Balance: Steady as you go
In today’s culture, it seems that we are always in search of the elusive life balance. But when a person survives a stroke, the word balance goes much further than simply finding an equilibrium between work and life: it takes on a very direct, literal, and physical meaning. Balance impairment tends to be a pronounced and concerning complication, and has been found to affect 83% of people with stroke (1, 2).
So what does balance mean? The verb form of the word balance is usually defined as “to keep or put something in a steady position so that it does not fall,” and the noun form means “an even distribution of weight enabling someone or something to remain upright and steady” (3). This definition also brings to light another distinct and prevalent concern among stroke survivors: falling. Although there may be many different contributing factors to falls in older adults (and especially those who have experienced a stroke), the balance impairment that comes with reduced sensory and motor abilities after stroke is thought to be one major cause. Unfortunately, it is also thought that problems with balance and mobility after a stroke may cause a higher fear of falling. Often a fear of falling is connected to avoidance: avoiding activities that were once very meaningful in order to avoid falling.(1) As you can probably guess, this can then affect quality of life!
Factors that affect balance
When it comes to stroke, a lot of factors can affect sitting and standing balance. Here are some of the most common reasons:
- hemiparesis (weakness on one side of the body)
- decreased control of the trunk (the middle section of your body)
- altered weight distribution patterns when sitting/standing related to weakness
- impaired vision
- decreased attention/focus
- decreased sensation in the affected leg (and arm)
- decreased proprioception (awareness of the position/movement of a body part)
- decreased range of motion in the affected limbs/trunk
- impaired reflexes/reactions to sudden movement or position changes
- increased fear/anxiety related to possibly falling
What can you do to help?
First of all, remember that each individual person is different and experiences stroke and stroke recovery differently! One of the most important things to do first is to figure out which factors seem to be the most obvious ones affecting your balance, so that those can be dealt with. Some research shows that most often weakness and sensation deficits have the greatest impact on balance.(5) However, one person may have weakness and vision deficits, while another may have impaired reflexes and have trouble feeling the ground with their feet (and many more combinations!)
There are many options for you to work on balance. Keep in mind, many of these can help with balance in general - not just balance after a stroke!
Because a lot of balance difficulties are related to weaker muscles (in the legs, arms, and trunk), working to improve muscle strength can help. The stronger the muscles, the more control they have in keeping you upright. This doesn’t necessarily mean you need to join a gym if that’s not in your comfort zone!
Strengthening can be accomplished in several ways: completing your home exercise program and/or weight bearing activities suggested by your therapist, working on increasing your activity tolerance by gradually progressing the amount of time you spend doing everyday tasks (especially while you are standing up), and participating in group exercise classes that include agility and weight shifting. These options can help improve functional balance, mobility, and reflexes which can also help with fall prevention after a stroke. (4) The CDC has noted that increasing physical activity helps to decrease the risk of falls, in large part related to improving balance. (5)
Sometimes simply taking a deep, slow breath and truly focusing on a task can improve balance during that task. Often, we pay attention to too many details and try to multitask. Or we get distracted by too much information! While this can easily happen to anyone, it can have more serious consequences after a stroke because other factors (such as weakness) come into play. With increased concentration often comes better preparation while approaching a task, and better focus on the particular balance skills needed for that given task.
Along with concentration, a slower pace during a given task can improve the ability to remain balanced. With hasty, more abrupt motions, the body has less time to react and adapt the posture that is necessary to stay upright. By moving slower, you can “check” yourself more frequently and make sure that you aren’t starting to lean too far. In cases where your sensation is impaired and you can’t quite feel how your feet are positioned on the ground, moving slower will allow you to have more time to use other senses (such as vision) to check yourself.
Improving base of support
Your base of support refers to your body’s points of contact with the ground surface beneath you. After a stroke, it is more important than ever to be aware of how your feet are positioned while you are standing, reaching, stepping, turning, and just generally performing everyday tasks. If your foot positioning changes so that your base of support is smaller, this could reduce your balance greatly. Examples of less-safe positions are: feet too close together, one foot in front of the other, feet twisted in different angles, or standing on one foot (even briefly) while shifting your weight during an activity.
Before performing a task, get in the habit of doing a quick check of your feet to see that they are at least shoulder-width apart, with your toes pointing forward. This may mean that you have to step closer to an object (like a cabinet!) while you are doing an activity.
Check back soon for the next installment with even more helpful tips to improve your balance!
Remember that balance is a complicated skill that can be greatly challenged after a stroke. Because of the safety and fall risks involved with impaired balance, always make sure to check in with your OT, PT, and/or doctor to see if you are working to improve your balance in ways that are safest for you!
Schmid AA, et al. Fear of falling in people with chronic stroke. American Journal of Occupational Therapy, 2015; 69(3): 6903350020p1-6903350020p5.
Tyson SF, et al. Balance disability after stroke. Physical Therapy, 2006; 86(1): 30-8.
Lexico.com (powered by Oxford)
Marigold DS, et al. Exercise leads to faster postural reflexes, improved balance and mobility, and fewer falls in older persons with chronic stroke. Journal of the American Geriatrics Society, 2005; 53(3): 416-423.
Green, E, et al. Systematic review of yoga and balance: effect on adults with neuromuscular impairment. American Journal of Occupational Therapy, 2019; 73(1): 7301205150p1-7301205150p11.
Standing position image credit: https://journals.plos.org/plosone/article/figure/image?id=10.1371/journal.pone.0098224.g001&size=inline
All content provided on this blog is for informational purposes only and is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your doctor or 911 immediately. Reliance on any information provided by the NEOFECT website is solely at your own risk.
- Natalie Miller, OTR/LNatalie is an occupational therapist and health writer based out of Richmond, VA. Natalie recently pivoted into the pediatric setting after spending eleven years working in adult neurorehabilitation.