Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by a gradual decline in motor function and functional independence. The classical motor features include bradykinesia, rigidity, resting tremor, and postural instability, although patients may also experience a wide range of non-motor symptoms. As the disease progresses, difficulties with walking, turning, transfers, balance, and other activities of daily living become increasingly prominent. These limitations not only increase the risk of falls but also reduce independence and adversely affect quality of life [1,2]. The burden of Parkinson’s disease has increased considerably over recent decades, partly because of population growth, ageing, and improved survival [3]. Although pharmacological treatment, particularly dopaminergic therapy, remains central to symptom management, medication alone does not adequately address many of the functional problems experienced by patients. Gait disturbance, impaired postural control, reduced muscle strength, and balance deficits may persist despite appropriate medical treatment. For this reason, physiotherapy has become an important part of the multidisciplinary management of Parkinson’s disease [4]. Exercise-based rehabilitation can address several of these limitations through repeated and goal-directed movement. Aerobic exercise, strengthening, balance training, gait practice, flexibility exercises, and task-specific training have all been used in patients with Parkinson’s disease. Apart from their direct effects on physical performance, repeated exercise may facilitate motor learning and promote adaptive changes within neural networks involved in movement. Evidence from human studies suggests that physical exercise may influence markers of neuroplasticity and may contribute to positive changes in brain function and structure, although the mechanisms and magnitude of these effects continue to be investigated [5]. The clinical benefits of exercise in Parkinson’s disease are now supported by a growing body of evidence. A recent Cochrane network meta-analysis found beneficial effects of several forms of physical exercise compared with passive control, particularly gait, balance, functional, and multidomain training [6]. Similarly, a network meta-analysis involving 86 studies and 4,693 participants showed that different exercise approaches, including balance, resistance, sensorimotor, and alternative exercise interventions, can improve balance, postural stability, and general mobility in people with Parkinson’s disease [7]. Collectively, these findings support the integration of physiotherapy and structured exercise into the long-term multidisciplinary management of Parkinson’s disease. However, Parkinson’s disease does not affect every patient in the same way or to the same degree. The functional needs of a patient with relatively preserved mobility are different from those of an individual with postural instability, recurrent difficulty with transfers, or advanced mobility limitations. A uniform exercise prescription may therefore be difficult to apply across different stages of the disease. Exercise selection, intensity, complexity, and the level of assistance need to be adjusted according to the patient’s functional ability, balance, endurance, and safety. Current literature also shows considerable variation in the type, intensity, frequency, and duration of physiotherapy interventions, and the optimal exercise characteristics remain uncertain [8]. This provides a practical rationale for rehabilitation programs in which exercises are structured and progressively modified according to disease stage and individual functional capacity. A stage-based approach may offer particular clinical value because it allows rehabilitation goals to change as disability progresses. Patients with mild disease may benefit more from aerobic conditioning, strengthening, gait training, and challenging balance activities, whereas those with greater disability may require greater emphasis on assisted mobility, transfers, postural control, maintenance of joint movement, and functional activities. Such an approach can combine different components of physiotherapy within a structured program while maintaining individualization and safety. Evidence that multimodal interventions can provide meaningful benefits for gait, balance, and motor function further supports this type of rehabilitation strategy [6,7]. Despite growing evidence supporting exercise-based rehabilitation in Parkinson’s disease, the functional outcomes of programs tailored to disease stage and individual capacity require further investigation. A stage-based approach may offer a practical framework for addressing different levels of motor impairment through appropriately selected gait, balance, strengthening, and task-specific exercises. Therefore, the present study aimed to evaluate changes in functional mobility and balance following six weeks of supervised, stage-based structured physiotherapy rehabilitation in patients with chronic Parkinson’s disease.

Study Design and Setting This single-centre, uncontrolled pretest–posttest interventional study was conducted in the Departments of Neurology and General Medicine at Patna Medical College and Hospital, Patna, Bihar, India, over one year, from August 2025 to July 2026. Patients with clinically diagnosed chronic Parkinson’s disease attending the participating departments were screened for eligibility. Functional mobility and balance were assessed before and after a six-week supervised, stage-based structured physiotherapy rehabilitation program. Sample Size Calculation The sample size was calculated using G*Power software version 3.1.9.7 for a two-tailed paired-samples t-test comparing pre-intervention and post-intervention measurements. Assuming a standardized paired-difference effect size (Cohen’s dz) of 0.285, a significance level (α) of 0.05, and 80% statistical power (1−β), the minimum required sample size was calculated as 99 participants. Accordingly, the target sample size was rounded to 100 patients. Study Participants A total of 100 patients with clinically diagnosed chronic Parkinson’s disease, aged 50–70 years, were recruited using consecutive sampling. Patients classified within modified Hoehn and Yahr stages II–IV were screened according to predefined eligibility criteria. Patients were included if they were medically stable, able to understand and follow simple verbal instructions, and able to stand and ambulate independently or with minimal assistance sufficient to safely complete the functional assessments and prescribed rehabilitation program. For the purpose of the present study, chronic Parkinson’s disease was defined as a clinically established diagnosis of Parkinson’s disease associated with persistent motor symptoms and functional limitations requiring ongoing medical and rehabilitative management. Patients with severe cognitive impairment or dementia affecting their ability to understand or follow instructions; neurological disorders other than Parkinson’s disease that could independently affect mobility or balance; severe musculoskeletal disorders limiting lower-limb function; recent fracture or major orthopaedic surgery; severe visual or vestibular impairment affecting postural control; unstable cardiovascular or other systemic illness; or any medical condition contraindicating participation in the prescribed exercise program were excluded from the study. Baseline Assessment Following enrolment, demographic and relevant clinical information, including age, sex, duration of disease, ongoing antiparkinsonian medication, and stage of Parkinson’s disease, was recorded using a structured data collection form. Disease severity was classified according to the modified Hoehn and Yahr staging system. Functional mobility and balance were assessed at baseline before initiation of the rehabilitation program and reassessed after completion of the six-week intervention. Assessment of Functional Mobility Functional mobility was assessed using the Timed Up and Go (TUG) test [10]. Each participant was instructed to rise from a standard chair, walk a distance of 3 metres at a comfortable and safe pace, turn around, return to the chair, and sit down. The total time required to complete the task was recorded in seconds. A shorter completion time indicated better functional mobility. Assessment of Balance Balance and postural control were evaluated using the Berg Balance Scale (BBS) [11]. The scale consists of 14 functional tasks involving sitting, standing, transfers, reaching, turning, and maintaining different standing positions. Each item is scored from 0 to 4, giving a maximum total score of 56. Higher scores indicate better balance and postural stability. Stage-Based Structured Physiotherapy Rehabilitation All participants underwent a structured physiotherapy rehabilitation program for six weeks, five days per week, with each session lasting approximately 45 minutes. The program followed a stage-based approach, with the selection, intensity, and progression of exercises individualized according to the participant’s modified Hoehn and Yahr stage, functional ability, balance, endurance, and tolerance to exercise. All sessions were conducted under supervision to ensure correct performance and patient safety. The rehabilitation program included range-of-motion and flexibility exercises, muscle strengthening, postural correction, gait training, static and dynamic balance exercises, trunk mobility and stabilization, coordination training, transfer practice, task-specific functional activities, and aerobic conditioning. Verbal and visual cueing strategies were incorporated when required to facilitate movement initiation, improve step length and turning, and promote safer functional mobility. The choice and difficulty of exercises were modified according to the functional needs of each participant. For patients in modified Hoehn and Yahr stage II, the program focused mainly on maintaining mobility and preventing functional decline. Greater emphasis was placed on active range-of-motion and flexibility exercises, strengthening of the upper and lower limbs, postural correction, gait training, aerobic conditioning, and static and dynamic balance activities. Functional movements such as sit-to-stand, reaching, turning, and directional stepping were also practiced as tolerated. In stage III, where postural instability and balance impairment become more prominent, rehabilitation focused on improving balance, gait, and functional safety. The program included progressive static and dynamic balance training, gait and turning practice, coordination exercises, trunk stabilization, strengthening, and task-specific functional activities. External cueing was used when required, particularly during gait initiation, turning, and activities in which bradykinesia or difficulty in movement sequencing was evident. For patients in stage IV, exercises were modified according to the greater degree of functional limitation. The main goals were to maintain available mobility, facilitate safe transfers, preserve joint movement and muscle function, and support independence in daily activities. The program therefore included assisted gait training, transfer practice, trunk mobility, range-of-motion exercises, low-intensity strengthening, postural control exercises, and practice of functional activities. Appropriate physical assistance and safety measures were provided whenever required. Exercise intensity and progression were determined according to each participant’s clinical response and functional performance. Progression was introduced gradually by increasing the number of repetitions, exercise duration, resistance, balance challenge, gait complexity, and difficulty of task-specific activities. Exercises were progressed only when the participant could perform the prescribed activity safely, with adequate movement control and without excessive fatigue, dizziness, or loss of balance. When necessary, the level of difficulty was reduced or additional assistance was provided. Adherence to the rehabilitation program was monitored through attendance records maintained for each supervised session. The same overall rehabilitation framework was followed throughout the six-week intervention, while allowing stage-appropriate modification and individual progression based on the participant’s functional capacity and response to treatment. This approach was intended to provide a structured yet individualized rehabilitation program across different levels of Parkinson’s disease-related functional impairment. Outcome Measures The primary outcome measures were functional mobility and balance, assessed using the Timed Up and Go (TUG) test and Berg Balance Scale (BBS), respectively. Both outcomes were assessed at baseline and again after completion of the six-week structured rehabilitation program. The change in TUG and BBS scores from baseline to post-intervention assessment was used to evaluate the effectiveness of the rehabilitation program. Ethical Considerations Written informed consent was obtained from all participants before enrolment. The purpose and procedures of the study were explained to each participant, and confidentiality of personal and clinical information was maintained throughout the study. Participation was voluntary, and participants were free to withdraw from the study at any stage without affecting their routine medical care. Statistical Analysis Data were entered into Microsoft Excel and analyzed using IBM SPSS Statistics for Windows, version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were summarized as mean ± standard deviation (SD), while categorical variables were expressed as frequencies and percentages. The normality of paired differences was evaluated using the Shapiro–Wilk test and graphical assessment. Pre-intervention and post-intervention TUG and BBS scores were compared using the paired-samples t-test when the paired differences were approximately normally distributed; otherwise, the Wilcoxon signed-rank test was considered. Differences in mean improvement across modified Hoehn and Yahr stages II, III, and IV were assessed using one-way analysis of variance (ANOVA), subject to appropriate assumption checks. The magnitude of within-participant change was summarized using mean paired differences. Statistical significance was assessed using two-tailed tests, with p < 0.05 considered statistically significant.

A total of 100 patients with chronic Parkinson’s disease were included in the study. The mean age was 61.8 ± 6.2 years, and the majority of participants were male (62.0%). The mean duration of Parkinson’s disease was 6.4 ± 3.1 years. According to the modified Hoehn and Yahr classification, 38 patients (38.0%) were in stage II, 40 (40.0%) in stage III, and 22 (22.0%) in stage IV (Table 1). Table 1. Baseline Demographic and Clinical Characteristics of Patients With Chronic Parkinson’s Disease (n = 100) Characteristic Values Age (years), mean ± SD 61.8 ± 6.2 Age group, n (%) 50–59 years 36 (36.0%) 60–70 years 64 (64.0%) Sex, n (%) Male 62 (62.0%) Female 38 (38.0%) Duration of Parkinson’s disease (years), mean ± SD 6.4 ± 3.1 Duration of disease, n (%) <5 years 34 (34.0%) 5–10 years 49 (49.0%) >10 years 17 (17.0%) Modified Hoehn and Yahr stage, n (%) Stage II 38 (38.0%) Stage III 40 (40.0%) Stage IV 22 (22.0%) Following six weeks of structured physiotherapy rehabilitation, functional mobility and balance showed improvement compared with baseline. The mean TUG time decreased from 18.4 ± 4.8 seconds before intervention to 15.1 ± 4.1 seconds after intervention, representing a mean improvement of 3.3 seconds (p < 0.001). Similarly, the mean BBS score increased from 37.6 ± 7.2 to 43.2 ± 6.5, with a mean improvement of 5.6 points (p < 0.001) (Table 2 and Figure 1). Table 2. Comparison of functional mobility and balance before and after structured physiotherapy rehabilitation (n = 100) Outcome Pre-intervention (Mean ± SD) Post-intervention (Mean ± SD) Mean improvement P value TUG (seconds) 18.4 ± 4.8 15.1 ± 4.1 3.3 <0.001 BBS score 37.6 ± 7.2 43.2 ± 6.5 5.6 <0.001 (TUG, Timed Up and Go; BBS, Berg Balance Scale; SD, standard deviation.) Figure 1. Comparison of pre-intervention and post-intervention Timed Up and Go (TUG) test duration and Berg Balance Scale (BBS) scores following six weeks of structured physiotherapy rehabilitation. Data are presented as mean ± standard deviation. Stage-wise analysis demonstrated improvements in both functional mobility and balance across modified Hoehn and Yahr stages II, III, and IV. Mean TUG time decreased by 2.7, 3.5, and 3.7 seconds in stages II, III, and IV, respectively. Corresponding improvements in mean BBS scores were 4.9, 6.1, and 5.7 points. The reported within-stage differences were statistically significant for both outcome measures (p < 0.001) (Table 3). Table 3. Stage-Wise Comparison of Functional Mobility and Balance Before and After Structured Physiotherapy Rehabilitation Outcome H&Y stage n Pre-intervention (Mean ± SD) Post-intervention (Mean ± SD) Mean improvement P value TUG (seconds) II 38 14.8 ± 2.6 12.1 ± 2.3 2.7 <0.001 III 40 18.5 ± 3.2 15.0 ± 2.8 3.5 <0.001 IV 22 24.3 ± 3.9 20.6 ± 3.7 3.7 <0.001 BBS score II 38 44.1 ± 4.0 49.0 ± 3.5 4.9 <0.001 III 40 36.9 ± 4.3 43.0 ± 4.1 6.1 <0.001 IV 22 27.8 ± 4.2 33.5 ± 4.5 5.7 <0.001 (Values are expressed as mean ± standard deviation (SD). TUG, Timed Up and Go; BBS, Berg Balance Scale; H&Y, modified Hoehn and Yahr stage. P-values represent within-stage comparisons of pre-intervention and post-intervention measurements.) Comparison of mean improvement across modified Hoehn and Yahr stages II, III, and IV revealed no statistically significant between-stage difference in TUG improvement (F = 2.73, p = 0.071) or BBS improvement (F = 1.49, p = 0.230). Although improvements were observed within all three stages, the magnitude of change did not differ significantly according to disease stage (Table 4). Table 4. Comparison of Mean Improvements in Functional Mobility and Balance Across Modified Hoehn and Yahr Stages II–IV Outcome Stage II Stage III Stage IV F value Between-stage P value TUG improvement (seconds) (Mean ± SD) 2.7 ± 1.6 3.5 ± 1.9 3.7 ± 2.1 2.73 0.071 BBS improvement (points) (Mean ± SD) 4.9 ± 2.8 6.1 ± 3.2 5.7 ± 3.4 1.49 0.230 (Values are expressed as mean ± standard deviation (SD). Between-stage differences in mean improvement were analyzed using one-way analysis of variance (ANOVA). A p-value <0.05 was considered statistically significant. TUG, Timed Up and Go; BBS, Berg Balance Scale.) Figure 2. Comparison of mean improvements in Timed Up and Go (TUG) test duration and Berg Balance Scale (BBS) scores across modified Hoehn and Yahr stages II, III, and IV following six weeks of structured physiotherapy rehabilitation. Data are presented as mean ± standard deviation. Between-stage comparisons were not statistically significant for TUG (p = 0.071) or BBS (p = 0.230).

The present study observed significant improvements in functional mobility and balance following six weeks of supervised, stage-based structured physiotherapy rehabilitation in patients with chronic Parkinson’s disease. Mean TUG time decreased by 3.3 seconds, while the mean BBS score increased by 5.6 points, indicating favourable changes in functional performance. Improvements were observed across modified Hoehn and Yahr stages II, III, and IV. These findings are broadly consistent with previous systematic reviews demonstrating improvements in gait, balance, and functional mobility following exercise-based interventions in Parkinson’s disease [6,7,9]. However, the absence of a concurrent control group limits the extent to which these changes can be attributed specifically to the rehabilitation intervention. The improvement in functional mobility observed in our study is consistent with the findings of Mak and Wong-Yu (2021), who conducted a randomized controlled trial involving 70 patients with mild-to-moderate Parkinson’s disease. Their six-month community-based brisk walking and balance exercise program produced significantly greater improvements in TUG performance, gait speed, walking capacity, and dynamic balance than an active control intervention [12]. Similarly, Gaßner et al. (2022), in a randomized trial involving 105 patients, reported significant improvements in gait performance following individualized physiotherapy and treadmill training. Gait speed increased by 8.3% in the physiotherapy group and 4.2% in the treadmill group, without a significant difference between interventions [13]. These findings support the clinical relevance of structured gait-oriented rehabilitation. However, differences in intervention duration, exercise frequency, disease severity, and assessment methods prevent direct comparison of treatment effects with the present study. An important observation was the improvement in balance, reflected by the mean increase of 5.6 points in BBS scores. Giardini et al. (2018) evaluated two approaches to balance rehabilitation in patients with Parkinson’s disease and reported improvements in postural stability and gait speed following both platform-based and conventional balance exercises. Interestingly, TUG performance showed comparatively limited improvement, suggesting that different measures of mobility may respond differently to rehabilitation [14]. Biebl et al. (2022), in a randomized pilot study involving 26 patients, compared resistance training combined with gait training against resistance training combined with balance training over six weeks. Both approaches improved functional reach, while gait-oriented training produced more pronounced changes in several walking parameters [15]. The present findings are compatible with the potential benefits of combining strengthening, balance exercises, postural correction, and gait practice within a structured rehabilitation program. Multicomponent rehabilitation may be particularly relevant because Parkinson’s disease affects several interacting components of movement, including muscle activation, postural adjustments, movement initiation, and coordination. Strand et al. (2021), in a randomized trial involving 35 patients, examined 12 weeks of periodized resistance training with or without additional functional training. Both exercise approaches improved measures of functional performance, muscular strength, and balance, although some outcomes differed according to the training components [16]. Similarly, Rennie et al. (2021), in a secondary analysis of a randomized controlled trial involving 100 patients, demonstrated that ten weeks of challenging balance and gait training improved several spatiotemporal gait parameters, including step velocity, step length, and gait variability. However, these improvements were not retained at six-month follow-up [17]. These observations suggest that repeated, progressively challenging exercise can improve selected functional outcomes, while also emphasizing the importance of investigating whether such improvements persist after supervised rehabilitation ends. The mechanisms underlying improvement following structured physiotherapy are likely multifactorial. Repeated practice of functional movements may facilitate motor learning, improve movement efficiency, and enhance the coordination required for walking, turning, and transfers. Strengthening exercises may improve the muscular capacity needed for functional tasks, whereas balance training challenges postural responses and promotes greater control during standing and movement. External cueing may also help compensate for impaired internal movement regulation, particularly during gait initiation and turning. Exercise-related neuroplasticity has been proposed as another potential mechanism [5]. Nevertheless, Freidle et al. (2022), in a double-blind randomized controlled trial involving 95 participants, found no significant between-group improvement in balance performance or task-related brain activity following a ten-week HiBalance intervention [18]. This finding highlights the variability of rehabilitation responses and indicates that neuroplastic adaptations cannot be assumed from improvements in clinical performance alone. As neurophysiological outcomes were not evaluated in the present study, the observed functional changes cannot be attributed to any specific neural mechanism. A noteworthy aspect of the present study was the assessment of rehabilitation outcomes across modified Hoehn and Yahr stages II, III, and IV. Mean improvements in TUG performance were 2.7, 3.5, and 3.7 seconds, respectively, while corresponding improvements in BBS scores were 4.9, 6.1, and 5.7 points. Although improvements were observed within all three stages, between-stage differences were not statistically significant for either TUG (p = 0.071) or BBS (p = 0.230). These findings suggest that measurable functional improvements may occur across different levels of disease severity. However, the absence of statistically significant differences does not establish equivalent rehabilitation responses, particularly considering the unequal subgroup sizes and variation in baseline functional status. Individualizing exercise selection and progression according to disease stage and functional capacity remains clinically reasonable, although the comparative benefits of this approach require further investigation. The findings should also be considered alongside studies reporting limited or variable benefits from particular rehabilitation approaches. Çetin et al. (2024), in a randomized controlled study comparing exergame-based rehabilitation with conventional exercise, observed improvements in TUG performance and several functional outcomes in both groups, indicating that beneficial changes are not necessarily restricted to technologically enhanced interventions [19]. Conversely, Bezerra et al. (2022) found that adding action observation and motor imagery to gait training did not provide significant additional benefits for balance or freezing of gait compared with gait training alone [20]. These differences emphasize that rehabilitation outcomes depend not only on the inclusion of particular exercises but also on patient characteristics, treatment intensity, intervention duration, and the outcome measures employed. The present study evaluated an integrated rehabilitation program rather than individual components; therefore, the relative contribution of strengthening, gait training, balance exercises, or cueing strategies cannot be determined. From a clinical perspective, the findings highlight the potential relevance of structured, individualized physiotherapy within multidisciplinary Parkinson’s disease management. Current clinical practice recommendations support aerobic exercise, resistance training, balance exercises, gait training, and task-specific rehabilitation to address motor and functional impairments [21]. A stage-based framework may provide a practical approach in routine hospital-based rehabilitation services, including those in India, where patients present with varying degrees of motor disability and functional limitation. The use of established outcome measures such as TUG and BBS allows objective monitoring of changes in functional performance and may assist clinicians in adjusting rehabilitation goals according to individual needs. Further controlled studies are warranted to determine the comparative effectiveness, optimal duration, and sustainability of stage-based rehabilitation programs. Limitations of the Study: This single-centre study employed an uncontrolled pretest–posttest design, limiting causal interpretation and generalizability. The absence of a comparison group, potential medication-related variability, and possible repeated-testing effects may have influenced the observed outcomes. Furthermore, the six-week assessment period did not permit evaluation of long-term benefits, and the individual contributions of different rehabilitation components could not be determined. Nevertheless, the findings provide preliminary evidence supporting further investigation of individualized, stage-based physiotherapy rehabilitation through larger randomized controlled trials with longer follow-up.

The present study observed significant improvements in functional mobility and balance following six weeks of stage-based structured physiotherapy rehabilitation in patients with chronic Parkinson’s disease. Improvements were demonstrated across modified Hoehn and Yahr stages II–IV, without statistically significant differences in the magnitude of improvement between stages. These findings suggest that individualized, stage-based physiotherapy may be a useful component of multidisciplinary Parkinson’s disease management. Further randomized controlled trials with longer follow-up are required to establish its comparative effectiveness and long-term benefits.

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