A stroke can affect your balance in many different ways. You might have muscle weakness, dizziness, visual field loss and coordination difficulties and other issues causing balance problems. It is often possible to get treatment for these effects of stroke, including physiotherapy and balance retraining exercises. You may be able to use equipment to improve your stablity such as a stick or ankle-foot orthosis. 

If you are worried about falling, you can visit our page giving practical tips for avoiding a fall.

How does balance work?

Balance involves the coordination and stability of our bodies in our surroundings. It affects most day-to-day activities, such as moving around and reaching for objects. If your balance is impaired after a stroke, you may feel dizzy or unsteady. This can reduce your confidence and increase your risk of having a fall. If your balance problems last for a long time, you might find that they affect your quality of life. 

Balance is very complex and involves many different parts of the body such as your ears, eyes, and sensory nerves in your muscles and joints.

Balance problems and dizziness can also be caused by a number of health problems other than stroke. Treating an underlying condition can help improve your balance, and your GP can advise you about health checks and treatments available. Some of these conditions are covered in this guide, but you always need to take individual advice from a qualified health professional about any problems you may have.

How can stroke affect your balance?

To have good balance, different parts of the body, like the brain, eyes and limbs, need to work well together.

A stroke can affect your balance system, and the way in which the parts work together. Usually your body can overcome mild problems, but if they are more severe, your system will be unable to work effectively and you will probably feel unsteady. 

Weakness on one side of your body
A stroke often causes weakness on one side of your body, which can make it difficult to balance. At worst, you may find it difficult to sit up safely, or you may have difficulty standing. You may be able to walk but find that you cannot lift your toes quickly enough to stop them catching on the ground when you step. This is known as foot drop, and it can make you feel unsteady or more likely to trip. Or you may find that you have less energy, so that you tire easily and then become unsteady. 

Loss of sensation
The second main factor affecting balance is loss of sensation in your affected side, particularly your legs. If you cannot feel where your leg and foot are, especially when your foot is safely on the ground, it is very difficult to know how to move. You will automatically use your vision to compensate for the lack of feeling, which takes a lot of concentration and is tiring. It also means that you may be less aware of your surroundings. All of this increases your risk of having slips, trips and falls.

Vertigo
If a stroke happens in your cerebellum or brainstem – the areas that control balance in the brain – you may be left with vertigo. This means having a feeling that you or the world around you are moving or spinning. You can feel dizzy or lose your balance.

Concentration problems
After a stroke, moving around and keeping your balance may require more concentration, which is hard work. If your attention is distracted, it might be harder to concentrate on your balance. Many people who fall report that they were not paying attention, were thinking of other things or doing several things at the same time when they fell. One example is walking and talking at the same time - some stroke survivors stop walking if you speak to them. Other examples include coping with unpredictable situations such as crowds and uneven surfaces, turning or changing direction when walking or carrying things.

Perceptual problems
Some strokes can affect your ability to interpret your surroundings. It can be difficult to maintain your balance and plan how to move if you are unsure of your own position in relation to the space around you.

Spatial neglect
Spatial neglect, or inattention, means that your brain is not processing sensory information from one side. You might not be aware of one side of your body, and the space to that side. People with neglect may try to move but forget to move their weak leg, causing loss of balance. They might bump into or trip over objects they can’t perceive, causing a fall. Some people experience the sensation that they are upright even when they are leaning heavily to their weak side, sometimes to the extent that they cannot sit up safely. This is called ‘pusher syndrome’ and sometimes happens in the early days after a severe stroke. 

Vision problems
Vision is an important aspect of balance. Visual problems after stroke are quite common. They vary and include difficulty focusing, double vision, eye movement problems and blind patches.  It can be harder to make the subtle and rapid adjustments to your posture and movements to maintain your balance if you cannot see clearly around you.

Ataxia
Ataxia is the name for clumsy, uncoordinated movements. It is associated with strokes that happen in the back of the brain (cerebellum or posterior circulation). 

People with ataxia have difficulty producing movements quickly enough, and in the right order, to avoid losing their balance or to recover from a trip or slip. 

Side effects of medication
Some medicines commonly prescribed after stroke can cause dizziness or weakness. Some anticoagulants can cause dizziness, as well as some drugs for high blood pressure. Withdrawal from antidepressants can cause dizziness. Interactions between different medicines can also affect your balance.

Talk to your doctor if you have any concerns about the medicine you are taking, as you may be able to try new drugs or a different combination of drugs. Never stop taking any medication without speaking to your doctor first.

Other causes of balance problems
A range of other conditions not directly related to stroke can also cause dizziness and loss of balance. These include inner ear infections, migraines and confusion due to a urinary tract infection.

Recovering from balance problems

Dizziness symptoms can vary in severity and how long they last. The problems caused by stroke may mean that you are not able to move straight away. Being unable to move for a long time may affect how long it takes your balance problems to improve. 

From 24 hours after a stroke, with your therapists’ help, you can try to help your recovery by starting to get moving. Improvement tends to be fastest in the first few days or weeks after stroke, but can continue slowly for months or even years. However, everyone is different and there is no fixed time for recovery.

Physiotherapy to help your balance

A physiotherapist can assess you and recommend therapy or exercises that may help you to recover.

You should see a physiotherapist while you are in hospital. If you have left hospital, your GP can refer you for physiotherapy. Private physiotherapists and some NHS services will accept a selfreferral where you can go to them directly to request assessment and treatment. 

Balance retraining exercises

Exercise and balance retraining are very effective ways to treat balance problems. To be effective the exercises need to be:

  • Intensive – you need to do as much as you can, as often as you can.
  • Individual – you need to work on the things that you find difficult.
  • Functional – when it is safe to do so, you need to practice the everyday activities that you find difficult, such as standing up and sitting down, negotiating uneven surfaces and obstacles, changing direction and speed, walking up stairs.
  • Progressive – you need to move on to more challenging activities to keep improving.

Keeping your balance while sitting up in bed or on a chair may be the first thing your therapist addresses with you. Then they will start getting you to balance whilst standing, perhaps with the help of a hoist, or the support of other people. 

Exercises may then include step-ups, moving from sitting to standing position, practising reaching for objects and standing on unstable surfaces. 

Balance retraining may take place in oneto-one sessions with a physiotherapist. You may do exercises they prescribe in your own time (in hospital or at home), or in a group run by a physiotherapist either in hospital or in a community setting.

Exercises can take many forms and should be supervised by a physiotherapist who will provide individually tailored activities to progressively challenge you. People sometimes feel worried or scared about falling while practising exercises. If you are concerned, ask your therapist for advice to help you continue with your exercises and make the best possible recovery.

Exercise groups
Some stroke clubs and other community groups run exercise classes or offer other services to help people with disabilities stay active.

Treadmill training
Treadmill training may be useful as part of a programme to gradually increase your stamina. This may be available at your local physiotherapy department, or many areas offer an ‘exercise prescription scheme’ (different names are used in different areas).

This lets you work with a fitness trainer who is trained to work with people with disabilities at your local gym or fitness centre. They will be able to adapt the exercises and equipment to your needs. Your GP can tell you what is available in your area.

Gaze stabilisation
Gaze stabilisation exercises can help people with ongoing dizziness and vertigo. They need to be prescribed carefully and should be delivered by a physiotherapist who specialises in dizziness.  

Equipment to help with balance problems

A simple walking stick or four-point cane can improve your stability and improve your confidence, especially when walking outside. Even if you do not need to lean on the stick for support, people will often give you a little more time and space. It is important that any equipment is the correct size for you, so get professional help when choosing.

If you have foot drop (difficulty lifting your foot off the ground when walking) you may be offered an ankle-foot orthosis. This splint lifts your toes and supports your ankle so you can put your weight on your leg when you stand without catching your toes when you step forward. Your physiotherapist can prescribe a splint or may refer you to the local orthotics department. 

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