IMPROVEMENT IN BALANCE AND
THE APPREHENSION OF FALLING
IN POST-STROKE PATIENT
Novitri Sumardi, MD
Physical Medicine and Rehabilitation Department
Hasan Sadikin Hospital – Bandung
Jakarta, 20 – 23 November 2019
There are 3 major point in the topic
:
Stroke - Balance - Falls
What is Stroke?
■ Stroke is the sudden occurrence of permanent damage to an area of the brain
caused by a blocked blood vessel or bleeding within the brain. 1
Stroke Syndromes
■ A stroke syndrome is a set of symptoms that helps to identify which part of the brain has
been injured in stroke.2
Stroke Symptoms
■ The most common symptom is
weakness, though stroke can
produce a wide range of symptoms
What is Balance?
Balance is the ability to maintain the body’s center
of mass (COM) over its base of support (BOS). 3
Centre of Gravity/Centre of Mass in the
Human Body
■ In the anatomical position the COG/COM lies approximately
anterior to the 2nd sacral vertebra.
■ Since human beings do not remain fixed in the anatomical
position, the precise location of the COG changes constantly
with every new position of the body and limbs.
■ The base of support (BOS) refers to the area beneath an
object includes every point of contact that the object or person
makes with the supporting surface (feet or hands, or crutches
or the chair a person is sitting in)
How Balance Works?
■ Balance is achieved and maintained by a complex set of
sensorimotor control
■ The systems that include sensory input; integration of that
sensory input; and motor output to the eye and body
muscles.
■ Injury (such as : Stroke/CVA), disease, or the aging
process can affect one or more of these components
How Balance Works?...
Why Strokes Lead to
Balance Impairment and Falls?
Why Strokes Lead to Balance Impairment and Falls?
■ generally : decrease muscle strength
and postural reflexes
■ impaired sensory systems (vision, less
dynamic BP responses to changes in
posture, joint disease, cognitive
impairment, reduced reaction time,
and incontinence)
■ However, strokes can lead directly to
falls because of the vital role almost
every part of our brain plays in
maintaining balance
Incidence of Falls in Stroke
■ Falls are common at all stages after stroke.
■ Incidence : 3.4 - 17.8 falls per 1,000 patient days comparing to 2 - 7 falls per
1,000 patient days in the general inpatient population. 4
■ At 6 months, the incidence of falls is between 37 - 73 %. 4
■ After discharge from hospital, falls occur most often during the day, and most
often in the home (The lounge, bedroom, and garden)
■ The most likely activities at the time of falling are : walking or transferring. 4
Balance Assessment in Post- Stroke Patients
■ The most common scale and test are (5.6) :
• the Berg Balance Scale
• the Timed Up and Go Test
• the Tinetti Assessment Tool
• the Functional Reach Test
• the balance subscale of the Fugl-Meyer Assessment
■ Advantages :
– Not expensive equipment and are relatively fast
■ Disadvantages :
– The results are subjective
– Have the ceiling effect → insufficiently sensitive for the
detection and evaluation of slight balance-related alterations
Balance Assessment in Post- Stroke
Patients…
■ Mancini and Horak : these instruments are too simple to evaluate
the complex system of balance control
■ The optimal balance evaluation technique should include
objective and quantitative measurements that would provide
reliable findings → the application of computer technologies is
becoming increasingly common in clinical practice for an objective
evaluation of balance
Balance Assessment in Post- Stroke
Patients…
■ Instrumental studies
– Laboratory measurements are significantly more sensitive in the evaluation
of balance
– Posturography (static & dynamic) is one of the most common laboratory
techniques which employs force platforms for the determination of the
movement trajectory of the center of pressure.
– During posturography, information about body sway from the sensors in the
force platforms is relayed to the computer, and oscillation curves –
posturograms – are recorded.
Balance Assessment in Post- Stroke
Patients…
■ Accelerometry is one of the most recent balance
evaluation techniques.
■ Accelerometers will measure motion velocity
and acceleration of the body parts in three axes
(the vertical, the horizontal, and the transverse)
■ These devices are attached to the subject's
trunk and limbs, and computer equipment is
used to analyze the incoming signals.
■ The measurements may be carried out while the
subject is performing balance tests or is
engaging in daily activities .
■ The greatest advantage : portable & easy to use
Principles of Balance Retraining
■ Oliveira et al. identified the following mechanisms associated
with balance control [5]:
– Sensory processes and their integration (sensory afferents)
– Biomechanical constraints
– Movement strategies
– Cognitive processing
– Perception of verticality
Principles of Balance Retraining…
■ Sensory processes and their integration
– There are 3 main sensory mechanisms in the control of the body
position:
■ the somatosensory mechanism (the proprioceptive system, which
provides information about the position of different body parts
with respect to each other)
■ the visual mechanism (defines the position and the movements of
the head with respect to the surrounding objects)
■ the vestibular system (defines the direction and the acceleration
of body movements with respect to the gravity of the Earth)
– The sensory information is regulated dynamically and changes
depending on the altering environmental conditions
Principles of Balance Retraining…
■ Biomechanical constraints
– The major factors in balance is the control of body COM with respect to its
base of support
– The BOS is not fixed and may vary depending on the task, the movement,
individual biomechanics, and environmental factors.
– Any impairment in muscle force, range of motion, tone, or muscle control
will affect the maintenance of balance.
Principles of Balance Retraining…
■ Movement strategies
– 3 main movement strategies to restore balance
■ The ankle strategy → in cases where sway is relatively
mild, and the BOS is firm.
■ The hip strategy → used in the presence of greater or
faster disturbances or when the BOS is narrow or sloping,
and the ankle strategy is insufficient for regaining
balance, while the COM has to be restored quickly
■ The stepping strategy is an entirely independent strategy.
With this strategy, the adjustment to the BOS is achieved
through shifting the body COM
■ These compensatory strategies are useful for reducing
oscillations of the body COM resulting from abrupt and
unexpected balance impairment
Principles of Balance Retraining…
■ Cognitive processing
– Maintenance of balance are dependent on attention (focus),
experience, the environmental contexts, and the intentions
– The importance of cognitive processing directly correlates with
the difficulty level of the posture-related task that needs to be
performed.
– Patients whose cognitive processing is impaired due to
neurological disorders (post-stroke) may need more resources
for maintaining balance.
Principles of Balance Retraining…
■ Perception of verticality
– Spatial orientation with respect to gravity forces is
essential in maintaining vertical position of the
body when walking or performing various motor
tasks.
– Damage to the central system integrating
vestibular, somatosensory, and visual information
may disturb the normal perception of the position of
the body in space, and may affect certain
mechanisms responsible for the perception of the
verticality of the body.
Principles of Balance Retraining…
– Frequently, post-stroke patients with balance
disorders avoid shifting their weight on the
unaffected side. This phenomenon is frequently
referred to as the pusher syndrome.
– Its clinical manifestation : is the tendency to shift
the body weight more to the paretic side for fear of
falling on the unaffected side. Such cases
demonstrate impaired perception of the body's
verticality relative to the gravito-inertial force.
– The patients perceive the position of their body as
straight, while in reality their body is leaning toward
the paretic side.
How Exercise Improved Balance
■ The concept of stroke rehabilitation is currently based
on evidence of neuroplasticity(11).
■ Neuroplasticity is : the ability of the nervous system to
respond to intrinsic or extrinsic stimuli by reorganizing
its structure, function, and connections [12].
■ Neural plastic occur throughout the lifespan and are
associated with development and learning (experience)
How Exercise Improved Balance…
How Exercise Improved Balance…
■ Types of learning in the context of neuroplasticity (stroke recovery) are
focus in skill learning (task-based learning and activity-based learning)
■ In human studies, evidence suggests that skill learning induces cortical
reorganization and cortical changes may only occur with learning of
new skills and not just with repetitive use
■ A few topics highlighted outcomes and/or mechanisms of change at a
neurobiological level.
■ The underlying mechanisms or biomarkers that being proposed are
BDNF, functional connectivity, and brain activation. The neurobiological
mechanisms underlying recovery with varying severity of impairment
and in the longer term, are still incompletely understood
Balance training techniques in post-stroke
patients
■ Improvement in balance and walking after stroke is
accomplished by a combination of natural recovery and
rehabilitation intervention (8)
■ Scientific literature provides a number of methods and
instruments for balance and walking training after a stroke
■ Not all of them are always considered to be effective – there
are controversial evaluations as well
Balance training techniques in post-stroke patients…
■ Dual-task training is a technique that is frequently mentioned
in scientific literature. This is simultaneous performance of two
tasks. During balance training, while maintaining body
position, another task – usually of motor or cognitive character
– is performed (bouncing a ball against the ground, holding a
glass with water, etc. while standing on an unstable surface).
The results is significantly better.
Balance training techniques in post-stroke patients…
■ Video games (virtual reality) as a rehabilitation
technique attracted significant attention during the
last few years
■ Morone et al. evaluated the effect of video gamebased rehabilitation on balance and functional
recovery in post-CVA patients during the subacute
period and showed → a significant improvement in
their balance function and a reduction in
dependence in their daily activities, compared to
patients who received standard PT alone [9].
Balance training techniques in post-stroke patients…
■ A positive effect was also observed when using a treadmill for
balance training .
■ Studies conducted by Kag et al. and Yang et al. showed that
treadmill exercises with additional visual information yielded better
results in balance training than treadmill exercises alone
■ Various exercises and tasks for weight-shift training, sit-to- stand
training, and reaching tasks are frequently applied for balance
training in post-CVA patients
Balance training techniques in post-stroke patients…
■ There is also interest of exercises in water for the
rehabilitation of post- CVA patients.
■ Most studies comparing the effectiveness of balance
training in the water and in a gym showed that better
results were achieved during balance training in water
■ Water with its physical characteristics (hydrostatic
pressure, the lift force, and high density) reduce the
patients' fear of falls and injuries.
■ Water has a specific mechanical effect on the body,
reducing pain, peripheral edemas, can alter the
autonomic nerves system, and biomechanical muscle
and joint tension, and improving proprioception, which
creates better conditions for rehabilitation
Conclusion
■ A stroke is one of the most common causes of morbidity and longterm disability. The clinical symptoms are highly individual, but
balance disorders are the most common ones
■ Balance disorders not only impair daily activity, but also limit both
physical and social activity. This is the reason why the normalization
and/or restoration of the impaired balance function is important
Conclusion…
■ Many of balance assessment are rather subjective and
insufficiently sensitive, but now IT-based techniques is start
to be implemented in clinical settings
■ For management, balance restoration techniques using
complementary or alternative measures to traditional
physical therapy (PT) frequently helps to achieve better
results.
References
1.
Stein J, Brandstater ME. Stroke Rehabilitation. In : DeLisa’s Physical Medicine and Rehabilitation. Principle and Practice. 5th ed. Philadelphia :
Lippincott Williams &Wilkins, Wolter Kluwer business ; 2016. p. 551
2.
Balami JS, Chen RL, Buchan AM. Stroke sydrome and clinical management. Q J Med. 2013 ; 106:607 – 615
3.
Shumway-Cook A, Woollacott MH. Motor Control: Theory and Practical Applications.Philadelphia : Lippincott, Williams & Wilkins; 2001
4.
Dockery F, Sommerville PJ. Falls and Osteoporosis Post-Stroke. In : Management of Post-Stroke Complication.Bhalla A, Birns J, editors. Springer
International Pusblising Switzerland ; 2015. p. 241 – 276
5.
Oliveira CB, Medeiros RT, Frota NAF, Greters ME, Conforto AB. Balance control in hemiparetic stroke patients: main tools for evaluation. J Rehabil Res
Dev 2008;45(8):1215–26
6.
Sawacha Z, Carraro E, Contessa P, Guiotto A, Masiero S, Cobelli C. Relationship between clinical and Instrumental balance assessments in chronic
post-stroke hemiparesis subjects. J Neuroeng Rehabil 2013;10(95):1–7
7.
Mancini M, Horak FB. The relevance of clinical balance assessment tools to differentiate balance deficits. Eur J Phys Rehabil Med 2010;46(2):239–
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8.
Mulroy SJ, Kautz SA, and Sullivan KJ. Walking Recovery and Rehabilitation After Stroke. In : Stroke Rehabilitation & Recovery. 2nd ed. New York.
Demos Medical Publishing, LLC ; 2015. p. 384 – 403
9.
Morone G, Tramontano M, Iosa M, Shofany J, Iemma A, Musicco M, et al. The efficacy of balance training with video game-based therapy in subacute
stroke patients: a randomized controlled trial. Biomed Res Int 2014;1–6.
10.
Jung JH, Lee JY, Chung EJ, Kim K. The effect of obbstacle training in water on static balance of chronic stroke patients. J Phys Ther Sci 2014;26:437–
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Filippo TRM, Alfieri FM, Cichon FR, Imamura M, Batistella LR. Neuroplasticity and functional recovery in rehabilitation after stroke. Acta Fisiatr.
2015;22(2):93-96
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S. C. Cramer, M. Sur, B. H. Dobkin et al., “Harnessing neuroplasticity for clinical applications,” Brain, vol. 134, no. 6, pp. 1591–1609, 2011.
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