Seven studies examined group exercise therapy26–32 that focused on static and dynamic balance as well as fostered continued exercise involvement and goal achievement.29,30 The remaining 4 studies22,23,25 investigated the effect of balance exercise in one-on-one sessions. One-on-one programs emphasized different components of balance training such as sitting, standing, walking, and stair climbing exercises while reaching and with altering base of support22; intense mobility training23; or using the Kinesthetic Ability Trainer (KAT; LLC, Vista, CA, USA) to alter surface and sensory conditions while standing.25
Seven studies reported some form of exercise progression. For group therapy, the number of repetitions, the height of the exercise step, and the ankle weights were gradually increased in 2 studies.26,27 Other forms of progression included increased intensity and duration of exercise31,32 as well as increased complexity.31 As for the one-on-one programs, in 1 study, training progressed from sitting, to standing, to walking while altering the base of support and using tilt boards.22 Alternatively, complexity and difficulty of tasks were increased as participants improved.23 The Kinesthetic Ability Trainer was introduced with a high level of stability that was gradually reduced as participants progressed.25
Two programs provided 3-month follow-up after thatintervention.23,29 In the remaining studies, participants were assessed at the end of the intervention program, which lasted 4 weeks,24,25 8 weeks,22,26–29 9 weeks,30 or 6 months.31,32
Program Dosage and Attrition
Most group programs met 2 times per week for 1-hour exercise sessions over 8 to 9 weeks.30 Three studies reported no attrition (100% adherence),26,27,29 Macko et al28 reported 9% attrition (for nonmedical reasons), and Huijbregts et al30 reported 20% attrition (2 of 10 participants left the study, 1 for health reasons). In 2 studies, participants met for 6 months either 2 times per week32 or 3 times per week31 for a 1-hour training session. Eighteen percent of the participants dropped out of the intervention in a study by Stuart et al,32 mostly due to transportation problems. However, in a study by Michael et al,31 3 of 10 participants left the study, all for medical reasons. Other studies assessed outcomes of one-on-one training programs provided for either 45- to 60-minute sessions 2 times per week for 8 weeks22 or for 50-minute sessions 2 to 5 times per week for 4 weeks.24 The programs by Fritz et al23 and Gok et al25 were especially intense and involved daily 3-hour sessions for 10 days23 or 5-d/wk sessions (20 minute per session) for 4 weeks25 in addition to 2 to 3 hours of conventional rehabilitation daily. All one-on-one programs reported no attrition.
These findings suggest that important changes in balance performance can be achieved in participants in the chronic stage poststroke even participants are more than 10 years after stroke. The training program could be one-on-one, short and intense (10 days), or in a group format, for a longer period of time (from 8 weeks up to 6 months) at a lower intensity. Two nonrandomized controlled trials also suggest that balance performance of these patients can deteriorate with usual care for 6 months32 or no care for 9 weeks.30
Previous reviews5,8 have shown the positive effect of balance training on balance performance of individuals poststroke based on a small body of literature published prior to 2006. With a large number of recent studies investigating balance training from 2006 till present, our systematic review confirms the importance of specificity of training and supports the use of balance exercises to improve balance performance for individuals with moderately severe stroke, at least in the short term. Based on this evidence, it is possible to provide practical recommendations for exercise prescription of balance training programs for individuals poststroke across the continuum of recovery.
How Much Do We Train Balance?
For participants in the acute stage, studies that demanded high frequency and duration of training also had a high dropout rate, mostly due to medical reasons or fatigue.11,12 These findings suggest that daily training sessions lasting 90 minutes or more for 5 times per week may be excessive for an individual in the acute stage of stroke. On the other hand, evidence supports an exercise pattern of 2 to 3 sessions per week for 40 to 120 minutes per session14–17 or 5 sessions per week for 45 to 60 minutes per session.11,12 Not only were the attrition rates of these groups much lower and mostly for nonmedical reasons, but the improvements in the adherent participants were very similar to those seen with more intensive approaches. According to the National Institute of Neurological Disorders and Stroke, in-patient rehabilitation programs often involve at least 3 hours of active therapy per day, 5 or 6 days per week.33 Our findings suggest that improvement can be achieved with less rigorous programs in the acute stage. In the chronic stage, however, intense programs were feasible, demonstrated excellent adherence, and remained partially effective after 3 months.23,25 Despite these promising results, the optimal intensity for training is still unknown. It is yet to be established what would be more efficient: a relatively long but less frequent program22,26–32 or short intense interventions.23,25
Questions remain regarding whether training is optimally accomplished in groups or using a one-on-one approach. While one-on-one programs had 100% adherence,22–25 drop-out rates in group interventions in those in the chronic stage were generally higher,28,30 especially in the longer programs.31,32 Eight studies implemented group therapy interventions and showed improved balance as well as patient satisfaction in patients in both the acute and chronic stages. No study has directly compared outcomes associated with group versus one-on-one training. For participants in the chronic stage, some studies had no control groups27,28,31; in other studies, both groups received group therapy.26,29 For participants in the acute stage, group exercises were compared with individual training that a control group received, and both groups improved.12 Two studies showed the advantage of group therapy over usual care32 or no care30; the difference in balance performance between groups was significant postintervention not only because participants in the exercise groups improved but also because performance of the control group deteriorated over time. These findings suggest that in order to obtain maximal benefits of group therapy, close monitoring of class participants and careful selection of inclusion criteria are necessary.
How Do We Measure Balance?
Fifteen studies used the BBS as their balance outcome measure.11,12,14,16,17,20–24,27,28,30–32 This consistency is particularly interesting in light of findings from a recent systematic review that identified a total of 68 balance tests in the 29 studies reviewed.6 Findings from our review provide strong evidence that the BBS is very sensitive to changes in the acute stage11,12,16,17 or in the chronic stage for individuals who started with a low BBS score (ie ≤35).21,23,28,31 Conversely, the value of using the BBS for individuals with higher scores is questionable. For participants with higher scores, it is unclear whether little improvement was made or whether the test was not sufficiently sensitive to demonstrate change.20,24,27,30 Another consideration related to the BBS is that the test does not consider the extent to which an individual relies on vision to maintain balance; hence, it may not be appropriate to demonstrate a change as a result of multisensorial training with visual deprivation.20
Limitations of This Review
This review was limited to studies published in English and found in 3 databases. The strength of the recommendations made in this systematic review is only as strong as the published research. No level I randomized controlled studies were found, 5 studies were categorized as level III, and 6 as level IV. In addition, most studies did not have adequate follow-up and some had very small samples. More often than not, participants were exposed to several treatments in addition to the balance exercises, making it difficult to attribute improvement to one specific intervention. Lastly, this review examined only balance outcomes. As important as balance performance is for individuals poststroke, it is only one factor among many that should be considered in interdisciplinary rehabilitation.
There is moderate evidence to suggest that balance performance can be improved with balance training for individuals in the acute stage poststroke. Although 5 studies11,13,14,16,17 support this conclusion, in all those studies both the control and the experimental groups improved; hence, this recommendation should be taken in caution. For individuals in the acute stage, moderate evidence also suggests the following: First, exercising for 90 minutes or more for 5 sessions per week may be excessive and may be more likely to cause adverse effects compared with less demanding training patterns.11,12 Second, intensive balance training performed 2 or 3 times per week may be sufficient to improve balance performance.14,16,17 As for individuals in the subacute and chronic stages, moderate evidence suggests that balance performance can be improved with intensive individualized balance training programs,22,23,25 as well as with group exercise programs performed 2 times per week.26–30,32 Finally, limited evidence indicates that balance performance of individuals late after stroke might deteriorate in the absence of an intervention.30,32
Our understanding of the effects of balance training poststroke will be enhanced if studies include individuals with different levels of severity (especially high severity), additional complications, or specific anatomical balance lesions (eg, cerebellar or vestibular lesions). More high-quality randomized controlled studies, wherein examiners are blinded to group assignment, are needed in order to determine a feasible and effective training dosage (frequency, duration, intensity) for individuals poststroke. In addition, there is a need for tools to assess changes in balance performance in higher-functioning individuals, as well as to identify the specific system underlying balance impairment. Finally, studies with long-term follow-up poststroke are needed to measure the effect of specific balance training on individuals’ participation in the community and fall prevention.
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*Langhammer et al reported their outcomes in two separate publications.14,15
*Eser and Yavuzer et al reported their outcomes in two separate publications.18,19
APPENDIX A: The American Academy of Cerebral Palsy and Developmental Medicine (AACPDM) Evidence Rating Criteria10
Keywords:© 2010 Neurology Section, APTA
balance; exercise; stroke; systematic review; training