Gait and balance training are key components of post-stroke rehabilitation. Try these 7 pre-gait exercises to progress your walking skills today.

Walking After Stroke: 7 Exercise to Improve Strength and Balance

Walking independently after a stroke is one of the major goals in post stroke
rehabilitation. Your gait is your specific pattern of walking that occurs in
several phases that require specific patterns of muscle activation that allow
the joints of the lower limbs to move smoothly and synchronously in
coordination. The signals to these muscles can become disrupted after stroke,
especially if hemiparesis, or one sided muscle weakness, is present.

Gait training and balance training are key components of post stroke
rehabilitation to help you learn to walk, improve your balance and coordination,
and increase the strength of your hips, knees, and ankles to support your body
when you move.

Common gait deviations observed in patients post stroke include:

 * Decreased gait speed and cadence, or steps per minute
 * Decreased step length
 * Decreased stance time on the weakened leg
 * Decreased ankle dorsiflexion, limiting foot clearance
 * Decreased standing balance and stability, especially with weight shifting

These changes result from a compromised ability to generate force to propel the
body forward, instability of the pelvis that impairs balance, and decreased
strength of the weakened leg, limiting the ability to bear weight through that
side.



Gait deviations can reduce safety and efficiency of walking, resulting in
increased fall risk.

Key muscle groups that can benefit from strength training to improve gait
quality after stroke include the:

 * Tibialis anterior: to dorsiflex the ankle, the motion of lifting the foot up
   toward the body to clear the foot from dragging and prevent tripping when
   taking a step
 * Quadriceps: to extend the knee, providing stability to the knee to improve
   weight bearing tolerance and to prevent knee buckling
 * Hip flexors: to lift the leg up to increase foot clearance and step length
 * Glutes: to extend the hip, increasing the amount of force generated to propel
   the body forward, and to increase stability of the pelvis, to support balance
   with weight shifting between each leg and changing directions

Good outcomes for post stroke rehabilitation require a high degree of
motivation, participation, and engagement of the patient.


The human leg contains a multitude of muscles that work together to support
balance and walking.
Strength and Balance Exercises for Better Walking

1) Ankle Dorsiflexion
 * Goal: to improve ankle dorsiflexion strength to improve foot clearance
 * How-to [https://www.youtube.com/watch?v=SBrHvR0BomM]: Loop a resistance band
   around your foot so that the force is pulling your foot down. Activate your
   tibialis anterior by drawing your foot up toward your body.
 * Progression: Increase the resistance with a higher level of resistance band.
   


2) Marching
 * Goal: to increase hip flexor strength to improve foot clearance, and increase
   single leg strength and stability when standing and weight shifting.
 * How-to [https://www.youtube.com/watch?v=XIhqeDe4TLE]: (Sitting) Begin seated
   in a chair. Lift one leg up, hold for 2 seconds, then lower. Repeat on the
   other side. (Standing) Stand next to a table, chair, wall, or other stable
   object for support. Weight shift over onto one leg while slowly lifting up
   the other, hold for 2 seconds, then lower. Repeat on the other side. Hold
   onto something for support if needed.
 * Progression: Add ankle weights in sitting or standing to increase difficulty.
   For standing marching, challenge yourself by not relying on arm support to
   maintain your balance.


3) Bridging
 * Goal: to increase glute strength to improve force generation, step length,
   and gait speed
 * How-to: Lay down on your back with your knees bent and feet flat. Draw your
   stomach in and squeeze your glutes to lift your hips up without arching your
   lower back, then lower.
 * Progression: Add a resistance band around your knees to increase glute
   activation by abducting, or pushing your legs out, against the band.
   




4) Sit to Stand
 * Goal: to increase quadriceps and glute strength for improved leg strength and
   stability
 * How-to [https://www.youtube.com/watch?v=chw2oMUrh4U]: Sit in a chair, lean
   forward, and use your legs to stand up. Then slowly lower yourself back into
   the chair with control without “plopping.” Try not to use your arms to help
   push you up from the chair.
 * Progression: Add a resistance band around your knees to increase glute
   activation by abducting, or pushing your legs out, against the band, or lower
   the seat surface to make the movement more challenging.


5) Side Stepping
 * Goal: to increase glute activation and dynamic balance and stability with
   lateral weight shifting
 * How-to: Stand in front of a wall or counter to hold onto support if needed.
   Step to the side with one leg then follow with the other. Repeat several
   times, then change directions and repeat.
 * Progression: Add a resistance band around your knees to increase glute
   activation when side stepping. Challenge yourself by not relying on arm
   support to maintain your balance.




6) Forward to Backward Weight Shifting
 * Goal: to improve foot clearance, pelvis stability, and standing balance with
   weight shifting
 * How-to [https://www.youtube.com/watch?v=6mcW7CIvj3Q]: Stand next to a table,
   chair, wall, or other stable object for support. Weight shift forward by
   taking a step forward with one foot, then lift that leg up and move it back
   behind your body to weight shift backward. Repeat several times, then switch
   sides.
 * Progression: Add ankle weights to increase difficulty. Challenge yourself by
   not relying on arm support to maintain your balance.


7) Step-ups
 * Goal: to increase hip flexor strength for improved foot clearance and step
   length, quadriceps and glute strength for improved force generation and gait
   speed, and pelvis stability and standing balance with weight shifting
 * How-to: Stand in front of a step. Step with one foot followed by the other,
   then step down. Repeat several times, then switch sides.
 * Progression: Challenge yourself by not relying on arm support to maintain
   your balance. Increase step height for added difficulty.
   




References
Wang, Yijia, et al. (2020). Gait characteristics of post-stroke hemiparetic
patients with different walking speeds. International Journal of Rehabilitation
Research. 43(1), 69-75. doi: 10.1097/MRR.0000000000000391




--------------------------------------------------------------------------------

Looking for a fun and effective way to exercise leg and core muscles for
improved walking outcomes? Check out the Neofect Smart Balance system for
therapy clinics here [https://www.neofect.com/us/smart-balance].

Physical Therapy

Walking After Stroke: 7 Exercises to Improve Strength and Balance

Having good balance after a brain injury is crucial. Here are 5 sitting and standing exercises that you can start today for improved performance and safety.

10 Exercises to Improve Balance After Brain Injury

A brain injury can be a life-changing event, in ways both big and small. There
are many different causes of brain injuries, which include not only concussions
and traumatic brain injuries, but also events such as a stroke. Depending on the
severity of the brain injury and where in the brain the injury occurred, the
ability to balance may be affected. It is important to address balance issues to
decrease the risk of falls and other associated injuries, such as broken bones.


Balance Problems After Brain Injury: An Overview
 * How a Brain Injury Affects Balance
 * How to Improve Balance After Brain Injury
 * 5 Seated Exercises to Improve Balance
 * 5 Standing Exercises to Improve Balance

Balance problems including dizziness or lightheadedness may come on suddenly
after brain injury. You can make your daily activities safer by inviting a
supportive companion and identifying places to rest if needed. Post-Brain Injury Balance Disorders
Balance is a key part of everyday life and involves the coordination of many
different systems within our bodies. We use our ability to balance for
everything; from sitting and standing upright to walking and performing daily
tasks such as, cooking, cleaning, and self-care. Common balance disorders after
a brain injury may include:

 * A sensation of dizziness where it may seem as if you or your surroundings are
   moving.
 * Unsteadiness when standing upright and walking
 * Lightheadedness and associated unsteadiness

Issues with balance can occur as a result of damage to structures within the
inner ear (vestibular system), difficulty with eyesight (vision), or damage to
parts of the brain that help us sense where our body is in space
(proprioception). After a brain injury, most patients will work with their
doctor to determine the specific cause of imbalance. The doctor will monitor
things such as blood pressure and medication use, to ensure that these are not
contributing factors to a patient’s symptoms.



 Improving Balance After a Brain Injury
Some patients may attend physical therapy to begin working on improving their
balance. A therapist will perform a detailed evaluation in order to establish a
personalized treatment plan for each patient. Prescribed treatment and exercises
will then be performed to help improve symptoms. It is important to address both
strength and flexibility when exercising, since our bodies use different
strategies from various muscle groups to help us stay upright.

 5 Seated Strengthening Exercises to Improve Balance
 1. Practice sitting upright without support so that you have to use your core
    muscles. If this is easy, you can attempt to reach up, down, and to the
    side, and then return to center.



 2. If sitting on a stable surface (such as a hard chair) and reaching is also
    too easy, you can practice sitting on a less stable surface to further
    challenge your balance. For example, sit on a soft cushion, then progress to
    something like a big therapy ball. Be sure to stay in a corner or near a
    stable surface, so that you may have something to hold onto for safety as
    needed.
    
    
 3. Ankle exercises are also important because the muscles in our ankles are
    often some of the first to contract when we experience a loss of balance.
    Ankle exercises include performing heel raises and toe raises when sitting.
    You can also make circles, or trace the alphabet with your foot. Just be
    sure to hold your leg still so the movement is isolated only to the ankle
    joint and not the hip or knee joints.
    
    
    
 4. Practice moving from sitting to standing to strengthen your hip muscles.
    Use a light resistance band placed around the upper thighs to practice 
    clamshells
    [https://www.healthline.com/health/fitness-exercise/the-clamshell-exercise].
    A clamshell exercise can be performed by opening and closing the legs to
    work the outer hip muscles.
    
    
 5. Place a pillow between your knees and practice squeezing the pillow. Hold
    each squeeze for five seconds. This exercise will work the inner thigh
    muscles. Work up to performing three sets of ten repetitions of each
    exercise.
    
    

 5 Standing Exercises to Improve Strength and Balance
 1. Stretch your calf muscles to provide enough motion at the ankle joint for
    walking and balancing. You can use a stair at home and let one heel hang off
    the stair while holding onto the railing. Or you can perform a “Runner’s
    Stretch
    [https://www.popsugar.com/fitness/photo-gallery/3102547/image/3102808/Wall-Calf-Stretch]
    ” at the wall. Hold each stretch for 30-60 seconds.
 2. Perform the heel and toe raises for ankle strengthening in standing vs.
    sitting for added resistance.
    
 3. Perform “mini squats [https://www.youtube.com/watch?v=X8XutSsocx4]” at a
    support surface, such as the counter or back of a sofa. Be sure to send your
    bottom backwards as if you are sitting in an invisible chair, so that your
    knees do not go over your toes.
 4. Challenge your balance in standing. First, stand with your feet together. If
    this is easy, you can switch your foot position and place one foot in front
    of the other so the heel of your front foot touches the toes of your back
    foot. Progress to standing on one foot
    [https://www.youtube.com/watch?v=7SF7AYh2_Yw] when you are ready. Try to
    hold each position for at least 30 seconds. You can make this activity even
    more challenging by closing your eyes, or performing head turns or nods
    while attempting to balance.
 5. Perform reaching in standing and try to move your arms and body over your
    feet without moving your feet. You can practice reaching up, down, and side
    to side. To make exercises four and five even more challenging, you can try
    standing and reaching on an unstable surface. For example, place a couch
    cushion on the floor and try balancing and reaching while standing on the
    cushion.

Always have family member or friend supervise for safety during balance
exercises.
As with any physical activity, please make sure you have been cleared by your
doctor before starting a new exercise routine. Also, because you will be
challenging your balance, please make sure that you perform these activities
with a caregiver or near a stable surface that can provide support to prevent
falls or additional injury.  Balance work can be challenging, but it will make a
difference in your ability to perform daily activities safely and independently.


Call (888) 623-8984 or email info@neofect.com to rehab smarter with Neofect
today!

Balance

Last week we talked a bit about how balance can be seriously affected after a stroke, and we began to talk about things you can do to improve your balance and overall safety. Before we get to some more strategies to improve your balance, let’s talk about some differences in types of balance that may affect you.

Improving Balance After Stroke - Part 2

Last week we talked a bit about how balance can be seriously affected after a
stroke, and we began to talk about things you can do to improve your balance and
overall safety. Look back here
[https://blog.neofect.com/regaining-balance-after-a-stroke-part-1/] if you would
like to take a few minutes to refresh yourself on the first few balance
strategies!

Remember, each person may experience balance difficulties in a different way
after having a stroke. To experience the most well-rounded gains, you may want
to choose a few options from the list for improving your balance and safety.
Always consult with your physician and/or therapist before starting a new
exercise program, especially after a stroke. While advocating for yourself, be
sure to explain what your plans are for addressing balance so that you can
collaborate with your practitioner and make decisions that are the best and
safest for you!



Types of balance
Before we get to some more strategies to improve your balance, let’s talk about
some differences in types of balance that may affect you.

Sitting balance: your ability to keep yourself steady while accomplishing a task
from a seated position (in a chair, wheelchair, or at the edge of the bed, for
example)

Standing balance: your ability to keep yourself upright while accomplishing
tasks while up on your feet

Static balance: keeping control of your upright position while not moving around
(for example, sitting on a stool at the counter waiting for the coffee to brew,
or standing still holding a walker while looking into the closet for your
clothes)

Dynamic balance: maintaining steadiness while body parts are in motion/changing
position (for example, keeping steady while bending to load dishes into the
dishwasher, or controlling your body while sitting and putting on your socks)

Your body’s needs for postural control can change frequently throughout a given
task, requiring you to change from sitting to standing, or from static to more
dynamic stability, depending on the demands of each activity you are trying to
accomplish. For example, you may start off your day sitting in a static position
on the edge of your bed while you open your eyes and think about the day ahead.
While you reach toward the ground to grab and put on your slippers, your sitting
balance becomes dynamic. When you stand to look out the window at the weather,
you are more static, and then when you reach into the closet and shift your
weight to put on your robe, your standing balance becomes more dynamic. It is
important to address all types of balance so that you have more control over
your position and maximize your safety throughout all of the day’s tasks.

Balance Strategies
Here are some additional strategies to improve your balance, whether you are
sitting or standing, and whether you are more still or moving about.

Address the vision component
In some cases, a stroke can impact a person’s vision in some fairly complex
ways. When this happens, survivors may have difficulty using their eyes to fully
scan and track in their environment, or they may start to feel dizzy or see
double with slight movements of their eyes. They also may experience a visual
neglect, where the brain is not giving them proper signals to fully notice
objects in part of their environment. All of these complicated scenarios can
make it difficult to stay upright in an ever-changing environment with multiple
different task demands.

Working on specific vision-related exercise programs set by your therapist can
help to reduce the impact these deficits can have. Your OT is specially equipped
to recommend how to improve your ability to fully and steadily scan your entire
environment, locate obstacles to avoid, and reduce dizziness/double vision to
make it easier to remain balanced while sitting, standing, and walking
throughout your activities. In the meantime, make sure you try to look back and
forth and take note of obstacles in your path that may be trip hazards.

Improve sensation, proprioception, and vestibular reactions
Along with the sense of vision, the body uses other complex senses to keep
itself upright. Our brains help us to take inputs from our body as we move about
in our environment, and put them all together to detect whether an arm is
outstretched enough to grasp the counter, whether we are steady or wavering, and
whether our feet feel firmly planted on the ground. After a stroke, these
signals can get mixed up and make it difficult to tell what our bodies are doing
to keep us upright.

Your therapist can describe a detailed plan to help you work on all of these
sensory skills. Some activities may include weight bearing to achieve better
input through your joints, practicing placing and holding various positions to
get a clearer sense of what is the “right” upright position to keep balanced,
and using various modalities for sensory reintegration in your feet, limbs, and
trunk so that you can feel the surfaces used to keep upright and remember how to
interact with your environment more safely.



Modify the environment or task
In many cases, your OT will recommend options to make your environment safer
[https://blog.neofect.com/fall-prevention-techniques-for-stroke-survivors/], as
well as offer ideas for how to approach a task so that you can still complete it
despite your impaired balance. While these strategies may not directly improve
your balance skills, they do maximize your potential for independence while you
are coping with decreased balance. Some examples may include:

 * Using various types of adaptive equipment in the home such as tub benches and
   grab bars, which can help you to perform a task more steadily
   
   
 * Performing a task while sitting instead of standing (such as sitting at a
   table to fold laundry) if your sitting balance is better than your standing
   balance
   
   
 * Moving closer to an activity before reaching to keep a better base of support
   and avoid more challenging dynamic balance if needed (such as stepping closer
   to a cabinet before opening the door)
   
   



Try yoga
The practice of yoga promotes improvements in strength, muscle tone,
flexibility, breathing patterns, reaction speed, and concentration. It can be
modified based on skill level and safety/positional need (standing or sitting),
and can be taught at a one to one level, or in groups. It is relatively easy to
teach and perform, and research has shown that yoga intervention has improved
balance scores in post-stroke patients. (1, 2)

Here at Neofect, we want to support you in your unique rehabilitation journey.
Whatever strategies you choose, remember to think of your safety, and check in
with your regular physician and/or OT or PT to make sure your plan works best
for you.

References

Schmid, AA, et al. Poststroke balance improves with yoga: A pilot study. Stroke,
2012; 43: 2402-2407.

Hinsey, K, et al. Merging yoga and occupational therapy to improve balance and
fall risk factor management: A pilot study. American Journal of Occupational
Therapy, 2016; 70(4): 7011515237p1-7011515237p1.

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.

Stroke Recovery

Improve Balance After Stroke: Part 2

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.

Regaining Balance After a Stroke - Part 1

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
[https://blog.neofect.com/fall-prevention-techniques-for-stroke-survivors/].
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 [https://blog.neofect.com/hemiplegia-vs-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!

Strengthening
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)



Concentrating
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.

Moving slowly
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!

References

 1. Schmid AA, et al. Fear of falling in people with chronic stroke. American
    Journal of Occupational Therapy, 2015; 69(3): 6903350020p1-6903350020p5.
    
    
 2. Tyson SF, et al. Balance disability after stroke. Physical Therapy, 2006;
    86(1): 30-8.
    
    
 3. Lexico.com (powered by Oxford)
    
    
 4. 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.
    
    
 5. 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
[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.