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

In the first of our regular series from the National Institute for Health Research, we look at stroke.


Why was this study needed?

Around 110,000 people in England have a stroke every year. Approximately half of these 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 after 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 Organisation 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 34 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: mean difference (MD) 2.22 points, 95 per cent confidence interval (CI) 1.26 to 3.17 (28 trials, 985 participants). The scale is a 56 point scale and an eight-point change is considered an important difference.
  • The Functional Reach Test: MD 3.12 cm, 95 per cent CI 0.90 to 5.35 (five trials, 153 participants).
  • The Sensory Organisation Test: MD 6.77 per cent, 95 per cent CI 0.83 to 12.7 (four 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 per cent CI 0.22 to 3.07; eight trials, 338 participants) and Sensory Organisation Test (MD 3.91 per cent, 95 per cent 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 per cent CI 1.71 to 5.78) and gait training (2.26 points, 95 per cent 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?

NICE 2013 guidance on stroke rehabilitation (CG162, June 2013) 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.
The Scottish SIGN guidance on management of patients with stroke (SIGN 118, June 2010) 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 programmes focused on improving balance could try these interventions.
However, the trials were small, assessed outcomes on various scales, and used a variety of interventions that 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. 


This project was funded by a grant from The Netherlands Organisation for Scientific Research (NOW). Published on 15 November 2016 by the NIHR Dissemination Centre.  

Further information

Commentary: Dr Jacqui Morris gives her reaction

'The conventional assumption is that the greatest potential for recovery after stroke is during the first few months after onset.  This high quality review challenges that assumption, showing that task-specific exercise therapy may improve balance capacity late after stroke onset. Good balance is critical for walking and undertaking activities independently and safely. Improving balance may therefore reduce falls and prevent unnecessary hospital admissions, and their detrimental consequences for quality of life and confidence of people with stroke.   

'However therapy services are typically not set up to routinely deliver such therapy six months and more after stroke. Innovative approaches to delivering this training must be developed, alongside cost-effectiveness studies showing the value of investment in such services. The task-specific nature of effective balance training means it should be orientated towards tasks that people undertake in everyday life. Working with stroke survivors and their families to find ways to empower them to safely build balance-specific training into their daily routines and activities would provide a person-centred approach likely to promote adherence. 

'Technological solutions, such as gaming, mobile technology applications and tele-rehabilitation systems that people can use at home, may also be effective for supporting and monitoring engagement in therapy and for provision of remote feedback. These solutions should be developed more fully and evaluated. Time to train therapists to deliver tailored task-training through technology?'


  • Dr Jacqui Morris (Grad Dip Phys, MSc, PhD) is reader in rehabilitation research, School of Nursing and Health Sciences, University of Dundee
Dr Jacqui Morris (Grad Dip Phys, MSc, PhD) is reader in rehabilitation research, School of Nursing and Health Sciences, University of Dundee

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