Square-Stepping Exercise Linked With Improved Executive Functioning in Parkinson Disease

Adherence to 8-week square-stepping exercise training among patients with Parkinson disease was associated with significant improvement of executive functioning, as well as cognitive functioning for those with mild cognitive impairment.

Square-stepping exercise (SSE) may significantly improve executive functioning in patients with Parkinson disease (PD), according to study findings published in Geriatric Nursing.

As a popular and well-known exercise for the older population, SSE includes multidirectional steps that can become progressively more challenging and complex, in which attention, memory, and executive function all play key roles.

The additional positive effects on lower extremity muscle strength, balance, flexibility, and cognitive function in older adults through the exercise program was noted by researchers to be of particular utility for patients with PD who are affected by executive dysfunction, even in the early stages of the disease.

“With disease progression, many patients with PD show mild cognitive impairment (MCI). Cognitive decline could further cause loss of independence and reduced quality of life in people with PD. Consequently, this issue should be seriously considered,” they said.

“SSE appears to be a promising intervention to improve executive function in people with PD. However, there is still insufficient evidence to support the benefits of SSE in PD.”

The study authors conducted a single-blind randomized controlled pilot trial of 28 patients with PD recruited between March 2018 and August 2020 from Mackay Memorial Hospital to investigate the effects of SSE on executive functioning. A subgroup analysis was also performed to assess the effects of SSE on executive function in patients with PD who have MCI.

Participants were randomly assigned to the experimental group (n = 14) that received the SSE program for 8 weeks, twice a week, or the control group (n = 14) that received conventional therapy at the same rate.

The primary outcomes of the trail making test and digit span task and secondary outcomes of global cognition and quality of life measuredwere evaluated via the Montreal cognitive assessment and the Chinese translation of the 39-item PD questionnaire, respectively, before the intervention, after the intervention, and at a 1-month follow-up.

During the intervention period, most participants, except for a dropout in the control group, completed the 16 exercise sessions and showed full participation in each session. Five participants did not complete the follow-up assessments (3 in the experimental group and 2 in the control group).

In evaluating the within-group differences at the 3 time points, time effects were shown only in the experimental group, with significant improvements for executive function observed in the digit span task forwards (P = .004) and the digit span task backwards (P = .002). A near-significant trend for improvement in part A of the trail making test was also observed (P = .069) after SSE training.

Findings of the post hoc analysis additionally showed significant improvement in the outcomes assessed compared with pre-intervention in the experimental group: The score of the digit span task forwards at 1-month follow-up was higher than that at pre-intervention (P = .002), and scores of the digit span task backwards at post intervention (P = .013) and at the 1-month follow-up (P = .004) were higher than those at the pre-intervention.

Regarding secondary outcomes, a trend toward significance was observed in the Montreal cognitive assessment (P = .064) in the experimental group, and the score improved significantly at the 1-month follow-up (P = .012). No significant improvement was observed for the 39-item PD questionnaire after intervention in both groups.

Furthermore, the subgroup analysis indicated that the digit span task forwards, digit span task backwards, and the Montreal cognitive assessment in patients with PD with MCI improved significantly after intervention in the experimental group.

“Overall, the findings of this study indicated that SSE could be a recommendation for the treatment of reducing cognitive impacts in PD,” concluded researchers.


Liu HH, Wang RY, Cheng SJ, Liao KK, Zhou JH, Yang YR. Effects of square-stepping exercise on executive function in individuals with Parkinson’s disease: A randomized controlled pilot study. Geriatr Nurs. 2022;47:273-279. doi:10.1016/j.gerinurse.2022.08.004

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