"𝗜 𝗳𝗮𝗹𝗹 𝗼𝗳𝘁𝗲𝗻. 𝗪𝗵𝗮𝘁 𝗱𝗼 𝗜 𝗱𝗼?"

Bottom line: You can make your balance better, and have less falls (and have less fear of falling). But it takes a lot of work, because of course it does. And, don't work on the wrong thing. OK, New Bottom Line: It's hard work, and a fundamental mistake (BOOMER JOKE ALERT) may trip you up. 

Is it a balance problem?

The outside world sees the cause for unsteady walking as a balance problem. If somebody falls they go to therapy for balance training, because they lost their balance. 

But, you may say, I don't have bad balance. I know what upright is, but my muscles won't fire when I tell them to, so I fall! It's a muscle problem, not a balance problem. If that's the way you look at it, you're not wrong.

I'm going to say something pretty radical here, so make sure you check with the appropriate healthcare worker before buying into this... 

You may not have a balance problem. 

Balance problems come form a loss or deficit of one or more of the following:

1. Proprioception: the ability to imagine where your body is in space without looking at it. 
2. Eyesight: the ability to find "true north" and/or where the horizon is.
3. Vestibular sense:  the ability to sense movement, and know where your head and body are in space. When the vestibular system is not working it's the classic inner ear problem:  Meniere's disease, dizziness, vertigo.

Proprioception, Eyesight, Vestibular sense. Let's just call them: PEV

It's only a balance problem if you have a problem with one or more of PEV.

And a lot of survivors have problems with PEV, no doubt. But lets say you're a survivor that does not have these problems, why do clinicians and everybody else say you have balance problems? Because: From the outside it looks like you have poor balance. And you do lose your balance. So how is that not balance problem? In any case, you might say: Who cares what the cause is? Even if there's another cause, its a distinction without a difference. I'm still a fall risk.

It's important to know what is causing the "balance problems" because you don't want to bark up the wrong tree. And, it is true, there may be multiple trees. What's another tree? Muscles.

You may have fine PEV (unless you drink a lot, it which case you need another kind of rehab:) So its something else: Muscles. Maybe you know damned well where you are and what you need to do to retain your balance. But the stroke stops you from moving your muscles correctly to "catch" yourself. 

But again, so what? Well, here's the thing. PEV stuff has a "neoplastic model"—a way of changing the brain to lesson or fix the problem. And if you have problems with them, then focus on PEV.

But if you don't have balance problems related to PEV, but have muscles that won't cooperate, then the best recovery option is repetitive practice. 

I've been in stroke-specific research for a long time. And one of my fav quotes in clinical research is also one of the most obvious and most hilarious: Task-specific gait training improves gait post-stroke. (EBRSR)

Walking makes walking better. Hmmmm. Whoda thunk?

But what if you can't practice walking because you're afraid you'll fall? Here's some ideas (ASK A QUALIFIED HEALTHCARE WORKER ABOUT THESE SUGGESTIONS!)

Treadmills. Treadmills are never ending parallel bars. They expand the size of the gym with a very small footprint. Put a mirror in front of them and they become instantaneous feedback machines. They also provide an essential bit of quantifiable data: speed of gait. 

Recumbent, 4-limb bilateral trainer. Recumbent trainers do not have to break the bank. Inexpensive ones can be found for $350 or so. These are essential not only as a pre-ambulation device, but also because they develop cardiovascular and muscular strength. The thing is, fatigue leads to falls. And if your walking has been compromised by stroke, walking takes twice as much muscular and cardio strength as it takes someone who walks "normally."  "banking" both muscle and cardio strength are essential to doing the hard work of recovery.

Some sort of harnessing system for gait training. Stroke recovery works best with over-challenge. Challenge drives neuroplasticity and neuroplasticity drives recovery. It's impossible to over challenge with standard gait training (a gait belt and guarding). The fear of falling on the part of the survivor and the therapist runs headlong into the challenge that needs to be realized. If the survivor is harnessed, falls are impossible and challenge flourishes. Partial weight sported walking is but one option that requires harnessing. Speed intensive treadmill training (also known as speed dependent treadmill training) has shown stellar efficacy in increasing speed of gait. And speed is good. The usual suspect in this category is the LiteGait. Over ground systems may be a better option for some gyms. NeuroGym, Biodex and other companies make over ground systems that provide an inexpensive harnessing option.

One last important note:

Falls very often happen in four situations:

• Starting walking

• Stopping walking

• Turning

• Uneven surfaces

So if you find yourself in one of those four situations (and it may happen hundreds of times a day) stop, consider, and then go.