HOLISTIC STROKE SOLUTIONS Episode 5: Counterintuitive Balance Training After Stroke

Counterintuitive Strategies for Balance Improvement After Stroke: A Science-Based Approach

Abstract

Traditional stroke rehabilitation often focuses on compensatory strategies and assistive devices. However, emerging research uncovers counterintuitive approaches that challenge traditional thinking and lead to better outcomes for balance recovery. This comprehensive review explores evidence-based strategies such as ankle mechanism optimization, barefoot training on uneven surfaces, selective brace removal, hip-pelvic strengthening, weighted gait training, and vestibular-visual integration. Each method is backed by current research and includes practical applications for stroke survivors, caregivers, and rehabilitation professionals.

Introduction

Balance rehabilitation is extremely important during stroke recovery and is closely linked to secondary injuries like falls. Early in recovery, stroke patients focus on regaining walking ability. However, traditional rehabilitation often emphasizes safety through compensation rather than restoring normal function. Recent neuroscience research suggests that counterintuitive strategies may better enhance neuroplasticity and functional recovery.

Stroke remains a major global health challenge, requiring comprehensive and innovative rehabilitation approaches to improve outcomes. This article offers evidence-based counterintuitive strategies that question traditional methods while ensuring safety through appropriate progression and monitoring.

Section 1: Ankle Mechanisms and Foot Mobility - The Foundation of Balance

The Critical Role of Ankle Dorsiflexion

Ankle dorsiflexion can activate brain areas in stroke patients, similar to walking (Yang et al., 2022). The ankle acts as the main balance strategy during small disturbances, making its function essential for postural stability.

Underlying Mechanisms:

The central controller uses sensory information to generate descending commands that produce corrective muscle forces to stabilize the body (Liu et al., 2021). The central nervous system (CNS) injuries post-stroke lead to muscle weakness and spasticity in the affected limb(s), often accompanied by drop foot and varus foot. Spasticity and connective tissue changes around the ankle limit dorsiflexion and interfere with balance and gait performance. Improving the functional range of dorsiflexion is essential in post-stroke rehabilitation (Ravichandran & Janakiraman, 2021).

Research Evidence:

A recent study found that robot-assisted and manual ankle stretching training yielded similar significant improvements in ankle properties and balance after a stroke. However, only the robot-assisted stretching training significantly improved spasticity and stiffness of dorsiflexion (Liu et al., 2021). Weight-bearing mobilization with movement (WBMWM) enhanced ROM of the ankle joint, balance, and gait function in patients with chronic stroke. It is believed that posterior talar glide and dorsiflexion of the ankle, combined with MWM, improved dorsiflexion, ankle joint stability, and gait movement (Kim et al., 2022).

Eversion Training: The Neglected Component

Counterintuitive Approach: Rather than focusing solely on dorsiflexion, comprehensive eversion training addresses the oft-neglected frontal plane stability that is crucial for dynamic balance.

Practical Applications:

1. Progressive Ankle Mobilization Protocol:
   
   
• Begin with passive posterior talar glides in weight-bearing positions
• Progress to active-assisted dorsiflexion with eversion emphasis
• Advance to resisted eversion in functional positions
2. Intelligent Stretching Protocol:
   
   
• Use velocity-controlled stretching where stretching speed inversely relates to joint resistance.
• Apply 20-minute daily sessions for optimal spasticity reduction
• Monitor for improvements in Modified Ashworth Scale scores

Section 2: Walking on Uneven Surfaces - Multi-System Balance Challenges

The Multi-System Challenge

Walking on uneven terrain is unique because the surfaces are typically compliant, non-uniform, and therefore unpredictable. Recovery of community mobility after stroke is critical because it is linked to the health benefits of increased physical activity, enhanced quality of life through active participation in life roles, and a reduced risk of depression (Carod-Artal et al., 2000). Real-world environments present diverse surface challenges that standard rehabilitation often fails to address. Walking on uneven surfaces challenges multiple physiological systems simultaneously, providing a comprehensive training stimulus that promotes better integration of balance systems than training on predictable, flat surfaces.

Multi-System Integration During Uneven Surface Walking

1. Somatosensory System Challenges:

• Variable ground contact requires constant adaptation of proprioceptive feedback.
• Foot and ankle mechanoreceptors must process rapidly changing surface information.
• Enhanced sensory discrimination promotes improved body awareness.

2. Visual System Demands:

• Increased visual scanning and processing requirements
• Integration of visual flow information with vestibular inputs
• Improved visuospatial processing for obstacle navigation

3. Vestibular System Activation:

• Head movements during surface negotiation challenge the vestibular-ocular reflex
• Dynamic balance corrections require vestibular-spinal integration
• Enhanced central processing of conflicting sensory information

4. Motor System Adaptations:

• Predictive motor control for anticipated surface changes
• Reactive balance responses to unexpected perturbations
• Improved inter-limb coordination and timing

Section 3: Barefoot Training on Uneven Surfaces - Sensory Reintegration

The Counterintuitive Principle

Real-world walking activity is vital for poststroke patients because it encourages their participation in the community and physical activity. Walking may also be related to adapting to different ground surface conditions (Nagai et al., 2022). Traditional rehabilitation typically takes place on predictable, flat surfaces. However, performing any balance exercise on an uneven surface like CobbleFoam immediately enhances the benefits of the movement. Because of the variability of the uneven surface, the brain and muscles are engaged more deeply to keep the body upright and balanced (OPTP, 2024).

Research Foundation:

After walking on uneven surfaces, it was confirmed that ankle muscle activity decreased during normal flat walking, which increased muscle efficiency. Additionally, improvements in gait balance ability during training on uneven surfaces were observed (Lee et al., 2015). Walking on uneven terrain causes significantly increased pelvic accelerations, but healthy young individuals show no significant change in head accelerations (Menz et al., 2003). Similar to the changes seen in step parameters, healthy adults modify their gait kinematics to enhance balance and avoid falls when walking on uneven terrain (MacLellan & Patla, 2006).

Mechanisms of Action:

1. Enhanced Proprioception: Uneven surfaces provide rich sensory feedback that promotes sensory reintegration
2. Motor Learning: Variable practice conditions enhance motor learning compared to constant practice
3. Muscle Coactivation: The deep intrinsic stability system of the foot-ankle-knee complex will be activated to a much greater degree, building strength and joint integrity

Progressive Protocol:

Phase 1: Static Balance on Foam (Weeks 1-2)

• Stand barefoot on medium-density foam with eyes open, then closed
• Progress from double-leg to single-leg stance
• Duration: 30 seconds to 2 minutes per trial

Phase 2: Dynamic Weight Shifts (Weeks 3-4)

• Weight shifts in all directions on the foam surface
• Add cognitive tasks (counting, word generation)
• Include head movements to challenge the vestibular system

Phase 3: Locomotor Training (Weeks 5-8)

• Walking barefoot on artificial grass surfaces (2cm height variance)
• Progress to natural terrain under supervision
• Include direction changes and obstacle navigation

Safety Considerations:

• Always maintain fall protection (harness systems or spotting)
• Begin with surfaces that provide moderate challenge without excessive risk
• Monitor for excessive fatigue, which may increase fall risk
• Progressis  based on individual tolerance and improvement

Section 3: Strategic Brace Removal - Promoting Neural Recovery

The Counterintuitive Concept

While ankle-foot orthoses (AFOs) provide immediate stability, the study results show significant increases in cadence, stride length, step length, and speed when using plastic AFOs compared to not using AFOs (Zareen et al., 2025). However, carefully timed periods without bracing may support better long-term recovery by encouraging active neural control and muscle activation.

When and How to Remove Braces Safely:

Criteria for Brace Removal Trials:

• Adequate voluntary dorsiflexion (>5 degrees active range)
• Minimal to moderate spasticity (Modified Ashworth Scale ≤2)
• Safe standing balance for >30 seconds
• Cognitive ability to follow safety instructions

Progressive Removal Protocol:

1. Seated Activities: Remove the brace during seated balance training
2. Supported Standing: Brief periods (2-5 minutes) in parallel bars
3. Dynamic Training: Specific exercises targeting ankle control
4. Functional Integration: Gradual integration into mobility training

Monitoring and Safety:

• Continuous assessment of fall risk
• Regular reassessment of muscle function
• Immediate brace reapplication if safety is compromised
• Documentation of progress and setbacks

Section 4: Hip-Pelvic Girdle and Gluteal Strengthening - The Proximal Foundation

Research Evidence for Hip-Centric Approach

Pelvic instability is common during standing and walking after a stroke. Inadequate muscle activation and poor movement control around the pelvis can cause difficulty with mobility and daily activities (Karthikbabu et al., 2018). Exercises that generated the highest gluteal muscle forces included: 12 RM split squat, single-leg Romanian deadlift (hip hinge), and single-leg hip thrust for gluteus maximus. For gluteus medius, exercises included side plank, 12 RM single-leg squat, and single-leg Romanian deadlift (hip hinge) (Ebert et al., 2017).

Underlying Mechanisms:

During anterior-posterior weight shifts, the forward trunk inclination with anterior pelvic tilt was encouraged to activate the gluteus maximus and the lower trunk abdominals. Pelvic stability in walk standing and step standing positions was achieved through dynamic weight shifts, guided by tactile cueing of the lower trunk abdominals and gluteus maximus (Karthikbabu et al., 2018).

Evidence-Based Strengthening Protocol:

Foundation Phase: Supine and Side-lying Isometric Exercises (Weeks 1-4)

These foundational exercises represent the safest and most appropriate starting point for hip stability and strength development in early stroke recovery:

1. Supine Hip Abduction Isometric Holds:
   
   
• Patient lies supine with affected leg in slight abduction
• The therapist provides resistance at the lateral knee/ankle
• Hold contractions for 5-10 seconds, building to 30 seconds
• Focus on gluteus medius activation without compensatory patterns
• Progress: 3 sets of 5-10 repetitions
2. Side-lying Hip Abduction (Affected Side Up):
   
   
• The patient lies on the unaffected side
• Lift the affected leg against gravity
• Begin with therapist assistance, progress to independent
• Essential for rebuilding basic gluteus medius function
• Progress: 2-3 sets of 8-15 repetitions
3. Supine Hip Extension (Bridge Preparation):
   
   
• Begin with bilateral knee flexion, feet flat on the bed
• Small pelvic tilts progressing to mini-bridges
• Focus on gluteus maximus activation
• Critical for trunk-pelvic stability foundation
4. Side-lying Hip External Rotation (Clamshells):
   
   
• Side-lying with knees flexed, feet together
• Rotate top knee outward, maintaining foot contact
• Targets the posterior gluteus medius and deep rotators
• Essential for pelvic stability during weight bearing

Intermediate Phase: Supported Weight-Bearing (Weeks 5-8)

Progress to these exercises only when the foundation phase shows adequate strength and control:

1. Supported Standing Hip Abduction:
   
   
• Standing with parallel bar or wall support
• Lift the affected leg sideways against gravity
• Prepare for advanced single-leg activities
2. Mini-Squats with Support:
   
   
• Bilateral squatting motion with upper extremity support
• Focus on hip-dominant movement pattern
• Prerequisite for advanced strengthening

Advanced Phase: High-Force Generation Exercises (Weeks 9-16)

These exercises should only be attempted with adequate supervision and demonstrated safety:

1. Loaded Split Squats:
   
   
• Progress from body weight to 12RM external load
• Focus on affected leg as lead leg when safe
• 3 sets of 8-12 repetitions
• Requires: Independent standing balance and adequate lower extremity strength
2. Single-Leg Romanian Deadlifts:
   
   
• Begin with significant support, progress to independent
• Emphasize hip hinge pattern over knee flexion
• Target gluteus maximus and medius simultaneously
• Requires: Single-leg standing ability for >30 seconds
3. Side Planks for Gluteus Medius:
   
   
• Body weight side plank demonstrated highest forces for gluteus medius and minimus (Ebert et al., 2017)
• Progress from modified (knees down) to full side plank
• Hold for 15-60 seconds, multiple sets
• Requires: Adequate trunk and shoulder stability

Critical Progression Principles:

• Peak gluteal muscle forces increased by 28-150 N when exercises were performed with 12RM external resistance compared with body weight only (Ebert et al., 2017)
• Foundation exercises are mandatory before progressing to weight-bearing activities
• Many stroke survivors may remain in the foundation/intermediate phases for months
• Advanced exercises require significant therapist assistance and fall protection systems
• Monitor for proper movement patterns before increasing load or complexity

Section 5: Walking with Weights - Central Axial Loading and Center of Pressure Optimization

The Science Behind Weighted Walking

Research has shown that varying amounts of weight loading can be effective for improving the walking performance of adults. There were significant differences in walking distance, walking speed, and walking cadence between different weight loading conditions (Kim et al., 2017).

Center of Pressure Mechanisms:

The Center of Pressure (COP) is a key concept in studying human movement and balance. When a person stands or walks, their body pushes against the ground, which reacts with an equal and opposite force called the ground reaction force (Quijoux et al., 2021). Center of pressure velocity indicates body acceleration rather than overall speed during quiet standing, implying that COP measurements reflect neural control strategies for maintaining balance (Masani et al., 2014).

Research Evidence:

Studies examining weight loading at 0%, 1%, and 2% of body weight revealed significant activation of the gluteus medius muscle at 1% loading. The study compared the three groups and found a significant difference between 1% and 2% (Lee, 2013).

Practical Weight Loading Protocol:

Phase 1: Trunk Loading (0.5-1% body weight)

• Use weighted vests for even distribution
• Begin with 0.5% body weight for 10-15 minutes
• Progress to 1% body weight as tolerated

Phase 2: Limb-Specific Loading (1-2% body weight)

• Additional weight consists of two devices (weights and jacket) and two different weights (0.1 kg and 0.5 kg) were used during gait training
• Apply ankle weights to affected limb
• Monitor for improved hip flexion and step length

Benefits for Multiple Systems:

• Glenogumeral (Shoulder) Function: Trunk loading improves postural alignment
• Hip-Knee Position: Enhanced proprioceptive feedback improves joint positioning
• Central Axial Loading: Promotes spinal alignment and core activation

Safety and Monitoring:

• Start with minimal weights (0.1-0.5kg initially)
• Monitor heart rate and exertion levels
• Assess for any increase in abnormal movement patterns
• Progress slowly and systematically

Section 6: Vestibular, Visual, and Head-Eye Training - Sensory Integration

The Critical Need for Vestibular Training

There is limited evidence supporting the use of vestibular rehabilitation therapy (VRT) to improve balance and gait in stroke patients. However, recent systematic reviews show promising results (Meng et al., 2023). VRT was effective in enhancing balance in stroke patients. The most effective VRT protocol for improving balance involved GSE combined with swivel chair training, followed by head movement, then GSE or eye–head movements, with a 4-week intervention period (Meng et al., 2023).

Mechanisms of Vestibular Dysfunction Post-Stroke:

Some scholars found that balance exercises can enhance motor coordination by remodeling nerve synapses and activating astrocytes to improve the patient's balance. However, early post-stroke multisensorial training, under visual deprivation with somatosensorial and vestibular stimulation, could be more effective than a traditional approach (Yelnik et al., 2008).

Evidence-Based Vestibular Rehabilitation Protocol:

Phase 1: Gaze Stability Exercises (Weeks 1-2)

• X1 viewing: Keep eyes focused on the target while moving the head horizontally
• X2 viewing: Move head and target in opposite directions
• Progress from slow to faster head movements
• 2-3 minutes per exercise, 2-3 times daily

Phase 2: Head Movement Training (Weeks 3-4)

• Seated head movements in all planes
• Standing head movements with varying base of support
• Add cognitive tasks during head movements

Phase 3: Integrated Vestibular-Visual Training (Weeks 5-8)

• Dynamic visual tracking during movement
• Swivel chair vestibular rotational training maximises the physiological stimulation on semi-circular canal by repeatedly changing the flow direction and speed of endolymphatic fluid (Meng et al., 2023)
• Environmental challenges (different lighting, visual complexity)

Research Outcomes:

Six randomized controlled trial studies met the inclusion criteria for this systematic review. The pooled standardized mean difference (SMD) favored the intervention as an effective treatment for balance recovery, with a large effect size (0.94; 95% confidence interval [CI] 0.39 to 1.48) (Rayner et al., 2024). Higher values of walking speed and stride length were observed in the VR group. The results of the between-group comparison highlight significant differences between the two groups in various clinical scale scores (Tramontano et al., 2018).

Section 7: Integration and Practical Implementation

Combining Strategies Safely

The key to implementing these counterintuitive approaches lies in careful progression and integration. The evidence suggests that the optimal program to improve walking ability involves repetitive and intensive practice, which is continually incremented in difficulty according to the tolerance of the participant (Eng & Tang, 2007):

Week 1-2: Foundation Building

• Ankle mobilization and strengthening
• Basic vestibular exercises
• Introduction to foam surfaces

Week 3-4: Skill Development

• Selective brace removal during specific activities
• Hip strengthening progression
• Advanced vestibular training

Week 5-8: Integration and Challenge

• Barefoot uneven surface training
• Weighted walking protocols
• Complex multisensory challenges

Week 9-12: Functional Application

• Real-world surface navigation
• Community integration preparation
• Long-term maintenance planning

Assessment and Monitoring Tools

Primary Outcome Measures:

• Berg Balance Scale (BBS)
• Timed Up and Go (TUG)
• 10-Meter Walk Test
• Dynamic Gait Index (DGI)

Secondary Measures:

• Center of pressure analysis when available
• Modified Ashworth Scale for spasticity
• Falls Efficacy Scale for confidence
• Community mobility questionnaires

Safety Protocols and Contraindications

Absolute Contraindications:

• Severe cognitive impairment preventing safety awareness
• Uncontrolled seizures
• Severe vestibular disorders causing nausea/vomiting
• Acute medical instability

Relative Contraindications:

• Severe spasticity (Modified Ashworth Scale 4)
• Significant orthostatic hypotension
• Recent falls with injury
• Severe visual impairments

Safety Requirements:

• Appropriate fall protection systems
• Qualified supervision during novel activities
• Emergency protocols established
• Regular medical monitoring

Conclusion

These counterintuitive methods for balance training after stroke challenge traditional rehabilitation ideas while providing evidence-based alternatives that may improve recovery outcomes. The evidence indicates that the best program to enhance walking ability involves repetitive and intensive practice that is gradually increased in difficulty based on the participant's tolerance. Integrating ankle mechanism optimization, barefoot uneven surface training, strategic brace removal, hip-pelvic strengthening, weighted gait training, and vestibular-visual rehabilitation creates a comprehensive approach that targets multiple systems at once. Success depends on careful assessment, gradual implementation, ongoing monitoring, and adjustments tailored to individual responses. For stroke survivors and their care teams, these methods offer hope for better recovery through techniques that encourage true neural plasticity rather than simple compensation. The key is implementation with proper expertise, safety precautions, and a commitment to evidence-based progression.

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