NORMAN — neurological rehabilitation for 30 years.Balance and gait disorders can develop after a stroke or traumatic brain injury, and in Parkinson’s disease, multiple sclerosis, ataxia, cerebral palsy, spinal cord injuries and other conditions of the nervous system.
Therapy results
Causes
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Neurological rehabilitation
Balance and gait disorders are among the most common problems in neurological patients. They can appear after a stroke, a traumatic brain injury, and in Parkinson's disease, multiple sclerosis, ataxia, cerebral palsy, spinal cord injuries and other conditions of the nervous system.
For the patient and their family, the problem usually does not begin with a medical label. It begins with simple observations:
the patient sways while walking, loses balance when standing up, is afraid to take a step on their own, walks with their legs wide apart, trips, drags their foot along the floor, leans their trunk to one side, cannot turn around safely or falls during ordinary household activities.
Such symptoms should not be dismissed simply as "weakness after an illness". In many cases they are the result of damage to specific neural mechanisms responsible for controlling movement, posture, muscle tone, sensation, coordination and the body's orientation in space.
Neurological rehabilitation is then not only about strengthening the legs. Its aim is to rebuild the safest and most functional way of moving that is possible.
Neurological balance
Balance is the ability to maintain a stable body position both at rest and in motion. In practice, this means that the patient is able to sit, stand, get up, shift their body weight, walk, stop, turn and respond to a loss of stability.
Several systems work together to maintain balance:
the nervous system, the muscles, the joints, deep sensation, vision, the vestibular system, the cerebellum, the brainstem, the cerebral cortex and the neural pathways connecting the brain with the limbs.
This is why balance disorders in a neurological patient rarely have a single, simple cause. Several factors often overlap:
paresis, sensory disturbances, spasticity, ataxia, visual disturbances, fear of falling, poor physical condition, pain, dizziness, cognitive impairment and problems with planning movement.
A patient may have strength in their legs and yet still be unable to walk safely. They may also be able to do exercises in bed but not be able to transfer that ability into standing up, walking and everyday functioning.
This is one of the most important differences between simply strengthening the muscles and neurological rehabilitation.
Neurological gait
Gait disorders mean an abnormal, unstable or ineffective way of moving. They can affect the pace, the length of the step, the position of the feet, the work of the trunk, the symmetry of movement, the shifting of body weight, control of the knee, hip or foot, or the ability to start and stop walking.
In neurological patients we often see:
a shuffling gait, a wide-based gait, a shortened step, gait asymmetry, foot drop, a lack of knee control, leaning of the trunk, difficulty turning around, sudden stopping, small steps, an ataxic gait, a spastic gait or a gait with a high risk of falls.
Gait disorders may be apparent immediately after an illness, but they can also build up gradually, for example in Parkinson's disease, multiple sclerosis or degenerative conditions of the nervous system.
Causes
The causes depend on the type of condition, the location of the damage and the patient's general state of health. Most often the problem results from several mechanisms.
After a stroke, a brain injury, a spinal cord injury or other damage to the nervous system, one or more limbs may be weakened. The patient then does not shift their body weight correctly, overloads the unaffected side, avoids loading the affected side and develops a compensatory, often unsafe, walking pattern. Paresis often affects not only the leg but also the upper limb and hand, which further disrupts symmetry and balance.
The patient may not properly feel the ground, the position of their foot, the tension in their muscles or the position of a limb. Their walking then becomes unsteady, especially after dark, on uneven ground, when their eyes are closed or when changing direction.
Increased muscle tone can make it harder to bend the knee, position the foot, move the limb and control the trunk. The patient may walk stiffly, "throw" the leg out to the side, catch their toes on the ground or have difficulty with a smooth step.
Ataxia causes a loss of smooth control over movement. Walking may be unsteady, wide, irregular and hard to predict. The patient often looks as though they cannot "aim" their movement at the right spot.
After brain damage there may be problems with vision, the visual field, judging distance, neglect of one side of space or hand–eye coordination. Such a patient may bump into objects, fail to notice obstacles or misjudge the distance to the stairs, a chair or a threshold.
Walking requires more than just strength. It also requires attention, planning, risk assessment and quick reactions. A patient with memory and cognitive impairments may walk worse in more complex situations: in a crowd, while talking, amid noise, on stairs or away from home.
After one or more falls, the patient often begins to fear moving. They stiffen the body, shorten their step, look only at their feet, avoid loading the limb and reduce their activity. Over time this leads to further weakening, a decline in physical condition and an even greater risk of falls.
Causes
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After a stroke
After a stroke, balance and gait disorders are very common. They may result from hemiparesis, sensory disturbances, spasticity, problems with vision, coordination disorders, one-sided neglect, cognitive impairment or damage to the structures responsible for controlling posture.
A patient after a stroke may:
not load the affected side, lean their trunk to one side, shorten their step, drag their foot along the floor, catch their toes, have difficulty standing up, lose their balance when turning, be afraid to walk without support, or walk only along a wall, with a walking frame or with the help of another person.
It is worth remembering that after a stroke the leg usually recovers faster than the arm, which we discuss in more detail in our article on when hand function returns after a stroke.
A common mistake is to judge improvement solely by whether the patient "is walking now". More important questions are:
are they walking safely, can they stop and turn around, do they control the affected side, are they not overloading the unaffected side, are they not reinforcing compensations, can they get up from a chair, can they cope with a threshold, the bathroom, the stairs and fatigue.
Rehabilitation after a stroke should include not only learning the step itself, but also working on trunk control, shifting body weight, stabilisation, sensation, balance, muscle tone, lower limb function, safe transfers and the prevention of falls.
In practice, a patient after a stroke often needs task-based therapy: standing up, sitting down, standing, walking, turning around, overcoming obstacles, learning balance reactions and gradually increasing their independence.
Parkinson's disease
In Parkinson's disease, problems with gait and balance can build up gradually. The patient often begins to walk more slowly, with a shorter step, a stooped posture and less arm movement. Over time, difficulties may appear with initiating movement, turning around and stopping, as well as so-called freezing, that is a sudden "freezing" of the gait.
The family may notice that the patient:
takes small steps, shuffles their feet, speeds up uncontrollably, has difficulty getting through a doorway, stops in narrow passages, loses their balance when turning, or falls forwards or backwards.
In Parkinson's disease, rehabilitation must be matched to the mechanism behind the problem. You work differently with a patient who mainly has stiffness and slowness, differently with a patient who has freezing, and differently again with someone who has had falls and has a strong fear of walking.
Balance exercises, gait training, learning strategies to overcome freezing, and working on rhythm, step length, trunk rotation, transfers, strength, endurance and the safety of everyday activities are all important.
Multiple sclerosis
In multiple sclerosis, balance and gait disorders may result from muscle weakness, spasticity, sensory disturbances, damage to the cerebellum, problems with vision, dizziness, fatigue and the fluctuating course of the condition.
A characteristic feature is that the patient's ability can change over the course of the day. A person with MS may walk better in the morning and worse after exertion, in the heat, during an infection, under stress or as fatigue builds up.
This is why rehabilitation in MS cannot rely solely on intensively "pushing" the exercises. It must take into account fatigue, temperature, recovery, safety, the risk of falls and each patient's individual capabilities.
The aim of therapy is to improve or maintain function, increase safety, reduce the risk of falls, make better use of preserved ability and teach the patient strategies for coping with everyday situations.
Ataxia
Ataxia means a disorder of movement coordination. It can occur after a stroke, in conditions of the cerebellum, in genetic conditions, in multiple sclerosis, after brain injuries and in other forms of damage to the nervous system.
A patient with ataxia often walks with a wide base, sways, makes movements with an excessive range, has difficulty positioning the foot precisely and cannot smoothly control the direction of movement. The problem does not always stem from a lack of strength. It often stems from a lack of precise control over movement.
In the rehabilitation of ataxia, exercises for balance, coordination, trunk stabilisation, limb control, gait training and learning safe strategies for moving about are all important. Therapy should be graded, well supervised and adapted to the level of falls risk.
Brain injury
After a traumatic brain injury, gait and balance disorders can take on a very varied character. In one patient paresis predominates, in another ataxia, and in the next disturbances of tone, slowness, cognitive problems, impulsiveness or visual disturbances.
This is particularly important because a patient after a brain injury may be physically able to walk but still not be safe. They may misjudge risk, fail to notice obstacles, have attention disturbances, react with a delay or overestimate their abilities.
Rehabilitation should therefore include not only training the muscles and gait, but also a functional assessment, safety, learning movement control, and working on balance, spatial orientation, transfers and everyday activities.
Cerebral palsy
In cerebral palsy, gait disorders usually result from damage to the developing nervous system. They may involve spasticity, weakness, restricted range of movement, abnormal positioning of the feet, knees and hips, balance disorders and entrenched compensations.
In children and adolescents, gait rehabilitation requires an assessment of the whole movement pattern, not just a single muscle. What matters is how the child places their foot, how the pelvis works, whether the knees turn inwards, whether toe-walking appears, how the child maintains their balance and whether their way of walking leads to overloading.
The aim of therapy is the greatest possible independence and safety, the prevention of secondary deformities and an improvement in the quality of everyday functioning.
Falls
In neurological patients, a fall can have serious consequences. It can lead to fractures, head injuries, a loss of confidence, a fear of moving and a further reduction in activity.
After a fall, the patient often begins to walk less. Reduced activity leads to a decline in strength, condition and endurance. This in turn increases the risk of further falls. A vicious circle is created:
a fall, fear, reduced movement, weakening, even greater instability, another fall.
This is why the rehabilitation of balance and gait should be started as soon as possible after a neurological event — regardless of whether the patient lost the ability to walk suddenly as a result of a stroke or injury, or the disorder built up gradually. The sooner systematic therapy is begun, the greater the chances of regaining safe mobility. This is shown by the story of a patient who went from a wheelchair to their first steps.
Indications
Rehabilitation is worth considering when the patient meets one or more of the following criteria:
Assessment and therapy
Rehabilitation should begin with a functional assessment. The therapist must check not only whether the patient can walk a few metres, but also how they do it.
The assessment may cover:
muscle strength, muscle tone, range of movement, sensation, trunk control, balance reactions, the way of standing up, transfers, limb loading, foot positioning, step length, gait symmetry, falls risk, fatigue, pain, concentration, fear of moving and the level of independence in everyday activities.
Only after such an assessment can therapy be selected.
Rehabilitation methods
Therapy is selected individually to suit the patient's problem — each method has its own indications and purpose. Below is a general overview of the methods used in gait and balance rehabilitation. This information is for guidance only — all exercises and therapeutic methods should be discussed with a specialist and matched to the patient's individual condition.
Without a stable trunk, safe walking is difficult. A patient may have strength in their legs, but if they do not control the centre of their body, they will lean, compensate and lose their balance.
Many neurological patients avoid loading the weaker side. Therapy teaches safe weight shifting, control of the pelvis, work of the lower limb and the gradual rebuilding of trust in the affected side of the body.
Exercises may include standing, changing position, responding to being pushed off balance, working on stable and unstable surfaces, controlling posture, exercises with the eyes closed, tasks involving head movement, and work with the trunk and limbs. Each exercise must be matched to the patient's problem and properly supervised.
This includes learning the correct movement pattern, step length and the work of the foot, knee, hip, pelvis and trunk. It can be carried out on the ground, on a treadmill, with body-weight support, with supervision, and using equipment, biofeedback or assistive devices.
The patient must be able to use their improvement in everyday life. This is why exercises are important for standing up, sitting down, turning around, getting over a threshold, walking on different surfaces, negotiating stairs, and using the bathroom, the bed, a chair and the car.
For some patients, fear is one of the main limitations. Rehabilitation must gradually rebuild a sense of safety, but without false haste. The patient should learn to move under controlled conditions, with good supervision and a clear goal.
Sometimes orthoses, crutches, a walking frame, handrails, suitable footwear, adapting the bathroom or reorganising the home space are needed. The aim is not to make the patient dependent on equipment, but to improve safety and enable greater activity.
Causes
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Prognosis
In many cases, the patient's balance, gait and safety can be improved. However, the extent of the improvement depends on the cause, the extent of the damage, the time since onset, age, coexisting conditions, motivation, the intensity of therapy and the capacity of the nervous system.
After a stroke, improvement may be greatest in the first few months, but rehabilitation is still worthwhile later on, particularly when the patient has not made the most of their full potential, has developed entrenched compensations or still has functional problems. You can read more about the time frames for therapy in our article on how long rehabilitation after a stroke takes.
In progressive conditions such as Parkinson's or MS, the aim is not always a full "reversal" of symptoms. The aim may be to slow the loss of function, improve safety, cope better with symptoms, reduce the risk of falls and maintain independence for as long as possible.
In ataxia or after severe brain injuries, therapy may focus on improving control, compensation, safety and quality of life.
The most important thing is not to judge the prognosis solely by the name of the condition. Two patients with the same diagnosis may have completely different potential for rehabilitation.
Home exercises
Home exercises can be a very important part of therapy, but with balance and gait disorders they should not be chosen at random.
Some exercises done without supervision can reinforce a poor movement pattern or increase the risk of falls. This applies particularly to patients with paresis, ataxia, spasticity, sensory disturbances, one-sided neglect, cognitive problems or a strong fear of moving.
The safest model is:
a specialist assessment, setting goals, supervised therapy, instruction for the patient and family, and only then home exercises as a complement to the process.
The family often wants to help as much as possible, but does not always know how to support the patient safely, how not to pull on the affected limb, how not to reinforce an abnormal gait and when to stop an exercise.
Rehabilitation centre
A rehabilitation centre is worth considering when the patient needs intensive, multidisciplinary work, or when outpatient and home rehabilitation is not enough.
This applies particularly to patients who:
Common mistakes
Mistakes worth avoiding in the process of gait and balance rehabilitation.
If the patient does not control their trunk, does not load the affected side or does not have a stable standing position, attempting to walk without proper preparation can reinforce an abnormal movement pattern.
A neurological patient often spontaneously uses the unaffected side. Therapy should gradually bring in the weaker side, but in a safe and controlled way.
A patient may have strength but lack coordination. They may also be able to make a movement while lying down but not be able to use it while walking.
If the patient cannot feel their foot properly or has visual field disturbances, working on the muscles alone will not solve the problem.
A patient may exercise well in the gym but still fall in the bathroom, by the bed or when getting up during the night. Rehabilitation must transfer to real activities.
Balance exercises must be a challenge, but they must not be a gamble. A fall can set the patient back both functionally and psychologically.
FAQ
They are common, but they should not be ignored. They may result from paresis, sensory disturbances, spasticity, problems with vision, coordination or trunk control. They call for assessment and suitably selected rehabilitation.
Because walking depends on more than just strength. It also requires sensation, balance, coordination, trunk control, correct muscle tone, attention and the ability to plan movement.
It can help if it is matched to the cause of the problem. Balance exercises, gait training, learning transfers, improving strength, controlling tone, assessing the environment and safety instruction are all important.
Yes, but the exercises should be matched to the symptoms. You work differently with a small step, differently with freezing, and differently again with a patient who has had falls.
Yes, but you have to take fatigue, temperature, recovery time and the patient's current condition into account. Too much overload can worsen their functioning.
Yes. Rehabilitation can improve movement control, balance, coordination and safety, although the results depend on the cause of the ataxia and the degree of damage to the nervous system.
No, provided the walking frame is chosen as an element of safety and therapy. The problem arises when equipment replaces rehabilitation or is poorly chosen.
Yes, but after instruction. Incorrect support can increase the risk of a fall or reinforce a poor movement pattern.
When gait or balance disorders appear suddenly, worsen rapidly or are accompanied by new neurological symptoms: disturbances of speech, vision, sensation, strength or consciousness, a severe headache or sudden dizziness.
Summary
Balance and gait disorders in neurological conditions are not solely a muscle problem. They are often the complex result of damage to the nervous system and of disturbances of sensation, coordination, muscle tone, vision, attention and postural control.
This is why effective rehabilitation should be individual, functional and safe. Its aim is not just to complete an exercise, but to improve the patient's real life: standing up, walking, transfers, moving around the home, avoiding falls and regaining the greatest possible independence.
For patients after a stroke or a brain injury, and for those with Parkinson's disease, multiple sclerosis, ataxia, cerebral palsy and other neurological conditions, balance and gait disorders should be treated as one of the key areas of rehabilitation.
The next step
We are here to answer any questions you may have about the rehabilitation process.
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