• Users Online: 269
  • Print this page
  • Email this page

 Table of Contents  
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 41-45

Identifying the relationship between upper limb dysfunction and balance in subacute and chronic stroke hemiparetic patients: A cross-sectional study

1 Department of Physiotherapy, Sikkim Manipal College of Physiotherapy, Sikkim Manipal University (SMU), Gangtok, Sikkim, India
2 Physiotherapy Center, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India

Date of Submission27-Jun-2022
Date of Acceptance02-Nov-2022
Date of Web Publication28-Nov-2022

Correspondence Address:
Tittu Thomas James
National Institute of Mental Health and Neurosciences (NIMHANS), Hosur Road, Near Bangalore Milk Dairy, Bengaluru 5600029, Karnataka
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jsip.jsip_10_22

Rights and Permissions

Background: Balance deficits in patients with stroke hemiparesis impair functional performance. Influence of the upper limb dysfunction on balance impairments is least studied in this population. The aim of this study was to identify the relationship between the upper limb dysfunction and balance deficits in patients with stroke hemiparesis. Materials and Methods: A multi-center cross-sectional study was undertaken by recruiting patients with subacute or chronic stroke hemiparesis above the age of 35 years. Patients those who fulfilled the study criteria were recruited and were assessed for their upper and lower limb dysfunction and balance using the following outcome measures; Fugl–Meyer Assessment Scale for Upper Extremity (FMA-UE) and Lower Extremity (FMA-LE), Trunk Impairment Scale (TIS), and BESTest scale. Spearman correlational analysis and linear regression were performed to identify the relationship between the variables. Results: A total of 22 patients were recruited with a mean age of 53.55 ± 11.26 years. A significant correlation was identified between all outcome measures assessed except between FMA-UE and TIS (ρ = 0.394, P = 0.069). Regression analysis identified 25% changes in the BESTest scores can be explained by FMA-UE score (P = 0.018). Conclusion: The study found a relationship between the upper extremity motor function and the balance in the subacute and chronic stroke patients.

Keywords: Balance, stroke hemiparesis, upper limb dysfunction

How to cite this article:
Sharma RK, Rai D, Gupta S, James TT, Menaria S, Dhargave P. Identifying the relationship between upper limb dysfunction and balance in subacute and chronic stroke hemiparetic patients: A cross-sectional study. J Soc Indian Physiother 2022;6:41-5

How to cite this URL:
Sharma RK, Rai D, Gupta S, James TT, Menaria S, Dhargave P. Identifying the relationship between upper limb dysfunction and balance in subacute and chronic stroke hemiparetic patients: A cross-sectional study. J Soc Indian Physiother [serial online] 2022 [cited 2023 Jun 10];6:41-5. Available from: jsip-physio.org/text.asp?2022/6/2/41/362058

  Introduction Top

Stroke is a neurological disease caused by abnormal blood flow to the brain. Due to the abnormal blood flow to the brain, it causes weakness (paresis) or plegia (complete loss of movement) on the contralateral side of the body and the axial musculature.[1] Stroke survivors present with neurological impairments like the deficit in motor control of limbs along with cognitive deficits, communication disorders, or disorders in visuospatial perception lead to a significant decreased performance in the activities of daily living (ADL).[1],[2] Poststroke hemiplegic or hemiparesis individuals had even more postural wobble, asymmetric overall weight, decreased weight shifting capability, and decreased stability capability.[3]

The spatial relationships between various body segments and its control are crucial to functional performance, so a deficit in ADL performance in stroke is markedly dependent on balance, trunk control, and upper extremity dysfunction.[3] Balance plays an important role in maintaining the equilibrium and the center of gravity during movement of the body.[4] Poststroke the patient’s ability to maintain erect and upright posture reduces, leading to balance dysfunction that increases the risk of fall and reduces the functional activity.[5]

To maintain balance and postural control, the three systems are essential, that is, the motor, sensory, and higher brain cognitive facilities but stroke patient loses all of these functions leading to the diminished balance, which eventually restricts the center of gravity (COG) transmission towards the hemiparetic side.[6] Bipedal standing balance is integrally unstable and must be actively controlled to avoid falling. This involves constant interactions between the sensorimotor and multi-segmented musculoskeletal systems, which seem to be difficult to identify and comprehend.[6],[7] Falls generally occur as part of the larger perturbational context than merely keeping one’s balance. Fixing gaze, reaching to grab an object, and maintaining equilibrium, for example, are all subtasks of standing reach. These subtasks must be coordinated, and sensorimotor resources must be adequately distributed among them.[6]

Therefore, it is necessary to find the relationship between axial and lower limb balance and upper limb dysfunction and ascertain the magnitude of balance deficit in upper limb dysfunction. If the relationship is established, it will enable the rehabilitation professionals to identify and explore dysfunctions in balance strategies that contribute to upper limb dysfunction and identify ways to mitigate threats to upper limb recovery. Anecdotal events suggest that there are changes in balance post-upper limb dysfunction. Therefore it is hypothesized that there may be a relationship between upper limb dysfunction and balance. This study will explore whether there is any association between the upper limb function and balance in subacute and chronic stroke.

  Materials and Methods Top

We designed a cross-sectional study design over a period of 6 months among the subacute and chronic stroke. The ethical clearance was granted by the ethical committee of the institution. Informed consent form was obtained from the participants before recruitment of patients to the study.

The study recruited subacute and chronic stroke hemiparetic patients with an NIH score of <20, age above 35 years, and of both genders. Those who had a history of recurrent stroke, any acute medical illness, visual/ hearing impairments, apraxia, aphasia, and those who were not willing to participate in the study were excluded. The outcome measures assessed were Fugl–Meyer Assessment Scale (FMA-UE and FMA-LE), Trunk Impairment Scale (TIS), and BESTest scale.

Patients diagnosed with stroke and referred by the physician for physiotherapy were evaluated according to the inclusion and exclusion criteria and were recruited for the study. Fugl–Meyer Assessment (FMA) scale was developed as the first quantitative evaluative instrument for measuring sensorimotor stroke recovery. The Upper Extremity (FMA-UE) scale has seven components; upper extremity (reflex activity, volitional movement within synergies, volitional movement mixing synergies, volitional movement with little or no synergy, normal reflex activity), wrist, hand, coordination/speed, sensation, passive joint motion, and joint pain. There are five components for the Lower Extremity (FMA-LE) scale; lower extremity (reflex activity, volitional movement within synergies, volitional movement mixing synergies, volitional movement with little or no synergy, normal reflex activity), coordination/speed, sensation, passive joint motion, and joint pain. TIS is used to assess the impairment of trunk, the scale consists of three sub-sections; static sitting balance, dynamic sitting balance, and trunk coordination. The examination of balance was done using the BESTest scale, which is a quantitative assessment tool that helps to determine the type of balance deficits. It has 36 items that evaluate performance of six balance domains; biomechanical constraints, stability limits/verticality, anticipatory responses, postural responses, sensory orientation, and stability in gait. It takes approximately 55 to 60 minutes to complete the assessment.

Statistical analysis

Descriptive statistics will be used to summarize the demographic data. Spearman correlation coefficient was used to analyses the relation between the outcome measures. Linear regression analysis was performed with FMA-UE as an independent variable. For all the statistical procedure, a value of P < 0.05 was considered statistically significant. Statistics were analyzed using IBM SPSS software program, version 20.0.

  Results Top

Forty-four participants with stroke were screened for this study, out of which only 22 participants were included in this study. The mean age of participants was 53.55 ± 11.26 years. The demographic data of the participants enrolled in the study are given in [Table 1].
Table 1: Demographic details of the study population

Click here to view

According to the NIH Stroke Scale, 11 participants had a minor stroke severity (NIHSS <4) and the rest of the participants had moderate stroke severity (NIHSS 5–15). [Table 2] shows the mean values of the outcome measures assessed, and its correlation with each other.
Table 2: Outcome measures and their correlation

Click here to view

There was a significant positive moderate correlation identified between FMA-UE vs. BESTest, and FMA-LE vs. TIS. The relationship between FMA-UE vs. FMA-LE, FMA-LE vs. BESTest, and TIS vs. BESTest was found to be significantly strong and positive. The linear regression analysis between FMA-UE and BESTest scores found a significant relationship, with 25% of the change in BESTest scores can be explained by the FMA-UE scores (R2 = 0.25, P = 0.018). The regression equation derived is “BESTest Score = 6.215 + 0.619 x FMA-UE scores.”

  Discussion Top

Hierarchical reflex theory suggests that balance and postural control development is acquired during integration of sequential series of equilibrium and postural reactions, which involves maturation of system showing attitudinal responses progressing to tilting and equilibrium reactions to maintain center of gravity within the base of support in response to a destabilizing tilt and surface.[8] These reactions and responses appear in conjunction with upper extremities and trunk going into postures to align the COG within base of support. The most primal example of use of upper extremity and trunk is seen in righting responses which is seen abundantly in parachute, or protective responses, protecting from fall and other cortically induced balance responses like sideways stepping in response to instability.[9] These responses may become deficient and inefficient in pathological conditions like stroke, with involvement of paretic upper extremity.

The upper extremity, in contrast to the paretic lower limb, may be the reason for poor balance.[5] In this study this hypothesis was tested to see whether there was any association between the upper limb and the balance in the subacute and chronic stroke. Reactive postural response and sensory orientation was related with paretic extremity function in this study. This is a valid outcome apparently normal upper extremity takes part in demonstrating postural response while recovering from external and internal perturbation. This maneuver ensures the COG is maintained within base of support efficiently with minimal muscle function.[10] Paretic or hypertonic arm and leg are significant contributor to arm swing asymmetry and trunk rotation asymmetry which has potential influence on gait velocity. This finding has been reported in Parkinsonism.[10] The diminished upper extremity response during the minimal perturbation is unable to maintain COG within base of support.

Thrane et al.[11] reported the importance of arm motor skills and mobility when walking, and losing postural balance, and suggested that arm movements may serve as a counterweight to move the body’s center of gravity away from the fall direction, and others contend that arm movements serve as a protection function, reaching for external supports when you are about to fall. El-Nashar et al.[12] concluded that the most prominent role of arm movement in postural balance recovery when falling is to move the angle of the arm so that the person’s center of gravity is moved closer toward equilibrium. According to the study, walking usually causes the arms to swing in the opposite direction as the legs, which helps to keep the COM within the base of support.[12] When an individual seems to have a stroke and it has hemiparesis, the upper extremity movements may be nonexistent or minor, and that they will often walk with the affected arm in front of their chest or side of their hip. Although the patient’s arm swing is limited or nonexistent, he or she is at high risk of falls while walking.[2] This confirms the finding in this study where Fugl Meyer Assessment score of the affected upper limb is significantly related with the reactive postural response of the BESTest scale.

Literature suggests that deficient sensory feedback from paretic limb is contributor toward sensory distortion in the homunculus and interferes with sensory orientation. This could be explained by general fact that quantum of effects of sensory destabilizing activities are reflected by increased sway which is not controlled by paretic lower limb.[13] The other plausible reasons could be the onus of sway control falls on non-paretic limb over a small base of support and hence the cone of stability reduces.[14] The present study shows there is impaired postural control when the visual cue is restricted which increases the risk of fall in the patients with stroke.

Sensory feedback regulates the postural maintenance and influences reactive balance abilities and associated safety elements.[15] Moreover, muscle strength is a strong predictor of functional balance performance, but not reactive balance. This also suggests that patterns of association for functional and reactive balance differ and specific assessment tools are needed for these two categories of balance problems to check clinically. The impairments described above suggest that center of mass is shifted to the unaffected side of the body and hence individuals with stroke are not able to maintain their posture upright.[16]

Real-time somatosensory feedback must be encoded and provided to the motor system through integrative loops for precise motor control in order to perform most tasks efficiently. However due to lack of feedback due to disrupted pathways, the gain of sensory coding increase in the non-affected cortex and hence there is difficulty in exerting force on the ground from paretic leg to the ground.[15] This further increase the reliance on non-paretic limb preventing the development of accurate internal models of the body for postural control.[2] Interventions like use of virtual reality paradigms to increase paretic upper limb activity in rehabilitation process of improving balance could be studied and will further validate the results of this study.

  Conclusion Top

This study showed a relationship between the upper extremity motor function and the balance in the subacute and chronic stroke patients. It may be clinically crucial to be aware that balance in subacute and chronic stroke patients is affected not only by the lower limb impairment, but also by the upper limb dysfunction.

Financial support and sponsorship

Not applicable.

Conflicts of interest

There are no conflicts of interest.

  References Top

Lee DH, Park SH, Han JW. Effect of bilateral upper extremity exercise on trunk performance in patients with stroke. J Phys Ther Sci 2017;29:625-8.  Back to cited text no. 1
Rafsten L, Meirelles C, Danielsson A, Sunnerhagen KS. Impaired motor function in the affected arm predicts impaired postural balance after stroke: A cross sectional study. Front Neurol 2019;10:912.  Back to cited text no. 2
Chen IC, Cheng PT, Chen CL, Chen SC, Chung CY, Yeh TH. Effects of balance training on hemiplegic stroke patients. Chang Gung Med J 2002;25:583-90.  Back to cited text no. 3
Shin JW, Don Kim K. The effect of enhanced trunk control on balance and falls through bilateral upper extremity exercises among chronic stroke patients in a standing position. J Phys Ther Sci 2016;28:194-7.  Back to cited text no. 4
Narayan KA, Pandian S, Abhilasha CR, Verma A. Does the motor level of the paretic extremities affect balance in poststroke subjects? Rehabil Res Prac 2014;767859:1-7.  Back to cited text no. 5
Barton JE, Graci V, Hafer-Macko C, Sorkin JD, Macko RF. Dynamic balanced reach: A temporal and spectral analysis across increasing performance demands. J Biomech Eng 2014;121009:1-13.  Back to cited text no. 6
Basílio ML, de Faria-Fortini I, Polese JC, Scianni AA, Faria CD, Teixeira-Salmela LF. Handgrip strength deficits best explain limitations in performing bimanual activities after stroke. J Phys Ther Sci 2016;28:1161-5.  Back to cited text no. 7
Zhang B, Kan L, Dong A, Zhang J, Bai Z, Xie Y, et al. The effects of action observation training on improving upper limb motor functions in people with stroke: A systematic review and meta-analysis. PLOS One 2019;14:e0221166.  Back to cited text no. 8
Morioka S, Osumi M, Nishi Y, Ishigaki T, Ishibashi R, Sakauchi T, et al. Motor-imagery ability and function of hemiplegic upper limb in stroke patients. Ann Clin Transl Neurol 2019;6:596-604.  Back to cited text no. 9
Lewek MD, Poole R, Johnson J, Halawa O, Huang X. Arm swing magnitude and asymmetry during gait in the early stages of Parkinson’s disease. Gait Posture 2010;31:256-60.  Back to cited text no. 10
Thrane G, Alt Murphy M, Sunnerhagen KS. Recovery of kinematic arm function in well-performing people with subacute stroke: A longitudinal cohort study. J Neuroeng Rehabil 2018;15:67.  Back to cited text no. 11
El-Nashar H, ElWishy A, Helmy H, El-Rwainy R. Do core stability exercises improve upper limb function in chronic stroke patients? Egypt J Neurol Psychiatr Neurosurg 2019;55: 38-47.  Back to cited text no. 12
Kim JO, Lee BL. Effect of upper extremity coordination exercise during standing on the paretic side on balance, gait ability and activities of daily living person with stroke. Phys Ther Rehabil Sci 2017;6:53-8.  Back to cited text no. 13
Hoffmann G, Schmit BD, Kahn JH, Kamper DG. Effect of sensory feedback from the proximal upper limb on voluntary isometric finger flexion and extension in hemiparetic stroke subjects. J NeuroPhysiol 2011;106:2346-56.  Back to cited text no. 14
Borich MR, Brodie SM, Boyd LA. Understanding the role of the primary somatosensory cortex: Opportunities for rehabilitation. Neuropsychologia 2015;79(Pt B):246-55.  Back to cited text no. 15
Eng JJ, Tang PF. Gait training strategies to optimize walking ability in people with stroke: A synthesis of the evidence. Expert Rev Neurother 2007;7:1417-36.  Back to cited text no. 16


  [Table 1], [Table 2]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Tables

 Article Access Statistics
    PDF Downloaded104    
    Comments [Add]    

Recommend this journal