Efficacy of Mental Imagery to Improve Dorsiflexor

Component of Gait Among Post Stroke Hemiplegic

Patients

Submitted to the Institutional Ethics Committee

Submitted by:
Pasang Doma Sherpa
MPT Neurology
Batch: 2022-2024
System ID: 2022824838
Sharda School of Allied Health Sciences
Sharda University

UNDER THE SUPERVISION OF:

Dr. Apoorva Tiwari
Assistant Professor
Department of Physiotherapy
Sharda School of Allied Health Sciences
Sharda University
 INTRODUCTION

According to WHO, stroke is “rapidly developing clinical signs of focal or global

disturbance to cerebral function, with symptoms lasting 24 hours or longer, or leading
to death with no apparent cause than of vascular origin and includes cerebral
infarction, intracerebral hemorrhage, and subarachnoid hemorrhage”.
Imbalance of upper limb, lower limb and trunk activities is a major symptom of
stroke.1 Observations like decrease in mobility, perception, muscle strength, voluntary
movement control, sensation, tone and balance can be seen in patients after stroke.2
Motor recovery after stroke is most likely to occur within the initial 3 months and
initially the gradual progression of recovery curve levels at about 6 months to a year
post stroke (Skilbeck et. Al).
Gait abnormality and difficulty in ambulation has been observed in about 80% of
stroke survivors.3 Ankle and foot is found to be prone to spasticity, resulting in
deformities like equinus, varus, and equinovarus. 4 Increased spasticity of ankle and
foot has a relative effect on the knee, hip and trunk position and control due to a
kinetic chain effect. In presence of an equinus deformity, the ground reaction force is
shifted anterior to the knee joint causing hyper extension of knee in order to keep the
center of gravity within the forefoot. In order to clear the spastic foot from the floor,
additionally increased knee and hip flexion is required during the swing phase. It is
not possible to perform hip and knee flexion due to the presence of abnormal synergy
of lower limb as a result of spasticity. So, further hip hiking and leg circumduction is
performed in order to clear the floor. Another prime observation is decreased base of
support due to the presence of equinus deformity leading to decrease in stance phase
in order to minimize the fall risk. Thus, ankle and foot deformity is associated with
kinetic and kinematic deviations during gait, like asymmetrical gait, slow speed,
decreased hip, knee and ankle dorsiflexion during swing phase.5
Two main muscles responsible for the ankle plantarflexion are gastrocnemius and
soleus. Spasticity of these muscle leads to plantar flexion deformity.
Mental Imagery (MI) is defined as the ability to mentally plan and perform an action
without any overt action (Decety, 1996). MI is an active participation practice where
the individuals imagine or visualizes the activity or a certain task.6
Practice of mental imagery can be carried out indirectly by instructing the patient to
make a perceptual judgment like hand laterality tasks or directly by instructing the
patient to mentally rehearse any action or complex behavior.7
Gait is comprised of combined movements which involves several sensorimotor
systems with the controlled balance between the automatic and cognitive processes.
Prime areas of central nervous system, from the spinal generators to the cortex,
interact with one another to produce gait (Duysens and Vande Corommert, 1998).
Multi-modal sensory information must be constantly integrated to deal with the
changes in the environment.8
Coordinated muscle activation is believed to be elicited by the central pattern
generators (CPG) in the spinal cord (Grillner, 2006). Similarly the locomotor regions
of the brainstem and related structures in the reticular formation are likely to
mediate gait movement in both quadrupeds and bipeds (Takakusaki et al. , 2003).
Initiation and termination of gait is produced be the activity of Supplementary Motor
Area (SMA) (Crenna and fringo; 1991, Jian 1993; McFadyan 1993). Single photon
emission computed tomography (SPECT) and near-infrared spectroscopy (NIRS)
neuro imaging studies have demonstrated that human gait is associated with
widespread cortical brain activity involving the SMA, primary motor cortex, primary
somatosensory cortex, and sub cortical structures.9
A study by Kazumi, Hanakawa, et al. revealed that the areas of central nervous
system like supplementary motor area and premotor cortex, which are responsible
for gait were active during the mental imagination of gait.10
 REVIEW OF LITERATURE

1. Vijaya Chakrapani et al (2016) conducted a study on assessing the power of the

muscle and walking pattern among stroke patients who are able to walk after the
in motor imagery (MI) intervention. There were 40 participants in the randomized
controlled trial, of which 40 were randomly assigned to physical exercise (control
team) and physical plus mental exercise (experimental team) teams. Both groups
of subjects performed task-oriented training for the lower extremity four days a
week for three weeks, lasting 45–60 minutes. Additionally, experimental team
participated in half an hour of lower limb movement exercises for MI exercise.
Prior and post intervention (after three weeks), assessment of isometric muscular
power of the lower limb was measured with the application of a hand-held
dynamometer as well as a 10m walk speed was done. Task specific motor
imagery exercise enhances the performance of paretic muscle as well as gait
efficiency in stroke patients who are able to walk, according to the study findings.
2. Dong-Sik, Choi et al (2017) conducted a study to see how motor imagery affects
muscular control of upper body and joint sensation in patients of stroke. 12
participants were randomly classified into two categories; one category received
the motor imagery exercise whereas other category received neuro developmental
therapy. In contrast to the control category that was given NDT for 30 minutes,
the trial group received motor imagery exercise for 10 min with NDT targeting
upper body motions for 20 min. For four weeks, both groups received treatment
five times each week. After the intervention, trunk muscular activity was
evaluated using wireless EMG. Proprioception only significantly improved in the
experimental group. According to the study, motor imagery can help stroke
patients with proprioception and trunk muscle activity.
3. Eun kyu, Hyun Wang et al. (2020) performed a study to assess the effectiveness
of graded motor imagery training as a home exercise programme for improving
upper extremity movement in long term stroke patients. 42 subjects were split
into 2 groups, with the intervention group being given a motor imagery training
programme to be done at home for 8 weeks while the control group received
traditional therapy. The intervention group significantly improved in tests
utilizing the various functional assessment scales. Additionally, the intervention
 group's manual function test score for arm motion was much higher than that of
the control group. GMI can therefore aid stroke patients in restoring upper limb
motor capabilities
4. Mohammad et al. performed a study to compare effectiveness of two studies
which were Proprioceptive Neuromuscular Facilitation (PNF) and MI along with
working memory. These techniques were incorporated and applied on Multiple
sclerosis (MS) patients. 30 MS patients who were male were divided into 3
divisions: PNF, MI and working memory exercise, and collaboration in this
quasi-experimental study. Pre- intervention and post-intervention tests were all
included. Prior and post intervention measurements included TUG test, ROM,
and amount muscle spasm in knee extension. Each group underwent a 6-week
exercise intervention. The study's findings indicated that MS patients' balance,
ROM, and spasticity can be improved with PNF, MI, working memory, and
collaborated training.
5. Kazumi et al. Conducted a study of a brain process in mental imagery and gait
analysis. Sixteen patients were scanned using a Tesla MRI to study videograpic
clips of six types. A behavioral investigation found a link between the actual
walking cadence and during mental walking with impact of virtual walking
stimuli, demonstrating actual walking and gait imagery share a planning process
of gait.
6. Waziha et al. conducted a study to check the impact of MI on lower extremity
movements for stroke patients in the sub-acute period. Using a non-probability
consecutive sampling approach, 80 patients with sub-acute stroke who had strong
perceptions, a Mini Mental Score Exam score of 25 or higher, and 3/5 manual
muscle testing grade system in the legs were selected. Allocation of patients into
two division were done. First division received conservative training, which also
included strengthening and balancing exercises, and the other division got the
conservative intervention with visual imagery. According to the study's findings,
conservative treatment and mental visualization work together to help sub-acute
stroke patients build their brain networks.
7. Vijaya et al. Conducted a study where the benefit of mental practice on functional
ability and quality of life in stroke individuals who could walk were investigated.
24 hemiparetic patients who could walk 10m and had high imagery ability were
assigned to one of two divisions: physical practice and physical + mental
 practice. Subjects in all division received task-oriented lower extremity training
for 45 minutes six times per week for three weeks. While for imaging practice,
experimental team got 15 min of lower limb exercises that were audio-based.
Various outcome measures were used to evaluate functional mobility among all
teams. The findings suggest that lower limb imagery training can supplement
routine physiotherapy in improving functional mobility in long term stroke
patients who can walk.
8. Lucia et al. Performed a study that in motor imagery and mental gait imitation,
the internal pacemakers are triggered differently. 24 healthy adults were taken for
the study. Subjects mentally copied a model exhibited while moving with the
same route in half of the trials (mental imitation condition). Furthermore,
participants executed continuous ankle dorsiflexion as substitute for stepping
movements in half of the trials. Gait imaging recruited dorsal premotor and
posterior parietal areas known to contribute to walking pattern adaptation to
environmental signals, in addition to areas linked with lower limb movement
performance. Motor imagery recruited a larger network than mental imitation, in
along with brainstem similar to the mesencephalic locomotor region (MLR).
9. Laura et al. conducted a study to investigate how the visual cues impact brain
patterns of stimulated gait. Twenty-nine subjects performed three different gait
activities including motor execution, TUG with visual cues and TUG without
visual cues. A stopwatch was used to record the times for each activity. Both
externally and internally cued mental imagery were found to be related with
neuro functional activation of the gait-specific motor system.
10. Matthieu et al. conducted a study of activity of brain in mental visualization of
gait and gait-like plantar stimulation. The connection between gait's mental
images and plantar surface stimulation for foot wearing korvit boots was studied
using functional MRI. Eighteen right handed subjects were taken. It was
determined that collaborating mental imagery with mechanical stimulation of
plantar gave additional information on brain activity related to gait and looks
suitable in order to assess gait control of upper-level.
 RESEARCH GAP

Several researches have examined the clinical efficacy of mental imagery in various
fields such as improving gait, functional mobility and quality of life, improving upper
arm functions and balance. A few studies have recognized the effect of mental
imagery in walking ability. However, the study of effects of mental imagery training
specific to ankle and foot movement and its corresponding progress in gait is limited.
Therefore, the aim of this study is to find the combined effect of mental practice to
increase the range of motion of ankle dorsiflexion and further improvement of
dorsiflexor components of gait in post stroke individuals with plantar flexion
deformity.

AIM OF THE STUDY

The aim of this study if to examine the efficacy of mental imagery practice in
improving ankle dorsiflexion and corresponding improvement of dorsiflexor
component of gait among post stroke hemiplegic patient with foot drop.

OBJECTIVE OF THE STUDY

 To evaluate the effectiveness of mental imagery practice in improving the range
of ankle dorsiflexion.
 To improve gait by reducing the spasticity of the muscles involved in plantar
flexion.
 HYPOTHESIS

We hypothesized that there is a significance of mental imagery in improving the

dorsiflexor component of gait by increasing the range of ankle dorsiflexion.

METHODOLOGY
Study design: Pre-post experimental study
Study setting: Department of physiotherapy, Sharda Hospital, UP
Study subjects: Post stroke patients with plantar flexion deformity
Study duration: 1 year
Sample size: 52
Sample size calculation:
Sample size required is 26 for each group
Therefore, total sample size= 26×2=52
The sample size was calculated with the help of following parameters:
 Effect size (d) = 0.8
 Probability of α error= 0.05
 Power (1-β) = 0.8 (80%)
 Two-sided test (2 tailed)
 Equal allocation of the group

Inclusion criteria:
 All types of stroke (spasticity to recovery phase)7
 Age (45-70)
 Both genders
 No auditory or visual impairment
 GCS stable (12-15)
 Cognition (more than 24 score in MMSE)7
 Foot drop present

Exclusion Criteria:
 Auditory or visual impairment present
 Non-ambulant
 Non-cooperative patient
 GCS less than 12
 Foot drop absent

OUTCOME MEASURES
Manual muscle strength testing (MMT)
MMT will be used to examine the strength of ankle dorsiflexors and plantar
flexors.
Goniometer to determine the range of motion of ankle dorsiflexion
Modified Ashworth Scale to examine the spasticity of ankle plantar
deformity.
Rivermead Visual Gait Assessment (RVGA) to examine the gait
components.

All the outcome measures will be performed at the baseline and post-
intervention.
 STUDY PROCEDURE
Conventional therapy
Stretching of gastrocnemius and soleus muscle with a frequency of two times a week
for 6 weeks, intensity of 8 repetitions 3 sets, type- active assisted, time 10-20 minutes.
Conventional gait training will involve breaking down the gait cycle, training and
improving the abnormal parts, then reintegrating them into ambulation to return to a
more normal gait cycle.11 These include:
 Symmetrical weight bearing between lower limbs in stance
 Weight shifting between lower limbs.
 Stepping training over level and unlevel surface
 Heel strike or limb loading acceptance.
 Single leg stance with stable balance and control.
 Push off or initial swing of moving leg.11
4 repetitions 2 sets with total duration of 20 minutes for 3 days per week for 6 weeks.

Mental Imagery
Each patient will perform a movement in response to given video. Prior to the
movement performance, patient will be given functional imaginary cues to imply
while performing the movement.12
Procedure:
Individuals will move the ankle into plantar flexion and dorsiflexion in response with
the movement of an individual performing ankle movement shown in the video.
Prior to performing the movement, patients will be given instruction to focus on the
functional intent of the task.
Participants will be instructed to “imagine you are tapping on the floor while
performing the movement”.
Frequency: 5 days per week for 6 weeks
Intensity: 2 sets of 10 minutes
Type: 20 minutes
 STUDY PROTOCOL

Providing information about the study and taking informed consent

Screening for inclusion and exclusion criteria

Taking demographic details and physical assessment

GROUP A
GROUP B
Mental imagery +
Conventional
Conventional
therapy
therapy

Pre and post outcome measures will be assessed: MMT, Goniometer,

Modified Ashworth Scale and Rivermead Visual Gait Assessment

Total duration : 6 weeks

STATISTICAL ANALYSIS
All the data will be collected and analyzed using SPSS software.
1

REFERENCES

Dong-Sik, Dong-Duk, et.al : The effect of motor imagery training for trunk movements on trunk
control and proprioception in stroke patients J. Phys. Ther. Sci. 29: 1224–1228, 2017
2
Vij, J.S, N.K, et.al : Efficacy of NDT based gait training in correction of gait pattern of post stroke
hemiplegic patients. Journal of exercise science and physiotherapy. Vol 8, No. 1, 30-38, 2012 Exercise
Science and Physiotherapy, Vol.
3
Jørgensen, H.S.; Nakayama, H.; Raaschou, H.O.; Olsen, T.S. Recovery of walking function in stroke
patients: The copenhagen stroke study. Arch. Phys. Med. Rehabil. 1995, 76, 27–32.
4
Deltombe, T.; Wautier, D.; De Cloedt, P.; Fostier, M.; Gustin, T. Assessment and treatment of spastic
equinovarus foot after stroke: Guidance from the mont-godinne interdisciplinary group. J. Rehabil.
Med. 2017, 49, 461–468.
5
Bensoussan, L.; Mesure, S.; Viton, J.M.; Delarque, A. Kinematic and kinetic asymmetries in
hemiplegic patients’ gait initiation patterns. J. Rehabil. Med. 2006, 38, 287–294.
6
Vijaya, Chakrapani, Shennoy et al. ; Effects of mental imagery on functional mobility and quality of
life in ambulant stroke subjects. International journal of scientific research Volume 2, Isuue 5 May
2013 ISSN no. 2277-8179
7
Laura, Silvia et al. ; Eyes wide shut, How visual cues affect brain patterns of stimulated gait. 22 June
2020 DOI: 10.1002/hbm.25123
8
Mathhiu, Cedric, et al. :Brain activity during mental imagery of gait versus gait-like plantar
stimulation: A novel combined functional MRI paradigm to better understand cerebral gait control.
published: 06 March 2017 doi: 10.3389/fnhum.2017.00106
9
Fukuyama et al.; Brain functional activity during gait in normal subjects. July 1997. Neuroscience
letters. 228(3):183-186 DOI: 10.1016/SO304-3940(97)00381-9
10
Kazumi, Hanakawa et al. ; Neural mechanisms involved in mental imagery and observation of
gait.Department of Cortical Function Disorders, National Institute of Neuroscience, National Center of
Neurology and Psychiatry
11
Sirajahemad, Daxa et al.; The effect of mirror therapy on the gait of chronic stroke patients:
National journal of physiology, April 13,2018; June 2018
12
Lucy, Jill et al.; Motor imagery during movement activates the brain more than movement alone after
stroke HHS Public access October 2014 46(9): 843–848. doi:10.2340/16501977-1844
 SHARDA UNIVERSITY
CONSENT FORM
SL No.
DATE:
NAME
FATHER/HUSBAND’S NAME:
The details of the study entitled “Efficacy of Mental Imagery to Improve Dorsiflexor Component of
Gait Among Post Stroke Hemiplegic Patients”.

1. I understand the purpose of the study and I have right to withdraw from the study at any point in time
during the investigation. I can decline to answer to my particular question if it offends my privacy in
any form without losing the right to be treated.
2. I understand that my participation in this study will be kept confedential and in primarily mean for
research and for the benefits for the society.
3. I give consent for my details to be use in this study. I understand that on completion of the study, if I
withdraw from the study, my personal report form will be destroyed. I also understand that if there is
any problem with any of the examination test or measurement taken. I will be informed and the report
will be confidential.
4. I do hereby give my consent voluntarily without any inducement to take part in the study and I have
an objection to use of data in my publication

Signature of patient Signature of investigator

Name – Pasang Doma Sherpa
Mob No. - 9650212469
 शारदा विश्वविद्यालय

सहमति पत्र

एसएल नं.

तारीख:

नाम

पिता/पति का नाम:
अध्ययन का विवरण "हेमिप्लेजिक रोगियों के बीच चाल के डोरसिफ्लेक्सर घटक में सुधार के लिए

मानसिक इमेजरी की प्रभावकारिता" शीर्षक से दिया गया है।

1. मैं अध्ययन के उद्देश्य को समझता हूं और मुझे जांच के दौरान किसी भी समय अध्ययन से हटने

का अधिकार है। यदि मेरे विशेष प्रश्न से किसी भी रूप में मेरी निजता को ठे स पहुँचती है तो मैं

इलाज का अधिकार खोए बिना उसका उत्तर देने से इंकार कर सकता हूँ।

2. मैं समझता हूं कि इस अध्ययन में मेरी भागीदारी गोपनीय रखी जाएगी और मुख्य रूप से

अनुसंधान और समाज के लाभ के लिए होगी।

3. मैं इस अध्ययन में अपने विवरण का उपयोग करने के लिए सहमति देता हूं। मैं समझता हूं कि

अध्ययन पूरा होने पर, यदि मैं अध्ययन से हट जाता हूं, तो मेरा व्यक्तिगत रिपोर्ट फॉर्म नष्ट हो
जाएगा। मैं यह भी समझता हूं कि यदि किसी जांच परीक्षण या माप में कोई समस्या आती है। मुझे

सूचित किया जाएगा और रिपोर्ट गोपनीय रहेगी।

4. मैं अध्ययन में भाग लेने के लिए बिना किसी प्रलोभन के स्वेच्छा से अपनी सहमति देता हूं और

मुझे अपने प्रकाशन में डेटा के उपयोग पर आपत्ति है

मरीज के हस्ताक्षर अन्वेषक के हस्ताक्षर

नाम - पसांग डोमा शेरपा

मोबाइल नंबर – 9650212469

 PATIENT INFORMATION SHEET

“ Efficacy of Mental Imagery to Improve Dorsiflexor Component of Gait Among Post Stroke
Hemiplegic Patients”.
 What is the purpose of the study?
The purpose of this study is to investigate the effect of mental imagery practice in improving
dorsiflexion component of gait among hemiplegic patients.
 Why have I been chosen?
You have been approached because you fulfil the entry criteria for the study. The following criteria
–patients with present history of stroke falling in spastic to recovery phase with foot drop.
 Do I have to take part?
It is up to you to decide whether or not to take part. If you do, you will be given this information
sheet to keep and be asked to sign a consent form. You are still free to withdraw consent from the
study at any time and without giving a reason.
 What will happen to me if I take part?
Participation in the study will have to follow an physiotherapy exercise protocol with conventional
therpay and mental imagery practice protocol according to the groups allocated. Once the
participants have consented to participate in the study, He/she will have to follow a set of a
predesigned treatment protocol for conventional therapy and mental imagery according to their
respected groups.
 What are the Possible Benefits of taking part?
Increased range of motion, reduced spasticity, improved strength and better gait performance .
 What happens when the Research stops?
If the research stops, the researcher has to explain the reasons to the participants.
Will my taking part in this study be kept confidential?
Yes, the information about you will only be known to the researcher. All information about you
will be held using a unique research number. So that you cannot be identified in any results
 publications or publicity related to the study.
The researcher should be able to tell the participants about the results when they are likely to be
published.
 Who reviewed the study?
The Institutional Ethics Committee will review the study.
Contact Information: -
Researcher name – Pasang Doma Sherpa MPT(Neuro)
Address – Sharda Hospital
Phone no- 9560212469

रोगी/प्रतिभागी सूचना पत्रक

"हेमिप्लेजिक रोगियों के बीच चाल के डोरसिफ्लेक्सर घटक में सुधार के लिए मानसिक इमेजरी

हस्तक्षेप की प्रभावकारिता"।

 अध्ययन का उद्देश्य क्या है?

इस अध्ययन का उद्देश्य हेमिप्लेजिक रोगियों के बीच चाल के डोरसिफ़्लेक्सन घटक को बेहतर बनाने

में मानसिक कल्पना अभ्यास के प्रभाव की जांच करना है।

 मुझे क्यों चुना गया है?

आपसे संपर्क किया गया है क्योंकि आप अध्ययन के लिए प्रवेश मानदंडों को पूरा करते हैं।

निम्नलिखित मानदंड - स्ट्रोक के वर्तमान इतिहास वाले रोगी पैर गिरना

विकृ ति के साथ स्पास्टिक से रिकवरी चरण में आते हैं।

 क्या मुझे भाग लेना होगा?

इसमें भाग लेना है या नहीं यह निर्णय लेना आपके ऊपर है। यदि आप ऐसा करते हैं, तो आपको यह

सूचना पत्रक रखने के लिए दिया जाएगा और एक सहमति प्रपत्र पर हस्ताक्षर करने के लिए कहा

जाएगा। आप अभी भी किसी भी समय और बिना कोई कारण बताए अध्ययन से सहमति वापस लेने

के लिए स्वतंत्र हैं।

 अगर मैं भाग लूंगा तो मेरा क्या होगा?

अध्ययन में भाग लेने के लिए आवंटित समूहों के अनुसार पारंपरिक थेरेपी और मानसिक इमेजरी

अभ्यास प्रोटोकॉल के साथ फिजियोथेरेपी व्यायाम प्रोटोकॉल का पालन करना होगा। एक बार जब

प्रतिभागियों ने अध्ययन में भाग लेने के लिए सहमति दे दी, तो उन्हें अपने सम्मानित समूहों के
अनुसार पारंपरिक चिकित्सा और मानसिक कल्पना के लिए पूर्वनिर्धारित उपचार प्रोटोकॉल के एक सेट

का पालन करना होगा।

 भाग लेने के संभावित लाभ क्या हैं?

गति की सीमा में वृद्धि, लोच में कमी, बेहतर ताकत और बेहतर चाल प्रदर्शन।

 जब अनुसंधान बंद हो जाता है तो क्या होता है?

यदि शोध रुक जाता है, तो शोधकर्ता को प्रतिभागियों को इसका कारण बताना होगा।

क्या इस अध्ययन में मेरी भागीदारी को गोपनीय रखा जाएगा?

हां, आपके बारे में जानकारी के वल शोधकर्ता को ही पता होगी। आपके बारे में सारी जानकारी एक

अद्वितीय शोध नंबर का उपयोग करके रखी जाएगी। ताकि आपको अध्ययन से संबंधित किसी भी
परिणाम प्रकाशन या प्रचार में पहचाना न जा सके ।

शोधकर्ता को प्रतिभागियों को परिणामों के बारे में बताने में सक्षम होना चाहिए जब उनके प्रकाशित

होने की संभावना हो।

 अध्ययन की समीक्षा किसने की?

पोस्ट ग्रेजुएट रिसर्च बोर्ड अध्ययन की समीक्षा करेगा।

संपर्क जानकारी:

शोधकर्ता का नाम - पसांग डोमा शेरपा एमपीटी (न्यूरो)

पता-शारदा हॉस्पिटल

फ़ोन नंबर- 9560212469

 CASE RECORD FORM

Name:
Age:
Gender:
Address:
Occupation:
Dominant side:
Affected side:

Assessment of Rane of Motion:

Movement Pre Post
Ankle dorsiflexion

Manual muscle strength testing score

Muscle Pre Post
Gastrocnemius
Soleus

Modified Asthworth Scale scores

Movement Pre Post
Ankle dorsiflexion

Gait Assessment and Intervention Tool (G.A.I.T) scores

Pre-score Post score