Balance Training After Stroke

Why balance goes after a stroke

Balance is not one skill. It depends on muscles strong enough to correct a sway, sensation in the feet that tells the brain where the floor is, vision, the inner ear, attention, and confidence. A stroke can affect several of these at once. Someone may have a reasonably strong leg yet fall because they cannot feel the weak foot. Another person has good feeling but does not notice things on their left side, which is common with left-sided weakness, and walks into the door frame.

A small group of people actively push themselves towards the weak side and resist being straightened, which can look like stubbornness to the family. It's a recognised problem called pusher behaviour, and it needs specific handling by the physiotherapist rather than more effort from the family.

This is why balance issues after stroke are assessed before any exercise is chosen. The cause shapes the training.

Make the space fall-safe before you start

Every balance exercise involves a deliberate small risk of losing balance. That is how the system learns. So the set-up has to make a loss of balance harmless. The best spot in most homes is a corner of the kitchen: a heavy counter in front to hold, a wall on one side, and a sturdy chair placed behind the person so they can sit straight down if needed.

• Helper stands slightly behind and to the weak side, close enough to hold the hip or a gait belt, not the arm.
• Floor dry and clear, no rug edges, and the person in rubber-soled footwear.
• Practice when the person is fresh, not straight after a heavy meal or late at night.
• Never practise standing balance alone until the physiotherapist has cleared it.

Sitting balance comes first

If someone cannot sit steadily on the edge of a bed, standing work will be unsafe and not very useful. Sitting balance practice is done on a firm surface (a firm bed edge or a chair without arms against the wall) with both feet flat on the floor and hips and knees at roughly right angles.

Start with simply sitting tall without the hands for support, then add slow shifts of weight from one buttock to the other. Next comes reaching: forward to a glass on a table, sideways to a box on the bed, across the body towards the weak side, and eventually down towards the floor to pick up a slipper. Each direction challenges balance differently. Reaching towards the weak side is usually hardest and most useful. The sitting balance exercises page shows several of these, and trunk strengthening after stroke builds the muscles that make them possible.

Balance training after stroke: standing progressions

Standing work moves through small steps, each one a little harder than the one before. We move on only when the current stage is steady and confident, which might take a few days or several weeks.

• Stage 1

  Standing at the counter holding with both hands, feet apart, weight shared evenly. Slow shifts of weight side to side and forward and back.

• Stage 2

  One hand on the counter, then fingertip touch only, then hands hovering just above it.

• Stage 3

  Feet closer together, then one foot slightly in front of the other, still within reach of the counter.

• Stage 4

  Turning the head to look over each shoulder, reaching for things at different heights, standing on a slightly softer surface such as a doormat, with the therapist present.

Closing the eyes or standing on one leg are much harder and are only added when the therapist judges it safe. The leg control exercises work alongside these stages, because a knee that buckles will undo any amount of balance practice.

Reaching and stepping practice

Most falls at home happen during movement, not while standing still: turning to answer the phone, reaching up to the kitchen shelf, stepping back from the wash basin. So balance training includes these exact movements. Reaching to cupboards at different heights while holding the counter. Stepping forward, back and sideways with each foot and returning to the start. Turning on the spot in small steps rather than twisting on one foot.

A physiotherapist may also practise reactive balance, gently nudging the person to see if they take a protective step. This is a skill in its own right and should only be done with a trained person. For people who need more freedom to practise without risk, overhead track training at our clinic lets them try harder tasks with a safety system holding them.

Dual-task practice: balance with a busy mind

Many people can stand and walk safely when concentrating, then wobble when someone speaks to them. Daily life rarely gives us single tasks. Once standing balance is steady, we add a second task: answering questions while standing at the counter, carrying a cup while walking a short distance, counting backwards in threes while stepping. This kind of practice matters most for people with memory and attention changes after stroke, and should be built up gradually.

When losing balance after stroke is a warning sign

A slow, gradual decline in balance over weeks usually means deconditioning, a new joint problem, a medicine change or fear after a near fall. It needs a review, not panic. A sudden change is different. If balance goes suddenly, especially with dizziness, new weakness, slurred speech, facial droop or vision loss, call 112 or 108 for an ambulance at once.

Falls also deserve a proper response. After any fall, even without injury, tell the physiotherapist. Fear of falling often makes people move less, which weakens them further, and older adults are more affected by this cycle, as described in stroke recovery in older adults. The fall risk calculator gives the family a rough idea of where things stand between visits.

Balance is one strand of a full stroke rehabilitation programme, and walking builds directly on it; the guide to walking after a stroke picks up from here. For how all of this fits together over time, see the main stroke recovery guide.

Frequently asked questions