NIHR Signal Exercise therapy may still improve balance when started a long time after a stroke

Published on 15 November 2016

Exercise therapy may improve balance for people in the chronic phase of recovery six or more months after stroke. The most effective training regimens seem to be those that focus on balance, weight shifting and gait training. Though significant, the improvements in function may still be small.

Often little recovery can be expected beyond six months of stroke, and available treatments may be limited. This review found that exercise therapy in this population gave small improvements, generally in the scale of a few points on a scale of about 50, depending on the balance test used.

This review included a large number of small trials, but most were high quality studies. They assessed a variety of interventions, many of which may not be routinely available to people in the chronic phase of stroke in the NHS. Nevertheless, this research provides useful information for patients and health professionals that late improvements in balance in the chronic phase of stroke are possible.

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Why was this study needed?

Around 110,000 people in England have a stroke every year. Approximately half will depend on care and help with daily activities after stroke, with balance problems common. Rehabilitation aims to help people regain function and independence.

In the first two to three months following a stroke there can be some recovery of function, but little if any further recovery is expected beyond six months. Therefore, knowing the effects of exercise therapy in this “chronic” ongoing phase is important.

Previous studies on this topic have been inconclusive and have not looked at whether training effects differ depending on whether it’s the acute or chronic stage after stroke. It is also unclear which type of training is most effective. This review investigated the effects of exercise therapy on balance capacity for people in the chronic stage after a stroke.

What did this study do?

This systematic review and meta-analysis identified 43 randomised controlled trials of adults in the chronic phase six months or more after stroke.

Exercise therapy, usually delivered by a physiotherapist, had to be targeted towards restoring function or reducing pain. Electric devices such as treadmills could be used; assistive devices like walkers could not. Training duration in total varied widely across trials, from two to 62 hours in split sessions.

Balance capacity was the ability to achieve balance in any posture. Studies measured this using different tests, such as the Berg Balance Scale (designed to measure balance of older adults in a clinical setting) and Sensory Organization Test (providing information on the impairments underlying balance problems, such as vision). Outcomes were pooled when at least three studies had used the same test.

Despite being small, the thirty-four studies included were considered high quality and nine were moderate quality, suggesting we can have confidence in the results.

What did it find?

  • Exercise therapy significantly improved balance scores immediately after the intervention as measured on three tests:
    • The Berg Balance Scale (see Definitions): mean difference (MD) 2.22 points, 95% confidence interval (CI) 1.26 to 3.17 (28 trials, 985 participants). The scale is a 56 point scale and an 8 point change is considered an important difference.
    • The Functional Reach Test: MD 3.12 cm, 95% CI 0.90 to 5.35 (5 trials, 153 participants).
    • The Sensory Organization Test: MD 6.77%, 95% CI 0.83 to 12.7 (4 trials, 173 participants).
  • Exercise therapy had no significant effect on Postural Sway Velocity in three studies measuring this outcome (89 people).
  • One to five months after the exercise therapy intervention, significant improvements were still seen on the Berg Balance Scale (MD 1.65 points, 95% CI 0.22 to 3.07; 8 trials, 338 participants) and Sensory Organization Test (MD 3.91%, 95% CI 0.10 to 7.73; 3 trials, 151 participants).
  • Looking at the type of exercise therapy, significant improvements on the Berg Balance Scale were seen immediately after balance and/or weight-shift training (3.75 points, 95% CI 1.71 to 5.78) and gait training (2.26 points, 95% CI 0.94 to 3.58) but not after multisensory training or high intensity aerobic training. Intensity of training had no effect on Berg Balance Scale improvement.

What does current guidance say on this issue?

NICE 2013 guidance on stroke rehabilitation recommends physiotherapy for people who have weakness, sensory problems or balance difficulties that affect function. Forty-five minute rehabilitation sessions on at least five days a week are recommended initially after stroke. Intensity may then be tailored to the person’s needs if more rehabilitation is needed at a later stage.

Therapy is advised to continue until the person is able to maintain or progress function either independently or with assistance from others.

SIGN’s 2010 guidance on management of stroke recommends the following for gait, balance and mobility problems: ankle foot orthoses, individualised interventions, gait-orientated physical fitness training, muscle strength training and increased intensity of rehabilitation. 

What are the implications?

This review found that for people in the chronic phase following a stroke, balance capacity can be improved slightly by exercise therapy. Evidence suggests the most effective training regimens were those that focused on balance, weight shifting and gait training. Rehabilitation programs focused on improving balance could try these interventions.

However, the trials were small, assessed outcomes on various scales, and used a variety of interventions which may not be routinely available to this population in the NHS.

The review provides useful information for patients and health professionals that late improvements in balance in the chronic phase of stroke are possible, though the benefits may be small.

Citation and Funding

van Duijnhoven HJ, Heeren A, Peters MA, et al. Effects of exercise therapy on balance capacity in chronic stroke: systematic review and meta-analysis. Stroke. 2016;47(10):2603-10.

This project was funded by a grant from The Netherlands Organization for Scientific Research (NOW).

Bibliography

NHS Choices. Stroke. London. Department of Health; 2014.

NICE. Stroke rehabilitation in adults. CG162. London. National Institute for Health and Care Excellence; 2013.

NICE. Stroke in adults. QS2. London. National Institute for Health and Care Excellence; 2010.

SIGN. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. 118. Edinburgh. Scottish Intercollegiate Guidelines Network; 2010.

Why was this study needed?

Around 110,000 people in England have a stroke every year. Approximately half will depend on care and help with daily activities after stroke, with balance problems common. Rehabilitation aims to help people regain function and independence.

In the first two to three months following a stroke there can be some recovery of function, but little if any further recovery is expected beyond six months. Therefore, knowing the effects of exercise therapy in this “chronic” ongoing phase is important.

Previous studies on this topic have been inconclusive and have not looked at whether training effects differ depending on whether it’s the acute or chronic stage after stroke. It is also unclear which type of training is most effective. This review investigated the effects of exercise therapy on balance capacity for people in the chronic stage after a stroke.

What did this study do?

This systematic review and meta-analysis identified 43 randomised controlled trials of adults in the chronic phase six months or more after stroke.

Exercise therapy, usually delivered by a physiotherapist, had to be targeted towards restoring function or reducing pain. Electric devices such as treadmills could be used; assistive devices like walkers could not. Training duration in total varied widely across trials, from two to 62 hours in split sessions.

Balance capacity was the ability to achieve balance in any posture. Studies measured this using different tests, such as the Berg Balance Scale (designed to measure balance of older adults in a clinical setting) and Sensory Organization Test (providing information on the impairments underlying balance problems, such as vision). Outcomes were pooled when at least three studies had used the same test.

Despite being small, the thirty-four studies included were considered high quality and nine were moderate quality, suggesting we can have confidence in the results.

What did it find?

  • Exercise therapy significantly improved balance scores immediately after the intervention as measured on three tests:
    • The Berg Balance Scale (see Definitions): mean difference (MD) 2.22 points, 95% confidence interval (CI) 1.26 to 3.17 (28 trials, 985 participants). The scale is a 56 point scale and an 8 point change is considered an important difference.
    • The Functional Reach Test: MD 3.12 cm, 95% CI 0.90 to 5.35 (5 trials, 153 participants).
    • The Sensory Organization Test: MD 6.77%, 95% CI 0.83 to 12.7 (4 trials, 173 participants).
  • Exercise therapy had no significant effect on Postural Sway Velocity in three studies measuring this outcome (89 people).
  • One to five months after the exercise therapy intervention, significant improvements were still seen on the Berg Balance Scale (MD 1.65 points, 95% CI 0.22 to 3.07; 8 trials, 338 participants) and Sensory Organization Test (MD 3.91%, 95% CI 0.10 to 7.73; 3 trials, 151 participants).
  • Looking at the type of exercise therapy, significant improvements on the Berg Balance Scale were seen immediately after balance and/or weight-shift training (3.75 points, 95% CI 1.71 to 5.78) and gait training (2.26 points, 95% CI 0.94 to 3.58) but not after multisensory training or high intensity aerobic training. Intensity of training had no effect on Berg Balance Scale improvement.

What does current guidance say on this issue?

NICE 2013 guidance on stroke rehabilitation recommends physiotherapy for people who have weakness, sensory problems or balance difficulties that affect function. Forty-five minute rehabilitation sessions on at least five days a week are recommended initially after stroke. Intensity may then be tailored to the person’s needs if more rehabilitation is needed at a later stage.

Therapy is advised to continue until the person is able to maintain or progress function either independently or with assistance from others.

SIGN’s 2010 guidance on management of stroke recommends the following for gait, balance and mobility problems: ankle foot orthoses, individualised interventions, gait-orientated physical fitness training, muscle strength training and increased intensity of rehabilitation. 

What are the implications?

This review found that for people in the chronic phase following a stroke, balance capacity can be improved slightly by exercise therapy. Evidence suggests the most effective training regimens were those that focused on balance, weight shifting and gait training. Rehabilitation programs focused on improving balance could try these interventions.

However, the trials were small, assessed outcomes on various scales, and used a variety of interventions which may not be routinely available to this population in the NHS.

The review provides useful information for patients and health professionals that late improvements in balance in the chronic phase of stroke are possible, though the benefits may be small.

Citation and Funding

van Duijnhoven HJ, Heeren A, Peters MA, et al. Effects of exercise therapy on balance capacity in chronic stroke: systematic review and meta-analysis. Stroke. 2016;47(10):2603-10.

This project was funded by a grant from The Netherlands Organization for Scientific Research (NOW).

Bibliography

NHS Choices. Stroke. London. Department of Health; 2014.

NICE. Stroke rehabilitation in adults. CG162. London. National Institute for Health and Care Excellence; 2013.

NICE. Stroke in adults. QS2. London. National Institute for Health and Care Excellence; 2010.

SIGN. Management of patients with stroke: Rehabilitation, prevention and management of complications, and discharge planning. 118. Edinburgh. Scottish Intercollegiate Guidelines Network; 2010.

Effects of Exercise Therapy on Balance Capacity in Chronic Stroke: Systematic Review and Meta-Analysis

Published on 17 September 2016

van Duijnhoven, H. J.,Heeren, A.,Peters, M. A.,Veerbeek, J. M.,Kwakkel, G.,Geurts, A. C.,Weerdesteyn, V.

Stroke , 2016

BACKGROUND AND PURPOSE: The purpose of this systematic review and meta-analysis was to investigate the effects of exercise training on balance capacity in people in the chronic phase after stroke. Furthermore, we aimed to identify which training regimen was most effective. METHODS: Electronic databases were searched for randomized controlled trials evaluating the effects of exercise therapy on balance capacity in the chronic phase after stroke. Studies were included if they were of moderate or high methodological quality (PEDro score >/=4). Data were pooled if a specific outcome measure was reported in at least 3 randomized controlled trials. A sensitivity analysis and consequent subgroup analyses were performed for the different types of experimental training (balance and/or weight-shifting training, gait training, multisensory training, high-intensity aerobic exercise training, and other training programs). RESULTS: Forty-three randomized controlled trials out of 369 unique hits were included. A meta-analysis could be conducted for the Berg Balance Scale (28 studies, n=985), Functional Reach Test (5 studies, n=153), Sensory Organization Test (4 studies, n=173), and mean postural sway velocity (3 studies, n=89). A significant overall difference in favor of the intervention group was found for the Berg Balance Scale (mean difference 2.22 points (+3.9%); 95% confidence interval [CI], 1.26-3.17; P<0.01; I2=52%), Functional Reach Test (mean difference=3.12 cm; 95% CI, 0.90-5.35; P<0.01; I2=74%), and Sensory Organization Test (mean difference=6.77 (+7%) points; 95% CI, 0.83-12.7; P=0.03; I2=0%). Subgroup analyses of the studies that included Berg Balance Scale outcomes demonstrated a significant improvement after balance and/or weight-shifting training of 3.75 points (+6.7%; 95% CI, 1.71-5.78; P<0.01; I2=52%) and after gait training of 2.26 points (+4.0%; 95% CI, 0.94-3.58; P<0.01; I2=21, whereas no significant effects were found for other training regimens. CONCLUSIONS: This systematic review and meta-analysis showed that balance capacities can be improved by well-targeted exercise therapy programs in the chronic phase after stroke. Specifically, balance and/or weight-shifting and gait training were identified as successful training regimens.

The Berg Balance Scale was developed to measure balance among older people with impairment in balance function by assessing the performance of functional tasks.

A change of eight points is thought to imply a genuine change in function between two assessments among older people who are dependent on care and living in residential care facilities.

It is a 14-item scale (ranging from 0-4, total score possible 56) designed to measure balance of the older adult in a clinical setting. It takes 15 to 20 minutes to complete.

Interpretation:

  • 41-56 = low fall risk
  • 21-40 = medium fall risk
  • 0 –20 = high fall risk

Expert commentary

This excellent review is a combination of predominately small trials using a variety of interventions, many of which are not available in the NHS at a time when often no treatment at all is available for chronic stroke. So the ability to translate it directly to the NHS are currently limited but the concept that late improvements can be of significance to patients is a very important one to therapists and patients. It is a good basis for a definitive trial.

Professor Catherine Sackley, Chair in Rehabilitation & Head of Physiotherapy, Kings College London

Categories

  •   Stroke, Physical therapy