Full Text 01

Physiotherapeutic perspectives on balance control after stroke: exercises,
experiences and measures

To
Olle and Nisse
Örebro Studies in Care Sciences 75
MIALINN ARVIDSSON LINDVALL
Physiotherapeutic perspectives on balance control

after stroke: exercises, experiences and measures
Cover: Illustration made by Gry Arvidsson inspired by the art piece "Balance"
of Richard Brixel
© Mialinn Arvidsson Lindvall, 2018
Title: Physiotherapeutic perspectives on balance control after stroke: exercises,

experiences and measures
Publisher: Örebro University 2018
www.oru.se/publikationer-avhandlingar
Print: Örebro University, Repro 04/2018
ISSN 1652-1153
ISBN 978-91-7529-247-2
Abstract
Mialinn Arvidsson Lindvall (2018) Physiotherapeutic perspectives on balance
control after stroke: exercises, experiences and measures. Örebro Studies in
Care Sciences 75.
The overall aim of this thesis was to investigate physiotherapeutic per-

spectives on balance after stroke, in terms of exercises, experiences and
measurements. Study I was a pilot randomized controlled trial with 46
persons who had had a stroke, 24 of whom were included in the inter-
vention group and 22 who were included in the control group. The in-
tervention consisted of 8 weeks of body awareness therapy (BAT). There
were no significant differences over time between the groups in the out-
come measures of balance, walking, self-reported balance confidence
and quality of life. Study II had a qualitative design using content analy-
sis. Participants in the intervention group from Study I and the four
physiotherapists who had been in charge of the BAT were interviewed.
One overall theme emerged: “Simple yet challenging”, which was based
on six categories. Study III investigated the validity and test-retest relia-
bility of the Six-Spot Step test (SSST), an instrument used to assess the
ability to take load on each leg. A cross-sectional design with 81 persons
who had had stroke was performed. The convergent validity was strong
to moderate, and the test-retest reliability was good. In Study IV a mixed
method design including both qualitative and quantitative data collec-
tion was used. The participants’ experiences of balance and its influence
in everyday life were presented in two themes: “Feeling dizzy and unsta-
ble is a continuous challenge” and “Feeling trust and confidence despite
dizziness and unsteadiness”. Taken together, the different data sets pro-
vided complementary and confirmatory information about balance. All
participants experienced the balance limitations as a continuous chal-
lenge in everyday life, yet they also felt trust and confidence.
In summary, BAT can be a complement in physiotherapeutic stroke
rehabilitation and the SSST can be used as a measuring instrument of
walking balance in persons with stroke. Living with balance limitations
was experienced as a challenge but the participants were still able to
manage their everyday life and activities.
Keywords: Stroke, balance, physiotherapy, measures, experiences
Mialinn Arvidsson Lindvall, School of Health Sciences

Örebro University, SE-701 82 Örebro, Sweden
Abbreviation
BAT Body Awareness Therapy
WHO World Health Organization
WCPT World Confederation for Physical Therapy
ABC scale activities-specific balance confidence scale
BBS Berg balance scale
DGI dynamic gait index
FSST four square step test
NIHSS national institutes of health stroke scale
SSST six- spot step test
SF-36 short form 36
TST modified timed stands test
TUG timed up and go test
TUG cognitive timed up and go test cognitive
ICC intraclass correlation coefficient
SD standard deviation
SE standard error
SRD smallest real difference
SRD% a percentage value of the smallest real difference
SEM standard error of the measurement
SEM% a percentage value of the standard error of the
measurement
Table of Contents
LIST OF PUBLICATIONS ....................................................................... 11

BACKGROUND ...................................................................................... 12
Stroke ....................................................................................................... 12
Balance ..................................................................................................... 13
Physiotherapy and rehabilitation .............................................................. 14
Definitions ........................................................................................... 14
Rehabilitation after stroke ................................................................... 14
Physiotherapy after stroke .................................................................... 15
Body Awareness Therapy ......................................................................... 15
Balance measurements .............................................................................. 16
Experience of balance after stroke ............................................................ 17
RATIONALE ........................................................................................... 18
AIMS........................................................................................................ 19
MATERIALS AND METHODS .............................................................. 20
Study design ............................................................................................. 20
Sampling and participants ........................................................................ 20
Body Awareness Therapy intervention in Study I ................................. 23
Measurements, Studies I, III and IV ..................................................... 24
Body function ...................................................................................... 24
Dynamic balance.................................................................................. 24
Walking balance................................................................................... 25
Walking endurance .............................................................................. 26
Balance confidence ............................................................................... 26
Quality of life....................................................................................... 27
Data collection ......................................................................................... 27
Data analysis ............................................................................................ 29
ETHICAL CONSIDERATIONS .............................................................. 33
RESULTS ................................................................................................. 35
Study I. Body Awareness Therapy in persons with stroke: a pilot
randomized controlled trial .................................................................. 35
Study II. Body Awareness Therapy for patients with stroke: experiences
among participating patients and physiotherapists............................... 35
Study III. Validity and test-retest reliability of the Six-Spot Step Test in
persons after stroke .............................................................................. 37
Study IV. “I can still manage” – a mixed method study of balance after
stroke ................................................................................................... 41
MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 9

DISCUSSION ........................................................................................... 43
Results summary .................................................................................. 43
Body Awareness Therapy in persons with stroke ................................. 43
Properties of the Six-Spot Step Test in persons with stroke .................. 46
Living with balance limitations after stroke ......................................... 48
Methodological considerations ................................................................. 50
Measurements ...................................................................................... 50
Participants .......................................................................................... 50
Data collection ..................................................................................... 51
Data analysis ........................................................................................ 52
CONCLUSION ........................................................................................ 53
CLINICAL IMPLICATIONS ................................................................... 54
SAMMANFATTNING PÅ SVENSKA ..................................................... 55
ACKNOWLEDGEMENT ........................................................................ 58
REFERENCES ......................................................................................... 61
10 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

LIST OF PUBLICATIONS
This thesis is based in the following papers, which are referred to in the
text by their Roman numerals:
I. Lindvall MA, Forsberg A. Body Awareness Therapy in persons

with stroke: a pilot randomized controlled trial. Clinical
Rehabilitation 2014, 28: 1180–1188.
II. Lindvall MA, Anderzén Carlsson A, Forsberg A. Basic Body

Awareness Therapy for patients with stroke: experiences
among participating patients and physiotherapists. Journal of
Bodywork & Movement Therapies 2016, 20: 83–89.
III. Lindvall MA, Appelros P, Anderzén Carlsson A, Forsberg A.

Validity and test-retest reliability of the Six-Spot Step Test in
persons after stroke. Physiotherapy Theory and Practice.
Accepted for publication.
IV. Lindvall MA, Appelros P, Forsberg A, Anderzén Carlsson A. “I

can still manage” – a mixed method study of balance after
stroke. Submitted.
Papers I-III have been reprinted with permission from the publishers:
SAGE Publications Ltd, Elsevier Ltd, and Taylor & Francis Group.

BACKGROUND
Stroke
Stroke is the most common cause of serious, long-term disability among
adults (1). The World Health Organization (WHO)’s definition of stroke
is: “rapidly developing clinical signs of focal (or) global disturbance of
cerebral function, with symptoms lasting 24 hours or longer or leading to
death, with no apparent cause other than that of vascular origin” (2).
Stroke events are either ischaemic (85%) or haemorrhagic (15%).
Symptoms depend largely on the location and size of the stroke (3).
Globally the burden of stroke is increasing, with the majority of the
burden being in the low and middle-income countries (1). In Sweden there
are about 25 000–30 000 new incidents of stroke per year (4, 5). The
number of women who suffer from stroke is slightly lower than that of
men. In both women and men, however, stroke is a disease mainly for the
ageing population. The median age for having a stroke in Sweden is 74
years for men and 78 years for women (5). Although the incidence of
stroke has declined, the prevalence of living with stroke has increased
because of the ageing population. Stroke is the somatic disease requiring
the most treatment days in hospital. The total social cost of stroke in
Sweden is estimated to be SEK 18.3 billion annually (5, 6).
Having a stroke is often a life-changing event, as many stroke survivors go

from being independent to being dependent. Motor impairment with
muscular weakness and limited muscular control is seen in about 80% of
persons with stroke (7, 8). After a stroke, impaired postural stability and
mobility are common due to various deficits such as hemiparesis, affected
sensory function, and spasticity (8). Besides causing impaired postural
stability, hemiparesis can also lead to asymmetrical posture, restricted
walking balance and dependency in activities of daily living (9-11). Many
activities of daily living require the ability to perform activities
simultaneously, such as performing a secondary task while walking, which
can be challenging for persons with stroke (12, 13). With asymmetric
stance and impaired balance, there is a high risk of falling (14, 15).
After stroke there is an acute phase where the patient sometimes is not
medically stable. The duration of the acute phase varies depending on the
severity of stroke. During the first week, spontaneous recovery often takes

place (16, 17). The recovery after stroke is complex, usually a
combination of spontaneous and learning-dependent processes, including
restoring the functionality of damaged neural tissue (restitution),
reorganization of partly spared neural pathways to relearn lost functions
(substitution) and improvement of the disparity between the impaired
skills of the patient and the demands of their environment (compensation)
(16). Most improvements take place during the first 6 months, but
functional improvement may continue even beyond that time (6, 16).
Regaining their walking ability and being part of the society are important
factors for many stroke survivors (18).
Balance
The word “balance” is often used in association with terms such as
“stability” and “postural control”. In this thesis, “balance” is used
synonymously with “postural control”. According to Shumway-Cook and
Woollacott (19), postural control is an interaction between the individual,
the task and the environment. Having postural control involves
controlling one’s position in space for stability by keeping the centre of
mass within the base of support. All activities require postural control and
every task has an orientation component and a stability component.
However, the stability and orientation requirements will vary depending
on the task and the environment (20). To keep the body in position
requires a complex interaction of the musculoskeletal, neuromuscular, and
cognitive systems (19). In persons with stroke all the systems involved in
balance may be negatively affected (19); therefore, balance is often
impaired after stroke (8, 9, 16, 17, 20, 21).
To be in balance requires the ability to be in equilibrium while standing

and while moving. This includes the ability to shift weight from side to
side and back and forth and to make flexible movements (19). This may
be challenging for persons after stroke, because of muscle weakness,
spasticity and impaired sensory function. The base of support may be
compromised owing to limited ability to take load on both legs and an
asymmetric posture might be seen (9, 14). Walking balance can be
described as the ability to control the centre of mass within the base of
support so as to remain upright while walking (10).

Balance includes different types: static balance, which aims to maintain a
stationary upright position; dynamic balance, which maintains the balance
while moving; proactive balance, which prepares the body for a shift of
the centre of gravity; and reactive balance, which includes a movement or
a muscular response to have, the ability to maintain stability when
something unforeseen occurs (19). In physiotherapeutic assessment and
treatment all these types need to be recognized and targeted (7).
Physiotherapy and rehabilitation
Definitions
According to the World Confederation for Physical Therapy (WCPT),
physiotherapy is a service provided by physiotherapists to individuals and
populations to develop, maintain and restore maximum movement and
functional ability throughout their lifespan. Physiotherapists are concerned
with identifying and maximizing quality of life and movement potential
within the spheres of promotion, prevention, treatment/intervention,
habilitation and rehabilitation (22). Physiotherapy is based on knowledge
about the body and its movement needs, which is central to determining
strategies for diagnosis and interventions. Rehabilitation is described by
the WHO as a process that enables the individual to identify problems and
reach his or her optimal ability, with the aim to facilitate independence
and social integration (23).
Rehabilitation after stroke

Rehabilitation after a stroke starts early, with functional exercises and
respiratory care. There is strong evidence that rehabilitation after stroke
should focus on functional exercises, and be intense (24). Rehabilitation
after stroke is life-long and the overall aim is to enable activities of daily
living. Stroke rehabilitation should focus on each patient’s needs and be
individualized and task-oriented (17, 25-31). Multidisciplinary team care,
in which the physiotherapist is one of the members of the team, plays an
important role in stroke rehabilitation (32). Recovery can continue for
months or years after stroke, well beyond the formal rehabilitation period.
It is therefore important to continue training (21, 33).

Physiotherapy after stroke
In persons with residual disability after stroke, balance impairment is
often the reason for enlisting the support of a physiotherapist (22). With
the goal being to prevent falls, one focus in physiotherapy is to improve
walking and balance ability (29, 34). It is also important to enhance
balance confidence to further improve walking capacity to enable
participation in everyday life (35, 36). There are several studies that have
shown positive impact on balance and walking using environment-specific
training (30), as well as strength and fitness training (27, 28, 37) and
specific walking training (29). However, there is limited knowledge about
what is the most beneficial type of training for stroke patients (38). A
physiotherapeutic method focusing on stability limits and postural control
is Body Awareness Therapy (BAT). In Sweden, BAT is performed in
primary health care but not regularly in persons after stroke.
Body Awareness Therapy

Body Awareness Therapy is often led by a physiotherapist and can be
conducted individually or in groups. The method is inspired by Tai Chi
movements, focusing on postural stability by challenging a person’s
stability limits (39, 40). Body Awareness Therapy can be described from
two perspectives: the experience of the body (the experience dimension)
and the actions and behaviour in movement and activities (the movement
dimension) (41). The focus of BAT is on finding a new attitude towards
the body, thus strengthening the person’s resources, and integrating them
into everyday life. A core movement is stimulation of the central axis
through weight transfers from left to right, and rotation around the centre
of the body. By including these simple repetitive movements that challenge
a person’s stability limits, postural control can be improved (39, 40).
Another central element of BAT is to make the person aware of their

movements and of their own body, as well as making them reflect on how
their body feels when performing the movements. To perform a movement
slowly many times gives the person the possibility to experience the body
and its limits. Movements can be performed in supine or, sitting position
or standing. Balance control, free breathing and coordination are
integrated in the movements. Body Awareness Therapy has been used for
various conditions in different physiotherapy contexts, e.g. for psychiatric
disorders (41, 42), chronic pain (43) and schizophrenia (42), in traumatic

femoral amputees (44), and for eating disorders (45) and irritable bowel
syndrome (46). Reported positive effects are improved quality of life (45,
46), self-efficacy, body awareness and attitude towards the body, as well
as improved self-esteem (41, 42) and also reduced pain (43). Body
Awareness Therapy has not previously been used as a balance exercise,
but in a study by Sjodahl et al, the outcome measure was gait and, among
other results, the authors report decreased need of walking aids in a group
of persons with unilateral transfemoral amputations (44).
Balance measurements
In clinical practice and research it is important to evaluate changes,
improvements or deteriorations after an intervention. It is vital that the
measuring instrument reflects the impairments, activity limitations or
restrictions of interest. It is also important that the measure is both reliable
and valid, and that it is suitable for the functional level of the patient:
neither too easy nor too difficult. To facilitate the usability of a measure it
is preferable that the procedure should be quick and easy and possible to
perform in different environments.
There are advanced laboratory facilities aimed at measuring balance, but

in clinical practice, advanced technological devices are often not available.
In physiotherapy clinics, balance and walking are often evaluated by
different functional tests, such as the Timed Up and Go (TUG) test (47)
and different tests of walking such as speed, endurance and dual-task
performance tests (48-50).
To measure balance an instrument should include different types of

balance such as static, dynamic, and pro- and reactive balance (19).
Another aspect of balance is subjectively experienced balance
performance. Examples of instruments of subjective experience of certain
limitations, such as fear of falling or self-rated balance confidence, are the
Falls Efficacy Scale and the Activities-specific Balance Confidence Scale
(51, 52). Balance confidence is a usable factor in enhancing and predicting
balance and walking ability post-stroke (35, 53-55).
To measure balance in persons after stroke there are several valid and
reliable measurements used in both clinical practice and research, such as
the Berg Balance Scale (BBS) (56, 57), the Dynamic Gait Index (DGI) (50,

58) and the TUG test (47, 59). However, the asymmetric weight
distribution (17) may not be fully captured by these instruments and
therefore the question arises whether the measure called Six-Spot Step Test
(SSST) (60) could be of use. This test was originally developed as a
walking test for persons with multiple sclerosis (MS) (60). It includes a
dual-task challenge with a forced weight shift from one foot to another,
while walking a short distance. The SSST can be seen as a measure of
walking balance including a dual-task.
The SSST could provide a comprehensive picture of walking capacity after

stroke, but its psychometric properties, validity and reliability in persons
with stroke need to be evaluated prior to using it in clinical practice and
research.
Experience of balance after stroke

To get a more comprehensive picture of balance limitations after stroke it
is important to also focus on the individual’s perspective. An important
part of balance assessment is to gather self-reported information on
participation in social roles and activities. To develop more individualized
rehabilitation interventions and to more individually describe a person’s
balance, knowledge about both perceived and measured balance is
required (35, 61).
Qualitative studies in which persons with stroke have had the opportunity
to describe their experience of balance control in everyday life are scarce.
Having good balance is described as an important factor in outdoor
walking and participation in exercises (62, 63). Experience of fears related
to falls (64, 65) can vary from limited awareness to pervasive fear (65).
Smith et al suggest that discussing strategies and assessing fear of falling
could help the persons to manage their fears (64). To have sufficient
balance is mandatory for activity and participation but there is a lack of
knowledge about how persons who have had a stroke experience their
own balance. This could be a barrier to understanding the complexity of
impaired balance and to further developing patient-centred interventions.

RATIONALE
After a stroke many persons remain chronically disabled, with a need for
further rehabilitation. Rehabilitation focusing on balance and walking is a
way to increase activities and perceived participation in society.
The movements in BAT aim to challenge the limits of stability and

strengthen the patient’s own resources. Studies using BAT in different
diagnosis groups have shown improved postural control. With its focus on
balance, BAT may be beneficial also for persons with hemiparesis after
stroke.
Body Awareness Therapy is often used and performed by physiotherapists

in primary health care. There may be some differences in physiotherapists’
and patients’ descriptions of characteristics of a physiotherapy session.
Therefore, to get a deeper and fuller description of a course of BAT it is
valuable study to both the effects of the therapy, and patients’ and
physiotherapists’ experiences of it.
Although there are several valid and reliable measures of balance for
persons with stroke, there is a need to also measure unilateral limitations
and asymmetric weight distribution during walking. The SSST includes
these aspects of balance and can be used in the assessment procedure, but
its psychometric proprieties have not been investigated for stroke. There
are several studies presenting outcome of balance using test instruments
and rating scales; however, few studies report on persons with stroke
describing their balance limitations in their own words. By combining all
these different perspectives, this thesis will investigate and contribute to a
wider understanding and knowledge of balance in persons who have had a
stroke.

AIMS
The overall aim of this thesis was to investigate different aspects of
balance control after stroke, in terms of exercises, experiences and
measurements.
In Study I the aim was to investigate the effects of BAT on balance,

mobility, balance confidence, and subjective health status in persons with
stroke. In Study II the aim was to describe the experience of an 8-week
programme of BAT from the perspective of both persons with stroke, and
physiotherapists. In Study III we aimed to investigate the convergent and
discriminant validity and test-retest reliability of the SSST in persons with
stroke. The aim of Study IV was to describe experiences of living with
balance limitations after a first-ever stroke. A further aim was to
investigate the concordance between experiences of balance limitations,
perceived balance, and measured balance control in order to reach a more
comprehensive understanding of balance in this population.

MATERIALS AND METHODS
Study design
Four separate data collection procedures were used in this doctoral thesis.
Study I was a randomized controlled trial (RCT) with an experimental
intervention consisting of 8 weeks of BAT and an untreated control group.
Study II was a qualitative descriptive interview study. In Study III a cross-
sectional design was used to investigate the validity and test-retest
reliability of the SSST. In Study IV a mixed method design including both
qualitative and quantitative data collection was used.
Sampling and participants

Table 1 presents background variables of the participants in Studies I–IV.
In Studies I–III, persons diagnosed with stroke were recruited using
convenience sampling through primary health care centres in Region
Örebro County. In Studies I and II the inclusion criteria were: >6 months
since onset of the most recent stroke, ability to walk a distance of 100
metres with or without assistance, and subjectively experienced balance
impairment. Study I was a pilot study to evaluate BAT in persons with
stroke and based on this type of study it was considered reasonable to
include 20–25 participants in each group. Altogether 69 invitation letters
were sent out by mail and after 1 week each person was contacted by
phone and provided with verbal information about the study. Forty-six
persons agreed to participate, of whom 24 were randomized to the
intervention group and 22 to the control group. Randomization to
intervention or control was conducted in blocks of four to six persons at
each primary health care centre, using sealed envelopes that were opened
after the baseline tests. For participants randomized to the control group,
no further intervention was carried out, and all participants were
instructed to continue with their usual daily activities. There were three
dropouts in the intervention group.
All persons who completed the intervention in Study I were invited by

mail and also by phone to participate in the interviews in Study II and all
agreed to be interviewed. The four physiotherapists who were responsible
for the BAT intervention were likewise invited to be interviewed and all
agreed. They had further training and 15–20 years of clinical experience in

in BAT. A total of 21 persons with stroke and four physiotherapists
agreed to participate in the study.
In Study III the inclusion criteria were: >6 months since onset of the most
recent stroke, self-reported walking impairment, and walking ability of at
least 10 metres with or without using a walking aid. We aimed to recruit
about 80 individuals as recommended for reliability studies (66, 67). The
persons with stroke received both written and verbal information about
the study. Letters were mailed to them or handed to them by the
physiotherapists at the health care center. Each person was thereafter
contacted by telephone and provided with verbal information about the
study. A total of 81 persons agreed to participate in the study.
In Study IV, the inclusion criteria were: having had a first-ever stroke in
2015–2016, living in Örebro County, and having reported impaired
balance ability, unaffected speech, independence in toileting and dressing,
and walking ability indoors and outdoors with or without a walking aid,
in the 3-month follow-up questionnaire of the Swedish Stroke Register
(Riksstroke). Study IV had a mixed method design (68) with a qualitative
approach and it was aimed to include about 20 persons. A total of 45
persons were consecutively by mail and thereafter by phone to invite them
to participate. As well as using a consecutive approach, a purposeful
sampling was used based on background variables, such as age and sex, in
order to achieve a maximum variation sample. Twenty persons initially
agreed to participate; however, one person later declined further
participation, thus giving a sample size of 19 participants.
Exclusion criteria in all studies were: having medical, physical or cognitive

impairment that affected the ability to actively participate or to
understand written and verbal instructions. Self-reported impairments
other than stroke that significantly affected gait performance were further
exclusion criteria.

Table 1 Background variables of the participants in Studies I–IV
Study I Study II Study III Study IV

Variables Intervention Control
group group
(n=24) (n=22) (n=21) (n=81) (n=19)
Mean (standard deviation) (range)
Age, yrs 62.1 (11.4) 65.6 (9.2) 62.1 (10.9) 70.3 (7.9) 76.7 (11.8)
(42–82) (42–81) (42–80) (51–86) (42–92)
Time since most 4.1 (3.8) 4.2 (4.5) 4.0 (4.1) 4.8 (5.0) 15 (6.1)
recent stroke, yrs (0–15) (0–15) (0–15) (0.5–31) (4–22)*
N (%)
Male/female 12 (50%)/ 15 (68%)/ 11 (52%)/ 47 (58%)/ 9 (47%)/
12 (50%) 7 (32%) 10 (48%) 34 (42%) 10 (53%)
Hemiparesis, 11 (45.8%)/ 15 (68.2%)/ 11 (52.4%)/ 35 (43.3%)/ 10 (52.6%)/
right/left 13 (54.2%) 7 (31.8%) 10 (47.6%) 46(56.8%) 9 (47.4%)
Type of stroke
Intracerebral 16 (66.7%) 18 (81.8%) 13 (61.9%) 60 (74.1%) 16 (84.2%)
infarction
Intracerebral 8 (33.3%) 4 (18.2%) 8 (38.1%) 18 (22.2%) 3 (15.8%)
haemorrhage
Subarachnoid 0 (0%) 0 (0%) 0 (0%) 3 (3.7%) 0 (0%)
haemorrhage
Previous strokes 1 (4.2%) 7 (31.8%) 1 (4.8%) 9 (11.1%) 0 (0%)
One or more falls in 9 (37.5%) 9 (40.9%) 8 (38.1%) 34 (42.0%) 7 (36.8%)

the past 3 months
Walking aids
None 8 (33.3%) 5 (22.7%) 7 (33.3%) 27 (33.3%) 8 (42.1%)
Unilateral 11 (45.8%) 14 (63.6%) 10 (47.6%) 25 (30.9%) 2 (10.5%)
support:
walking stick/crutch
Bilateral 5 (20.8%) 3 (13.6%) 4 (19.0%) 23 (28.4%) 9 (47.4%)
support:
rolling walker
Wheelchair outdoors 0 (0%) 0 (0%) 0 (0%) 6 (7.4%) 0 (0%)
*In Study IV, time since most recent stroke is given in months.

Body Awareness Therapy intervention in Study I
In the RCT the experimental intervention consisted of BAT conducted in
groups for 8 weeks, 60 minutes once a week, in a quiet room at each of
the four primary health care centres, one group per centre. Participating in
four out of eight sessions was set as a minimum for each person taking
part in the intervention. The intervention was led by physiotherapists with
further training and 15–20 years of clinical experience in body awareness
therapy. The choice of movements in the intervention was based on
previous studies on BAT and BAT experience of the physiotherapists
involved. Prior to the intervention the physiotherapists and researchers
decided on a framework including a list of specific movements. The
participants were instructed to wear comfortable clothes and no footwear
so as to be able to be in contact with the floor during the movements.
The sessions started and ended with the participants sitting on chairs.
Together with the physiotherapist, the participants reflected on the
exercises, experiences, bodily and mental aspects, and their expectations
before the upcoming session. The intention was that they should relate
how the movements felt in their bodies, and how they had integrated the
movements in their everyday life. All group sessions followed the same
structure; however, exercises were individually adjusted and the intensity
and degree of difficulty were increased by the physiotherapists over the 8-
week period.
Movements were performed in sitting, standing and supine position.

Participants were asked to focus on their breathing and the contact with
the chair and the floor. They explored their stability limits by shifting their
weight forward, back, and from left to right, until they felt in balance. In
standing, the centre line was stimulated through rotation of the body, with
the arms softly moving. The participants were encouraged to incorporate
the movements in their daily life; however, no specific home exercises were
given.

Measurements, Studies I, III and IV
Body function
The National Institutes of Health Stroke Scale: Items 5 and 6 was used to
assess stroke severity (69). In item 5, with the patient in a supine position,
the arm was lifted to 45 degrees; in item 6, also in supine position, the leg
was lifted to 30 degrees. Performance was graded from 0 = able to hold
the arm for 10 seconds/the leg for 5 seconds, to 4 = no movement in either
arm or leg (Study III).
Modified Timed Stands Test: The TST is a measure of overall lower

extremity function and has been found to be valid in rheumatoid arthritis
and other chronic diseases (70). Time was noted as the participants rose
from a chair ten times. Participants were permitted to use the hand rails
on the chair (71) (Studies I and III).
Dynamic balance
Berg Balance Scale: Score on the BBS was the primary outcome measure in
Study I. The BBS measures the ability to assume and maintain a given
position while performing a voluntary movement. The scale consists of 14
tasks of varying difficulty that are found in the activities performed in
everyday life. One task is to rise from sitting to standing position, another
to reach forward, or to pick up something from the floor or stand on one
leg. The tasks are graded 0–4. The BSS is a reliable and valid measure for
persons with stroke (57, 72) (Study I).
Timed Up and Go test: The TUG test was developed as a measure of

functional mobility (47) and has been found to be valid and reliable in
persons with stroke (59). In the TUG test the time is recorded when the
person rises from a chair, walks 3 metres, turns and walks back and sits
down again(47) (Studies I and III).
The Timed Up and Go cognitive: The TUG cognitive test is a measure of

functional mobility including a dual-task measure. The TUG cognitive has
prognostic validity and can be used to predict falls in elderly people (73).
In the TUG cognitive the time taken for the person to perform the TUG
test while repeatedly subtracting 3 from a randomly chosen number is
recorded (74) (Study I).

Four Square Step Test: The FSST is a clinical test of dynamic standing
balance. The FSST has good intra- and interrater reliability as well as
validity in stroke (75, 76). The FSST tests the ability to quickly step over
four sticks of 2.5 cm height placed on the floor at 90 degrees to each other
and marking four squares. The person steps forward, backward and
sideways, first in a clockwise and then in an anti-clockwise direction,
putting most of the load on one leg at a time but making contact with the
floor in each square with each foot (77). The time was noted as the
participants completed the task without touching a stick. Two trials were
performed and the mean value of these was calculated
(Study III).
Walking balance
Dynamic Gait Index: The DGI assesses dynamic balance in eight items
representing different walking tasks. The DGI has been found to be valid
and reliable, with good interrater reliability, in persons with stroke (58).
The tasks are: changing walking speed, walking while turning the head,
walking around or over obstacles, and walking with a pivot turn.
Performance in each item is rated by the physiotherapist on a 4-point scale
ranging from 0 = severe impairment, to 3 = normal walking ability
without a walking aid. The maximum total score is 24 points (50) (Study
III).
Six-Spot Step Test: The SSST is performed in a taped walkway (test field)
that is 5 metres long and 1 metre wide. A circle with a 20 cm diameter is
marked in the middle of each end line of the test field. Two more circles of
the same size are marked on each of the sidelines of the test field, with a
distance from the end line of 1 metre and 3 metres on one side, and 2
metres and 4 metres on the other side. One of the end circles is empty and
is used as the starting point. A cylindrical wooden block, with a diameter
of 8 cm and a height of 4 cm, and weighing 134 grams, is placed in the
centre of the other five circles (60) (see Figure 1). The test person starts in
the empty circle at one of the short sides of the test field and the test starts
when the participant first lifts one foot from the start circle. The
instruction is to do the test in fast walking, criss-crossing from circle to
circle and in each trial using the same foot to shove the blocks out of the
circles. The test ends when the last block is shoved out of the end circle.
The SSST was performed in four trials, and the mean value of these was

calculated; two trials for shoving with the paretic and two for shoving
with the non-paretic limb (60). The SSST had not been validated for
stroke previously (Studies III and IV).
Figure1. Schematic overview of the Six-Spot Step Test (SSST) test field
Walking endurance
Six-minute walk test: The 6-minute walk test is a measure of walking
endurance that has been found to be valid and reliable in persons with
stroke (48). In the 6-minute walk test in this study, the person walked
during 6 minutes and the distance in metres was recorded. A track lap of
30 metres, with every third metre marked, was used (Study I).
Balance confidence
Activities-specific Balance Confidence scale: The ABC scale is a patient-
reported questionnaire that assesses self-rated balance confidence when
performing daily activities (51, 78). The ABC scale has been found to be
valid and reliable in persons with stroke (79). A validated Swedish version
of the ABC scale was used (79). Using an 11-point scale, the participants
reported how safe and secure they felt when performing 16 different
indoor and outdoor activities, ranging from 0% = not at all safe and
secure, to 100% = completely safe and secure. The item scores were
summarized and then divided by 16 (the number of items) (Studies I, III
and IV).

Quality of life
Short Form 36: Subjective mental and physical perceived health status was
measured using the Swedish version of the Short Form 36 (SF-36) Health
Survey questionnaire (80, 81). The SF-36 contains 36 questions grouped
into eight health domain scales. Two aggregated summary scores were
calculated, the physical component summary score and the mental
component summary score. A higher score indicates better subjective
health status (Study I).
Data collection
In all the studies the data were collected in a consistent order, starting
with background variables such as demographic characteristics, then
progressing to use of walking aids, and self-reported number of falls
during the last 3 months.
Study I: In Study I, data collection took place at four health care centres
from October 2011 to December 2012 and was performed by four
clinically experienced physiotherapists. The follow-up tests were
conducted 1 and 6 weeks after the intervention period (9 and 14 weeks
post-baseline, respectively). All measures were performed in a
standardized order and if walking aids were used, they were used during
all test occasions. The same physiotherapists performed the pre-, post- and
the follow-up testing using the BBS, TUG test, TUG cognitive test, 6-
minute walk test and TST. The ABC scale and SF-36 were completed by
the participants.
Study II: In Study II the individual semi-structured interviews (82) with the
participants took place at the participants’ respective health care centre
about 1 week after the intervention ended, from December 2011 to
January 2013. The doctoral student (M.L.A.L.) conducted all the
interviews. An interview guide was used, covering experiences of changes
in the body, balance and daily living, as well as reflections on the structure
and content of the intervention. The interviews lasted between 10 and 40
minutes. For practical reasons, the four physiotherapists were interviewed
in pairs. The same interview guide as used for the participants was used
for the physiotherapists. The interviews were conducted by the doctoral
student (M.L.A.L.) and a second author (A.F.), and lasted approximately

1.5 hours each. All interviews were audio-recorded digitally and
transcribed verbatim.
Study III: The data collection took place at five primary health care centres
in Örebro county in Sweden from June 2014 until November 2015. The
tests were performed by five physiotherapists specialized in neurological
physiotherapy, including the author, M.L.A.L., performing 70% the data
collection. The tests were performed on two occasions, 3–7 days apart.
The tests were performed in a standardized order, starting with the ABC
scale, followed by the TST, the FSST, the DGI, the TUG test and, finally,
the SSST. To keep all conditions as stable as possible, the same
physiotherapist performed the tests on both occasions, at the same
location in an ordinary hallway at the primary health care centres, and at
around the same time of the day. If the person needed a walking aid, it
was used during both test occasions. At the first test occasion all balance
and walking tests were performed; on the second test occasion only the
SSST was performed. The participants were instructed not to change their
activity habits between the two test occasions. During the tests they wore
comfortable shoes and if necessary they could rest between the measures.
Study IV: Data were collected in Örebro County from October 2016 to
January 2017. The data collection was conducted at a place chosen by the
participants, in the participants’ home (n=16) or at their health care centre
(n=3). The data consisted of qualitative interviews and data from
measurement of balance using the SSST and the ABC scale. All data were
collected on the same occasion, starting with the interview. The semi-
structured individual interviews started with a broad initial question,
followed by more specific questions based on the study’s aim (68). The
participants were asked to describe their experience of balance and
balance impairment in their everyday life, including strategies to handle
situations that challenged balance control, and how impaired balance
affected their life. The doctoral student (M.L.A.L.) conducted the data
collection. The interviews took 20–60 minutes, and all interviews were
audio-recorded digitally and transcribed verbatim. One pilot interview
was performed to test the procedure. The pilot interview was not included
in the total sample.

Data analysis
For the statistical analyses, SPSS version 21.0 and 22.0 (IBM Corp,
Armonk, NY, USA) and SAS version 9 (SAS, Cary, NC, USA) were used.
To present baseline characteristics and results of the outcome measures,
descriptive statistics with mean, standard deviation (SD), minimum and
maximum for continuous variables, and number and percentage for
categorical variables were used. The confidence interval was 95% and the
level of significance was set at 0.05.
In Study I intention-to-treat analysis was performed, with data from the

last test carried forward. Differences between the intervention and control
groups were analysed using independent sample t-test. Paired sample t-test
was used to investigate changes within the groups: from baseline at week 0
to follow-up at week 9, and from baseline at week 0 to follow-up at week
12–14.
In Study II a qualitative content analysis was performed using an inductive

approach. Both manifest and latent content analysis were performed (83).
The analysis was conducted using the software program Microsoft Word.
The physiotherapists’ and patients’ interviews were analysed separately in
the manifest analysis until the preliminary categories were identified. The
preliminary categories from the respective data sets were then merged
based on common content, and abstracted into six categories and one
joint theme covering the content from the perspectives of both the patients
and the physiotherapists.

The analysis steps, described in greater detail, were:
Manifest analysis (analysis close to the text):

1. The text was read through and listened to several times by the
authors.
2. Meaning units were identified.
3. Each meaning unit was condensed and labelled with a code, while
still preserving the core meaning.
4. The codes were sorted and abstracted into preliminary categories,
illustrating the manifest content of the data.
5. The preliminary categories identified from the analyses of the
physiotherapists’ and patients’ interviews were merged, based on
common content, and abstracted into categories.
Latent analysis (interpretation of the underlying meaning):

6. The categories were reflected on, discussed, and either changed or
retained. The aim was to identify and formulate an underlying
theme combining the different parts into a whole.
In Study III, to evaluate the convergent validity between the first test
session of the SSST and the other measures, Spearman’s and Pearson’s
correlation coefficients were calculated with correlation coefficients <0.30
interpreted as weak, 0.30–0.59 as moderate, and ≥0.60 as strong (84).
Evaluation of validity includes defining the extent to which an instrument
measures what it intended to measure (85); convergent validity means that
two measures are believed to reflect the same phenomenon while
discriminant validity reflects measures that are believed to assess different
characteristics (85).
Reliability testing by definition includes evaluating reproducibility of

values of a test in repeated trials in the same individual(s) (67). To fully
assess the reliability of a measurement tool, several statistical methods are
needed (86). The intraclass correlation coefficient (ICC) is one (87). The
ICC reflects the agreement between two measurements. Here, ICC2.1 was
used since this also provided the basis for the calculations of the standard
error of the measurement (SEM).

The SEM and the smallest real difference (SRD) are other statistical
methods used. The SEM is calculated as the square root of the within-
subject mean square error from the analysis of variance (67, 88). The
SEM% indicates measurement error independent of the units of the
measurement. The SEM% represents the limit for the smallest change that
indicates a real change for a group of individuals. To define the limit for
the smallest change that indicates a real change for a single individual, the
SRD (89) was used. Also, the SRD can be divided by the mean of the
measurements and multiplied by 100, to give a percentage value (SRD%)
(59, 86). Wilcoxon’s signed-rank test was used for analysis of systematic
changes between the repeated measures. A Bland-Altman plot was used to
visually present the data (90). Bland-Altman plots are useful for
determining whether the difference between the measurements is
dependent on the mean of the measurements. The possibility of
heteroscedasticity can be addressed by performing the Pearson’s
correlations coefficient test between the mean and the absolute difference
between test 2 and test 1 and the mean values of the two sessions (91, 92).
An outlier was considered to be present when the difference between the
two tests sessions exceeded 2 SDs.
In Study IV the qualitative and the quantitative data were analysed

separately (68, 93). The qualitative analysis was performed using the
software program NVivo 11 (QSR International, Victoria, Australia),
using an inductive qualitative content analysis. The analysis covered both
the manifest and the latent content (83). The analysis in Study IV was
performed in the same stepwise order as in Study II up to step 4. In Study
IV a latent analysis was performed as the next step and in the latent
analysis the categories were reflected on in order to identify underlying
themes combining the parts into a whole. Two themes were finally
identified, reflecting the interpretation of the underlying meaning.
For the statistical analyses, SPSS version 22.0 (IBM Corp, Armonk, NY,
USA) was used. The results together with the baseline characteristics were
presented by descriptive statistics, median, mean, SD and percentages.
The mixed analysis was performed in a stepwise procedure (see Figure 2).
The qualitative and quantitative data were first separately analysed. In the
final step, using the qualitative categories as the starting point, an overall
interpretation of any emerging pattern was performed, by adding

quantitative data into a joint display with the categories. The median SSST
and ABC outcome for the individuals represented in each category were
calculated, to determine whether there were any visible patterns emerging
from the data. In this step, by going beyond numbers and allowing the
results from the different data sets to complement each other a mixed
result emerged.
Figure 2. Overview of the stepwise procedure in Study IV

ETHICAL CONSIDERATIONS
All four studies (I–IV) have been approved by the Regional Ethical Review
Board, Uppsala, Sweden (Studies I–II: 2011/085, Study III: 2014/058,
Study IV: 2016/307 and 2016/307-1). Study I was registered in the
Clinical Trials Database (NCT01613339). All studies were conducted
according to the tenets of the Declaration of Helsinki regarding ethical
principles for medical research (94, 95).
All participants received both verbal and written information about the
respective study, and gave a written consent. In Studies I–III the
participants were a convenience sample of persons with stroke visiting the
primary health care centre. They were recruited by physiotherapists with
experience in neurological stroke rehabilitation. The doctoral student
(M.L.A.L) worked part-time at one of the primary health care centres but
had no ongoing professional contact with any of the participants.
Participants in Study IV were identified from the Swedish Stroke Register
(Riksstroke) and were contacted by mail and phone and had no earlier
contact with the physiotherapist responsible for the recruitment. It is
possible that persons who frequently visited the primary health care centre
may have felt obliged to participate in the studies. For this reason, all
persons were assured by the physiotherapist responsible for the
recruitment that participation was voluntary, that they could leave the
study at any time without giving any reason and that participation in the
study did not affect other therapy at the primary health care centre (94).
One ethical consideration is that performing a balance test might bring the
fact of impaired balance back to the person’s mind. Other aspects that
could have impact on the persons mind is the interview sessions. Therefore
in Studies II and IV the persons had the opportunity to choose the
interview location and determine where they would take the balance tests.
If the interview session or the balance measure recalled any negative
feelings or any concerns related to the study they could contact the author
at any time. The author could help arrange for participants to get
psychological help if needed. None of the participants in any study
reported any negative aspects or asked for further help.
Further, since all of the participants had impaired balance there was a risk
for accidental falls when performing the balance measures. The balance

measures in the studies were, however, measures usually performed in
clinical practice and the physiotherapists responsible for the data
collection were used to applying these tests.
In order to preserve confidentiality, all data and interview transcripts were

provided with a code and no unauthorized persons had access to
information about the participants. The data have been confidentially
handled and are presented separately for each group. In the qualitative
studies we have coded citations and have here cited them verbatim (96).

RESULTS
Study I. Body Awareness Therapy in persons with stroke: a pilot
randomized controlled trial
There were no significant differences in outcome measures over time
between the intervention group and the control group. Within the
intervention group, significant differences were found between the baseline
test and the follow-up test at week 9 for the BBS, where the mean change
in the intervention group was 3.6 points and in the control group 0.9; and
at week 14, where a mean change of 3.6 points was measured in the
intervention group versus 1.3 points in the control group. Significant
differences were also found within the intervention group at follow-up
week 9 for the TUG cognitive test and the 6-minute walk test, and at week
14 for the TUG cognitive test. Within the control group, significant
improvements were found between baseline and the follow-up test at week
14 for the TUG cognitive test and the modified TST.
Study II. Body Awareness Therapy for patients with stroke:

experiences among participating patients and physiotherapists
An overall theme, “Simple yet challenging”, emerged from the latent
content analysis of the six categories, figure 3. The word “simple”
describes small movements and simple exercises which everyone was able
to participate in, regardless of functional status. “Simple” also illustrates
the fact that no special equipment was needed. On the other hand, it was
“challenging” for the patients who had physical impairments post-stroke,
to face their limitations when performing the balance movements. It was
also a challenge to be aware of and contemplate their bodies, and to
mentally concentrate and stay focused.

Figure 3 Overview of the theme and categories in Study II
Both patients and physiotherapists described changes after the BAT

intervention. Changes such as improved balance were reported by patients
and physiotherapists alike. Some patients reported less use of walking aids
and several said that after the intervention they were able to walk longer
distances, and had better posture. Improved balance in many ways led to
increased self-confidence. For example, one patient reported taking the
step towards walking in open spaces with no support. The patients
expressed that the movements and the way of thinking in BAT were useful
in everyday life. Several described using the weight shifting movements to
place weight on both sides of the body. Almost all the patients reported
that BAT left them with a general positive feeling and with an increased
sense of wellbeing and peacefulness in their bodies. The physiotherapists
agreed with the patients regarding the patients’ wellbeing and
peacefulness. On the other hand, the intervention brought certain
challenges. One of these, which was mentioned by both physiotherapists
and patients, was related to concentration. Some participants were
frustrated at not being aware of or able to feel certain parts of the body
because of the effects of stroke; according to the physiotherapists, needing
to deal with these frustrations was challenging.

Under the category “Integrated knowledge” (Figure 3) both the patients
and the physiotherapists expressed that the movements were useful in
everyday life, as expressed in the quotations below.
… I think it’s an excellent complement [to regular training] … certain
things that I feel are clearly going to be useful to me at home … Not all of
the exercises, but … the thing about walking … when I walk, how I should
hold myself so that I can … relax and feel, how can I say this, the weight or
the balance, if you can call it that … just the bit about … how I should
position my body – how straight I am, if I am straight, left and right sides
… I try to equalize the pressure on each side, if I can put it that way.
Because it’s often been one side that has had to bear most of the load …
(Participant 21)
… he found he could concentrate, he could use [the exercises] in his daily
life to reduce his spasticity … (Physiotherapist)
Study III. Validity and test-retest reliability of the Six-Spot Step

Test in persons after stroke
The SSST demonstrated strong convergent validity with the TUG test, DGI
and FSST, and moderate convergent validity with the TST and the ABC
scale (Table 2). Table 3 presents the mean values from the two test
sessions of the SSST. Participants walked significantly faster while shoving
the blocks with their non-paretic leg. Thirty-one participants (38%) used
one or two canes or crutches to perform all tests.
The mean difference between the first and the second test was about 1
second (Figure 4) (Table 3). The Bland-Altman plot gives more values
under the line than above, illustrating a better performance in the second
test, where 57 (70%) of the participants improved on their performance in
test 2 (Figure 4). The plot also shows that the intra-individual SD
increased with increased time taken to perform the SSST (Figure 3).
Indications of heteroscedasticity, with larger variability for higher test
values, were also seen in the plot. Pearson’s correlation coefficient for the
absolute difference between test 2 and 1 and the mean of the two sessions
was 0.70. One outlier was found (Figure 4), and after it had been
removed, heteroscedasticity diminished to a value of 0.60. The test-retest
results of the SSST are presented in Table 3. The ICC2.1 values for the
SSST ranged from 0.93 to 0.96. The SEM% values ranged between 14.7%

and 20.0%. The SRD% values ranged between 40.8% and 55.4%; the
lowest value is based on the mean of the four trials on the SSST (Table 2)
Table 2 Correlations between the Six-Spot Step Test (SSST) and the other tests,
using Pearson’s correlation coefficient for timed measures and Spearman’s
correlations for rating scales
Test Correlation p-value
coefficient
Timed Up and Go (TUG) test, seconds 0.918 <0.0001

Four Square Step Test (FSST), seconds 0.857 <0.0001
Timed Stands Test (TST), seconds 0.568 <0.0001
Dynamic Gait Index (DGI), points (0–24) -0.832 <0.0001
Activities-specific Balance Confidence (ABC) scale, % -0.596 <0.0001

Table 3 Results of the Six-Spot Step Test (SSST) n=81 performed on two test occasions and showing scores for shoving with the paretic versus the non-paretic
limb, and the test-retest results.
Occasion 1 Occasion 2 Difference test 2-1
Variable Mean time Within Mean time Within SEM SRD 95% ICC2.1 Mean (SD) Systematic
(SD), group p- (SD), Group SEM% SRD% SRD (95% Limits of changes p-
seconds/ value seconds/ p-value CI) agreement value
Median Median Median
(min/max) (min/max) (min; max)
Mean of four SSST measures 23.7 (15.8)/ 22.7 (17.7)/ 3.42 9.48 -10.47 0.96 -0.99 (4.77) 0.0011
MIALINN ARVIDSSON LINDVALL

17.1 16.1 14.7% 40.8% to 8.49 (0.94; (-10.33; 8.36)
(9.1; 85.6) (8.6;96.4) 0.97) -1.55
(-10.7; 21.9)
Mean of two measures 25.0 (16.8)/ 24.1 (19.8)/ 4.90 13.59 -14.53 0.93 -0.94 (6.92) 0.0017
shoving with the paretic limb 18.0 16.7 20.0% 55.4% to (0.89; (-14.49; 12.61)
(8.9; 86.8) (9.3; 106.5) 12.65 0.95) -1.56
(-17.13;34.00)

Mean of two measures 22.4 (15.6)/ 21.4 (16.1)/ 3.94 10.91 -11.94 0.94 -1.03 (5.50) 0.0008
shoving with the non-paretic 16.6 16.0 18.0% 49.8% to 9.88 (0.91; (-11.82; 9.76)
limb (8.7; 98.7) (7.8; 87.2) 0.96) -1.19
(-22.70; 24.94)
Difference of shoving between 2.6 (7.3)/ 0.0001 2.7 (6.9)/ <0.0001
the paretic and the non-paretic 1.4 0.99
limbs (-26.2; 24.6) (-21.9;31.5)
CI = confidence interval; ICC2.1 = intraclass correlation coefficient, SEM = standard error of measurement; SEM% = standard error of measurement, in per cent
values; SRD = smallest real difference; SRD% = smallest real difference
Physiotherapeutic perspectives on balance control

39
Difference test 2- test 1, in seconds
Mean of test 1
and test 2
Figure 4 Bland-Altman plot showing the mean time (in seconds) achieved
in test 1 and test 2. Dotted lines represent means (bold dotted line) and
limits of agreement (light dotted line).

Study IV. “I can still manage” – a mixed method study of balance
after stroke
All participants experienced the balance limitations as a continuous
challenge in everyday life, yet they also felt trust and confidence. Two
themes, “Feeling dizzy and unstable is a continuous challenge” and
“Feeling trust and confidence despite dizziness and unsteadiness” and
seven categories emerged from the latent analysis of the interview data.
Both themes illustrate that the impaired balance caused feelings of
dizziness and unsteadiness.
The first theme, “Feeling dizzy and unstable is a continuous challenge”,

contains the participants’ descriptions of balance as a constant feeling of
dizziness and unsteadiness. Muscle weakness was expressed as limiting
balance in daily life and this caused feelings of anxiety, insecurity and
frustration. For many, the balance limitations became more prominent in
the dark. The first theme also contains descriptions of the dependence on
physical support and the experience that everything took a lot of time.
“…I don’t take long walks nowadays…I feel a little wobbly…because of
that ‘balance business.” (Participant 2)
“…get dressed, but it takes so much more time than what it used to
take...Things that used to be practically automatic now take time.”
(Participant 17)
In the second theme, “Feeling trust and confidence despite dizziness and
unsteadiness”, the participants described their capacities and feelings of
confidence about still being able to do things themselves in spite of their
balance impairment. Balance in everyday life was limited, yet the
participants were, to a varying degree, active in social activities. They
described having accepted their new life situation and said they were
confident in their ability to manage their everyday activities.
“… they help me, they do, but that...I’m stubborn person and I want to
manage on my own for as long as I can…”(Participant 11)
“…You can’t say there have been problems; rather...small challenges have
arisen, but nothing so significant that I was not able to deal with
it.”(Participant 17)

Results for the quantitative measures were: a median time of 20.24
seconds (range 8.9–113.3) for the SSST, and a median score of 67.5 (range
29–98) in the ABC scale.
The mixed results illustrating that almost all participants are represented
in every qualitative category. There was no explicit association between
those scoring low on the ABC test and/or walking slowly in the SSST, and
the categories representing experiences of limitations, nor between those
scoring higher, walking faster and categories not showing limitations. The
different data sets provide different, somewhat complementary and
confirmatory information on balance. The mixed results illustrate that
impaired balance can be experienced as a challenge and, at the same time,
that the individual can feel trust and confidence, no matter how they score
on the ABC scale or perform on the SSST.

DISCUSSION
Results summary
The overall aim of this thesis was to investigate different aspects
of balance after stroke, in terms of exercises, experiences and measurements.
The first two studies evaluated using BAT in people with stroke. In the
RCT no significant differences over time were found between the
intervention group after 8 sessions of BAT and the controls. In the
qualitative evaluation the participants who had been included in the
intervention group described that exercising with BAT resulted in
experience of improved balance, as well as a feeling of harmony. Also,
they related that it was possible to integrate the BAT movements in their
daily life.
The SSST showed strong convergent validity with other instruments of

walking and high test-retest reliability. The mixed method results of a low
to moderate self-rated balance confidence and slower performance in the
walking test did not signify more negative experiences of balance. The
qualitative data included participants’ descriptions of experience of
dizziness and unsteadiness. Despite continuous challenges with balance,
they were able to manage their everyday life and activities.
Body Awareness Therapy in persons with stroke

In the quantitative evaluation, there were no significant differences over
time in any of the outcome measures between the groups. However,
regarding the primary outcome measure in Study I, BBS score, we found a
significant improvement over time in the intervention group compared
with no improvement in the control group. To the best of our knowledge,
only two other studies have applied BAT in persons with stroke. Recently
Bang and Cho (97) presented an RCT evaluating the effects of BAT on
balance performance in persons with chronic stroke, and Bang et al.
presented another RCT on effect of BAT on visual spatial neglect in
persons with acute stroke (98). In both studies 15–20 minutes of BAT had
been offered as an add-on therapy to walking or task-oriented training
(97, 98). Of the two, the sample with chronic stroke were the most
comparable to our sample. In that small study twelve persons with chronic
stroke were randomized to 20 minutes of BAT and 30 minutes of walking
training, five times a week, for 4 weeks. The control group received

walking training for 30 minutes, five times a week, for 4 weeks. Bang and
Cho present significant between-group differences on BBS and TUG
results (97).
There are both differences and similarities between the study by Bang et
al(97) and Study I in this thesis. The BAT intervention in both studies was
based on the same framework of movements, but the intensity of BAT in
Bang et al was much greater and their intervention consisted of both BAT
and walking training. By contrast, in our Study I the intervention consisted
only of BAT and the controls received no intervention. These studies
together suggest that BAT can be used as a complement to physiotherapy
but further studies are needed to evaluate the specific effects that BAT may
have for patients with stroke, as well as which exercises are the most
suitable and at what intensity. In studies including other patient groups,
such as fibromyalgia patients (99) and transfemoral amputees (44), the
intervention lasted much longer, namely, once a week for 3 months (99)
and 10 months (44). Based on these studies it can be deduced that longer
and more intensive interventions with BAT are optimal. On the other
hand, all these studies have small patient samples and the results should be
interpreted with care. There is no gold standard for what constitutes the
most beneficial physiotherapeutic training for stroke patients (37). As BAT
consists of simple, repetitive movements, with the aim of strengthening the
person’s resources and finding a new attitude towards the body, it can be
seen as a complement to balance training in persons with stroke.
In the qualitative study (Study II), exercising with BAT was described as
simple yet challenging. The participants experienced that they had to face
their limitations and explore stability limits in different positions, as well
as using varying body weight distribution. We were not able to measure
body weight distribution. In the study by Sjodahl et al in participants with
transfemoral amputation, a more symmetric body weight distribution and
less use of walking aids was reported (44). The authors used gait analysis
and force plates to examine changes in the legs post-intervention (44). In
future research in persons with stroke (a population who often experience
difficulties with weight distribution), it would be interesting to use force
plates when evaluating BAT.
In Study II both the patients and the physiotherapists were interviewed.

The results showed that the narratives of the physiotherapists and the

participants were mostly similar. Despite some differences pertained to
physiotherapists’ and patients’ perspectives of a physiotherapy session
where both parties were involved. A physiotherapist’s perspective will
probably reflect and be based on theoretical knowledge while patients’
perspectives are built on each individual’s previous life, habits and bodily
experiences (100). In Study II, the physiotherapists’ narratives
strengthened and confirmed the experiences of the persons with stroke.
Both parties described that the movements had an impact on balance
performance and also that the movements could be integrated in everyday
life. Some also mentioned that they experienced increased self-confidence.
Similar findings, with experience of better contact with the body,
increased awareness of movement behaviour and changes in posture and
balance, were also seen in persons with schizophrenia and their
physiotherapists (42, 101). Feelings of harmony and a sense of wellbeing
and peacefulness were reported by the patients in our study. The
physiotherapists observed reduced tension in the patients, as well as new
experiences of connecting with the body. Similar results have also been
reported by Hedlund and Gyllensten (101) and Gyllensten et al (102) who
studied experiences of BAT in schizophrenia populations.
In our study, BAT was described as mentally challenging by both the

patients and the physiotherapists. In BAT, a patient has to listen to the
body by focusing on both doing and what is experienced by the body. The
physiotherapeutic focus in BAT is on resources, and not limitations (102).
The patients expressed that it was a challenge to be focused and work
through the mind, by thinking of and observing the body and being aware
of both sides of the body. The physiotherapist confirmed this description
and described the challenge of being the group leader when the
participants had difficulty with concentration. A possible explanation for
concentration difficulties could be cognitive deficits and difficulties with
doing several things at the same time (8). Cognitive status and fatigue
were not examined, which can be seen as limiting factors and important
variables to consider in future studies.
What was highlighted by almost all participants was the value of being
part of a group with other persons with stroke. Group activities are often
seen as valuable (103) and the participants felt comfortable to share
similar experiences and appreciated the opportunity to do so. Although no
effects were identified in Study I, the positive experiences narrated by

participants in the qualitative study suggest furthers studies to evaluate
BAT in stroke. Previously, positive effects and experiences of BAT have
been presented in both qualitative and quantitative studies (42-45). Body
Awareness Therapy gives the opportunity to focus on the body while
performing weight shifts and rotations. An intervention in which BAT is
combined with more stroke-specific movements such as stepping and
walking tasks might be a good alternative for increasing balance
performance in persons post-stroke.
Properties of the Six-Spot Step Test in persons with stroke

Balance deficits can be a continuous challenge for persons post- stroke, as
can taking load on the hemiparetic leg (9, 17). This thesis investigated the
psychometric properties of a measuring instrument, the SSST, which
includes several components that may be challenging for people with
hemiparesis after stroke. These components include dual tasks, such as
weight shifts or kicking with one leg while walking, and also a cognitive
component to plan the performance. Multiple tasks are often performed
simultaneously in everyday activities. A measure that has a close relation
to everyday life performance can be expressed as ecologically valid (104,
105). To improve balance, challenging dual-task exercises are preferred
(106, 107), as plain walking might not be enough of a challenge (19).
In Study III in this thesis, the SSST showed strong convergent validity with
the TUG test, the DGI and the FSST. Most previous studies of the SSST
were performed in people with MS (60, 108-110). In a study by Fritz et al
(108), a strong correlation between the SSST and the TUG has been
shown. Tests involving longer distances, such as the 2-minute and 6-
minute walk tests, have also been used in studies by Fritz et al (108) and
Sandroff and colleagues (108, 110). Sandroff et al also showed moderate
to strong correlation with balance confidence. They highlighted the
novelty of the SSST as a measure of ambulatory function also including
elements of balance confidence. In this thesis the SSST also showed
moderate correlations with the ABC scale and therefore the SSST could
give valuable information about feelings of confidence in ability to carry
out activities at home and in the community, as assessed by the ABC scale.
The correlation coefficients between the SSST and the FSST and the DGI
indicate that the SSST can capture dynamic balance also in persons with
stroke.

The ICC2.1 values for the SSST in Study III in this thesis ranged from 0.93
to 0.96. In the study by Pavan et al, 75 persons with MS performed the
retest after 2 hours with about the same median time in both tests and
with an ICC at 0.98 (109). In the study by Nieuwenhuis et al, 41 persons
performed the retest after 1–2 hours, with an ICC value of 0.95 (60). A
difference between the MS studies and Study III in this thesis was the time
between the test and the retest. In Study III the retest was performed after
3–7 days. This time limit was set to avoid a possible learning effect. The
participants were instructed not to change their activity habits between the
two test occasions and in persons who had their stroke onset more than 6
months previously no differences are to be expected in such a short time.
In a study by Callesen et al (111) the retest was taken after 2 days,
likewise showing high ICC values.
Based on the high SRD% and SEM% values in the present study, the most
suitable way of applying the SSST is to calculate a person’s mean time for
four trials during which they shove twice with each leg. This is how the
SSST was applied in the original study by Nieuwenhuis et al (60) in people
with MS.
Due to stroke deficits, persons with stroke often have a hemiparetic side
(8). Therefore, in Study III the test-retest involved shoving with both the
paretic and the non-paretic limb. The reliability values were high for both
performances. Participants achieved a faster performance in the SSST
when standing on their paretic leg while shoving the block with their non-
paretic limb, compared with the opposite. The paretic limb often lacks
strength and coordination and in our study population this might have
made the test more challenging and slowed down the performance.
Another possible explanation for a faster performance when shoving with
the non-paretic side could be the possibility to take a quick step with that
leg to restore balance after the kick.
The variability of within-subject measurements in our study showed

limited sensitivity for detecting changes beyond the error threshold due to
fairly high SEM% and SRD% values. There are no universally accepted
limits for SEM% but Flansbjer et al (59) suggest that values ≤10% are
clinically relevant with respect to sensitivity. When introducing a new

measurement it is important that it is valid and reliable in its context, as
well as being usable.
The SSST was easy and quick to perform in the primary health care
settings as in the home environment and the participants enjoyed the
“game like” kicking in the test, as has also been reported in a previous
study using the SSST (108). Based on the results of this study, the SSST is
a valid measure of balance during walking; however, its sensitivity for
capturing changes over time needs to be further evaluated.
Living with balance limitations after stroke

Having postural control is an interaction of the individual with the task to
be done and the environment (19). To investigate these three perspectives
of balance control we set up a mixed method study including a measure of
balance during walking, assessment of balance confidence, and qualitative
interviews. The participants described that despite the continuous balance
challenges they were able to manage their lives. Have active coping
strategies had previously been found to have a positive impact on quality
of life after stroke (112, 113) and subjectively experienced wellbeing was
seen to be related to the ability to manage the consequences of stroke
(112). The results in the instruments testing balance during walking and
balance confidence complemented the narratives in the interviews.
Several of our participants expressed that dizziness was a problem. This

finding has also been reported in other studies and dizziness can be a
barrier to community participation (64, 65). Balance and dizziness were
experienced as a challenge when walking outdoors. However, walking
outdoors was important to several participants. It was something they did
every day, and it was a daily routine they did not want to miss. For others,
it was more like training or part of activities such as going to the grocery
store or to church. Outermans et al (62) described what keeps people after
stroke from walking outdoors. They stated that outdoor walking is linked
to the intention to walk, as well as to walking ability and the opportunity
to walk (62). All these three factors related to outdoor walking were in a
certain way also linked to the experience of balance in Study IV. In the
narratives, experience of balance was closely related to the participants’
intention and to their attitudes to balance confidence. It was also related
to their ability, in terms of functional impairments, and to the opportunity

they had, of carrying out activities such as visiting friends. Walking and
balance seem to be close related, as also mentioned by Simpson et al (63).
In the present study all participants were able to walk in the community;
in future studies it would be interesting to investigate balance experiences
in persons with greater walking limitations.
Experiences of balance also included feelings of fear of falling. To have

something to grab on to, such as walking aids, another person or a wall,
was expressed by several of the participants as giving feelings of safety.
Feelings of fear of falling in relation to balance and walking are also
mentioned by Simpson et al (63). In their study, fear of falling and losing
balance was experienced as a barrier to exercise and community
participation (63). Fear of falling is common among persons with stroke,
and to help these persons to manage their fears related to falls it is
suggested to talk about fear of falling (64). In this thesis the participants
described fear of falling as a challenge; however, they said that they
managed their life even despite this fear. In future research it would be of
interest to establish which strategies can make persons with stroke feel in
balance in relation to fear of falling.
The participants’ narratives and their scoring on the ABC scale were not
always consistent. The participants had a median ABC score of 67.5%. In
a study by Yiu et al, persons with stroke were reported to maintain lower
balance confidence compared with controls for at least 12 months post-
stroke (114). A balance confidence score of <80 indicates that there is
room for improvement (78). Even though the participants in our study
rated perceived balance confidence as low to moderate (67.5), they
expressed feelings of acceptance, indicating that they had found solutions
in their post-stroke life. These findings are similar to a study by Kubina et
al (2013), in which persons with stroke highlighted the importance of
being in charge of decisions and contributing in social relationships (115).
To get a broader perspective, gain further knowledge and involve these
persons in balance rehabilitation, a mix of measured balance, self-rated
balance and asking the persons about experience of balance is preferred.

Methodological considerations
To meet the overall aim of this thesis, which includes both qualitative and
quantitative studies. We have described and investigated balance from
different perspectives such as exercise, measuring instruments and
experiences.
Measurements
The included measurements were chosen for different reasons. The
objective as well as the subjective measures covered the different types of
balance: dynamic balance (e.g. balance while walking) and static balance.
The instruments are often used in stroke rehabilitation. However,
measures of cognitive functions and fatigue, if repeated, might have
captured more subtle changes when evaluating BAT. A gait analysis with
force plates might also have captured changes in balance performance. In
Study III a cognitive test and a test screening for falls would have been
valuable for testing the usability of SSST as a test in everyday life.
In Studies II and IV the data source was qualitative interviews. The

credibility was strengthened by the fact that all the qualitative interviews
were performed by the doctoral student (M.L.A.L), who is clinically
experienced in balance and stroke rehabilitation. To increase
dependability and ensure that all interviews concerned the same topics,
interview guides were used in both studies (104).
Participants
Recruitment of the participants in Studies I–III was by convenience
sampling of persons visiting the primary health care centre. Convenience
sampling has limitations, such as that persons participating in clinical
studies have volunteered to participate and are often positive towards the
research and study method and motivated to improve, which may have
influenced the results in these studies, and may therefore threaten the
external validity. In Study I the participants were informed that they
would be allocated to either the control or the intervention group. Some of
the participants allocated to the control group expressed disappointment
at not receiving the intervention and started exercising on their own. This
may explain the improvement seen in some of the measures for the control
group and, again, this constitutes a threat to the external validity (104).

In Study I it was considered reasonable to include 20 participants in each
group because the study had an exploratory approach as BAT had not
previously been used in persons with stroke. In Study II the sample size
was based on the qualitative aim to achieve an in-depth understanding
(83); also, it was aimed to include all participants from the intervention
group in Study I. In Study III the sample size of 81 persons was selected
based on recommendations in the literature (59, 66, 67). The sample size
in Study IV was based on the mixed method procedure (93). Priority was
given to the qualitative data (83) and it was intended that both qualitative
and quantitative data should be from the same population (93), ending in
a relatively small quantitative data collection.
Data collection
In all four studies the data collection was performed in a standardized
order and the test protocol was followed carefully. In all studies the
physiotherapists who participated in the data collection were specialized in
neurological physiotherapy, with clinical experience in physiotherapy for
patients with stroke. In Studies I and III, to strengthen the internal validity
the physiotherapists were introduced to the study protocol, all the
measuring instruments and the procedure. All conditions were kept as
stable as possible. In Study I none of the physiotherapists performing the
data collection participated in the intervention. They were not blinded, but
they had no insight into the intervention. To increase the internal validity
in Studies I and III, the same physiotherapists performed the retests, at the
same location in an ordinary hallway at the primary health care centre,
and around the same time of the day.
A limitation of Study I was that there was no reflection on the

participants’ activity habits between the test occasions. The participants
were instructed not to change their activity habits between the test
occasions. However, just to be part of an intervention study can increase
overall activity level. In future studies, using an activity log or diary or an
activity bracelet would be valuable, to receive further knowledge on any
side activities.
The intervention in Study I continued for 8 weeks. This time period was
based on how physiotherapists in primary health care in the county
usually conduct BAT, and was also selected for practical reasons such as

avoiding vacation periods and preventing high dropout rates. Longer
interventions have been performed in one study by Gyllensten et al (41)
and it is acknowledged that, to see changes over time, longer interventions
may be needed. The selected movements were based on earlier BAT
studies (39, 40) and the experience of the physiotherapists responsible for
the intervention. All persons participating in the intervention in Study I,
participated in the interviews in Study II. This can be seen as a strength;
first, as both negative and positive experiences of BAT thus could be
captured and, secondly, as the level of functioning after stroke differed
between the individuals, a broad perspective of experiences could be
reached.
Data analysis
In Study II, two out of the three authors (M.L.A.L) and (A.F) had a pre-
understanding as physiotherapists in stroke rehabilitation, (A.A.C) is a
registered nurse, experienced in qualitative methods. Studies III and IV
also included a neurologist specialized in stroke (P.A). The mixed
experience of the researchers may increase the credibility of the findings
(116, 117) as it likely brought a broad perspective to the analysis.
Throughout the qualitative analysis procedure, to support trustworthiness
(83, 104, 116) the results were discussed and reflected on in a back and
forth process and all authors were engaged in the data analysis in various
steps. The analysis was performed in both the software programs
Microsoft Word (Microsoft Corp., Seattle, WA, USA)’and NVivo 11 (QSP
International, Victoria, Australia). There are strengths and limitations
with both. The analysis process is presented both in the text and in figures,
with meaning units, categories and themes given. Quotes have been
presented to support the text and further enhance the credibility of the
study (83).

CONCLUSION
In summary, the pilot study evaluating effects of BAT in persons with
stroke showed no significant differences in balance, mobility, balance
confidence, and subjective health status after 8 weeks of BAT compared
with an control group. According to the patients’ and physiotherapists’
narratives, exercising with BAT was simple but challenging. Experiences
of improved balance as well as feelings of harmony were reported.
However, further studies are needed to determine optimal intensity of
intervention, exercises and outcome measures.
The SSST includes a weight shift in combination with a dual-task activity

during walking, thus being a challenging instrument for persons with
balance impairment after stroke. The SSST showed strong convergent
validity with other instruments of gait and balance. The findings in this
study suggest that the SSST can be used as a complementary measure of
walking balance in stroke rehabilitation although sensitivity to changes
over time must be further investigated.
Persons with balance limitations after stroke related that they were able to
manage their life, although this could at times be challenging. Evaluation
of balance during walking and self-rated balance confidence
complemented the subjective narratives of living with balance limitations.
The participants related that everyday life was challenged by the
continuous feeling of dizziness and instability.

Clinical implications
• Body Awareness Therapy can be a complement in
physiotherapeutic stroke rehabilitation; however, further studies
are needed to establish optimal intensity and length of the
therapy, as well as determine outcome measures.
• Body Awareness Therapy includes simple but challenging

exercises that can be individually adjusted and are possible to
perform for persons who have had a stroke.
• The Six-spot Step test can be a complementary measure of

walking balance in stroke rehabilitation. It includes a dual-task
activity and also has a game like aspect.
• To get a fuller picture of balance and an assessment of balance

among persons who have had a stroke, perceived and measured
balance can give valuable information. However, for an accurate
description, this information should be complemented by asking
these persons about their experiences and challenges.

SAMMANFATTNING PÅ SVENSKA
(Physiotherapeutic perspectives on balance control after stroke: exercises,
experiences and measures)
Stroke är den vanligaste orsaken till neurologisk funktionsnedsättning hos
vuxna. Stroke är ett samlingsnamn för hjärninfarkt och hjärnblödning. I
Sverige är det ca 25 000-30 000 som får stroke varje år. Nedsatt motorisk
funktion i form av bl.a. nedsättning av balans och gångfunktion är vanligt
efter stroke. Andra orsaker som kan påverka balans och gångfunktion är
nedsatt sensorisk funktion, synnedsättning, spasticitet samt nedsatt
kognitiv förmåga. Det övergripande målet med strokerehabilitering är att
personen ska kunna leva ett aktivt liv och kunna delta i samhället.
Rehabiliteringen bör vara individualiserad och uppgiftsspecifik. Oavsett
funktionsnivå kan förbättring av funktion ske månader och år efter
insjuknandet. Den fysioterapeutiska behandlingen syftar bland annat till
att förbättra gångförmåga och balans samt till att förebygga fall. Att
förbättra gångförmågan är något många drabbade skattar som det
viktigaste efter en stroke. Det finns olika metoder att träna balans, men
det saknas dock evidens för att någon specifik behandlingsmetod är mer
effektiv än någon annan. För att mäta förändring av balans behövs valida
och reliabla mätinstrument, avsedda för den specifika patientgruppen och
anpassade till kontext. Det finns studier som mäter tillit och tilltro till
balans, men det finns få studier där patienterna själv beskriver sin
upplevelse av balans. För att rehabiliteringen av personer med
funktionsnedsättning efter stroke ska bli så optimal som möjligt är det
betydelsefullt att lyssna på patientens behov och önskningar, och det är
därför viktigt att lyfta fram patienternas perspektiv.
Det övergripande syftet i doktorandprojektet var att undersöka och

beskriva olika aspekter av balans hos personer som fått en stroke;
avseende träning, mätinstrument, och upplevd balans. I Studie I
undersöktes effekter av basal kroppskännedomsträning, i syfte att träna
balans. Det är en metod som tidigare inte använts i behandling personer
med stroke. Basal kroppskännedom är en metod med enkla
rörelseövningar med fokus på rörelsekvalitet, kroppsmedvetenhet och
rörelsebeteende. Centralt är att hitta en inre mittlinje i kroppen och utifrån
den utföra olika övningar som t.ex. tyngdöverföringar, hållningsövningar,
rotationer runt mittlinjen och samtidigt ha en fri andning. Av de 46
personer som tackat ja att delta i studien lottades 24 till träningsgrupp

med basal kroppkännedom och 22 till kontrollgrupp. Mellan grupperna
fanns det inga signifikanta skillnader över tid avseende balansförmåga,
tilltro till balans och subjektivt upplevd hälsa. Avseende utfall fanns
signifikanta förbättringar över tid inom träningsgruppen för 4 av 7
mätinstrument och inom kontrollgruppen för 3 av 7 mätinstrument.
Personerna som deltog i träningsgruppen erbjöds även att delta i studie II,
en intervju studie, med syftet att beskriva upplevelsen av 8 veckor av basal
kroppkännedom med utgångspunkt från både personerna med stroke,
samt fysioterapeutens perspektiv. Intervjuerna fokuserade på personernas
upplevelse av behandlingen med basal kroppskännedom. Instruktörerna i
basal kroppskännedom (fysioterapeuter) intervjuades i par, de övriga
individuellt. Resultatet presentarades i ett huvudtema ”Simple yet
challenging” som baserades på sex kategorier. Både deltagarna och
fysioterapeuterna upplevde att balansen utmanades och att träningen gav
möjligheter att reflektera över kroppen och dess funktion. I Studie III
undersöktes validitet och reliabilitet för Six-Spot Step Test (SSST) hos
personer med stroke. SSST ger en objektiv mätning av balans, och är
utvecklat samt validerat för personer med multipel skleros, men inte för
personer med stroke. SSST är ett mätinstrument där personen utför
tyngdöverföringar i aktivitet, genom att gå 6 meter och sparka omkull fem
klossar med ett ben i taget. Testet avspeglar sensomotoriska funktioner
som styrka av nedre extremitet, spasticitet och koordination och balans
samt till en viss del syn och kognition. En tvärsnittsstudie med mätning av
postural stabilitet och gång, samt en upprepad mätning efter en vecka
genomfördes. Samstämmighet av SSST mättes genom korrelation med
validerade gång- och balans instrument; Activities-specific Balance
Confidence scale (ABC-skalan), Timed Stands Test, Four Square Step Test,
Dynamic Gait Index och Timed Up and Go. SSST visade sig ha god
validitet och reliabilitet, men det fanns en begränsad känslighet vid
upprepade mätningar. I Studie IV var fokus på upplevelsen av balans efter
stroke. Syftet var att beskriva balans hos personer som fått en stroke, med
utgångspunkt i upplevd påverkan i dagligt liv, självskattad balans samt
balans mätt med validerat mätinstrument. Studien hade en deskriptiv
studiedesign, med mixed methods som innebar en semistrukturerarad
intervju, objektivt mätt balans med SSST samt självskattad balans med
ABC-skalan. Resultatet presenterades i två teman baserade på sju
kategorier. Personerna upplevde att balansen var en ständig utmaning,
med yrsel och ostadighet, men ändå så klarade de sin vardag. De tre olika
datainsamlingsmetoderna, fångade delvis olika aspekter på balans hos

personer med stroke, resultaten kompletterade varandra, några bekräftade
varandra, men inga resultat var direkt motsägelsefulla. Ett genomgående
mönster i alla kategorier var att nästan alla personer var representerade i
alla kategorer.
Genom att använda olika datainsamlingsmetoder så har i avhandlingen

framkommit olika aspekter på balans. Träning med basal
kroppskännedom i 8 veckor gav ingen statistisk säkerställd skillnad
gällande balansförmåga mellan grupperna. Personerna med stroke och
fysioterapeuterna beskrev att balansen utmanades av basal
kroppkännedom och att träningen gav möjligheter till att reflektera över
kroppen och dess funktion. För personer med stroke så hade SSST ha god
validitet och reliabilitet med en begränsad känslighet vid upprepade
mätningar. Personerna med stroke upplevde att balansen var en utmaning
men att de lyckades hantera sitt vardagliga liv. Den objektiva och den
självskattade balansmätningen kompletterade den subjektiva upplevelsen
att leva med balans nedsättning.

ACKNOWLEDGEMENT
This work was carried out at the Faculty of Medicine and Health, Örebro
University and the University Health Care Research Centre, Örebro,
Sweden. I wish to express my warmest gratitude to all those who have
helped and supported me throughout this thesis. I could not have
completed this on my own. Special thanks are due to:
All the persons with stroke who generously contributed their time to make
this thesis possible.
Anette Forsberg, my main supervisor for your enormously engagement.

Thank you for guiding me in the academic world with your great
knowledge, all the time you spent for supervision and your patience.
Agneta Anderzén Carlsson, my supervisor for your positive approach and

for your firm belief that everything will work out to the best. Without you
article II have never been finished never been “simple yet challenging”.
Peter Appelros my supervisor for your elegant and valuable comments on

writing and your great knowledge in stroke.
Margareta Möller Professor, head of department of the University Health

Care Research Center (UFC), for giving me the opportunity to be part of
your creative research environment.
Kumla vårdcentral, with Annika Roman and Lennart Svärd for support
during all these years. All colleges at the Rehabilitation department at
Kumla healthcare centre for your always positive attitudes and your
tolerance with me popping in some days at the week.
Peter Engfeldt head of department at the former Allmänmedicinskt

forskningscentrum, who made it possible for me to start this journey in
the academic world.
The Medical Library, USÖ and Birgitta Eriksson for all your help with the
Endnote, databases searches and requires of articles.

The Neurophysiotherapists group, Helena Tholin, Steven Allen, Anna
Lövgren, Nicklas Borgkvist and Ewa Pettersson, my colleagues in the
primary health care. For support and practical help.
Martin Eriksson Crommert for your enormous valuable ability to explain

and guide me in wonderful world of statistics. Always with a smile!
The running team at UFC; Marie Matérne, Emma Nilsing Strid, Lars
Hagberg, Anna Duberg and Karin Hilden for connecting running and
research in a much higher level. After a run no scientific mountain is too
high or too step.
To all my research colleges at University Healthcare Research Centre, for

all the enjoyable seminaries and for support making my doctoral student
period a pleasant journey. Especially thanks to former and present
doctoral students Anna Carling, Cecilia Bergh, Kristina Luhr and Anna
Philipsson.
Susanne Collgård for assistance when the computer and I didn’t

understand each other and for bringing a peaceful atmosphere of just
being you.
Miriam Pikkemaat from the National research school in general practice

for sharing and cheering both science and running.
Elisabeth Westerdahl for traveling companions in many dimensions!
For financial support, the Swedish Stroke Association, The Neurology

Section from the Swedish Association of Physiotherapists, Norrbacka-
Eugenia Foundation, and the Research Committee, Örebro County
Council
Friends for always being there and for helping me getting things into
perspective, not always knowing what I was doing but supported anyhow.
My parents in law, for your never ending of support in practical help as

babysitting and just everyday life struggles.

My parents Thage and Lisbeth because you encouraged me to do what I
want in life and always supported it. Thank you for always being there.
My French parents for having a second home in the mountain where I can
reload my batteries.
My sisters Sophia and Gry, we help and encourages each other. We will
always do!
My husband Henrik, this has not been possible without you. We did it!
Olle och Nisse, mina hjältar. Jag är så stolt, glad och lycklig över att vara
er mamma.

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Publications in the series
Örebro Studies in Care Sciences*
1. Gustafsson, Margareta (2003) Konsekvenser av en akut traumatisk

handskada. En prospektiv studie av patientens situation under det
första året efter olyckan.
Doktorsavhandling/Doctoral thesis with focus on Nursing.
2. Jackson, Karin (2005) Att vara förälder till ett för tidigt fött barn
– en prospektiv studie om upplevelsen av föräldraskap och möten
med vården.
3. Odencrants, Sigrid (2005) Måltidsrelaterade situationer och
äringstillstånd ur patienters med kroniskt obstruktiv lungsjukdom
n
och sjuksköterskors perspektiv.
Vetenskaplig uppsats för licentiatexamen/Academic essay.
4. Göransson, Katarina (2005) Emergency department triage
– a challenging task for Swedish emergency nurses.
5. Eldh, Ann Catrine (2005) Patienters upplevelser av och uttryck för
fenomenet delaktighet i hälso- och sjukvård.
6. Florin, Jan (2005) Clinical judgement in nursing – a collaborative
effort? Patient participation and nurses’ knowledge.
7. Ekwall, Ewa (2006) Women’s Experiences of Primary and Recurrent
Gynecological Cancer.
8. Pettersson, Ingvor (2006) Significance of Assistive Devices in the
Daily Life of Persons with Stroke and Their Spouses.
Doktorsavhandling/Doctoral thesis with focus on Occupational
Therapy.
9. Carlsson, Eva (2006) Understanding persons with eating difficulties
and communication impairment after stroke – patient experiences
and methodological issues in qualitative interviews.
* Seriens namn var tidigare (nr 1–24) ”Örebro Studies in Caring Sciences”.
10. Göransson, Katarina (2006) Registered nurse-led emergency
department triage: organisation, allocation of acuity ratings and
triage decision making.
11. Eldh, Ann Catrine (2006) Patient participation – what it is and
what it is not.
12. Isaksson, Ann-Kristin (2007) Chronic sorrow and quality of life in
patients with multiple sclerosis.
13. Florin, Jan (2007) Patient participation in clinical decision making
in nursing – a collaborative effort between patients and nurses.
14. Johansson, Agneta (2007) Adolescents’ perspective on mental
health and health-promoting dialogues.
15. Frisk, Margot (2007) Asthma and respiratory symptoms related to
the housing environment.
Doktorsavhandling/Doctoral thesis with focus on Occupational
T herapy.
16. Forslund, Kerstin (2007) Challenges in prehospital emergency care –
patient, spouse and personnel perspectives.
17. Odencrants, Sigrid (2008) The complexity of nutritional status for
persons with chronic obstructive pulmonary disease – a nursing
challenge. Doktorsavhandling/Doctoral thesis with focus on Nursing.
18. Tollén, Anita (2008) Vardagen och förväntningar på dagrehabilitering
– en studie i äldre personers uppfattningar.
19. Dwyer, Lise-Lotte (2008) Dignity in the end of life care – what does
it mean to older people and staff in nursing homes?
20. Lidskog, Marie (2008) Learning with, from and about each other:
Interprofessional education on a training ward in municipal care for
older persons. Doktorsavhandling/Doctoral thesis.
21. Tinnfält, Agneta (2008) Adolescents’ perspectives – on mental health,
being at risk, and promoting initiatives.
Doktorsavhandling/Doctoral thesis with focus on Public Health.
22. Carlsson, Eva (2009) Communication about eating difficulties after
stroke – from the perspectives of patients and professionals in health
care. Doktorsavhandling/Doctoral thesis with focus on Nursing.
23. Källström Karlsson, Inga-Lill (2009) Att leva nära döden. Patienters
och vårdpersonals erfarenheter inom hospicevård.
24. Österlind, Jane (2009) När livsrummet krymper.
25. Liedström, Elisabeth (2009) Experiences of Chronic Sorrow and
Quality of Life in Next of Kin of Patients with Multiple Sclerosis.
26. Petersson, Pia (2009) Att göra abstrakta begrepp och komplexa
situationer konkreta. En avhandling om deltagarbaserad aktions-
forskning i svensk vård och omsorg.
27. James, Inger (2010) Bakom rutinerna. Kunskap och omvårdnads-
praxis i mänskliga gränssituationer.
28. Thoroddsen, Ásta (2010) The role of standardised nursing languages
in representing nursing and supporting nurses as knowledge workers.
29. Pettersson, Camilla (2010) Parents’ Possibility to Prevent Underage
Drinking. Studies of Parents, a Parental Support Program,
and Adolescents in the Context of a National Program to Support
NGOs.
Doktorsavhandling/Doctoral thesis with focus on Public Health.
30. Rydlo, Cecilia (2010) Fighting for the otherness. Student nurses’
lived experiences of growing in caring.
Doktorsavhandling/Doctoral thesis.
31. Ek, Kristina (2010) Att leva med mycket svår kronisk obstruktiv
lungsjukdom – ett liv i slowmotion.
32. Fröding, Karin (2011) Public Health, Neighbourhood Development,
and Participation. Research and Practice in four Swedish Partnership
Cities. Doktorsavhandling/Doctoral thesis.
33. Kollén, Lena (2011) Dizziness, balance and rehabilitiation in
vestibular disorders. Doktorsavhandling/Doctoral thesis.
34. Wallerstedt, Birgitta (2012) Utmaningar, utsatthet och stöd i palliativ
vård utanför specialistenheter. Doktorsavhandling/Doctoral thesis.
35. Ewertzon, Mats (2012) Familjemedlem till person med psykossjukdom:
bemötande och utanförskap i psykiatrisk vård.
36. Fossum, Mariann (2012) Computerized Decision Support System in
Nursing Homes. Doktorsavhandling/Doctoral thesis.
37. Henriksson, Anette (2012) A support group programme for family
members: an intervention during ongoing palliative care.
38. Hälleberg Nyman, Maria (2012) Urinary catheter policies for
short-term bladder drainage in hip surgery patients.
39. Thorstensson, Stina (2012) Professional support in childbearing, a
challenging act of balance. Doktorsavhandling/Doctoral thesis.
40. Geidne, Susanna (2012) The Non-Governmental Organization as
a Health promoting Setting. Examples from Alcohol Prevention
Projects conducted in the Context of National Support to NGOs.
41. Lidström Holmqvist, Kajsa (2012) Occupational therapy practice for
clients with cognitive impairment following acquired brain injury –
occupational therapists’ perspective.
42. Tollén, Anita (2013): Äldre personers dagliga liv och betydelsen av
dagrehabilitering. Doktorsavhandling/Doctoral thesis.
43. Pajalic, Zada (2013): Matdistribution till hemmaboende äldre
personer ur flera perspektiv. Doktorsavhandling/Doctoral thesis.
44. Olsson, Annakarin (2013): Daily life of persons with dementia and
their spouses supported by a passive positioning alarm.
45. Norell Pejner, Margaretha (2013): The bright side of life. Support in
municipal elderly home care. Doktorsavhandling/Doctoral thesis.
46. Karlsson, Ulf (2013): Arbetsterapeuters attityd till och uppfattning om
forskningsanvändning samt professionen ur ett manligt perspektiv.
47. Salzmann-Erikson, Martin (2013): Caring in intensive psychiatry.
Rhythm and movements in a culture of stability.
48. Lindner, Helen (2013): The Assessment of Capacity for Myoelectric
Control. Psychometric evidence and comparison with upper limb
prosthetic outcome measures. Doktorsavhandling/Doctoral thesis.
49. Ohlsson-Nevo, Emma (2013): Colorectal cancer: Patients’ and next-
of-kin’s experiences and the effects of a psycho-educational program.
50. Falk-Brynhildsen, Karin (2013): The effect of preoperative skin
preparation on bacterial growth during cardiac surgery.
51. Jaensson, Maria (2013): Postoperative sore throat and hoarseness.
Clinical studies in patients undergoing general anesthesia.
52. Elisabeth Liedström (2014): Life Situation as Next of Kin to Persons
in Need of Care: Chronic Sorrow, Burden and Quality of Life.
53. Johansson, Anita (2014): Ändlös omsorg och utmätt hälsa:
Föräldraskapets paradoxer när ett vuxet barn har långvarig psykisk
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54. Brobeck, Elisabeth (2014): Samtal som stöd för patienters
livsstilsförändringar: en viktig del av sjuksköterskans hälsofrämjande
arbete. Doktorsavhandling/Doctoral thesis.
55. Lindh, Marianne (2014): Adherence to hygiene routines in
community care – the perspective of medically responsible nurses in
Sweden. Vetenskaplig uppsats för licentiatexamen/Academic essay.
56. Källstrand-Eriksson, Jeanette (2014): Being on the trail of ageing.
Functional visual ability and risk of falling in an increasingly ageing
population. Doktorsavhandling/Doctoral thesis.
57. Jonny Geidne (2014): Implementation and Sustainability in a Swedish
Setting Approach for Health Promotion-Research and Practice in
four Partnership Cities. Vetenskaplig uppsats för licentiatexamen/
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58. Ekwall, Eva (2009): Women’s Experiences of Gynecological Cancer
and Interaction with the Health Care System through Different Phases
of the Disease. Doktorsavhandling/Doctoral thesis.
59. Wätterbjörk, Inger (2014): Couples’ experiences of an information
model about prenatal screening. Decision-making and satisfaction.
60. Ek, Bosse (2014): Prioritering vid utlarmning i prehospital vård.
61. Dahlkvist, Eva (2015): The Garden/Patio in Residential Care
Facilities for Older People - Characteristics and the Users Perspectives.
62. Faag, Carina (2015): A comprehensive nurse-led intervention for
patients with peripheral vestibular disorders: the feasibility and
benefits. Vetenskaplig uppsats för licentiatexamen/Academic essay.
63. Biswas, Animesh (2015): Maternal and Neonatal Death Review
System to Improve Maternal and Neonatal Health Care Services in
Bangladesh. Doktorsavhandling/Doctoral thesis.
64. Islam, Farzana (2016): Quality Improvement System for Maternal
and Newborn Health Care Services at District and Sub-district
Hospitals in Bangladesh. Doktorsavhandling/Doctoral thesis.
65. Algilani, Samal (2016): ”To be at one’s best” -The evolution of Opti-
mal Functionality and its possible implementation in an ICT-platform.
66. Fredriksson, Ingela (2016): Leisure-time youth-center as health-promotion
settings. Vetenskaplig uppsats för licentiatexamen/Academic essay.
67. Larsson, Madelene (2016): Formal Female Mentoring Relationships as
Health Promotion. Vetenskaplig uppsats för licentiatexamen/Academic
essay.
68. Barzangi, Jir (2017): Infant Dental Enucleation in Sweden:
Perspectives on a Practice among Residents of Eastern African Origin.
69. Hugelius, Karin (2017): Disaster response for recovery: survivors’
experiences, and the use of disaster radio to promote health after
natural disasters. Doktorsavhandling/Doctoral thesis.
70. Ewertsson, Mona (2017): Lärande av praktiska färdigheter inom
sjuksköterskeprofessionen-studier av lärande i olika arenor.
71. Sundqvist, Ann-Sofie (2017): Perioperative patient advocacy – having
the patient’s best interests at heart. Doktorsavhandling/Doctoral thesis.
72. Rasoal, Dara (2017): Perspectives on Clinical Ethics Support and
Ethically Difficult Situations: Reflections and Experiences.
73. Wistrand, Camilla (2017): Swedish operating room nurses´ preventive
interventions to reduce bacterial growth and surgical site infections,
and to increase comfort in patients undergoing surgery.
74. Luhr, Kristina (2018): Patient Participation from the Patient’s
Preferences, That’s What Counts. Doktorsavhandling/Doctoral thesis.
75. Arvidsson Lindvall, Mialinn (2018): Physiotherapeutic perspectives
on balance control after stroke: exercises, experiences and measures.

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Physiotherapeutic perspectives on balance control after stroke: exercises,

experiences and measures

MIALINN ARVIDSSON LINDVALL

Physiotherapeutic perspectives on balance control

© Mialinn Arvidsson Lindvall, 2018

Title: Physiotherapeutic perspectives on balance control after stroke: exercises,

Print: Örebro University, Repro 04/2018

The overall aim of this thesis was to investigate physiotherapeutic per-

Keywords: Stroke, balance, physiotherapy, measures, experiences

Mialinn Arvidsson Lindvall, School of Health Sciences

LIST OF PUBLICATIONS ....................................................................... 11

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 9

10 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

I. Lindvall MA, Forsberg A. Body Awareness Therapy in persons

II. Lindvall MA, Anderzén Carlsson A, Forsberg A. Basic Body

III. Lindvall MA, Appelros P, Anderzén Carlsson A, Forsberg A.

IV. Lindvall MA, Appelros P, Forsberg A, Anderzén Carlsson A. “I

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 11

Having a stroke is often a life-changing event, as many stroke survivors go

12 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

To be in balance requires the ability to be in equilibrium while standing

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 13

Physiotherapy and rehabilitation

Rehabilitation after stroke

14 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

Body Awareness Therapy

Another central element of BAT is to make the person aware of their

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 15

There are advanced laboratory facilities aimed at measuring balance, but

To measure balance an instrument should include different types of

16 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

The SSST could provide a comprehensive picture of walking capacity after

Experience of balance after stroke

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 17

The movements in BAT aim to challenge the limits of stability and

Body Awareness Therapy is often used and performed by physiotherapists

18 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

In Study I the aim was to investigate the effects of BAT on balance,

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 19

Sampling and participants

All persons who completed the intervention in Study I were invited by

20 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

Exclusion criteria in all studies were: having medical, physical or cognitive

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 21

Study I Study II Study III Study IV

One or more falls in 9 (37.5%) 9 (40.9%) 8 (38.1%) 34 (42.0%) 7 (36.8%)

22 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

Movements were performed in sitting, standing and supine position.

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 23

Modified Timed Stands Test: The TST is a measure of overall lower

Timed Up and Go test: The TUG test was developed as a measure of

The Timed Up and Go cognitive: The TUG cognitive test is a measure of

24 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 25

26 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 27

28 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control

In Study I intention-to-treat analysis was performed, with data from the

In Study II a qualitative content analysis was performed using an inductive

MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control 29

Manifest analysis (analysis close to the text):

Latent analysis (interpretation of the underlying meaning):

Reliability testing by definition includes evaluating reproducibility of

30 MIALINN ARVIDSSON LINDVALL Physiotherapeutic perspectives on balance control