Reactive Balance Training for Stroke

Overseen By Avril Mansfield, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Toronto Rehabilitation Institute

Disqualifiers: Parkinson's, Cognitive impairment, Osteoporosis, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: 5

Duration: 1 week

63 Participants Needed

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests a new type of training called reactive balance training (RBT) to help stroke survivors improve balance and reduce fall risk. Participants will join one of three groups with varying training intensities or a walking group serving as a control. The goal is to determine if more intense RBT improves balance faster than less intense RBT. The study seeks individuals who had a stroke over six months ago and can stand and walk independently. As an unphased trial, this study offers a unique opportunity to contribute to innovative research that could enhance rehabilitation methods for stroke survivors.

Will I have to stop taking my current medications?

The trial information does not specify whether you need to stop taking your current medications. It's best to discuss this with the trial coordinators or your doctor.

What prior data suggests that reactive balance training is safe for stroke patients?

Research has shown that reactive balance training (RBT) can lower the risk of falls by improving individuals' ability to catch themselves when they lose balance. Studies have found this training particularly beneficial for stroke survivors, as it enhances their balance reactions.

RBT is generally manageable for most people, with no strong evidence of major side effects. This likely stems from its focus on improving balance through controlled exercises. Physiotherapists often oversee these sessions, ensuring safety.

Although specific data on side effects is lacking, the training typically involves low-risk activities aimed at enhancing balance, rather than intense physical exercises. Participants can thus expect a safe environment while developing their balance skills. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Researchers are excited about Reactive Balance Training (RBT) for stroke recovery because it introduces a unique approach to improving balance and preventing falls. Unlike traditional stroke rehabilitation options, which often focus on static exercises and gait training, RBT uses dynamic, unpredictable movements to challenge the body's natural balance responses. This method employs a custom moving platform to simulate real-life balance disturbances in multiple directions, which can accelerate the brain's ability to adapt and improve balance. High-intensity RBT, in particular, pushes participants beyond their usual balance limits, potentially leading to faster improvements in stability and confidence in everyday activities.

What evidence suggests that this trial's treatments could be effective for improving balance in stroke patients?

This trial will compare different intensities of reactive balance training (RBT) for stroke recovery. Research has shown that RBT can improve balance in people who have had a stroke. However, limited information exists on whether it boosts confidence in avoiding falls. One review found that this training might not always prevent falls in everyday life. Another study discovered that RBT can reduce fall rates by 23% in older adults compared to regular exercises. Although results are mixed, RBT has the potential to improve balance and reduce falls, making it a promising option for stroke recovery. Participants in this trial will be assigned to high-intensity RBT, moderate-intensity RBT, or a walking control group to evaluate the effectiveness of these approaches. ^{2 3 5 6 7}

Who Is on the Research Team?

Avril Mansfield, PhD

Principal Investigator

University Health Network, Toronto

Are You a Good Fit for This Trial?

This trial is for individuals who have had a stroke and are at risk of falling. They should be in the chronic phase of their recovery, meaning some time has passed since their stroke. The study aims to find out if high-intensity balance training can improve balance reactions faster than moderate-intensity training or just walking.

Inclusion Criteria

I had a stroke more than 6 months ago.

Exclusion Criteria

Cognitive impairment (Montreal Cognitive Assessment score <26) or severe language or communication difficulties affecting understanding instructions

I have a neurological condition like Parkinson's that affects my balance.

Currently attending in- or out-patient physiotherapy or supervised exercise

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo reactive balance training (RBT) or walking control sessions for 1 hour over 4 consecutive days

1 week

4 visits (in-person)

Follow-up

Participants are monitored for retention of learning and adverse outcomes post-training

1 week

1 visit (in-person)

Long-term follow-up

Participants are assessed for falls efficacy and fall incidence over an extended period

12 months

What Are the Treatments Tested in This Trial?

Interventions

• Reactive Balance Training

Trial Overview

The study tests reactive balance training (RBT) intensity levels on improving balance after a stroke. Participants will be randomly assigned to either high-intensity RBT, moderate-intensity RBT, or a walking control group without platform movements, with sessions lasting one hour over one week.

How Is the Trial Designed?

Group I: High intensity reactive balance training Experimental Treatment 1 Intervention

Training sessions will be overseen by a physiotherapist and will last for 1 hour over 4 consecutive days.Participants assigned to the RBT groups will experience 36 multi-directional (left-, right-, and forward-fall) perturbations in each training session, presented in an unpredictable sequence. Balance perturbations will be provided using a custom moving platform. Participants assigned to high-intensity RBT will experience perturbations at 150% of the multi-step threshold; for example, for a multi-step threshold of 2 m/s\^2 the high intensity will be 3 m/s\^2.

Group II: Moderate intensity reactive balance training Active Control 1 Intervention

Training sessions will be overseen by a physiotherapist and will last for 1 hour over 4 consecutive days.Participants assigned to the RBT groups will experience 36 multi-directional (left-, right-, and forward-fall) perturbations in each training session, presented in an unpredictable sequence. Balance perturbations will be provided using a custom moving platform. Participants assigned to the moderate-intensity RBT group will experience perturbations at the multi-step threshold.

Group III: Walking control group Placebo Group 1 Intervention

Training sessions will be overseen by a physiotherapist and will last for 1 hour over 4 consecutive days. Participants in the walking control group will complete 36 unperturbed walking trials on the moving platform in each training session.

Who Is Running the Clinical Trial?

Toronto Rehabilitation Institute

Lead Sponsor

Trials

55

Recruited

6,000+

Heart and Stroke Foundation of Canada

Collaborator

Trials

131

Recruited

72,600+

Published Research Related to This Trial

A review of nine studies involving 364 participants found insufficient evidence that perturbation-based balance training effectively reduces falls in individuals with stroke.

The training protocols varied widely among studies, leading to inconsistent results regarding the impact of this training on common fall risk factors, highlighting the need for more high-quality research in this area.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A systematic review of perturbation-based balance training on reducing fall risk among individuals with stroke. Brown, D., Simpkins, C., Yang, F.[2023]

Perturbation-based balance training (PBT) significantly improved reactive balance control in individuals with chronic stroke, as evidenced by a decrease in the frequency of extra steps taken in response to support-surface perturbations after 6 weeks of training.

In contrast, traditional balance training did not show similar improvements, highlighting the effectiveness of PBT in rehabilitation programs aimed at reducing fall risk in stroke patients.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Does Perturbation-Based Balance Training Improve Control of Reactive Stepping in Individuals with Chronic Stroke? Schinkel-Ivy, A., Huntley, AH., Aqui, A., et al.[2019]

The study aims to evaluate whether perturbation-based balance training can effectively reduce fall occurrences in individuals with chronic stroke, addressing a significant post-stroke complication.

Participants will undergo training twice a week for 6 weeks, with follow-up assessments on falls and balance confidence over 12 months, potentially leading to improved mobility and daily activity engagement.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Perturbation training to promote safe independent mobility post-stroke: study protocol for a randomized controlled trial. Mansfield, A., Aqui, A., Centen, A., et al.[2019]

This study investigates the effectiveness of perturbation-based balance training (PBT) compared to conventional intensive balance training (CIBT) in improving reactive stepping ability in 24 adults with chronic incomplete spinal cord injury over 8 weeks.

The primary outcome measures the ability to recover balance using a single step, which will help determine which training method is more effective for enhancing balance control and reducing fall risk in this population.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Intensive Balance Training for Adults With Incomplete Spinal Cord Injuries: Protocol for an Assessor-Blinded Randomized Clinical Trial. Unger, J., Chan, K., Scovil, CY., et al.[2023]

Reactive balance training (RBT) significantly reduces the likelihood of falls in daily life for older adults and individuals with balance impairments, with a fall risk ratio of 0.76 compared to control groups.

While RBT is effective in decreasing falls, it is associated with a higher prevalence of adverse events (29% in RBT vs. 20% in control), indicating that while it is beneficial, caution is needed regarding potential risks.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

The Effect of Reactive Balance Training on Falls in Daily Life: An Updated Systematic Review and Meta-Analysis. Devasahayam, AJ., Farwell, K., Lim, B., et al.[2023]

Reactive balance training (RBT) significantly improved balance reaction impairments in individuals with sub-acute stroke, showing better outcomes in foot-off times and reduced reliance on preferred limb stepping compared to traditional balance training.

The study demonstrated that RBT not only led to immediate improvements post-intervention but also maintained these benefits at a 6-month follow-up, supporting its effectiveness in inpatient rehabilitation settings.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Improvements in balance reaction impairments following reactive balance training in individuals with sub-acute stroke: A prospective cohort study with historical control. Schinkel-Ivy, A., Huntley, AH., Danells, CJ., et al.[2021]

This pilot randomized controlled trial involves 36 stroke survivors to evaluate the effects of different doses of reactive balance training (RBT) on balance control and confidence, aiming to inform a larger study on optimal RBT dosage.

Participants will be assessed at multiple time points, including 6 months post-discharge, to track falls and physical activity, which will help determine the feasibility and necessary sample size for future trials.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Determining the optimal dose of reactive balance training after stroke: study protocol for a pilot randomised controlled trial. Mansfield, A., Inness, EL., Danells, CJ., et al.[2021]

Citations

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pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC9329815/

The Effectiveness of Perturbation-Based Training in the ...

PBT may improve balance in patients with stroke, however its effect on balance confidence was limited. The quality of the evidence was low or very low.

2.

sciencedirect.com

sciencedirect.com/science/article/abs/pii/S0268003323002097

A systematic review of perturbation-based balance training ...

The results indicated insufficient evidence supporting that perturbation-based balance training reduces falls in the laboratory and everyday living conditions ...

3.

clinicaltrials.gov

clinicaltrials.gov/study/NCT06555016

Optimal Intensity of Reactive Balance Training Post-stroke

The purpose of this study is to determine the optimal intensity of RBT post-stroke. The 'optimal' intensity is the intensity that improves reactive balance ...

4.

journals.plos.org

journals.plos.org/plosone/article?id=10.1371/journal.pone.0327937

Investigating the optimal reactive balance training intensity in ...

The primary outcomes are reactive stepping ability, measured using number of steps required to recover balance from a novel perturbation. Secondary outcomes ...

5.

medrxiv.org

medrxiv.org/content/10.1101/2025.07.23.25331962v1.full-text

Perturbation-based balance training improves reactive ...

This systematic review and meta-analysis revealed PBT reduced fall rates in older adults by 23% compared to control groups receiving standard ...

6.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC10875131/

Advances in balance training to prevent falls in stroke ...

Studies have shown that the incidence of falls in stroke patients is as high as 25–40%, and the injury rate is as high as 90, 32–83% of stroke ...

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frontiersin.org

frontiersin.org/journals/sports-and-active-living/articles/10.3389/fspor.2022.1015394/full

Perturbation-based balance training: Principles ...

Perturbation-based balance training has been gaining interest as an efficient and effective way to prevent falls in older adults.