balance training and its permutations | houston, tx
TRANSCRIPT
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BALANCE TRAINING AND ITS PERMUTATIONS
GAIN 2018- June 12th
-16th
| HOUSTON, TX
Grace M. Golden, PhD, ATC, CSCS | University of Oregon, Eugene, OR. | [email protected]
Overview:
Consider the typical ways you create balance challenges! Do you utilize particular exercises and progressions (ones you
prefer and if so, what are the criteria you use to create these progressions)? Ask yourself why you (or don’t) include
balance challenges in your training/rehabilitation regime? Now…..
If your argument is “I use balance training to improve proprioception”, reflect on what proprioception is. By definition,
proprioception is the acquisition, transmission and conversion of somatosensory afferent information (Lephart and Fu,
2000). This means it is related to the information we acquire, but not the way we respond to this information.
Proprioception is essentially “information in”. This information is resourced from various sensory receptors (muscle
spindles, Pacinian corpuscles, ruffini endings etc.) which have been stimulated by external stimuli (i.e. the environment).
The ecological question is “can we train the afferent transmission of information?”. Essentially, this would mean we
can influence the threshold of activation of the receptors and the rate of transmission of information along the
peripheral and central nervous system pathways amongst other factors. We do not have convincing evidence of
“training” the sensitivity to stimulus and rate of transmission of afferent nerve pathways (perhaps this is disappointing,
but this does not mean balance training is not useful!!). Nor does this mean proprioception is not important. Frank
Forencich (Play as Your Life Depends Upon It, 2003) states: “Proprioception is just a must a sense as vision and hearing
and just as vital. Without proprioception, our bodies would be blind.” If you have any doubt about this statement,
watch this documentary on Ian Waterman (The Man Who Lost His Body. https://www.youtube.com/watch?v=-
AIyimx8Ixw )
Subtle but important, when we focus on balance training (a.k.a postural stability training) we are creating opportunities
for the individual to improve their ability to maintain the projected center of mass (COM) within the limits of the base of
support (Shumway-Cook & Woollacott, 2001). Importantly, balance control is not only influenced by proprioceptive
information, but visual and vestibular information. We compare and contrast information from the three senses,
integrating all information and then respond to the information to maintain “upright” posture (essentially preventing
ourselves from falling) via neuromuscular pathways (efferent). In the event of soft-tissue injury, proprioceptors may be
damaged. In fact, individuals can suffer deafferentation (meaning loss of/injury to proprioceptors) after ligament or
other soft tissue injuries, which may not be possible to restore. Principally, this means the amount of afferent
information coming in from the proprioceptors is less and restoration or healing of these receptors is not likely.
However, faced with lesser afferent information, we can adapt by learning to make correct responses and maintain
balance in the new “state”, arguably by adapting to the comparison of received proprioceptive, vestibular, and
vestibular information. Essentially we reset the “gain” from the signal (Ashton-Miller et al. 2001), meaning in the
presence of lesser information, we adapt to provide the correct neuromuscular response. We learn what the
information means and how to respond with suitable corrections to the information to maintain balance, despite
receiving lesser information about our joint/limb position. This is similar in conditions in which the individual hasn’t
suffered proprioceptor injury, but is learning how to respond to the acquired sensory information from all 3 sensory
inputs. All of this means, the “trainability” of proprioception is suspect, but it does not negate the power of “balance
training”. Perhaps this explains why some individuals who suffer joint injury and/or ligament reconstruction, do not
have differences in balance control or “proprioception” in certain circumstances. There isn’t a direct cause and effect.
The take-home message from this overview is to declare “we are training balance control” not “we are training
proprioception”. Now that your attention is peaked, let’s consider additional factors!
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Constraints Based Movement Patterns
We can benefit from the concept of “constraints” directed self-organization during balance training. Essentially, every
action we carry out is the result of a complex interaction between the performer (individual), task, and the
environment (Shumway-Cook & Woollacott, 2001). Therefore we can “create” integrative movement experiences during
balance training (and all other types of tasks). Movement patterns emerge due to self-organization during the task as a
function of the ever-changing interaction of constraints. Briefly, constraints associated with the individual are related to
factors such as strength (e.g. sufficient or insufficient muscular strength of the lower extremity or core during balancing),
mobility (e.g. available ankle dorsiflexion or hip rotation) and their motivation and engagement. Environmental
constraints can be influenced by the level of predictability (e.g. open vs. closed skills tasks), the relative stakes associated
with completion of the task (high to low; consequences associated with being successful or not), as well as social values.
Task constraints influence the relative challenge of the movement skill and arguably one of the largest areas we can
modify and/or progress. If we strive to influence any of the 3 major constraints, we have options for which we can focus
on. In the figure below, the intersection of the movement pattern (in this case maintaining balance and stability), is
affected by various ways we consider and influence self-organization. In other words: “Balance is not a single quality.
Rather it is a combination of sensitivity, speed, and strength. In fact we say that balance is a communication skill.”
(Frank Forencich, Play As If Your Life Depends Upon It, 2003)
Individual
Environment Task
M
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How Can We Create Purposeful Balance Training Experiences?
Survey the athlete’s needs:
� Does your athlete need to maintain or acquire balance in an individual or shared space, or both?
Is balance more important at the � start, � entire, � ending of a task?
� What types of body shape(s) does your athlete need to maintain or acquire to balance?
� Does your athlete need to maintain or acquire balance in a variety of body shapes?
� What types of perturbations to balance control is your athlete likely to encounter?
Is the challenge related to � visual tracking (changes in head position and gaze stabilization), � hand-eye
coordination, � foot-eye coordination, direct contact with � objects or � opponents, environmental � visual
or � auditory distractions (maintaining selective attention), during � single or � bilateral stance (note the
type: � tandem stance, � squat stance), � conditions of notable fatigue, � cognitive (dual-task) or
other: ______________________________________________________________________________________
� Is manipulation (hold, push, pull, throw, catch, strike, deflect etc.) of an object necessary during balance control?
� What are the effort requirements associated with the maintenance of balance (how much muscle force is required)?
This may vary due to the demands of the task and whether the tasks are relevant to the athlete’s sport and position
requirements.
� Assess balance control (use measures do you feel are appropriate to establish a “baseline” for balance control
aptitude?)
Consider these suggestions for creating balance challenging activities:
� Avoid over reliance on unstable surfaces (Airex® pad, BOSU® ball, Dyna-Disc™s etc.) or conditions of “eyes-closed”.
Using unstable surfaces reweights vestibular and visual feedback to a different degree compared to using stable
surfaces (Osgard, 2011). Additionally, while emphasizing “eyes-closed” conditions can be somewhat helpful in
inducing “sensory substitution”, once vision is re-introduced, the individual has to learn how to integrate the 3
senses again. Emphasize sensory integration rather than sensory exclusion! Unless you have an athlete who
competes with their eyes closed, or on soft unstable surfaces, these are not the primary way to “increase the
challenge” associated with balance training. Challenge with perturbations to the body (shape, position of the COG
relative to the BOS, tracking, avoidance, etc.) not just with perturbations to the foot/ankle and “blinded” vision. If
you want the athlete to excel in an ankle position of inversion, use a slant board to position the foot/ankle in
inversion (slant-board) and challenge balance accordingly!
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� Vary how close to the limits of stability (the points at which the center of gravity approaches the limit of the base
of support) the task/posture should start at or be maintained. E.g. Avoid always have the trunk directly over the
hip, which is directly over the knee, which is directly over the foot. Change the body shape so the center of gravity is
near the edge or outside the base of support and then provide balance perturbation. This is much harder compared
to when “everything is already in alignment”.
� Rather than “maintaining balance”, create opportunities to “acquire balance”. This is often important in the
transition from locomotor skills to “stopping” or “landing”. Consider the difference between maintaining balance in
a particular leg stance (bilateral, tandem, single) during a variety of external perturbations compared to stepping or
landing into a particular stance (bilateral, tandem, single) and simultaneously effectively responding to external
perturbations. E.g. nudging an athlete in single leg stance vs. nudging an athlete as they land in a leap or hop. In
other words: “Balance is the ability to lose your balance, chase it down, catch it and bring it back home.” -Gary Gray
� Purposefully include opportunities for failure (as appropriate for the individual’s current functional level). This is not
to suggest we should “train failure”! However, if the individual has very few errors, the task isn’t challenging
enough! Provide balance challenges, not just balance exercises.
� Avoid multiple sets and reps of the same task; rather include multiple sets of appropriate and different tasks during
the training session. The difference in the task can be simple, but variability is necessary to facilitate adaptation.
Conceptually, this means rather than rehearsing a sequence of activities in which only 1 variation of the task if
provided (e.g. catching different size objects thrown from the same distance and same projective pathway; meaning
only mass is varied), rehearse a number of variations of the task: catching the same object from various distances,
orientation to where the athletes is facing, different projectile arc pathways. This will require different tracking and
receiving strategies (variability) while the constraint of “catching the same massed object” remains constant.
Postural control strategies are fast adapting, meaning we can typically adapt to the stimulus (challenge) and
therefore, changing the stimulus within the session is valuable. You can still repeat challenges from session to
session, but do not need to over emphasize repeating the same challenge in the same session. Rather than 3-5 sets
of the same task, utilize 3-5 sets of different tasks!
� Balance training, particularly single leg stance, creates high demands on the hip stabilizers. Essentially single-leg
balance training is hip training so avoid compounding the training session with additional isolated hip strengthening
(unless you want to fatigue the hip stabilizers and then challenge balance in the presence of hip musculature
fatigue- save this for advanced training conditions).
� Embrace your creativity capacity. You can use the ordinary in an extraordinary manner and make sure extraordinary
is purposeful.
� Remember, balance training benefits from “implicit learning” (conscious attention is directed away from the task at
hand and verbal instruction is minimal or absent; the learner is doing things they can’t talk about and learn but
rather needs to do them). This allows the learner to problem-solves and find solutions they can’t describe
(verbalize). Allow them opportunity to problem-solve and create every increasing challenging and motivating
opportunities do so!
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“Categories” of Balance Training Challenges
Vestibulo-Ocular Therapy Progressions
As suggested earlier, avoid relying on balance challenges in which the athlete “maintains stability” with their eyes
closed. Since our athletes needsto maintain balance with various head positions and eye tracking requirements relative
to their stance/activity, it is ecological to contest balance stability with various challenges to gaze relative to head
position. Essentially this is “spotting”, meaning keeping gaze focused on the same location even if the body is orientated
differently. Consider the importance of a wide-receiver needing to run straight ahead while turning and looking over
their left shoulder. The ability to maintain postural control (in this case “dynamic” postural control) while tracking an
object is not only dependent upon “proprioceptive” feedback from somatosensory information, but also to effectively
integrate visual, vestibular, and proprioceptive inputs. While the concept of “vestibulo-ocular therapy” is often utilized
to aid patients recovering from concussion, you will benefit your athletes by including these types of challenges when
training balance control. Additionally, you might find your athlete actually struggles or has symptoms (e.g. dizziness)
when you begin to incorporate these types of challenges in balance training due to vertigo when you otherwise didn’t
know they had a problem. If you find the athlete experiences dizziness or other types of symptoms, refer them for a
consult with your medical professionals. However, it is also the convention of vestibulo-ocular rehabilitation to
challenge the patient with the tasks which are “difficult” based upon symptoms to help them adapt (desensitize) and
progress and therefore you might be able to coordinate the types of vestibule-ocular rehabilitation exercises in
training/rehabilitation in a collaborative approach with other medical professionals.
Simple Permutations:
Note: in all of the following exercises you can change/vary stance: bilateral, tandem, single-leg.
Rapidly change head position in any of the directions (see figure below) while maintaining gaze (focus) at the center of
the target (i.e. head moves by gaze (eyes) stay stable on the target). Hint- start more slowly with rate of head rotation
and gradually increase.
Move the position of the target while keeping the head position stable (fixed) but follow the target with gaze (eyes).
The target can be moved by the athlete/patient (e.g. holding their thumb/object in front) or by the clinician (e.g.
holding a tennis ball in front of the athlete/patient).
Move the position of the target while rotating the head away from the target and follow the target with gaze (eyes).
The target can be moved by the athlete/patient (e.g. holding their thumb/object in front) or by the clinician (e.g.
holding a tennis ball in front of the athlete/patient).
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Changing Head Position and Visual Focus Relative to Limb Movements (similar by not identical to vestibulo-
ocular therapy)
Again, rather than balancing with eyes closed, keep eyes open and change head position during the balance task. This
can be done very simply:
While balancing (in different stances: tandem, single-limb) add:
-Head rotation: up, down, diagonally etc. Vary the range, rate, or variability of the order of rotations.
-Rotate head in a variety of directions while also changing arm or trunk position: e.g. while alternating an overhead
reach/press look right and then left or up and then down with each pressing motion. Arm position can be changed via
pressing overhead upward or diagonally, reaching forward, reaching laterally (unilaterally or bilaterally), pushing
forward, reaching behind, etc. Pressing and reaching can be unilateral or bilateral (synchronous or asynchronous in the
same plane or orthogonal plane and directions).The number of permutations is exponential! The head position can be
synchronized with the direction of the reach (e.g. reaching left and turning the head left) or a-synchronized (reaching left
and turning the head right). You will be amazed at how challenging it is to remain in balance stability by changing head
position! Reaching and pressing can be challenged with dumbbells, medicine balls, tubing/bands, cables, etc.
Shape-Shifting
The goal is to direct the athlete to acquire various body shapes and still maintain balance. “Shift your body shape into
different positions and still maintain balance stability.” Most often used in single-leg stance, it doesn’t have to be limited
to this stance (e.g. for regression, what if you applied a tandem stance with most weight on the front limb (70%) and
lesser weight on the contralateral limb (30%)?) Additionally, the challenge created in upper extremity overload or
position can be created in a variety of ways. For example, with simply reaching, the athlete can use single or bilateral
reaching in various directions (planes) and body positions (overhead with both hands >> overhead with both hands but
add trunk rotation >> adding different lower extremity positions for the non-weight bearing limb (e.g. high knee, straight
leg raise, in different directions [anterior, lateral, diagonal]). The manipulation associated with holding a stick, medicine
ball, dumbbell (in both hands or only one hand, or one in each hand) or other, change the demands of the task.
Experiment with which challenges are appropriate for the level of the athlete’s ability to remain stable and progress
accordingly. View images below and on the next page for some and not all possible shapes to explore:
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Heckling
(reactive perturbations or “unbalancing”, the term “heckling” is from the Exuberant Animal (Frank Forencich))
Heckle but also give them time to respond to the perturbation and make a suitable correction (regain balance)!
Approaches: Single or double handed heckling (perturbation) imposed on the athlete in a variety of locations on their
body (arms, shoulders, trunk, hips, thighs, etc.), directions (anterior, posterior, diagonal, rotation etc.), varying whether
you are pushing, pulling, rotating the individual or on an object they are holding in both hands (or one hand).
Permutations:
Bilateral squat stance
Tandem Stance
Hi-Low Tandem Stance (rear foot moderately elevated e.g. 20cm box)
Single Leg Stance
Change the body shape (overhead, reaching forward-lateral-diagonal)
Change the center of mass location (athlete holding on a heavier object: sandbag, MB, KB etc.)
Taking away “vision” meaning, ability to watch the foot by the patient by hugging a swiss/physio ball
Change ankle position with a slant board (challenging inversion, eversion, plantarflexion, dorsiflexion positions)
Examples:
Meet and Greet “Heckling”
Another form of “reactive perturbation”, the athlete moves into a positon and posture of shared space. The clinician can
vary the type (e.g. where on the body), direction, and magnitude of the perturbation. Since it is shared space, ensure
trust and mutual respect.
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Permutations:
Multiple directions (of the mover and the clinician)- planes, height transitions etc.
Add an implement
Examples:
Hand-Tag (reactive, tracking)
Provide either singular or double targets for the athlete to reach and touch. You can start with stationary targets (e.g.
set up 5-6 tennis ball on a table in various locations and have the athlete reach and touch the targets. You can start
reaching anteriorly then laterally left or right (relative to orientation of the stance foot). Also, consider whether the
reach and touch allows for crossing midline (across the body). Easier: reaching with right hand on right side of the body.
Harder: reaching with right hand across midline to the left side of midline. Vary: how close and far the athlete is
reaching as well as how high and how low. Start with single hand reaching, add bilateral reaching. Change the rhythm of
the changes to redirection to be less predictable. Depending upon the needs of the athlete, reaching and touching can
also be via “foot-eye” coordination- reaching and touching the target with their foot.
Permutations:
Tandem stance
Hi-Low Tandem Stance (rear foot moderately elevated e.g. 20cm box)
Single Leg Stance
Retro reach (reach behind) in either stance
Change center of mass location (by adding weight: sandbag hold, or height posture is maintained)
Add resistance through the upper extremity (Kesier, cables, theratubing: bilateral or unilateral upper extremity loading)
Change ankle position with a slant board (challenging inversion, eversion, plantarflexion, dorsiflexion positions)
Examples:
Note Airex® Pad not required!
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Push-Pull/Tug of War
Reactive perturbation- with partner, trying to unbalance each other with shared “space” with both individuals holding
onto the object or in direct contact with each other.
Permutations:
Bilateral Stance
Tandem Stance
Hi-Low Tandem Stance (rear foot moderately elevated e.g. 20cm box)
Single Leg Stance
Bear Hug
Ropes, towels, sticks, bands
Upper extremity only (dorsal vs. palmer surface- hand touching vs. hand grasping; elbows, shoulders)
Lower extremity only (instep vs. outside of foot)
Upper + lower extremity (all combinations of hand and foot contacts)
Adding bands with various combinations of upper and lower extremity (push vs. pull)
Add various locomotion patterns (walking) forward, lateral, etc. while pushing and pulling
Examples:
Tracking & Receiving or Striking
Related to hand-eye (or foot-eye) coordination and commonly used in rehabilitation, here are few ways to make the
balance tasks associated with object manipulation more exceptional, and highly engaging. Philosophical: “football
players shouldn’t only catch footballs nor basketball players only basketballs.” Yes, you can make it sport specific based
upon the object you use, but allow athletes to experiment with different types of objects (tennis balls, medicine balls,
various sport balls etc.)
Permutations:
Various stances: bilateral frontal plane, tandem stance, single leg stance
Two-handed vs. single-handed catching or passing
Vary how far/close the toss comes from and relative direction/positon relative to where the athlete is facing
Varying the type of “throw/toss” performed by the athlete
Using more than “1” ball in the task and if more than 1, vary the type (e.g. a tennis ball and a basketball)
Striking projectile objects (e.g. balls) with: their hand, sticks, racquets, sledgehammers etc.
Deflecting (the flying object/projectile rather than catching it)
Catching not only “balls”, but color coded balls (e.g. tennis balls with different colored dots or figures or numbers on
them, asking the athlete to report what color or object or number was on the ball)
Catching playing cards and identifying the suit or color or actual value on the card.
Adding cognitive tasks while catching (e.g. speaking words beginning with a particular letter, retro numbers by 7 etc.)
Sport specific object manipulation/tasks
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Examples:
2-Ball Alley Passing 2-Ball Circular Passing
2-Ball “Alternate Chest & Bounce
Pass” Single hand catch and wrap pass
(behind the back)
Avoidance
Rather than trying to catch an object or reach for a target, the athlete tries to avoid contact with or gaining possession of
the object or preventing the clinician from touching or taking away the object they possess. This is a “reactive” type of
challenge- reacting to where the ball is headed to avoid contact, reacting to where the clinician is directing their hand to
take away the ball, redirecting the object but not through grasping and gaining possession of it (e.g. swatting the ball
away).
Permutations:
Bilateral squat stance
Tandem Stance
Hi-Low Stance
Single stance
Wand (sticks)/ pool noodle
Dodge Ball (tennis ball)
Keep-away
Examples:
Note: Reference List will be provided/updated after GAIN for those interested!