3. Cerebral Circulation
(Medial surface of frontal and parital
lobes)
(Lateral surface of cereberal
hemisphere)
(Ventral surface of the temporal
and occipital lobes and the
medial surface of the occipital
lobes)
7. Balance
What is BALANCE?
Balance is a complex process involving the
reception and integration of sensory inputs and the
planning and execution of movement to achieve a goal
requiring upright posture. It is the ability to control the
centre of gravity (COG) over the base of support in a given
sensory environment.
8. Balance and Stroke
Balance problems are caused by
• motor,
• sensory (the somatosensory, visual and vestibular
systems) and
• cognitive impairments and are one of the most common
issues after stroke.
9. Types of Stroke Affecting Balance
Lateral Medullary (Wallenberg’s)
Medial Inferior Pontine
•Vertebrobasilar Artery Syndromes
Lateral Inferior Pontine
Medial midpontine
Lateral midpontine
Medial Superior midpontine
Lateral Superior midpontine
•MCA
•ACA
11. Type Of Stroke Artery Involved Structures Involved Balance Issue
Medial Midpontine
Syndrome
Paramedian Branch
of Mid-basillar
Artery
Middle Cerebellar
Peduncle
Limb and Gait Ataxia.
Lateral Midpontine
Syndrome
Short
Circumferential
Artery
Middle Cerebellar
Peduncle
Ataxia of Limbs
Medial Superior
Pontine Syndrome
Paramedian Branch
of Upper-basillar
Artery
Superior or Middle
Cerebellar Peduncle
Cerebellar Ataxia
Lateral Superior
Pontine Syndrome
Superior Cerebellar
Artery
Middle and Superior
Cerebellar Peduncle;
Vestibular Nuclei
Limb and Gait Ataxia,
Falling to side of
lesion.
Nystagmus.
Cerebellar peduncles connect the cerebellum to the brain stem.
(MidBrain – Sup; Pons – Middle; Medulla – Inferior)
13. • Sensory Organization Test (SOT) determines the effectiveness
of the CNS to utilize and integrate different sensory inputs.
1 Minimal sway
2 Mild sway
3 Moderate sway
4 Loss of balance
14. Outcome Measures
• Berg Balance Scale (BBS)
• Performance-Oriented Mobility Assessment
(POMA, Tinetti)
• Functional Reach Test (RT) and the
Multidirectional Reach Test (MDRT)
• Timed Up and Go Test (TUG)
15. Berg Balance Scale
Multitask test of 14 balance
tasks common in
everyday living
6 static balance items;
8 dynamic balance items
19. Stroke Specific
• The Postural Assessment Scale for Stroke
Patients (PASS)
• Trunk Impairment Scale
• Function in Sitting Test (FIST)
20. Types Of Balance Training
• Cycling
• Proprioception training
• Bobath approach
• Visual feedback or Biofeedback for trunk control
• Vision-deprived training
• Balance biofeedback
• Perceptual training
• Functional balance training
• Virtual reality
• Facilitation using ICE (Anterior Tibialis)
• Robotic Training
21. • Proprioception training - Natural balance and proprioceptive
reactions that we are attempting to retrain to make the
transition from a conscious to a subconscious state.
22. • Functional balance training - focusing more on functional,
task-specific training. Works on typical tasks that people
perform in their daily lives, such as reaching into a cupboard
for a cup or plate, or trying to carry a grocery bag
23. • Body weight support balance training - body weight may be
supported while standing or walking doing activities by a body
harness.
26. Virtual Reality - VR based
training puts the trainee in a 3D
environment relevant to the subject
matter via a specially designed
audio-visual headset.
Totally immerse the trainee in the
simulation, to the point where they
begin to respond to it just as they
would in a real-life situation.
27. • Force platform training - measure the ground reaction forces
generated by a body standing on or moving across them, to
quantify balance, gait and other parameters of biomechanics.
29. • Tai chi - Chinese martial arts, uses a series of slow, flowing
motions and deep, slow breathing to exercise the body and
calm the mind. Moving from one pose to another gradually,
shifting weight and extending limbs to challenge balance.
30. • Robotic Training - using robots that support overground gait and balance
training is that they allow individuals the ability to practice the types of
activities they will need to be competent in before returning to their home
and into the community.
31. • Vibrating Insoles - Using the principle of stochastic resonance,
vibrating insoles designed use small piezoelectric actuators to
deliver imperceptible mechanical vibrations to feet,
enhancing detection of nerve signals
33. Recent Advances
Study Outcome Measures Effectiveness
A clinical single blind study
to investigate the
immediate effects of
plantar vibration on
balance in patients after
stroke(1)
(Azam Karimi.,2017)
Mini-BESTest
(Anticipatory postural adjustments,
Postural responses,
Sensory orientation, and
Balance during gait)
Active vibration >
EFFECTIVE than placebo
vibration.
Does Robot-Assisted Gait
Rehabilitation Improve
Balance in Stroke Patients?
A Systematic Review (2)
(Eva Swinnen.,2014)
Berg Balance Scale (BBS),
Tinetti test,
postural sway tests,
Timed Up and Go (TUG) test.
No clear results.
Dual-task training effects
on motor and cognitive
functional abilities in
individuals with stroke
A Systematic Review(3)
(Ying He.,2018)
Laboratory measures (force plate),
Berg Balance Scale,
Dynamic Gait Index,
Functional Reach Test
Dual Task > EFFECTIVE than
Single Task.
34. Study Outcome Measures Effectiveness
Effect of a virtual reality
exercise program
accompanied by cognitive
tasks on the balance and
gait of stroke patients(4)
(In-Wook Lee.,2015)
Berg Balance Scale (BBS)
Timed Up and Go (TUG) test
EFFECTIVE
The Effects of Horse Riding
Simulation Training on Stroke
Patients’ Balance Ability and
Abdominal Muscle Thickness
Changes(5)
(Il-Hun Baek.,2014)
Effects of horse-riding
exercise on balance, gait, and
activities of daily living in
stroke patients(6)
(Yong-Nam Kim.,2015)
BioRescue system
Berg Balance Scale (BBS)
EFFECTIVE
EFFECTIVE
35. Study Outcome Measures Effectiveness
Effect of aquatic dual-task
training on balance
and gait in stroke patients(7)
(Kyoung Kim.,2016)
Berg balance scale,
Five Times Sit-to Stand Test,
Functional Reach Test,
10-Meter Walk Test,
Timed Up and Go Test,
Functional Gait Assessment
EFFECTIVE in both Balance
And Gait
Effects of motor imagery on
walking function and balance
in patients after stroke:
A Systematic Review(8)
(Rong-Qing Li.,2016)
Timed Up and Go Test (TUG),
Functional Reach Test (FRT),
Berg Balance Scale (BBS)
FugleMeyer (FM-B).
No difference in Balance
Effects of constraint-induced
movement therapy for lower
limbs on measurements of
functional mobility and
postural balance in subjects
with stroke: a randomized
controlled trial(9)
Emília Márcia Gomes.,2017
Berg Balance Scale (BBS)
Timed Up and Go Test (TUG),
Improvement in both groups
36. Study Outcome Measures Effectiveness
The effect of mirror therapy
on balance ability of subacute
stroke patients.(10)
(Myoung-Kwon Kim.,2016)
Balance Index (BI) scores Mirror Therapy is EFFECTIVE in
improving balance ability.
Effects of modified sit-to-
stand training on balance
control in hemiplegic stroke
patients: a randomized
controlled trial(11)
(Meng Liu.,2015)
Time and Weight-bearing
distribution during sit-to-stand
movement,
Centre of pressure sway
length during quiet standing,
Centre of pressure sway areas
during dynamic standing,
Berg Balance Scale
Rise time shortened,
Weight-bearing asymmetry
improved,
Centre of pressure sway
length was smaller
EFFECTIVE
37. Reference
1. Karimi-Ahmadabadi, A., Naghdi, S., Ansari, N. N., Fakhari, Z., & Khalifeloo, M. (2018). A clinical
single blind study to investigate the immediate effects of plantar vibration on balance in patients
after stroke. Journal of Bodywork and Movement Therapies, 22(2), 242-246.
doi:10.1016/j.jbmt.2017.04.013
2. Swinnen, E., Beckwée, D., Meeusen, R., Baeyens, J., & Kerckhofs, E. (2014). Does Robot-Assisted
Gait Rehabilitation Improve Balance in Stroke Patients? A Systematic Review. Topics in Stroke
Rehabilitation,21(2), 87-100. doi:10.1310/tsr2102-87
3. He, Y., Yang, L., Zhou, J., Yao, L., & Pang, M. Y. (2018). Dual-task training effects on motor and
cognitive functional abilities in individuals with stroke: A systematic review. Clinical
Rehabilitation,026921551875848. doi:10.1177/0269215518758482
4. Lee, I., Kim, Y., & Lee, D. (2015). Effect of a virtual reality exercise program accompanied by
cognitive tasks on the balance and gait of stroke patients. Journal of Physical Therapy
Science, 27(7), 2175-2177. doi:10.1589/jpts.27.2175
5. Kim, Y., & Lee, D. (2015). Effects of horse-riding exercise on balance, gait, and activities of daily
living in stroke patients. Journal of Physical Therapy Science, 27(3), 607-609.
doi:10.1589/jpts.27.607
6. Baek, I., & Kim, B. J. (2014). The Effects of Horse Riding Simulation Training on Stroke Patients’
Balance Ability and Abdominal Muscle Thickness Changes. Journal of Physical Therapy
Science, 26(8), 1293-1296. doi:10.1589/jpts.26.1293
38. 7. Kim, K., Lee, D., & Kim, E. (2016). Effect of aquatic dual-task training on balance and gait in stroke
patients. Journal of Physical Therapy Science, 28(7), 2044-2047. doi:10.1589/jpts.28.2044
8. Li, R., Li, Z., Tan, J., Chen, G., & Lin, W. (2017). Effects of motor imagery on walking function and
balance in patients after stroke: A quantitative synthesis of randomized controlled
trials. Complementary Therapies in Clinical Practice, 28, 75-84. doi:10.1016/j.ctcp.2017.05.009}
9. Emília Márcia Gomes De Souza E Silva, Ribeiro, T. S., Silva, T. C., Costa, M. F., Cavalcanti, F. A., &
Lindquist, A. R. (2017). Effects of constraint-induced movement therapy for lower limbs on
measurements of functional mobility and postural balance in subjects with stroke: A randomized
controlled trial. Topics in Stroke Rehabilitation,24(8), 555-561.
doi:10.1080/10749357.2017.1366011
10. Kim, M., Ji, S., & Cha, H. (2016). The effect of mirror therapy on balance ability of subacute stroke
patients. Hong Kong Physiotherapy Journal,34, 27-32. doi:10.1016/j.hkpj.2015.12.001
11. Liu, M., Chen, J., Fan, W., Mu, J., Zhang, J., Wang, L., . . . Ni, C. (2015). Effects of modified sit-to-
stand training on balance control in hemiplegic stroke patients: A randomized controlled
trial. Clinical Rehabilitation,30(7), 627-636. doi:10.1177/0269215515600505
39.
40.
41. Study Outcome Measures Effectiveness
The effect of aquatic therapy on postural
balance and muscle strength in stroke
survivors--a randomized controlled pilot
trial.
(Noh et al., 2008)
Berg Balance Scale Aquatic therapy is
EFFECTIVE in improving
balance in patients
with stroke.
The Effectiveness of the Bobath Concept in
Stroke Rehabilitation—Systematic Review
(Boudewijn J. Kollen.,2009)
Berg Balance Scale 4 studies (high-quality
RCTs)
EFFECTIVE
Training symmetry of weight distribution
after stroke: a randomized controlled pilot
study comparing task-related reach,
Bobath and feedback training approaches.
(Mudie MH.,2002)
Weight distribution Bobath most EFFECTIVE
treatment for
retraining sitting
symmetry after stroke
42. Study Outcome Measures Effectiveness
The influence of early cycling
training on balance in stroke
patients at the subacute
stage—Randomised Control
Trial.
(Katz-Leurer et al., 2006)
Postural Assessment Scale for
Stroke Patients (PASS)
Cycling training is more
EFFECTIVE than conventional
rehabilitation alone for
improving balance in patients
with stroke.
Symmetrical body-weight
distribution training in stroke
patients and its effect on fall
prevention–
(Cheng et al., 2001)
Occurrence of falls,
Sit-to-stand performance,
Body-weight distribution,
Rate of rise in force,
Sway in center of pressure
(COP)
Improvement in sit-to-stand
performance,
Body weight was distributed
more symmetrically on both
legs,
less mediolateral sway in the
COP when rising and sitting
down.
Use of visual feedback in
retraining balance following
acute stroke.
(Walker et al., 2000)
Postural sway,
Berg Balance Scale,
Gait speed,
Timed "Up & Go" Test
No difference btw the control
and experimental group
43. Study Outcome Measures Effectiveness
Rehabilitation of balance
after stroke with
multisensorial training: a
single-blind randomized
controlled study.
(Yelnik et al., 2008)
Berg Balance Scale (BBS),
Posturography,
Gait,
Functional Independence
Measure,
Nottingham Health Profile.
Dynamic balance (percentage
of double-limb stance time)
was IMPROVED in
multisensorial group
compared to the control group
(NDT)
Efficacy of treatment with a
kinaesthetic ability training
device on balance and
mobility after stroke: a
randomized controlled study.
(Alptekin N.,2008)
Functional Independence
Measure (FIM),
Fugl-Meyer Stroke Assessment
Instrument (FMA)
Static and Dynamic Balance
was IMPROVED than
compared to control group.
Effects of perceptual learning
exercises on standing balance
using a hardness
discrimination task (plantar
perception exercise) in
hemiplegic patients following
stroke: a randomized
controlled pilot trial.
Postural Sway Postural sway were
significantly decreased in the
experimental group.
44.
45. Cerebellum Pathways
From Cerbellar Cortex From Spinal cord and Internal Ear
AFFERENTS
( Frontal, Parietal,
Temporal & Occipital lobes
of the Cerebral Cortex )
49. Functions Of Cerebellum
• The cerebellum functions as
a coordinator of precise
movements by continually
comparing the output of the
motor area of the cerebral
cortex with the
proprioceptive information
received from the site of
muscle action; it is then able
to bring about the necessary
adjustments by influencing
the activity of the lower
motor neurons.
Tone
Balance & Posture Co-ordination
50. Signs and Symptoms of
Cerebellar Disease
• Hypotonia
• Postural Changes and Alteration of Gait
• Disturbances of Voluntary Movement (Ataxia)
• Dysdiadochokinesia
• Disturbances of Ocular Movement
• Disorders of Speech
