Relationship Between Balance, Arm Function and Body Awareness in People With Stroke

Stroke is one of the leading causes of mortality and long-term disability worldwide and continues to represent a major public health problem. Motor, sensory, perceptual, and cognitive impairments that occur following stroke frequently result in limitations in functional independence and participation in daily life activities. Among these impairments, balance disorders and upper extremity dysfunction are particularly common and may significantly affect quality of life and rehabilitation outcomes.

Balance impairment after stroke is associated with postural instability, altered weight distribution, impaired trunk control, and an increased risk of falls. Changes in muscle tone, muscle weakness, impaired motor control, and deficits in sensory processing may negatively influence both static and dynamic balance. In addition, upper extremity impairments are observed in a large proportion of individuals with stroke and often persist into the chronic stage. Due to the complexity of upper extremity movements and the development of learned non-use, recovery of upper extremity function is generally slower and less complete than recovery of lower extremity function.

Previous studies have demonstrated associations between balance, trunk control, mobility, and upper extremity function in individuals with stroke. Impairments in upper extremity motor performance may influence postural control and balance strategies, while deficits in balance may limit functional use of the affected upper extremity. However, the interaction between these variables has not been fully clarified, particularly when functional upper extremity performance is evaluated using both clinical and objective measurement methods.

Body awareness has emerged as another important factor that may influence functional recovery following stroke. Body awareness is a multidimensional concept involving the perception and interpretation of bodily sensations, movements, and physiological states. It contributes to motor planning, movement execution, postural control, and interaction with the environment. Sensory deficits, perceptual disturbances, and motor impairments following stroke may negatively affect body awareness. Recent studies have suggested that body awareness may be associated with balance, walking ability, trunk control, upper extremity function, fear of falling, and independence in activities of daily living. Nevertheless, research examining body awareness in stroke populations remains limited.

A better understanding of the relationships among balance, upper extremity skills, and body awareness may provide valuable information for the development of individualized rehabilitation strategies. Identifying factors associated with functional performance may also contribute to the selection of appropriate assessment tools and treatment approaches in stroke rehabilitation.

The purpose of this observational cross-sectional study is to investigate the relationship between balance, upper extremity skills, and body awareness in individuals with chronic stroke. The study will be conducted at the Department of Physical Medicine and Rehabilitation, Baskent University Hospital. A total of 53 individuals with chronic stroke who meet the eligibility criteria will be included.

All assessments will be completed during a single evaluation session. Demographic and clinical information including age, sex, disease duration, dominant side, affected side, educational status, occupation, and use of assistive devices will be recorded.

Cognitive status will be assessed using the Standardized Mini-Mental State Examination (SMMSE), and only individuals scoring 24 points or higher will be included in the study. Muscle tone will be evaluated using the Modified Ashworth Scale, and only individuals with spasticity grades of 2 or 3 in the shoulder, elbow, wrist, and finger flexor muscles according to the Modified Ashworth Scale will be included in the study. Passive shoulder flexion range of motion will be measured using a goniometer, and only individuals with at least 120 degrees of shoulder flexion range of motion will be eligible for participation.

Upper and lower extremity motor impairment will be assessed using the Fugl-Meyer Assessment Scale. Upper extremity functional performance will be evaluated using the Wolf Motor Function Test.

Balance will be assessed using both clinical and objective measurement methods. Clinical balance performance will be evaluated using the Berg Balance Scale. Objective balance assessment will be performed using the Tetrax computerized posturography system, which provides measurements related to postural stability, weight distribution, and fall risk under different sensory conditions.

Upper extremity reaction time will be evaluated using the Light Trainer Flash Light Exercise System. Participants will be instructed to respond to randomly illuminated LED targets as quickly as possible, and the number of successful responses and reaction times will be recorded.

Body awareness will be assessed using the Body Awareness Questionnaire. Relationships among balance parameters, upper extremity motor and functional performance, reaction time, and body awareness scores will be analyzed using appropriate statistical methods.

Statistical analyses of the study data will be performed using SPSS software (Version 22.0). The obtained data will be expressed as mean ± standard deviation (x ± SD) and number (n%). Relationships among balance, upper extremity measurements, and body awareness will be evaluated using Pearson correlation analysis when data are normally distributed and Spearman rank correlation analysis when data are not normally distributed. In all analyses, the level of statistical significance will be accepted as p < 0.05.

Inclusion criteria

• Individuals who experienced a cerebrovascular event at least 6 months previously
• Individuals between 18 and 75 years of age
• Individuals who have experienced stroke for the first time
• Individuals with shoulder, elbow, wrist, and finger muscle tone graded as 2 or 3 according to the Modified Ashworth Scale (MAS)
• Individuals scoring 24 points or higher on the Standardized Mini Mental State Examination
• Individuals with at least 120° of shoulder range of motion
• Individuals who are able to walk independently or with a walking aid

Exclusion criteria

• Presence of communication problems such as difficulties in reading, writing, or speaking
• Botulinum toxin injection within the last 3 months
• Presence of hemispatial neglect syndrome
• Presence of ataxia due to posterior circulation ischemia
• Bilateral involvement (bilateral hemiparesis)
• Having received physiotherapy within the last 6 months
• Presence of orthopedic problems such as shoulder subluxation, shoulder pain, contracture of the hand and wrist
• History of upper extremity or thoracic surgery
• Presence of stroke-related visual impairments (hemianopia)
• Presence of color blindness
• Use of antiepileptic medication
• History of convulsions