Clinical Practice Guidelines for Balance Training
The recommendations are graded by their level (I, II) and strength (A, B, C+, C, D, D+, D-) of evidence. Definitions for the level and strength of the recommendations are presented at the end of the "Major Recommendations" field.
Balance training (sit-to-stand) with force platform and auditory feedback versus control (no feedback), level I (randomized controlled trial [RCT]): Grade A for time up at follow-up, 33 months (clinically important benefit demonstrated); grade C+ for strength (dynamic knee extensors strength in concentric movement) at end of treatment, 6 weeks (clinically important benefit demonstrated without statistical significance); grade C for time up, body weight distribution on affected lower extremity in rising and sitting, strength (dynamic knee flexors strength in eccentric movement), physical performance, and activities of daily living at end of treatment, 6 weeks, time down and strength (dynamic knee extensors strength in concentric movement) at follow-up, 33 months, and strength (dynamic knee extensors strength in eccentric movement) at end of treatment, 6 weeks, and follow-up, 33 months (no benefit demonstrated); grade D for time down, strength (dynamic knee flexors in concentric movement), and motor function in sit to stand at end of treatment, 6 weeks, and body weight distribution on affected lower extremity in rising and sitting at follow-up, 33 months (clinically important benefit favoring control demonstrated). Patients with subacute and post-acute stroke.
Base of support training with extrinsic auditory feedback versus control, level I (RCT): Grade A for step width at end of treatment, 10 days (clinically important benefit demonstrated). Patients with subacute stroke.
Balance training with visual feedback versus control, level I (RCT) and level II (controlled clinical trial [CCT]): Grade A for motor function (Rivermead Motor Function Scale: global and gross motor function) at end of treatment, 4 weeks, functional status at end of treatment, 4 weeks, and follow-up, 8 weeks, timed task (duration of sit-to-stand), body weight distribution, rate of rise in force during sit-to-stand (% of body weight/second), dynamic balance (end point excursion* [right and backward], axis velocity** [right-left], and directional control*** [forward-backward]) at follow-up, 6 months (clinically important benefit demonstrated); grade C+ for static balance (center of gravity alignment: eyes open, sway vision, eyes closed/sway surface, and sway vision/sway surface) at follow-up, 6 months, motor function (Rivermead Motor Function Scale: lower extremity and trunk) at end of treatment, 4 weeks, dynamic balance (end point excursion* left and forward) at follow-up, 6 months, balance (postural sway eyes open) at end of treatment, 3 weeks (clinically important benefit demonstrated without statistical significance); grade C for static balance (center of gravity alignment: eyes closed, eyes open/sway surface) at follow-up, 6 months, functional mobility and balance (postural sway eyes opened) at follow-up, 1 month, and balance (Berg Scale) at end of treatment, 6 weeks, and follow-up, 1 month, gait speed at end of treatment, 4 weeks and 6 weeks, mobility (stride length, cadence, and gait cycle duration) at end of treatment, 4 weeks, balance (standing symmetry) at end of treatment 3 weeks, static balance (maximal stability eye open and eye closed), static balance (ankle strategy eyes open, eyes closed, sway vision, eyes closed/sway surface, and sway vision/sway surface), dynamic balance-axis velocity** (forward-backward) and dynamic balance-directional control*** (right-left), and timed task (duration of stand-to-sit) at follow-up, 6 months (no benefit demonstrated); grade D for static balance (maximal stability sway vision, eyes open/sway surface, eyes closed/sway surface, and sway vision/sway surface), static balance (ankle strategy eyes open/sway surface) at follow-up, 6 months, motor function (Rivermead Motor Function Scale: gross motor function) at follow-up, 8 weeks, balance (Berg Scale) at end of treatment, 3 and 4 weeks, functional mobility at end of treatment, 4 and 6 weeks, gait speed and balance (standing symmetry) at follow-up, 1 month (no benefit demonstrated but favoring control); grade D+ for balance (postural sway eyes closed) at end of treatment, 3 weeks, and follow-up, 1 month, functional mobility and gait speed at end of treatment, 3 weeks, motor function (Rivermead Motor Function Scale: global and lower extremity and trunk) at follow-up, 8 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute and post-acute stroke.
*End point excursion refers to the distance traveled by the center of gravity on the primary attempt to reach a target moving in a different direction in 0.8 seconds.
**Axis velocity is the average speed of the subject's center of gravity movement in the specified direction.
***Directional control is defined as the ratio of the actual distance traveled by the center of gravity from the center to end point excursion compared with the shortest distance between those two points (a straight line).
Balance training with visual feedback versus Bobath approach training, level I (RCT): Grade A for standing balance at end of treatment, 4 weeks, and follow-up, 2 weeks (clinically important benefit demonstrated); grade C+ for sitting balance at end of treatment, 4 weeks, and follow-up, 12 weeks, and standing balance at follow-up, 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for sitting balance at follow-up, 2 weeks (no benefit demonstrated). Patients with subacute stroke.
Balance training with visual feedback versus task-specific training, level I (RCT): Grade A for standing balance at follow-up, 2 weeks (clinically important benefit demonstrated); grade C+ for sitting balance at end of treatment, 4 weeks, and follow-up, 12 weeks, and standing balance at follow-up, 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for sitting balance at follow-up, 2 weeks, and standing balance at end of treatment, 4 weeks (no benefit demonstrated). Patients with subacute stroke.
Balance training with visual feedback versus control, level I (RCT): Grade A for standing balance at end of treatment, 4 weeks, and follow-up, 2 weeks (clinically important benefit demonstrated); grade C+ for sitting balance and standing balance at follow-up, 12 weeks (clinically important benefit demonstrated without statistical significance); grade C for sitting balance at end of treatment, 4 weeks (no benefit demonstrated); grade D+ for sitting balance at follow-up, 2 weeks (clinically important benefit favoring control demonstrated without statistical significance). Patients with subacute stroke.
Platform training versus control, level I (RCT): Grade A for standing balance at end of treatment, 3 weeks (clinically important benefit demonstrated); grade C for weight distribution at end of treatment, 3 weeks (no benefit demonstrated). Patients with subacute stroke.
Definitions:
Level of Evidence
Level I: Randomized controlled trials
Level II: Nonrandomized studies
Grade of Recommendation
Grade A: Evidence from one or more randomized controlled trials (RCTs) of a statistically significant, clinically important benefit (>15%)
Grade B: Statistically significant, clinically important benefit (>15%), if the evidence was from observational studies or controlled clinical trials (CCTs)
Grade C+: Evidence of clinical importance (>15%) but not statistical significance
Grade C: Interventions where an appropriate outcome was measured in a study that met the inclusion criteria, but no clinically important difference and no statistical significance were shown
Grade D: Evidence from one or more randomized controlled trials of a statistically significant benefit favoring the control group (<0%: favors controls)
Grade D+: Evidence of clinical importance (<-15% for controls) without statistical significance
Grade D-: Evidence from one or more randomized controlled trials of a clinically important benefit (<-15% for controls) that was statistically significant, where the number of participants in the study is equal to or higher than 100
