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 Table of Contents  
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 50-54

Square-stepping exercises versus conventional exercises on cognition and risk of fall in postmenopausal women: A randomized control trial

Department of Musculoskeletal Sciences, Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission29-Aug-2021
Date of Decision22-May-2022
Date of Acceptance24-May-2022
Date of Web Publication23-Jun-2022

Correspondence Address:
Dr. Roopa R Desai
Dr. D. Y. Patil College of Physiotherapy, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/amhs.amhs_197_21

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Background and Aim: Menopause is the cessation of menstruation resulting from the loss of ovarian follicular activity. During menopause, there is a loss of estrogen which diminishes protective reflexes, increment bone resorption, thus speeding up bone loss. This has been seen as significant factor for decline in postural balance. Functional imaging shows that estrogen also regulates neural movement during the execution of intellectual assignments. Thus, women attaining menopause complain of issues with memory. The aim of this study was to compare square-stepping exercises (SSEs) and conventional physiotherapy training on cognition and risk of fall. Materials and Methods: Thirty-five postmenopausal women, attained >5 years of menopause up to 65 years of age were included in the study and were randomly allocated into SSEs Group A (n = 18) and conventional physiotherapy training Group B (n = 17). Cognition was assessed by the Montreal Cognitive Assessment and balance was assessed by the Berg's Balance Scale at pre, post-2 weeks, and post-4 weeks of intervention. Results: Paired t-test and unpaired t-test were used for within and between-group analysis for Berg's Balance Scale. Wilcoxon test was used for within-group analysis and Mann–Whitney test was used for between-group analysis for Montreal Cognitive Assessment. The level of significance was determined by P < 0.05 at 95% confidence interval. Statistically significant improvements were seen in both groups (P < 0.05), whereas between-group analysis, there was no significant difference with P > 0.05. Conclusion: Both types of exercise protocol were equally effective in improving cognition and preventing the risk of fall in postmenopausal women.

Keywords: Balance, Berg's Balance Scale, memory, montreal Cognitive Assessment, risk of fall

How to cite this article:
Desai RR, Rathi NS, Palekar TJ. Square-stepping exercises versus conventional exercises on cognition and risk of fall in postmenopausal women: A randomized control trial. Arch Med Health Sci 2022;10:50-4

How to cite this URL:
Desai RR, Rathi NS, Palekar TJ. Square-stepping exercises versus conventional exercises on cognition and risk of fall in postmenopausal women: A randomized control trial. Arch Med Health Sci [serial online] 2022 [cited 2023 Feb 9];10:50-4. Available from: https://www.amhsjournal.org/text.asp?2022/10/1/50/347953

  Introduction Top

The term natural menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity“ is the definition by WHO (1999). Naturally, it occurs after 12 consecutive months of amenorrhea. In natural menopause, there is no other pathological or physiological cause.[1] It is accepted that estrogen may prevent cracks by diminishing bone loss, stimulating postural equilibrium thus diminishing the danger of falling. During menopause, there is a loss of estrogen which diminishes protective reflexes, increment bone resorption, thus speeding up the bone loss which has been seen as a significant factor for decline in postural balance. The estrogen loss that occurs during menopause fundamentally affects different body frameworks, for example, vestibular, visual, musculoskeletal, and sensory systems. Thus, all these changes can cause decline or ill-suited feedback to the postural control. There are certain postural changes which are observed in postmenopausal women such as – exaggerated lordosis, forward head, rounded shoulders, and flexed hip and knee and these changes might occur due to decrease in strength and endurance and loss of elasticity in connective tissues.[2] Functional brain imaging studies show that estrogen regulates neural movement during the execution of intellectual assignments. As the menopause advances, women report issues with memory, it can be recommended that hormonal changes related to menopause are connected to memory grumblings. The most widely recognized issues were trouble reviewing words or numbers, requiring memory help, and failing to remember why one was associated with specific conduct.[3]

In a study conducted by Schaafsma et al., 120 Australian women aged between 45 and 60 years, where their cognitive performance was assessed and revealed that 82% of women had memory complaints and the ratio of memory deficit was found more in postmenopausal women.[4] A study conducted by Borker et al. concluded that the most common problems in postmenopausal women were emotional (crying spells, depression, and irritability) 90.7%, headache 72.9%, lethargy 65.4%, burning micturition 58.9%, forgetfulness 57%, and musculoskeletal problems (joint pain muscle pain) 53.3%.[5] Menopause is the greatest danger factor for osteoporosis in women. Recurrence of falls is seen three times higher in postmenopausal women than in men in the later age of life.[6] It is said that individuals who are performing regular physical activities tend to have a positive impact on psychological and physical benefits and also improve their cognitive functions.[7] Details of Screening and eligibility of the participants is given in [Figure 1]. A systematic review with meta-analysis conducted by Northey et al. reviewed 39 articles with inclusion criteria of age 50 years or older having mild cognitive impairment and were given physical intervention. The study concluded that physical function helps in improving cognition and functional ability in the >50 age group population.[8]
Figure 1: Flow diagram for screening and eligibility of the participants (Adapted from CONSORT Flow Diagram 2010)

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There are various interventions given to postmenopausal women such as hormone replacement therapy, memory games, and problem-solving tasks that help in improving the cognitive function.[9],[10],[11] There are several trainings that have shown to be effective to improve balance, namely strength training, balance training, and square-stepping exercise (SSE). The balance training includes walking sideways, front and backward, toe walking, heel walking, and tandem standing which includes both static and dynamic positions.[12]

The SSE has been shown to improve the equilibrium, thus diminishing the danger of falls. Fisseha et al. conducted a systemic review and meta-analysis on the effect of SSE on older adults to prevent fall and injury related to fall, concluded that SSE is significantly effective in preventing fall down injuries by improving balance.[13]

Due to progress in menopause, many women have issues with memory and postural steadiness. The loss of equilibrium and expanded body influence are significant danger factors for falls in postmenopausal women. Furthermore, there is strong evidence supporting that estrogen loss during menopause affects cognition and postural balance. Thus, it is important to improve these functions to prevent future complications. Previous studies have shown that SSE has a good influence on balance and cognitive stimulation in the older population, but there is limited literature available regarding cognition and risk of fall in postmenopausal women. Thus, this study aimed to compare SSE and conventional physiotherapy training on cognition and risk of fall in postmenopausal women.

  Materials and Methods Top

It was a single-blinded, randomized, two-group, active-controlled trial. Ethical clearance was obtained from the Institutional Review Board (Ref. No. DYPCPT/IEC/33/2020). The study was registered under Clinical Trial India CTRI/2021/01/030280. Participants were recruited from January 2021 to June 2021.

A total of 60 postmenopausal women were screened for the study. Postmenopausal women ≥5 years for the last menstrual period up to 65 years, Mini-Mental State Examination score >24/30 as it indicates normal cognition, Berg's Balance Scale scores more than 41/56 indicating minimal fall risk were included in the study. Those with any neurological disease, musculoskeletal impairment such as severe joint pain in lower extremities or any injuries in lower limb <3 months, severe pain in the soft tissues or joints in upper extremities, severe balance impairment, and unstable cardiorespiratory conditions were excluded from the study. Thirty-five participants fulfilling the inclusion criteria were selected conveniently. The aim of the study was explained and written consent was obtained from all the participants. The procedure benefits and potentials risk of the study were explained before the session began. Blood pressure and pulse rate for every participant were taken pre-and posttreatment. All the necessary COVID-19-related precautions were taken such as the time given for the treatment to the participants was different to all as to avoid the crowd and maintain the social distancing, wearing of mask, pre-and posttreatment sanitizing of hands and materials that were used.

The participants were randomly divided into two groups. Group A (n = 18) was given SSE and Group B (n = 17) was given conventional physiotherapy training. Allocations were concealed with opaque sealed envelopes. Simple random sampling with the chit method was used for randomization. It was a single-blinded study, wherein participants were kept unaware of the groups they were assigned in.

The outcome measures used were the Montreal Cognitive Assessment and Berg's Balance Scale. Data were documented at pretreatment, post-2 weeks, and post-4 weeks of the treatment session.

Initially, participants were told to do warm-up exercises for 5 min, under the supervision of the therapist, which included stretching of the upper limb (biceps, triceps, forearm, wrist, and fingers) and lower limb (hamstrings, quadriceps, gastrocnemius – soleus) that was followed by joints movements. At the end, cooldown period was given with slow walking, swinging legs in standing, and stretching of the upper and lower limbs and trunk. Relaxation exercises and breathing exercises were given that lasted for 5 min.

Intervention protocol for Group-A

Participants were requested to perform exercise on the mat on a 2.5 m × 1.0 m into 40 squares, as seen in [Figure 2]. The SSE comprised a progression of forward, in reverse, sidelong, and inclining steps. Thus, with each pattern, the intricacy of the progression increased and challenging levels were performed by participants every week. Participants were instructed to walk (step) from one end of the mat to the other according to the step pattern provided. When they reached the end of the mat, they were instructed to return to their starting position by walking normally off the mat and starting the next stepping. Each participant repeated every sequence five times and then started a new pattern.
Figure 2: Participant performing square-stepping exercises

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The intervention was given for 5 consecutive days/week for 4 weeks. Duration of exercise per day was 30 min in Group A and around 15 min for the first 2 weeks, followed by 30 min in weeks 3 and 4 in Group B. Demonstration was given to all the participants before the beginning of the exercises. Two trials were given to each participant so that they could understand the sequence of exercise. The intervention for both groups was given for 5 consecutive days/week for 4 weeks. Exercise intervention protocol as mentioned in [Table 1].
Table 1: Intervention protocol for Group-B

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Participants were requested to stop immediately if they complained of any symptoms such as sudden chest pain, shortness of breath, dizziness, leg cramps, claudication, or any joint pain, signs of poor perfusion: light-headedness, confusion, pallor, cyanosis, nausea, or cold and clammy skin[14] during the exercises.

  Results Top

A total of 35 participants completed the treatment session for 20 days (18 in Group-A and 17 in Group-B). Data collection and interpretation were done using WINPEPI (version 11.65) and Primer of Biostatistics (version 7). Initially, the normality of data was checked by Shapiro–Wilk test, where data were found to be normally distributed for Berg's Balance Scale. For within group analysis, paired t-test was used. Between-group analysis was done by unpaired t-test. As data were not normally disturbed for the Montreal Cognitive Assessment so within the group, Wilcoxon signed-rank test and for between-groups Mann–Whitney sum test was used. The level of significance was determined by P < 0.05 at 95% confidence interval. [Table 2] shows comparison of age of participants in both the groups, that showed non-significant difference. Hence, they were comparable.
Table 2: Comparison of age in Group-A and Grou-B

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[Table 3] shows within and between-group analysis of the Montreal Cognitive Assessment in Groups A and B. Intragroup comparison shows significant improvement with P < 0.001 for both groups, confirming that there is a significant improvement in cognition. However, intergroup comparison between both the groups proves no significant difference between the group with P = 1.00 at post 2 weeks and P = 0.18 at post 4 weeks.
Table 3: Montreal Cognitive Assessment values of both the groups

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[Table 4] shows intragroup comparison for Berg's Balance Scale, shows statistically significant improvement with P < 0.001 for both groups, confirms that there is a significant improvement in balance. However, no significant difference was seen in intergroup comparison with P = 0.57 at post 2 weeks and P = 0.31 at post 4 weeks.
Table 4: Berg's Balance Scale values of both the groups

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  Discussion Top

In the current study, 35 participants meeting the inclusion criteria were distributed into two groups. Group A received SSE and participants in Group B received conventional physiotherapy training. Both groups performed exercises for a 5 days/week for 4 weeks.

Intragroup analysis showed significant improvement in both cognition and prevention in risk of fall in both the groups. The reason being that SSE triggers a physical function, cognitive function, and focused attention, memory, and executive functions. Thus, it assists sensory-motor integration which thereafter activates the thalamus of subcortical structures from the internal globus pallidus and cerebellum. It also helps in remembering the pattern which is done previously which stimulates internal signals from the basal nucleus. Teixeira et al. in their study incorporated SSEs on cognitive function of older people over 16 weeks. They concluded that SSEs involved mat exercises that require attention, memory, and execution of exercises, thus improving motor and cognitive stimuli, neurocognitive function enhanced brain activation, and neuroplasticity.[15] Another study conducted by Fisseha et al., in meta-analysis showed that SSEs were found to be significantly effective in fear of fall and thus improve balance in older adults. It helps in better functioning in reaction time and corrective steps and thus improving balance in individuals. They concluded that these exercises are based on proactive and reactive responses.[13]

Shigematsu et al. conducted a study, where leg strengthening exercises at light loads (20% of maximal strength) improved balance. The reason being that muscles is active throughout the concentric type of movement and also maintain force output. The exercise movement in the abovementioned study was similar to those of SSEs including extension of knees and ankle joints. The leg strengthening exercise is assumed to improve neural function by reducing response latency and effectively recruits postural muscles. Furthermore, the multidirectional steps used during SSE leads to activation of synergist and agonist leg muscles. Hence, it can be assumed that SSE can improve functional fitness of lower extremities, thus preventing fall.[16] Conventional physiotherapy training also showed significant improvement in cognition and prevention in risk of fall. The reason being that balance training provides a stimulus to vestibular, neuromuscular, and proprioception systems. Thus, the perception of self-motion and equilibrium is coded by vestibular systems concurrence with proprioception and visual signals. The connection between vestibular nuclei and the cerebellum hippocampus as well as prefrontal and parietal cortices provide information for cognitive function such as spatial function and memory. Rogge et al., in their study incorporated a balance training over 12 weeks for 2 days/week, where they concluded that balance training shows improvement in memory and spatial cognition, thus effects on executive memory were not observed.[17]

The results of this study can help us to set a protocol for postmenopausal women to improve cognition and balance as it has many advantages. It can be performed as an indoor activity with minimal space. It requires minimum investment. Postmenopausal women can utilize visual feedback while performing SSE on a special mat. Thus, it can serve as a new form of exercise in improving balance and cognition in postmenopausal women.

Limitations and future scope of the study

The study had smaller sample size as there was participation restriction of the majority of participants due to the fear of COVID pandemic. Hence, the results of the study cannot be collectively generalized. The fitness level of the participants before enrollment was not taken into consideration. Furthermore, the researcher was not certified to use the Montreal Cognitive Assessment scale. Further, studies can be done by taking body mass index into consideration.

  Conclusion Top

The present study conducted among postmenopausal women concluded that SSEs and conventional physiotherapy training are equally effective in improving cognition and preventing risk of fall.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Utian WH. The International Menopause Society menopause-related terminology definitions. Climacteric 1999;2:284-6.  Back to cited text no. 1
Halwagy MD. Effect of balance training on postural stability in obese postmenopausal women. Bull Fac Pharm Cairo Univ 2007;12:159-67.  Back to cited text no. 2
Henderson VW. Cognitive changes after menopause: Influence of estrogen. Clin Obstet Gynecol 2008;51:618-26.  Back to cited text no. 3
Schaafsma M, Homewood J, Taylor A. Subjective cognitive complaints at menopause associated with declines in performance of verbal memory and attentional processes. Climacteric 2010;13:84-98.  Back to cited text no. 4
Borker SA, Venugopalan PP, Bhat SN. Study of menopausal symptoms, and perceptions about menopause among women at a rural community in Kerala. J Midlife Health 2013;4:182-7.  Back to cited text no. 5
Gunendi Z, Ozyemisci-Taskiran O, Demirsoy N. The effect of 4-week aerobic exercise program on postural balance in postmenopausal women with osteoporosis. Rheumatol Int 2008;28:1217-22.  Back to cited text no. 6
Erickson KI, Hillman C, Stillman CM, Ballard RM, Bloodgood B, Conroy DE, et al. Physical activity, cognition, and brain outcomes: A review of the 2018 physical activity guidelines. Med Sci Sports Exerc 2019;51:1242-51.  Back to cited text no. 7
Northey JM, Cherbuin N, Pumpa KL, Smee DJ, Rattray B. Exercise interventions for cognitive function in adults older than 50: A systematic review with meta-analysis. Br J Sports Med 2018;52:154-60.  Back to cited text no. 8
Doty RL, Tourbier I, Ng V, Neff J, Armstrong D, Battistini M, et al. Influences of hormone replacement therapy on olfactory and cognitive function in postmenopausal women. Neurobiol Aging 2015;36:2053-9.  Back to cited text no. 9
Savulich G, Piercy T, Fox C, Suckling J, Rowe JB, O'Brien JT, et al. Cognitive training using a novel memory game on an iPad in patients with amnestic mild cognitive impairment (aMCI). Int J Neuropsychopharmacol 2017;20:624-33.  Back to cited text no. 10
Wang G, Zhao M, Yang F, Cheng LJ, Lau Y. Game-based brain training for improving cognitive function in community-dwelling older adults: A systematic review and meta-regression. Arch Gerontol Geriatr 2021;92:104260.  Back to cited text no. 11
Madureira MM, Takayama L, Gallinaro AL, Caparbo VF, Costa RA, Pereira RM. Balance training program is highly effective in improving functional status and reducing the risk of falls in elderly women with osteoporosis: A randomized controlled trial. Osteoporos Int 2007;18:419-25.  Back to cited text no. 12
Fisseha B, Janakiraman B, Yitayeh A, Ravichandran H. Effect of square stepping exercise for older adults to prevent fall and injury related to fall: Systematic review and meta-analysis of current evidences. J Exerc Rehabil 2017;13:23-9.  Back to cited text no. 13
Salmoirago-Blotcher E, DeCosta J, Harris K, Breault C, Dunsiger S, Santos C, et al. Exploring synergistic effects of aerobic exercise and mindfulness training on cognitive function in older adults: Protocol for a pilot randomized controlled trial. Medicine (Baltimore) 2018;97:e10626.  Back to cited text no. 14
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. 15
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. 16
Rogge AK, Röder B, Zech A, Nagel V, Hollander K, Braumann KM, et al. Balance training improves memory and spatial cognition in healthy adults. Sci Rep 2017;7:5661.  Back to cited text no. 17


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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