Introduction

Stroke is one of the major causes of permanent disability1. Stroke can have many causes and occurs mainly in old age, although it can occur at any age2. Most stroke survivors can perform limited activities of daily living (ADL) due to motor, sensory, emotional, and cognitive impairments3. Stroke patients commonly exhibit symptoms of hemiplegia and thus, as a result, have defects in voluntary movements, asymmetrical weight-shifts, gait, and body balance4. Stroke patients have decreased balance ability due to their centre of gravity shifting towards the unaffected side4. In the standing posture, approximately 61% to 80% of their body weight is concentrated on the unaffected lower extremity5. Due to these asymmetric postures, stroke patients may have frequent falls, limited independent gait, and reduced gait velocity6. This asymmetric gait in hemiplegic patients may cause reduced bone density on the affected side and an overall increase in energy expenditure on walking7,8. In addition to normal walking, stroke survivors fall during transfers between beds and the wheelchair and during standing turns9,10. These gait dysfunctions after stroke are the main cause of impaired functional ambulation, which in turn causes decreased social participation and poor quality of life. Therefore, enhancing the tolerance and capability to bear weight on the affected lower extremity and achieving good body balance during various functional activities and symmetric gait patterns are the main goals of rehabilitation for stroke patients11,12,13.

Multi-directional steps are essential for ADL because, while walking indoors, 35–50% of all steps consist of those steps that change the direction of movement, i.e. non-straight steps14. Normal individuals and stroke patients should have the ability to take steps in multiple directions to perform ADL safely. In previous studies, step training in various directions has been reported to improve balance and gait in older people and patients with Parkinson’s disease15,16. The stroke patients also have impaired ability to bear weight on the paretic side in all three directions of a step, i.e. forward, backward and lateral17. Therefore, a rehabilitation program for stroke survivors should include multi-directional step exercises (MSE) and weight shifting training. One previous study by Park et al.4 compared the multi-directional stepping training versus general physical therapy in stroke patients. Park et al. used two stair-shaped footholds (10 cm) and a weight rod for multi-directional stepping training. They reported improvement in the berg balance scale (BBS), timed up and go (TUG) test, 10-m walk test, and fall efficacy scores after performing multi-directional stepping training compared to general physical therapy. In their study, participants performed stepping exercises over stair-shaped footholds and across the weight rod by the non-paretic side while keeping the paretic side fixed over the ground.

It will be interesting to examine the effects of MSE along with weight-shifting when performed by the paretic side of the participants while keeping the non-paretic side fixed over the ground. To the best of our knowledge, no study has examined these effects in stroke patients. Since it will be difficult for participants to take steps over a foothold by their paretic side, therefore, in the present study these exercises will be performed on the flat surface. Thus, this study was conceptualized to examine the effects of MSE along with weight-shifting when performed as an adjunct to conventional therapeutic exercises (CTE), on balance and functional gait performance in patients with stroke. We hypothesized that the addition of MSE along with weight-shifting to a 4-week program of CTE improves balance and functional gait performance in comparison to CTE alone in stroke patients.

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