Grounded and Growing: How Hip and Knee Strategies Can Improve Balance After Stroke

The Building Blocks of Balance

Balance depends on multiple systems working together:

• Sensory input (from your eyes, inner ear, and body)

• Motor output (how your muscles respond)

• Cognitive control (focus, attention, and decision-making)

When stroke damages motor pathways, proprioceptive feedback, or the cerebellum, it impairs the body’s ability to react quickly and appropriately to shifts in position.

In healthy individuals, three key balance strategies are used depending on the situation:

1. Ankle strategy – used during small sway, like standing still on a firm surface

2. Hip strategy – used during larger or faster balance disturbances

3. Stepping strategy – used when the body’s center of mass moves beyond the base of support

For stroke survivors, ankle responses are often weak or delayed, especially on the affected side. That’s where hip and knee strategies become essential.

The Hip Strategy: Your Midline Anchor

The hip strategy involves rapid, coordinated flexion and extension of the hips to keep the body centered. Imagine standing on a bus that suddenly starts — your hips instinctively push backward or forward to stay balanced.

After a stroke, especially with hemiparesis or core weakness, this strategy may be underused or uneven. Training the hips to react and stabilize can reduce falls and improve walking confidence.

Exercises to strengthen the hip strategy:

• Lateral weight shifts: Practice shifting weight side to side in standing

• Mini-squats: Encourage controlled hip flexion and knee control

• Single-leg stance (with support): Challenges both hip and core stability

• Step taps to the side: A functional way to engage hip abductors

The Knee Strategy: The Often-Overlooked Shock Absorber

The knee strategy is less often named in rehab, but it plays a crucial role, especially for forward-backward balance. Slight knee flexion allows the body to adjust to surface changes and shift the center of gravity without toppling.

Knee locking — common post-stroke due to spasticity or weakness — reduces this adaptability and can cause compensatory stiffness in gait.

Exercises to activate the knee strategy:

• Sit-to-stand repetitions: Trains controlled flexion and extension

• Wall sits (short holds): Builds eccentric control

• Lunges (supported): Encourages weight shifting and knee alignment

• Balance pads or BOSU ball work (if appropriate): Adds proprioceptive challenge

Retraining Balance Post-Stroke: A Whole-Body Strategy

Research shows that balance retraining is most effective when it includes dynamic, functional movements (Pollock et al., 2014). Integrating hip and knee strategies into daily activities — like squatting to reach a drawer or stepping over objects — builds neural pathways through repetition and variation.

The OSET 2024 Conference highlighted the value of "task-specific rehab with multi-joint activation" — which means exercises that use hips, knees, and ankles together in real-world contexts. As one occupational therapist noted, “We don’t balance with muscles — we balance with habits.”

Takeaway: Balance Is Relearnable

Don’t underestimate the power of small movements. Whether you’re doing gentle squats at the kitchen counter or practicing side steps to music, you are re-teaching your body how to respond. The hip and knee strategies aren’t just backup systems — they can become your foundation for rebuilding steady, confident movement.

References:

1. Pollock, A., Baer, G., Pomeroy, V., & Langhorne, P. (2014). Physiotherapy treatment approaches for the recovery of postural control and lower limb function following stroke. Cochrane Database of Systematic Reviews, (4). https://doi.org/10.1002/14651858.CD008095.pub2

2. OSET Conference Proceedings, 2024.

3. Horak, F.B. (2006). Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? Age and Ageing, 35-s2, ii7–ii11.