How to restore balance following stroke?

By Rajul vasa B. Sc. P

T Applied

movement scientist Mumbai [India]

What is balance?

Balance is an ability of an individual to control, restore and regulate the COM [centre of mass] of the body automatically without thinking.

Following stroke, when one side of the body muscles are weak, paralyzed and may be they are spastic as well, it is unable to control, restore and regulate the COM against the force of gravity. This leads to….

Automatic switch of control of balance to the non paretic good side by selforganizing brain for; safety of COM is a priority for all living organism.

Sensory Proprioception

With balance control switched to good non paretic side by selforganized brain following stroke, the story does not end rather it begins……..

Selforganized brain also wants to secure the safety of COM by unloading the paretic lower limb of the responsibility of the large inertial mass of the head arm trunk to be born on the paretic hip, it endorses the mechanical unloading of paretic hip from unopposed pull of normal trunk muscles by neural endorsement of ongoing peripheral input from normal peripheral nervous system[PNS]

Unloading of lower limb results in consequential effect on the proprioceptors in the muscle and joint receptors. I believe that instead of poor proprioception there is hyper proprioception / hyperesthesia from unloading to make reloading of paretic lower limb an impossible task thereby maintain COM safety with good side.

Invisible consequences

Invisible changes begin to take place to enable the entire body to continue to function with paretic side of the body behaving differently in the 3 dimensional space during postural tasks when movement of COM needs to be controlled and restricted within the safe territory of good side of the central axis the vertebral column.

Walking in 3 dimensional space.

The imaginary balancing point of the body, the COM in a stroke subject shifts towards the good side of the central axis and unloading of paretic lower limb and shift of inertial load of head arms trunk onto good side restricts COM movement in unsafe territory of paretic side of the central axis in 3 dimensional space of X axis, Y axis and Z axis depending on where in space lies the safety and what remains unsafe and what could pose a threat when COM of the body needs to be accelerated forwards to walk. This leads to…

The new role for paretic side: To follow

With control on COM switched to non paretic good side, paretic body anatomically and mechanically connected to the good side at the central axis [the vertebral column] it (paretic side) learns a new role to play to remain functionally integrated with the good side by itself “following” the good side and by letting the good non paretic side to “lead” the entire body all the time against the force of gravity for; safety is a priority for all.

Visible Consequences

With new role to follow the good side and allow the good side to lead; the exchange of role between two sides of the body when normal before stroke, becomes a history and a past making “Normally abnormal, to be Normal” for stroke subject.

Paretic intrinsic foot muscles and ankle muscles though weak and paretic begins its efforts to maintain the grip with the floor by clawing the toes or hooking it to the ground and ankle joint goes in planter flexion to maintain contact with the support surface for balance, being the last segment of the multi link of lower limb which is constantly following the good limb and is connected to the good side at the pelvis; the basin.

What to do for hooking of the toes?

To get rid of the clawing and hooking of the toes to the ground, one needs to restore balance of head arm and trunk over the paretic hip of the paretic lower limb to begin with in different postures like Buddha, Side sitting, and Namaz.

Side sitting posture.

Try to destabilize the side sitting posture as under.

Make the stroke subject to sit as shown in fig 1, then ask him to move his good limb ( his paretic

limb must not move) as shown in fig 2

Buddha and Namaz posture

Buddha posture for good mechanical stability.

Namaz posture for mechanical stability.

Forward-backward

Standing on the paretic lower limb when the good limb moves forward and backward.

Click here to see the video

Balance thro’ paretic side

As you succeed to restore balance and COM control with paretic trunk and limbs hooking of toes, clawing of toes and other segmental changes in the upper limb and lower limb and trunk segments will disappear automatically.

Conclusion

Self organizing brain is responsible for safety of balance with good side but……

It is also responsible why the paretic lower limb gets incapacitated to reload the limb and to control and to restore COM, therefore all manmade efforts to retrain balance externally induced therapeutically and with high tech manmade machines cannot overpower the decision of the selforganized brain and therefore will only lead to compensation and compromise with vision and somatosensory touch on the wall, touch the furniture, cane crutch or therapists for balance and with adaptation become permanent making it very difficult to restore sensorymotor control for stroke subject unless therapeutics speak the same language of selforganized brain and that is controlling COM from within and not from outside with paretic limbs.