The effect of balance training with plantar flexor stretching on range of motion, balance, and gait in stroke patients: a randomized controlled pilot trial

  • Park, Ki-Suk ;
  • Choi, Jong-Duk
  • Received : 2015.10.23
  • Accepted : 2015.11.02
  • Published : 2015.12.26


Objective: The aim of this study was to investigate the effect of balance training with plantar flexor stretching on ankle dorsi flexion range of motion (ROM), balance, and gait ability in stroke patients. Design: A randomized controlled pilot trial. Methods: Thirty stroke patients volunteered to participate in this study. The subjects were randomly allocated to two groups: the experimental group (n=15) received the neurodevelopment therapy plus balance training with plantar flexor stretching for 20 minutes in one session. The control group (n=15) received the same neurodevelopment therapy plus plantar flexor static stretching for 20 minutes in one session. Both groups underwent sessions four times a week, for a total of 4 weeks. Measurements included passive range of motion (PROM), active range of motion (AROM) of ankle dorsiflexion using a goniometer, timed up and go (TUG), the functional reaching test (FRT), and the 10 m walk test (10 MWT). Results: There were significant improvements in AROM and PROM of ankle dorsiflexion, TUG, and FRT scores after the intervention in the experimental group (p<0.05). However, the control group showed no statistically significant differences except for PROM of ankle dorsiflexion. The experimental group showed a significant improvement in PROM, TUG, and FRT scores compared to the control group (p<0.05). Conclusions: Balance training with plantar flexor stretching improves ankle dorsiflexion ROM and balance ability in patients with stroke. Therefore, this therapeutic intervention will be effective for rehabilitation of stroke patients in the clinical setting.


Muscle stretching exercises;Postural balance;Stroke


  1. Park CH, Chung BI. Effects of treadmill training on hyperextension of the knee and cadence in patients with hemiplegia. Phys Ther Korea 2001;8:89-96.
  2. Korea National Statistical Office. Cause of death statistics 2011. Daejeon: Korea National Statistical Office; 2011.
  3. Wall JC, Charteris J, Turnbull GI. Two steps equals one stride equals what?: the applicability of normal gait nomenclature to abnormal walking patterns. Clin Biomech (Bristol, Avon) 1987; 2:119-25.
  4. Wade DT, Wood VA, Heller A, Maggs J, Langton Hewer R. Walking after stroke. Measurement and recovery over the first 3 months. Scand J Rehabil Med 1987;19:25-30.
  5. Bohannon RW, Larkin PA. Lower extremity weight bearing under various standing conditions in independently ambulatory patients with hemiparesis. Phys Ther 1985;65:1323-5.
  6. Yarkony GM, Roth EJ, Heinemann AW, Wu YC, Katz RT, Lovell L. Benefits of rehabilitation for traumatic spinal cord injury. Multivariate analysis in 711 patients. Arch Neurol 1987;44:93-6.
  7. Given JD, Dewald JP, Rymer WZ. Joint dependent passive stiffness in paretic and contralateral limbs of spastic patients with hemiparetic stroke. J Neurol Neurosurg Psychiatry 1995;59:271-9.
  8. Gao F, Ren Y, Roth EJ, Harvey R, Zhang LQ. Effects of repeated ankle stretching on calf muscle-tendon and ankle biomechanical properties in stroke survivors. Clin Biomech (Bristol, Avon) 2011;26:516-22.
  9. Lee KB, Park YH, Song EK, Yoon TR, Jung KI. Static and dynamic postural balance after successful mobile-bearing total ankle arthroplasty. Arch Phys Med Rehabil 2010;91:519-22.
  10. McHugh MP, Cosgrave CH. To stretch or not to stretch: the role of stretching in injury prevention and performance. Scand J Med Sci Sports 2010;20:169-81.
  11. Wolfson L, Whipple R, Judge J, Amerman P, Derby C, King M. Training balance and strength in the elderly to improve function. J Am Geriatr Soc 1993;41:341-3.
  12. Won JI, An CM. Knee strength and ankle range of motion Influencing gait velocity and gait asymmetry in patients with chronic stroke. Phys Ther Korea 2015;22:1-10.
  13. Yuk GC. The acute effects of 15 minutes Plantarflexor static stretch in quite stance. J Korean Soc Phys Med 2012;7:191-7.
  14. Kim JS. Effects of gastrocnemius stretching on $\alpha$-motor neuron excitability and ankle joint active dorsiflexion range of motion. J Korean Content Assoc 2009;9:278-86.
  15. Lee JH, Lee JH, Kwon WA, Kim JS. The effect of ankle joint muscle strengthening training and static muscle stretching training on stroke patients plantar pressure and gait. J Korean Acad Ind Coop Soc 2012;13:1153-60.
  16. Bressel E, McNair PJ. The effect of prolonged static and cyclic stretching on ankle joint stiffness, torque relaxation, and gait in people with stroke. Phys Ther 2002;82:880-7.
  17. Avela J, Finni T, Liikavainio T, Niemela E, Komi PV. Neural and mechanical responses of the triceps surae muscle group after 1 h of repeated fast passive stretches. J Appl Physiol (1985) 2004; 96:2325-32.
  18. Avela J, Kyrolainen H, Komi PV. Altered reflex sensitivity after repeated and prolonged passive muscle stretching. J Appl Physiol (1985) 1999;86:1283-91.
  19. Babault N, Kouassi BY, Desbrosses K. Acute effects of 15min static or contract-relax stretching modalities on plantar flexors neuromuscular properties. J Sci Med Sport 2010;13:247-52.
  20. Behm DG, Bambury A, Cahill F, Power K. Effect of acute static stretching on force, balance, reaction time, and movement time. Med Sci Sports Exerc 2004;36:1397-402.
  21. Song CH, Kim KR, Lee KJ, Shin DC, Lee YD. The effects of ankle position on static balance in healthy adult. J Spec Educ Rehabil Sci 2012;51:403-17.
  22. Almeida GL, Carvalho RL, Talis VL. Postural strategy to keep balance on the seesaw. Gait Posture 2006;23:17-21.
  23. Kisner C, Colby LA. Therapeutic exercise: foundations and techniques. 6th ed. Philadelphia: FA Davis; 2012.
  24. Carr JH, Shepherd RB. Neurological rehabilitation: optimizing motor performance. 2nd ed. Edinburgh: Churchill Livingstone; 2010.
  25. Lee WC, Park HS, Rha JD, Han YK, Cho JJ, Chang BC, et al. Measurement of the dorsiflexion range in the ankle. Korean J Sport Med 1998;16:29-34.
  26. Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. J Gerontol 1990;45: M192-7.
  27. Podsiadlo D, Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:142-8.
  28. Dean CM, Richards CL, Malouin F. Task-related circuit training improves performance of locomotor tasks in chronic stroke: a randomized, controlled pilot trial. Arch Phys Med Rehabil 2000;81:409-17.
  29. Rabin A, Kozol Z, Spitzer E, Finestone AS. Weight-bearing ankle dorsiflexion range of motion-can side-to-side symmetry be assumed? J Athl Train 2015;50:30-5.
  30. Vandervoort AA, Chesworth BM, Cunningham DA, Rechnitzer PA, Paterson DH, Koval JJ. An outcome measure to quantify passive stiffness of the ankle. Can J Public Health 1992;83 Suppl 2:S19-23.
  31. Lee SJ, Kwon BS, Park CH. The effect of passive stretching on the spasticity of ankle plantar flexor muscles. J Korean Acad Rehabil Med 2001;25:987-92.
  32. Gossman MR, Sahrmann SA, Rose SJ. Review of length-associated changes in muscle. Experimental evidence and clinical implications. Phys Ther 1982;62:1799-808.
  33. Nagano A, Yoshioka S, Hay DC, Himeno R, Fukashiro S. Influence of vision and static stretch of the calf muscles on postural sway during quiet standing. Hum Mov Sci 2006;25:422-34.
  34. Kim SG. Effect of treadmill gradient training on lower limb muscle activity in chronic stroke patient. J Korean Acad Ind Coop Soc 2012;13:220-6.

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