Balance and falls rehabilitation after neurological injury

Staying upright is an automatic skill that uses signals from the eyes, the vestibular organs of the inner ear and the receptors in joints and muscles, all coordinated by the brainstem, cerebellum and cortex. A stroke, traumatic injury, tumour, multiple sclerosis or Parkinson's disease can disrupt any link in this chain. Weak muscles, altered tone, reduced sensation, slowed reactions, neglect, freezing of gait and dizziness add to the risk.

Parkinson's UK notes that people who are stiffer or weaker are more likely to fall, and that freezing, where the feet suddenly cannot move forward for seconds or minutes, adds risk. Headway describes how brain injury may produce balance problems and dizziness through disruption of multiple systems, which is why assessment must find the cause before treatment is chosen.

A neurological physiotherapist will usually observe standing, transfers and walking, test strength, sensation and coordination, and review medicines, vision, footwear and the home environment. If vestibular problems are suspected, NICE says to provide central and peripheral vestibular assessment, and, if needed, exercises or procedures such as ocular motor exercises for stability or canalith repositioning manoeuvres.

Fatigue, pain, low mood, and bladder urgency also influence falls risk, which is why NICE's neurological rehabilitation guidance asks about these in the holistic needs assessment. Fall history, near misses and fear of falling are recorded because reduced confidence leads to less activity and weaker muscles.

For problems with stability, mobility or limb function, NICE recommends targeted exercises that may include the following.

• Functional, task-based training, practising the movements needed in daily life.

• Gait training, including treadmill training with or without body weight support.

• Balance exercises such as core stability work and perturbation-based balance training, in which the person practises recovering from small controlled pushes or shifts.

• Exercises using sensorimotor tasks.

• Wheelchair skills training where walking is not possible.

• Robotic or exoskeleton approaches, and hydrotherapy, where available.

• Gaming or virtual reality to help engagement.

NICE stroke rehabilitation guidance recommends offering walking training to people who can walk with or without help, to build endurance and speed, and considering treadmill training with or without body weight support. In addition to one-to-one therapy, it suggests group circuit training that includes an educational element, such as advice on preventing falls, and interaction with other participants to create peer support. Electromechanical gait training is advised only within research.

It also says to consider ankle-foot orthoses where difficulty with swing-phase foot clearance causes tripping and falling, or where stance-phase control problems such as knee and ankle collapse affect walking. They must be assessed, fitted and reviewed by qualified professionals, and the person needs to be able to put them on or have help to do so.

Headway explains that vestibular rehabilitation is the main treatment for most types of balance problem. It is a programme of head, eye, neck and body exercises performed under different visual conditions and on different surfaces so that the brain learns to rely on alternative signals, a process called vestibular compensation. Because the brain needs to sense dizziness in order to adapt, people sometimes need to reduce anti-vertigo medicines, but only after discussing it with a doctor.

Headway also lists general activities that support balance, such as building core strength and flexibility, walking, using a gym ball, practising weight shifts and walking on different surfaces, aqua aerobics, swimming and dancing. These should be started with professional advice.

In Parkinson's disease, NICE recommends offering Parkinson's-specific physiotherapy for balance or motor function problems and considering the Alexander technique. Physiotherapists teach strategies to overcome freezing, turning practice and safe ways of getting down to the floor and up again after a fall.

In multiple sclerosis, NICE suggests considering vestibular rehabilitation where fatigue or mobility problems are linked to limited standing balance, and supervised programmes of aerobic and moderate progressive resistance exercise. Spasticity, bladder urgency and fatigue are treated alongside because they contribute to falls.

NICE says occupational therapists and rehabilitation teams should identify and address environmental barriers at home, for example by moving items to accessible places, supplying equipment and adaptations, and helping people get funding where the NHS does not provide it. Parkinson's UK adds that physiotherapists and occupational therapists often work together to identify tripping hazards.

Anyone who falls repeatedly, or who has a fall with head injury, severe pain or new weakness, should be assessed urgently. People on blood-thinning medicines who hit their head need prompt medical review. Teaching the safe way to get up from the floor, and arranging a method of calling for help, are part of falls rehabilitation.