BALANCE TRAINING AND ITS PERMUTATIONS | HOUSTON, TX

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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!