Improving Balance Post-Stroke: Strategies For Better Stability

Stroke is a leading cause of death and disability worldwide, with balance being one of the most common impairments in patients post-stroke. Balance impairment is characterised by short supporting time and differences between the two sides of the body, which may increase the risk of falls.

Balance is a complex function that requires coordination of the legs, feet, and core, with the arms also playing a role in providing stability while walking. Therefore, regaining balance after a stroke is no easy task. However, it can be achieved through effective, evidence-based rehabilitation methods.

Balance exercises can help stroke patients regain stability. These exercises can be performed at home or in a clinic under the supervision of a trained caregiver or therapist. Basic level exercises for balance may seem simple but require strong neural connections to be performed successfully. Intermediate and advanced level exercises build on these basics and help improve balance further.

In addition to physical therapy, other interventions such as virtual reality training, aquatic therapy, and ankle-foot orthotics can also help improve balance in stroke patients.

Balance exercises and interventions aim to improve patients' ability to walk and perform daily activities, ultimately enhancing their quality of life.

Trunk training/seated balance training

Trunk training and seated balance exercises are essential for stroke patients to improve their balance and regain independence. Here are some detailed instructions for effective trunk training and seated balance exercises:

Trunk Training

• Lateral Trunk Flexion: Sit upright and tilt your right shoulder down towards your right hip. You can use your hand to reach down the side of the chair. Hold this position for 5 seconds, then return to the starting position. Repeat on the other side, performing a total of 10 repetitions. This exercise improves posture and targets the oblique abdominal muscles for better trunk control.
• Hip Abduction Side Kicks: Sit with your legs shoulder-width apart. Raise your affected foot slightly off the ground and feel the pressure on your core and leg. Kick your leg out to the side and then bring it back inwards. Challenge yourself by keeping your trunk still while moving your leg. Repeat 20 times. This exercise improves range of motion and hip strength.
• Trunk Circles: While seated, move your torso in clockwise circular motions, engaging your core muscles. Start with small circles and gradually increase their size to challenge your balance. Repeat 10 times, and then change directions. This exercise is excellent for improving balance by targeting various upper body muscles.
• Isometric Back Extensor Holds: Sit on the edge of a chair with your feet firmly planted on the ground. Gently press your back against the chair, contracting the muscles in your back. Hold for a few seconds, then return to an upright position, ensuring your back is straight. Repeat this exercise 10 times.

Seated Balance Exercises

• Weight Shift: Keep your back straight and slowly shift your weight to one side. Hold for a few seconds, then return to the center. Repeat on the other side. Perform 20–30 repetitions per session or adjust as needed.
• Single-Leg Knee Extensions: Sit upright with your core engaged. Extend one leg, then lower it to the ground. Repeat with the other leg, performing two sets of 15 repetitions.
• Reach with Clasped Hands: Keep your hands clasped together and reach forward as far as possible without losing balance. Hold for 5 seconds, then lean back and sit normally. Repeat 10 times. You can also practice reaching to either side.
• Seated/Standing Marching: Sit tall on the edge of your seat and alternately lift your knees as high as you can, engaging your core to keep your trunk stable. Practice for 3 rounds of 30 seconds each, focusing on posture rather than speed.

It is important to consult with a healthcare provider before attempting these exercises, and supervision may be necessary for safety. If any exercise causes pain, stop the activity.

Standing practice (i.e. sit-to-stand practice)

Standing Practice for Stroke Patients

Standing practice, also known as sit-to-stand practice, is a crucial exercise for stroke patients aiming to improve their balance and overall mobility. This exercise involves the patient starting in a seated position and then attempting to stand up without using their hands for support. Here is a step-by-step guide for stroke patients to improve their balance through standing practice:

Step 1: Starting Position

Begin in a comfortable seated position, preferably in a chair with armrests that can provide support if needed. Ensure your feet are positioned hip-width apart, and maintain good posture with your back straight and shoulders relaxed. Place your arms across your chest or on your thighs, avoiding any support from the chair's armrests.

Step 2: Initiating the Movement

Take a deep breath and slowly lean forward, leading with your chest, while simultaneously pushing through your feet to initiate the standing movement. It is important to maintain a controlled and steady movement, avoiding any abrupt or jerky motions that could compromise your balance.

Step 3: Standing Position

As you reach the standing position, focus on keeping your body aligned and maintaining your balance. Distribute your weight evenly across both feet, and ensure your knees are relaxed, not locked. Keep your arms across your chest or at your sides, and refrain from any compensatory movements, such as swaying or leaning to one side.

Step 4: Holding the Position

Maintain the standing position for a few seconds, concentrating on maintaining your balance and stability. Engage your core, and ensure your weight remains evenly distributed. Take slow, deep breaths to promote relaxation and focus.

Step 5: Returning to the Seated Position

To return to the seated position, slowly lean back, bending at the knees and hips, while maintaining your balance. Gently lower yourself onto the chair in a controlled manner, employing the same steady and deliberate movement as when you stood up. Avoid any abrupt movements or collapsing into the chair.

Step 6: Repetition and Progression

Start with a manageable number of repetitions and gradually increase them as your balance and strength improve. Challenge yourself by performing the exercise without relying on the armrests or by closing your eyes during the standing position to enhance your sense of balance.

Remember to perform this exercise under the supervision of a qualified therapist or healthcare professional, especially if you have any concerns or specific balance issues. They can offer personalized guidance and ensure your technique is correct, maximizing the benefits of standing practice for improving your balance post-stroke.

Force platform biofeedback and task-oriented training with or without multisensory intervention

Force platform biofeedback is a method of balance retraining for stroke patients that uses technology to provide patients with real-time feedback on their body's position and movement. This feedback can be visual, auditory, or a combination of both. The goal is to help patients improve their balance by making them more aware of their body's position and movements and encouraging them to correct any imbalances.

During force platform biofeedback training, the patient stands on a force platform—often a pair of pressure-sensitive pads—that measures the distribution of weight between the two feet. This information is then fed into a computer, which displays a visual representation of the patient's centre of pressure (COP) or centre of force (COF) on a monitor. Some systems also provide auditory feedback, such as a tone or beep, to indicate when the patient's weight distribution is uneven.

The visual representation of the patient's COP/COF can take various forms, such as a simple graph or a pair of footprints that fill with colour to indicate the amount of pressure exerted by each foot. The patient's COP/COF is typically represented in relation to a target position, which the patient tries to match by adjusting their posture and weight distribution. This target position may be a static point or a moving path that the patient tries to follow.

In addition to providing feedback on weight distribution, force platform biofeedback systems can also be used to train dynamic stability—the ability to move within a weight-bearing posture without losing balance. For example, the patient might be instructed to shift their weight from side to side or front to back while trying to minimise unnecessary swaying.

Force platform biofeedback can be combined with task-oriented training, which involves practising functional tasks such as reaching and grasping. In a virtual environment, the patient might be presented with a virtual arm that mimics the movement of their physical arm, providing visual feedback that allows them to adjust their movement in real time. Auditory feedback can also be incorporated, with music or other sounds that change in response to the patient's movements.

Multisensory intervention typically refers to the combination of two or more types of sensory feedback during training. For example, a force platform biofeedback system might provide both visual and auditory feedback. Additionally, multisensory intervention can involve the simultaneous training of multiple senses, such as using virtual reality to provide visual and auditory feedback while also engaging the patient's sense of touch through the use of a physical object or haptic feedback device.

Partial body weight support treadmill training

PBWSTT enables non-ambulatory hemiparetic patients to repetitively practice complex gait cycles. Initially, two or three therapists are required to assist the patient's movements on the treadmill. One therapist helps control the paretic foot and leg during the swing phase of gait, and ensures that the initial contact is made with the heel during the stance phase. A second therapist, standing behind the patient, assists weight shift and promotes hip and trunk extension.

Therapists should aim to practice stepping in as smooth and normal a pattern as possible, and not just repetitively. Treadmill speed should be increased and body weight support reduced as soon as possible. Biomechanical studies show that increasing body weight support decreases the muscle activity of relevant weight-bearing muscles in hemiparetic subjects.

PBWSTT has been shown to be superior to conventional physiotherapy with regard to the restoration of gait and improvement of ground walking velocity. In one study, patients who had been wheelchair-bound before therapy became ambulatory by the end of the study. In another study, a group that received PBWSTT scored significantly higher than the control group for functional balance, motor recovery, over-ground walking speed, and over-ground walking endurance.

PBWSTT may be a safe way for patients to begin walking when they are not able to walk safely by themselves, especially if they require two people to help them walk over the ground. It also allows them to start walking earlier after a stroke. However, some patients have reported finding the harness uncomfortable to wear, and some do not enjoy walking on a treadmill.

Balance training combined with virtual reality in the late phase of stroke

Virtual reality (VR) is an increasingly popular tool for rehabilitation after a stroke. VR training uses computer software to track a user's movements and lets them interact with a game presented on a television screen. VR training is especially useful for rehabilitation of arm function, balance, and walking after a stroke.

Benefits of VR Training

• VR training can be done at home, which is more convenient and accessible for patients.
• VR training is enjoyable and can be used for an unlimited period after a stroke.
• VR training has been shown to benefit upper extremity function, standing balance, gait, and overall function in the sub-acute and chronic phases after a stroke.
• VR training can be used as a supplemental therapy to traditional outpatient or community-based rehabilitation.
• VR training can be used to continue therapeutic exercise once a patient is discharged from formal rehabilitation.

VR Training for Balance

VR training can be used to improve balance after a stroke. VR training may be especially useful for patients with foot drop, a common cause of balance challenges after a stroke. Foot drop impairs the ability to lift the front portion of the foot, causing the foot to drag on the floor while walking and increasing the likelihood of falling.

VR Training in the Late Phase of Stroke

A study by Sheehy et al. examined the feasibility of using VR training in the home for patients in the late phase of stroke. The study found that VR training was feasible and safe for these patients. The results also suggested that VR training improved standing balance and gait equally to in-clinic VR training but at a lower cost.

Recommendations for VR Training

• VR training should be combined with conventional rehabilitation methods to address sensory deficits, cognitive changes, and attentional neglect.
• VR training should be used consistently and repetitively to encourage adaptive changes in the brain and improve balance.
• VR training programs should be designed to be engaging and motivating for patients.
• VR training should be used in addition to rehabilitative exercises on land and in the water.

Frequently asked questions