may be perceived as a limitation. While a his-
tory of multiple falls to assess tool validity is supported in
the literature,16,29 it is not clear whether a single isolated
fall over a 6-month period would justify fall risk designa-
tion, whereas multiple falls would. Fourth, the data were
collected from 1 PD-specialized clinic where all physical
therapists were PD specialists. This may limit generalizabil-
ity of findings to other settings where therapists may not
be as familiar with assessments in PwP. Additional research
that uses prospective methods with a larger and more
heterogeneous sample of PwP in a variety of settings is
needed to validate these findings and improve generaliz-
ability. It would also be interesting to assess the 3MBW test
for predicting falls in other patient populations (such as
Stroke and Multiple Sclerosis). This would help determine
whether fall risk could be better identified with the addi-
tion of the 3MBW to the battery of existing fall risk–screen-
ing tools.
Finally, the fall risk assessment measures of this study
assessed only functional mobility and, therefore, do not
fully assess the array of possible reasons for increased fall
risk; it is well known that falling is a complex and multifac-
eted issue.
CONCLUSION
The study was the first to evaluate the diagnostic accuracy
of the 3MBW test with fall history and compare its perfor-
mance with existing measures of fall risk in PwP. Backward
walking has been shown to be more difficult than forward
walking, even the early stages of PD, and could be used as
an additional functional outcome measure to detect
changes in the disease severity of PwP. The 3MBW with a fall
cutoff score of 4.2 seconds was able to predict falls similarly
or more accurately than other clinical measures in PwP
who reported a fall within the past 6 months. The 3MBW
test should be considered in the battery of tests that is
completed to predict falls in PwP.
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