Balance training

Balance training includes exercises to improve one’s agility and stability of gait (Mosby, 2009). There is moderate evidence that balance may be improved among stroke

survivors following individual balance training, with two to three times weekly sessions recommended in the acute phase (Lubetsky-Vilnai, Anat & Kartin; 2010). Mansfield et al.

(2018) showed that despite balance training having the potential to reduce falls, ongoing training is required to maintain the benefits.

Cheng et al. (2001) showed that symmetrical body-weight training in stroke survivors improved particpants’ sit-to-stand performance, with body-weight being distributed more symmetrically in both legs, leading to a decreased number of falls. Stroke fallers were also reported by Cheng et al. (1998) to put less weight on their paretic limb than the non-fallers during sit-to-stand manoeuvre, and Liu et al. (2016) found in a pilot study that stroke survivors given sit-to-stand training reported an improvement in weight-bearing symmetry during sit-to-stand manoeuvre.

1.5.5. Yoga

Yoga is the adoption of specific body postures combined with breathing practices and meditation, aimed to calm the mind (Yogapratap, 2009). Most studies focus on

mindfulness and stress-relief rather than on balance – although, balance was found to improve in some studies in a systematic review by Lazaridou and Tzika (2013). It is unclear to what extent balance did improve and which falls risk factors were addressed to gain optimum prevention of falls (Lazaridou et al., 2013). Despite Yoga showing a potential to improve balance in the general population (Ni et al., 2014; Saravanakumar, Higgins, van der Riet, Marquez & Sibbritt., 2015), there is not enough high-quality evidence to comment on the benefits and safety of Yoga in stroke rehabilitation (Lawrence et al., 2017).

1.5.6. Tai Chi

Most falls among high risk older adults occur at home whilst performing tasks such as cleaning, opening or closing doors, bathing, and getting in and out of cars (Stevens, Mahoney & Ehrenreich, 2014); these tasks involve leaning in different directions and moving the arms, which may cause the individual to lose their balance. Therefore, it is important that potential fallers maintain their balance through mindfulness of their posture and arm position whilst performing tasks. Tai Chi is a branch of Chinese martial arts that involves slow repetitive gentle movements (Liao, 2017). It involves mindfulness and awareness of where the body is in relation to the environment. Importantly,

mindfulness and awareness are present during weight shifting and stepping. Thus, Tai

Chi may be more plausible than Yoga and other alternative exercises. There is no definitive reason as to why Tai Chi may be more plausible, but it seems that Tai Chi has the potential to improve balance and reduce falls in stroke survivors by maintaining an awareness of where the body is in relation to the environment and being aware of each movement (Jimenéz-Martin, Meléndez-Ortega, Albers & Schofield, 2013). Thus, the most plausible mechanism of action for an improvement in balance is proprioception. Some studies have shown potential for Tai Chi to improve balance and reduce falls among stroke survivors, but the evidence is limited (Li et al., 2018b; Lyu et al., 2018; Wu et al., 2018). As well as proprioception, Tai Chi might address a further five of the modifiable fall risk factors for stroke presented in Figure 2 and Table 3 (muscle weakness, lack of physical activity, balance, fear of falling, and depression). There is some existing evidence on each of these factors. According to the evidence presented in Table 3, Tai Chi may improve balance in stroke survivors (Li et al., 2018b; Lyu et al., 2018; Wu et al., 2018).

Yoshinaga and Cai (2013) suggest that the mechanisms through which balance improves among stroke survivors practising Tai Chi are by strengthening the core of the body and symmetrical distribution of the centre of gravity which in turn improves muscle strength.

Some researchers suggest that Tai Chi may improve balance in stroke survivors through improvement of proprioception (Ding, 2012; Zhang et al., 2015). Previous studies have shown that physical activity is an important part of stroke rehabilitation to reduce disabilities, as well as promoting spontaneous neural functional recovery and regaining brain function in cerebral apoplexy. Thus, effective interventions for improving physical function are needed (Wu et al., 2018). Tai Chi is a form of physical activity which has been shown to improve physical function, incorporating the performance of ADLs, strength improvement, flexibility, co-ordination and balance all in one workout (Lyu et al., 2018). Evidence also suggests that depression may be improved in stroke survivors following Tai Chi Taylor-Piliae and Haskell, 2007; Wang et al., 2010; Zhang et al., 2015).

Few studies have explored fear of falling and falls among stroke survivors following Tai Chi. However, recent meta-analyses have been conducted on Tai Chi and falls (Winser, Tsang, Krishnamurthy & Kannan, 2018; Liu et al., 2019). Despite the evidence for Tai Chi and falls among stroke survivors being limited, this area deserves further study.

Therefore, the current study will explore fall reduction as a primary outcome with balance improvement as a secondary outcome, with additional outcomes for depression and fear of falling.

Another reason why Tai Chi would be appealing for this study is because it is inexpensive and does not require specialist equipment but does require specialist instruction. It is

also an exercise that can be practised at home. Therefore, Tai Chi seems to be the most appropriate exercise of all those common types itemised in Table 3.

There is a variety of different exercises that may address the needs of stroke survivors during rehabilitation: aerobic exercise, repetitive task training, strength training, balance training, Yoga and Tai Chi. Although the above exercises address some of the modifiable falls risk factors among stroke survivors, they have limitations and characteristics (e.g.

they require specialist equipment or not capable of being practiced at home) that make them unsuitable for stroke survivors. In principle, Tai Chi addresses most, if not all, modifiable falls risk factors among stroke survivors. Limited research on Tai Chi amongst stroke survivors is promising, with the additional benefit of being low-cost without

requiring any specialist equipment. After reviewing what exercises are available for stroke survivors, it has been concluded that Tai Chi appears to be the most suitable exercise for this study.

Reflections

Stroke is a leading cause of disability (RCN, 2016), and there is an increasing demand on NHS services from the increasing number of stroke survivors. Disability is not just a health problem but also a medical one (WHO, 2018a). Activity limitation is one factor affecting the ability of stroke survivors to perform ADLs. Additionally, stroke survivors experience a lack of involvement in social activities, such as leisure. A barrier to

activities such as leisure has been found to be lack of transportation and social provision, posing a problem when wanting to offer an exercise programme to stroke survivors.

Balance impairment among stroke survivors is often the reason for barriers to activities, and is a major falls risk factor, which is linked to other modifiable falls risk factors.

Stroke survivors are prone to having four or more of these falls risk factors. Therefore, an exercise programme for stroke survivors should address as many of these falls risk factors as possible to gain optimum falls prevention. There is a variety of possible exercises available for stroke survivors, but many are not suitable for a variety of reasons. Tai Chi addresses many, if not all, modifiable falls risk factors, and has the additional appeal of being inexpensive without requiring specialist equipment. Therefore, a literature review will be conducted in Chapter 2 to establish what evidence there is to support Tai Chi as an exercise, targeting fall prevention for stroke survivors, as well as to establish any gaps in evidence.