Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study

doi:10.1016/j.apmr.2003.05.012

Archives of Physical Medicine and Rehabilitation

Volume 85, Issue 6, June 2004, Pages 886-895

Presented in part at the XVth Congress of International Society of Postural and Gait Research, June 23–27, 2001, Maastricht, the Netherlands.

https://doi.org/10.1016/j.apmr.2003.05.012 Get rights and content

Abstract

de Haart M, Geurts AC, Huidekoper SC, Fasotti L, van Limbeek J. Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study. Arch Phys Med Rehabil 2004;85:886–95.

Objective

To identify and interrelate static and dynamic characteristics of the restoration of quiet standing balance in a representative sample of stroke survivors in the Netherlands during their inpatient rehabilitation.

Design

Exploratory study using an inception cohort with findings related to reference values from healthy elderly persons.

Setting

Rehabilitation center.

Participants

Thirty-seven inpatients (mean age, 61.6y; mean time poststroke, 10.0wk) with a first hemispheric intracerebral infarction or hematoma who were admitted to retrain standing balance and walking.

Intervention

Individualized therapy.

Main outcome measures

Center of pressure fluctuations were registered under each foot and in the sagittal and frontal planes separately by using a dual-plate force platform. The first balance measurements took place as soon as patients were able to stand unassisted for at least 30 seconds as well as 2, 4, 8, and, 12 weeks later. Quiet standing was assessed under 4 conditions: with and without a visual midline reference, with the eyes closed, and while performing a concurrent arithmetic task.

Results

The stroke patients showed excessive postural sway and instability, particularly in the frontal plane, compared with reference values. Frontal plane balance was, however, also most responsive to the effects of balance training and recovery (P<.001). The degree of visual dependency for frontal plane balance control showed a significant reduction in time (P<.02). Weight-bearing asymmetry, which was most pronounced in patients with disturbed sensibility or ankle clonus, diminished considerably during the first 4 weeks of the follow-up period (P<.02). Yet, a substantial degree of weight-bearing asymmetry persisted during the 8 weeks thereafter, and it continued to be aggravated by attentional distraction (P<.001). During the same period, static asymmetry (ie, the degree of pes equinovarus loading at the paretic side) and dynamic asymmetry (ie, the extent to which compensatory ankle moments are applied at the nonparetic side) did not show normalization at all, although motor selectivity of the paretic leg improved by 1 stage on the 6-stage Brunnstrom scale (P<.001) and the independency level of balance and walking skills improved by 2 points on the 6-point Functional Ambulation Categories (P<.001).

Conclusions

Balance recovery in postacute stroke inpatients is characterized by a reduction in postural sway and instability as well as by a reduction in visual dependency, particularly with regard to frontal plane balance. These restoration characteristics may be important factors underlying the relearning of independent standing and walking abilities. The clear lack of normalization for measures reflecting static and dynamic aspects of postural asymmetry suggests that the functional improvements in balance and gait must be more related to other mechanisms than to the restoration of support functions and equilibrium reactions of the paretic leg.

Section snippets

Participants

All patients with a first hemispheric intracerebral infarction or hematoma admitted to our rehabilitation clinic from November 1998 until November 2000 for retraining motor skills and self-care abilities were eligible. Patients who on admission already walked safely and patients with medication or nonstroke-related sensory or motor impairments that could interfere with their postural regulation were excluded. Basing our decisions on practical assessment, we also excluded patients with

Cohort

Five follow-up assessments were completed in 37 stroke patients. Patients’ biologic characteristics are in table 1. At the start of the balance training, 24 patients (65%) had a disturbed sensibility in their paretic leg, 19 patients (51%) had an ankle clonus, and 22 patients (59%) had a disturbed trunk control. In 16 patients (43%), some degree of visuospatial hemineglect was found. As for the functional measures, the median Brunnstrom stage was IV (range, II-VI) at the start of the balance

Discussion

The primary goal of this study was to identify and interrelate both static (ie, related to COP position) and dynamic (ie, related to COP movement) characteristics of the restoration of standing balance in a representative group of first-ever stroke survivors during their inpatient rehabilitation in the Netherlands to better understand underlying mechanisms of functional recovery. Only 2 patients were coincidentally lost to follow-up.

As expected, the study sample was relatively young and

Conclusions

To our knowledge, this is the largest study aimed at the recovery of postural characteristics of first-ever stroke survivors during their inpatient rehabilitation. Our results indicate that these patients suffer from severe postural instability as well as from several (both static and dynamic) aspects of postural asymmetry during quiet standing in the frontal and sagittal planes. Functional improvements during rehabilitation appear to be most prominent in the frontal plane, as indicated by a

Acknowledgements

We thank Bart Nienhuis for his technical assistance, and the Department of Physical Therapy and Ilse van Nes for help during the posturographic assessments.

References (49)

R. Dickstein et al.
Postural sway of the affected and nonaffected pelvis and leg in stance of hemiparetic patients
Arch Phys Med Rehabil
(2000)
R.P. Di Fabio
Lower extremity antagonist muscle response following standing perturbation in subjects with cerebrovascular disease
Brain Res
(1987)
R.P. Di Fabio et al.
Kinematic properties of voluntary postural sway in patients with unilateral primary hemispheric lesions
Brain Res
(1990)
F. Benvenuti et al.
Kinematic characteristics of standing disequilibriumreliability and validity of a posturographic protocol
Arch Phys Med Rehabil
(1999)
A.C. Geurts et al.
Intrasubject variability of selected force-platform parameters in the quantification of postural control
Arch Phys Med Rehabil
(1993)
A.C. Geurts et al.
Is postural control associated with mental functioning in the persistent postconcussion syndrome?
Arch Phys Med Rehabil
(1999)
N. Teasdale et al.
Attentional demands for postural controlthe effects of aging and sensory reintegration
Gait Posture
(2001)
S. Niam et al.
Balance and physical impairments after stroke
Arch Phys Med Rehabil
(1999)
M.C. Dault et al.
Influence of a visuo-spatial, verbal and central executive working memory task on postural control
Gait Posture
(2001)
T. Mulder et al.
Assessment of motor recovery and decline
Gait Posture
(2002)

M. Woollacott et al.

Attention and the control of posture and gaita review of an emerging area of research

Gait Posture

(2002)

G.G. Simoneau et al.

Role of somatosensory input in the control of human posture

Gait Posture

(1995)

P.T. Cheng et al.

Symmetrical body-weight distribution training in stroke patients and its effect on fall prevention

Arch Phys Med Rehabil

(2001)

A. Shumway-Cook et al.

Postural sway biofeedbackits effect on reestablishing stance stability in hemiplegic patients

Arch Phys Med Rehabil

(1988)

C.J. Winstein et al.

Standing balance trainingeffect on balance and locomotion in hemiparetic adults

Arch Phys Med Rehabil

(1989)

J. Mizrahi et al.

Postural stability in stroke patientsvectorial expression of asymmetry, sway activity and relative sequence of reactive forces

Med Biol Eng Comput

(1989)

C.M. Sackley

Falls, sway, and symmetry of weight-bearing after stroke

Int Disabil Stud

(1991)

G. Rode et al.

Predominance of postural imbalance in left hemiparetic patients

Scand J Rehabil Med

(1997)

Y. Laufer et al.

Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights

Clin Rehabil

(2000)

M.B. Badke et al.

Patterns of rapid motor responses during postural adjustments when standing in healthy subjects and hemiplegic patients

Phys Ther

(1983)

H. Petersen et al.

Auditory feedback regulation of perturbed stance in stroke patients

Scand J Rehabil Med

(1996)

R.R. Holt et al.

Ground reaction force after a sideways push as a measure of balance in recovery from stroke

Clin Rehabil

(2000)

T. Mulder et al.

Recovery of motor skill following nervous system disordersa behavioural emphasis

Baillieres Clin Neurol

(1993)

C. Owsley et al.

Timed instrumental activities of daily living tasksrelationship to cognitive function and everyday performance assessments in older adults

Gerontology

(2002)

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Maintaining upright posture in quiet standing is an important skill that is often disrupted by stroke. Despite extensive study of human standing, current understanding is incomplete regarding the muscle coordination strategies that produce the ground-on-foot force (F) that regulates translational and rotational accelerations of the body. Even less is understood about how stroke disrupts that coordination. Humans produce sagittal plane variations in the location (center of pressure, xCP) and orientation (Fx/Fz) of F that, along with the force of gravity, produce sagittal plane body motions. As F changes during quiet standing there is a strong correlation between the xCP and Fx/Fz time-varying signals within narrow frequency bands. The slope of the correlation varies systematically with frequency in non-disabled populations, is sensitive to changes in both environmental and neuromuscular control factors, and emerges from the interaction of body mechanics and neural control. This study characterized the xCP versus Fx/Fz relationship as frequency-dependent Intersection Point (IP) heights for the paretic and non-paretic legs of individuals with history of a stroke (n = 12) as well as in both legs of non-disabled controls (n = 22) to reveal distinguishing motor coordination patterns. No inter-leg difference of IP height was present in the control group. The paretic leg IP height was lower than the non-paretic, and differences from control legs were in opposite directions. These results quantify disrupted coordination that may characterize the paretic leg balance deficit and non-paretic leg compensatory behavior, providing a means of monitoring balance impairment and a target for therapeutic interventions.
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ArticleRecovery of standing balance in postacute stroke patients: a rehabilitation cohort study1

Abstract

Objective

Design

Setting

Participants

Intervention

Main outcome measures

Results

Conclusions

Section snippets

Participants

Cohort

Discussion

Conclusions

Acknowledgements

Arch Phys Med Rehabil

Brain Res

Brain Res

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Arch Phys Med Rehabil

Gait Posture

Arch Phys Med Rehabil

Gait Posture

Gait Posture

Gait Posture

Gait Posture

Arch Phys Med Rehabil

Postural sway biofeedbackits effect on reestablishing stance stability in hemiplegic patients

Arch Phys Med Rehabil

Standing balance trainingeffect on balance and locomotion in hemiparetic adults

Arch Phys Med Rehabil

Postural stability in stroke patientsvectorial expression of asymmetry, sway activity and relative sequence of reactive forces

Med Biol Eng Comput

Falls, sway, and symmetry of weight-bearing after stroke

Int Disabil Stud

Predominance of postural imbalance in left hemiparetic patients

Scand J Rehabil Med

Weight-bearing shifts of hemiparetic and healthy adults upon stepping on stairs of various heights

Clin Rehabil

Patterns of rapid motor responses during postural adjustments when standing in healthy subjects and hemiplegic patients

Phys Ther

Auditory feedback regulation of perturbed stance in stroke patients

Scand J Rehabil Med

Ground reaction force after a sideways push as a measure of balance in recovery from stroke

Clin Rehabil

Recovery of motor skill following nervous system disordersa behavioural emphasis

Baillieres Clin Neurol

Timed instrumental activities of daily living tasksrelationship to cognitive function and everyday performance assessments in older adults

Gerontology

Article
Recovery of standing balance in postacute stroke patients: a rehabilitation cohort study¹