Reactive Balance Training for Stroke

Overseen By Avril Mansfield, PhD

Age: 18+

Sex: Any

Trial Phase: Academic

Sponsor: Toronto Rehabilitation Institute

Disqualifiers: Lower-extremity amputation, Severe spasticity, others

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

Compensation: Varies

Number of Visits: 3

Duration: 4 weeks

What You Need to Know Before You Apply

What is the purpose of this trial?

This trial tests a new type of balance training to help reduce falls in people who have recently experienced a stroke. It seeks to determine how many sessions of reactive balance training (RBT) are needed to achieve significant improvements in balance and prevent falls. Participants will be randomly assigned to complete either 1, 3, or 6 sessions, each lasting 45 minutes. Individuals who have had a stroke, are currently receiving rehabilitation, can stand on their own for over 30 seconds, and can walk with or without a walking aid for at least 10 meters without assistance, might be suitable for this study. As an unphased trial, this study provides a unique opportunity to contribute to innovative research that could enhance rehabilitation strategies 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 seems focused on balance training, so it's best to discuss your medications with the trial coordinators or your doctor.

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

Research has shown that reactive balance training (RBT) is generally well-received and may help lower the risk of falls for people recovering from a stroke. One study found that RBT led to fewer falls after patients completed their stroke rehabilitation. In these studies, participants improved their balance and needed fewer steps to steady themselves after being nudged off-balance.

No reports of serious side effects from RBT have emerged, suggesting it is generally safe for stroke recovery. Since RBT focuses on improving balance through controlled exercises, it appears to be a gentle approach that fits well with rehabilitation needs.

For those considering joining a trial, RBT has shown promise in improving balance without causing harm in previous studies. ^{1 2 3 4 5}

Why are researchers excited about this trial?

Reactive balance training is unique because it directly addresses the sudden, unexpected loss of balance that stroke survivors often face. Unlike traditional balance exercises that may focus more on static stability, this method involves controlled perturbations, or gentle nudges, that help retrain the body's response to balance disruptions. Researchers are excited about this approach because it could potentially improve real-world mobility and reduce fall risk more effectively than conventional methods. By offering varying intensities, with options for one, three, or six sessions, it allows for a tailored approach to individual recovery needs, which could lead to faster and more effective rehabilitation outcomes.

What evidence suggests that reactive balance training is effective for reducing fall rates in people with stroke?

Studies have shown that reactive balance training (RBT) can improve balance and reduce falls in people who have had a stroke. Research indicates that RBT aids in reactive stepping, the body's way of preventing falls. In past studies, stroke survivors who participated in RBT fell less often than those who did not. For healthy older adults, even one RBT session led to lasting improvements in balance and fewer falls. However, stroke survivors might require more sessions to achieve similar benefits due to more severe impairments. This trial will compare different frequencies of RBT sessions: one session, three sessions, and six sessions. Overall, RBT appears promising in helping stroke survivors enhance their balance and reduce their risk of falling. ^{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, can stand on their own for more than 30 seconds, live in the community, and are receiving outpatient rehab at the Toronto Rehabilitation Institute. They must be able to walk over 10 meters with or without a walking aid but not another person's help.

Inclusion Criteria

I am currently in outpatient rehab at the Toronto Rehabilitation Institute.

I had a stroke not long ago.

Living in the community

Exclusion Criteria

I have recent injuries or conditions affecting my ability to walk or stand.

I have heart-related activity restrictions or unstable reactions to exercise.

I have severe muscle stiffness in my legs.

Timeline for a Trial Participant

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants receive reactive balance training sessions as part of routine out-patient rehabilitation

4 weeks

1-6 sessions (in-person)

Follow-up

Participants are monitored for safety and effectiveness after treatment

6 months

Postcards every 2 weeks, phone calls as needed

What Are the Treatments Tested in This Trial?

Interventions

• Reactive balance training

Trial Overview

The study tests how effective different amounts of reactive balance training (RBT) are in improving balance after stroke. Participants will be randomly placed into one of three groups to receive either 1, 3, or 6 sessions of RBT during routine outpatient rehabilitation.

How Is the Trial Designed?

Group I: 6 sessions Experimental Treatment 1 Intervention

Participants will complete six 45-minute sessions of reactive balance training. Participants will experience 40-60 perturbations during each session.

Group II: 3 sessions Experimental Treatment 1 Intervention

Participants will complete three 45-minute sessions of reactive balance training. Participants will experience 40-60 perturbations during each session. Participants will also complete 3 45-minute 'traditional' balance training sessions.

Group III: 1 session Active Control 1 Intervention

Participants will complete one 45-minute session of reactive balance training. Participants will experience 40-60 perturbations during this session. Participants will also complete 5 45-minute 'traditional' balance training sessions.

Who Is Running the Clinical Trial?

Toronto Rehabilitation Institute

Lead Sponsor

Trials

55

Recruited

6,000+

Heart and Stroke Foundation Canadian Partnership for Stroke Recovery

Collaborator

Trials

2

Recruited

90+

Published Research Related to This Trial

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]

The reactive balance test (RBT) demonstrated excellent intra- and inter-rater reliability for measuring visuomotor response time and accuracy in a study involving 21 healthy recreational athletes.

Test-retest reliability for the RBT was good for response time and moderate for accuracy, indicating that the test is reliable for group-level analyses in assessing balance and coordination.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Test-retest, intra- and inter-rater reliability of the reactive balance test in healthy recreational athletes. Tassignon, B., Verschueren, J., De Wachter, J., et al.[2021]

Impaired reactive balance control, particularly in the paretic limb and between-limb synchronization, significantly predicts an increased risk of falls in individuals discharged from stroke rehabilitation, based on a study of 95 participants over 6 months.

Specific measures such as decreased contribution of the affected limb to balance and increased step length variability were strongly associated with fall rates, indicating that rehabilitation should focus on improving these aspects to enhance safety post-discharge.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Do measures of reactive balance control predict falls in people with stroke returning to the community? Mansfield, A., Wong, JS., McIlroy, WE., et al.[2016]

In a study of 183 stroke patients, 42% underwent a reactive balance control assessment using the lean-and-release method, which was implemented in an inpatient rehabilitation program.

Patients who received the assessment were generally younger and had better functional mobility and balance, indicating that the assessment may be more applicable to those with less severe impairments, highlighting a need for further research to adapt the assessment for patients with greater disabilities.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Clinical implementation of a reactive balance control assessment in a sub-acute stroke patient population using a 'lean-and-release' methodology. Inness, EL., Mansfield, A., Biasin, L., et al.[2016]

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]

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) is seen as an advanced skill that can improve balance control, but there is variability in how clinicians implement it, indicating a need for standardized approaches and resources to enhance its feasibility.

Building trust between therapists and clients can improve confidence and reduce fear during RBT, suggesting that a supportive environment is crucial for effective training, especially for clients with neurological conditions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Rehabilitation clinicians' perspectives of reactive balance training. Jagroop, D., Houvardas, S., Danells, CJ., et al.[2023]

Citations

1.

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 ...

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pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC10696991/

Effects of different rehabilitation training on balance function in ...

About 83% of patients have some degree of balance dysfunction. Rehabilitation training is an effective means to improve the balance function of stroke patients.

3.

journals.plos.org

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

Investigating the optimal reactive balance training intensity in ...

RBT improves control of reactive stepping in stroke survivors and reduces the rate of falls within various populations, including people with stroke [13–15].

4.

medrxiv.org

medrxiv.org/content/10.1101/2025.07.24.25332137v1.full.pdf

Optimal reactive balance training characteristics post-stroke

In contrast to our results, others have found lasting improvements in reactive balance control with a very low volume of RBT among healthy older ...

5.

frontiersin.org

frontiersin.org/journals/neurology/articles/10.3389/fneur.2024.1167954/full

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

A study combined dual task training and aquatic and showed aquatic motor dual task training is more effective in improving balance and gait in ...

6.

pmc.ncbi.nlm.nih.gov

pmc.ncbi.nlm.nih.gov/articles/PMC7451480/

Determining the optimal dose of reactive balance training ...

Our non-randomised study suggests that RBT reduces fall rates after discharge from stroke rehabilitation. In our previous study, the ...

7.

medrxiv.org

medrxiv.org/content/10.1101/2025.06.26.25330322v1.full-text

Investigating the optimal reactive balance training intensity ...

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