Does perturbation-based balance training prevent falls among individuals with chronic stroke? A randomised controlled trial

Abstract

ObjectivesNo intervention has been shown to prevent falls poststroke. We aimed to determine if perturbation-based balance training (PBT) can reduce falls in daily life among individuals with chronic stroke.DesignAssessor-blinded randomised controlled trial.SettingTwo academic hospitals in an urban area.InterventionsParticipants were allocated using stratified blocked randomisation to either ‘traditional’ balance training (control) or PBT. PBT focused on improving responses to instability, whereas traditional balance training focused on maintaining stability during functional tasks. Training sessions were 1 hour twice/week for 6 weeks. Participants were also invited to complete 2 ‘booster’ training sessions during the follow-up.ParticipantsEighty-eight participants with chronic stroke (>6 months poststroke) were recruited and randomly allocated one of the two interventions. Five participants withdrew; 42 (control) and 41 (PBT group) were included in the analysis.Primary and secondary outcome measuresThe primary outcome was rate of falls in the 12 months post-training. Negative binomial regression was used to compare fall rates between groups. Secondary outcomes were measures of balance, mobility, balance confidence, physical activity and social integration.ResultsPBT participants reported 53 falls (1.45 falls/person-year) and control participants reported 64 falls (1.72 falls/person-year; rate ratio: 0.85(0.42 to 1.69); p=0.63). Per-protocol analysis included 32 PBT and 34 control participants who completed at least 10/12 initial training sessions and 1 booster session. Within this subset, PBT participants reported 32 falls (1.07 falls/person-year) and control participants reported 57 falls (1.75 falls/person-year; rate ratio: 0.62(0.29 to 1.30); p=0.20). PBT participants had greater improvement in reactive balance control than the control group, and these improvements were sustained 12 months post-training. There were no intervention-related serious adverse effects.ConclusionsThe results are inconclusive. PBT may help to prevent falls in daily life poststroke, but ongoing training may be required to maintain the benefits.Trial registration numberISRCTN05434601; Results.

Intense and unpredictable perturbations during gait training improve dynamic balance abilities in chronic hemiparetic individuals: a randomized controlled pilot trial

“…Other studies found similar results between + 3.6 points and 10 points on the ABC scale, over 10 to 30 training sessions using moveable platform perturbations,(46) manual perturbation in a standing position, (19) and an agility exercise program designed to challenge dynamic balance. (14) However, this improvement may not be directly related to perturbation as balance con dence increased by similar amounts between perturbation-and walking-only training.…”

“…Improvement in RNLI scores after perturbation training supports the fact that improvements in balance abilities translated into better participation and mobility in the community. Previous studies that used progressive standing perturbations (19) or low-intensity gait perturbations(20) did not transfer to daily-life mobility. It is possible that the more intense and higher number of gait perturbations used in our study may have had a better effect on mobility and thus on community reintegration.…”

“…(17) While gait perturbation training has already been reported as an effective method for reducing fall rates in older adults, (17,18) there is limited evidence on the effectiveness of perturbation training in individuals post-stroke. (19)(20)(21) Two recent studies used perturbations in a standing position, which had a limited effect on balance abilities, similar to control, traditional balance training. (19,22) Another study that used low-amplitude perturbations did not trigger large stepping responses.…”

“…(19)(20)(21) Two recent studies used perturbations in a standing position, which had a limited effect on balance abilities, similar to control, traditional balance training. (19,22) Another study that used low-amplitude perturbations did not trigger large stepping responses. (20) Lastly, gradual increases in treadmill speed of walking during the training sessions may be a confounder in these studies, (20,21) given that treadmill gait training is known to improve gait abilities (23) and possibly balance.…”

Assessment of dynamic balancing responses following perturbations during slow walking in relation to clinical outcome measures for high-functioning post-stroke subjects

“…Mans eld et al [22] suggested that post-stroke rehabilitation strategies for fall prevention should incorporate training of dynamic balancing responses following perturbations that challenge balance by focusing on remediating dysfunction of the more affected limb. Several studies reported that perturbation-based balance training has a positive effect on improvement of reactive dynamic balancing responses following unexpected loss of balance, which might reduce the risk of falling among older adults and clinical populations [14,[23][24][25][26][27].…”