Modifying center of pressure to reduce fall risk in adult stroke survivors: a scoping review

Stroke survivors face a 73% fall rate within the first year after leaving the hospital. These falls cause serious injuries in 40% of cases and lead to healthcare costs of over $50 billion each year. Many of these falls are due to ongoing center of pressure (COP) abnormalities, such as velocity increases of 2-3 times normal levels, weight-bearing asymmetry exceeding 70%, and limits of stability reduced by 40-60%. These issues are often not addressed by standard rehabilitation. Although COP measurements provide objective indicators of fall risk, there has been no comprehensive review of interventions aimed at correcting these modifiable deficits.

To systematically map the scope, variety, and characteristics of interventions aimed at adjusting COP variables in adult stroke survivors to reduce fall risk, while incorporating stakeholder insights on clinical implementation.

We conducted a scoping review following PRISMA-ScR guidelines, searching PubMed, MEDLINE, and the Cochrane Library from January 2015 to June 2025 for studies on COP-targeted interventions with fall-related outcomes. We extracted data on intervention details, COP parameters, measurement protocols, and clinical results. A diverse stakeholder panel of seven members, including stroke survivors, physiotherapists, and technology specialists, offered insights on implementation through structured consultations.

Nine studies with 306 participants mainly examined chronic stroke patients. The strongest evidence came from force-plate biofeedback across three studies, with effect sizes d = 0.52-0.84, showing consistent gains in sway velocity linked to a lower fall risk (r = 0.52-0.71). A 0.5 cm/s reduction in sway velocity correlated with about an 18% decrease in fall likelihood. Nevertheless, considerable methodological differences-such as equipment costs from $100 to $50,000 and varying measurement protocols-restrict clinical use. Stakeholders emphasized key factors: stroke survivors appreciated visual feedback ("seeing inside my own balance"), while clinicians highlighted the need to address time constraints and documentation. The review led to a resource-based implementation framework and consensus guidelines for standardized protocols.

COP interventions show promising potential for addressing the hidden issue of post-stroke falls, with force-plate biofeedback being ready for careful clinical application.Success hinges on shifting from generic approaches to personalized rehabilitation that reveals and addresses subtle balance problems. The combination of moderate to large effect sizes and stakeholder-approved implementation strategies provides a clear path to transform these ongoing fall risks into confident community mobility. Nevertheless, realizing this potential requires coordinated efforts to standardize measurements, develop practical trials, and implement strategies across systems, balancing scientific rigor with clinical realities.