(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Chapter 8: Regaining Stability and Balance Jenna Doherty-Restrepo, MS, ATC, LAT Rehabilitation

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved

Chapter 8: Regaining Chapter 8: Regaining Stability and BalanceStability and Balance

Jenna Doherty-Restrepo, MS, ATC, LATJenna Doherty-Restrepo, MS, ATC, LAT

Rehabilitation Techniques in Athletic Rehabilitation Techniques in Athletic Training Training


Factors that impact balanceFactors that impact balance– Muscular weaknessMuscular weakness– Proprioceptive deficitsProprioceptive deficits– ROM deficitsROM deficits

Balance is critical in dictating movement Balance is critical in dictating movement strategies within the closed kinetic chainstrategies within the closed kinetic chain

Vital component in rehabilitationVital component in rehabilitation– Proprioception and KinesthesiaProprioception and Kinesthesia

BalanceBalance


Postural Control Postural Control SystemSystem

ComponentsComponents– Sensory detection of body motions (Feed-forward)Sensory detection of body motions (Feed-forward)– Execution of musculoskeletal responses (Feedback)Execution of musculoskeletal responses (Feedback)

Balance is a static and dynamic processBalance is a static and dynamic process Disrupted balance occurs due to two factorsDisrupted balance occurs due to two factors

– Position of CoG relative to base of support is not Position of CoG relative to base of support is not accurately sensedaccurately sensed

– Automatic movements required to maintain the Automatic movements required to maintain the CoG are not timely or effectiveCoG are not timely or effective



Body position in Body position in relation to gravity is relation to gravity is sensed bysensed by– VisualVisual– VestibularVestibular– Somatosensory inputsSomatosensory inputs

Balance movements Balance movements involve a number of involve a number of jointsjoints– AnkleAnkle– KneeKnee– HipHip– Coordinated Coordinated

movement along movement along kinetic chainkinetic chain


Control of BalanceControl of Balance

Postural control relies on feedbackPostural control relies on feedback CNS involvementCNS involvement

– Sensory organizationSensory organization Determines timing, direction and amplitude of Determines timing, direction and amplitude of

correction based on inputcorrection based on input System relies on one sense at a time for orientationSystem relies on one sense at a time for orientation

– Muscle coordinationMuscle coordination Collection of processes that determine temporal Collection of processes that determine temporal

sequencing and distribution of contractile activitysequencing and distribution of contractile activity Balance deficienciesBalance deficiencies

– Inappropriate interaction among 3 sensory inputsInappropriate interaction among 3 sensory inputs Patient that is dependent on one system may be Patient that is dependent on one system may be

presented with inter-sensory conflictpresented with inter-sensory conflict


Sensory InputSensory Input– SomatosensorySomatosensory

Provides information concerning relative position of body Provides information concerning relative position of body parts to support surface and each otherparts to support surface and each other

– VisionVision Measures orientation of eyes and head in relation to Measures orientation of eyes and head in relation to

surrounding objectssurrounding objects Role in maintenance of balanceRole in maintenance of balance

– VestibularVestibular Provides information dealing with gravitational, linear, and Provides information dealing with gravitational, linear, and

angular accelerations of the head with respect to inertial angular accelerations of the head with respect to inertial spacespace

Minor role when visual and somatosensory systems are Minor role when visual and somatosensory systems are operating correctlyoperating correctly


Proprioception/KinesthesiaProprioception/Kinesthesia

Specialized variation of the sensory modality of Specialized variation of the sensory modality of touch, encompassing joint sense and positiontouch, encompassing joint sense and position

ProcessProcess– Input is received from mechanoreceptorsInput is received from mechanoreceptors– Stretch reflex triggers activation of muscles about a Stretch reflex triggers activation of muscles about a

joint due to perturbationjoint due to perturbation Results in muscle response to compensate for imbalance Results in muscle response to compensate for imbalance

and postural swayand postural sway

– Muscle spindles sense stretch in agonist, relay Muscle spindles sense stretch in agonist, relay information afferently to spinal cordinformation afferently to spinal cord

– Information is sent back to fire muscle to maintain Information is sent back to fire muscle to maintain postural controlpostural control


Closed Kinetic ChainClosed Kinetic Chain

BalanceBalance– Process of maintaining body’s CoG within base Process of maintaining body’s CoG within base

of supportof support– CoG rests slightly above the pelvisCoG rests slightly above the pelvis

Kinetic chainKinetic chain– Each moving segment transmits forces to Each moving segment transmits forces to

every other segmentevery other segment– Maintaining equilibrium involves the closed Maintaining equilibrium involves the closed

kinetic chain kinetic chain Foot = distal segment (fixed beneath base of Foot = distal segment (fixed beneath base of

support)support)


Balance DisruptionBalance Disruption

Body must be able to determine what Body must be able to determine what strategy to utilize in order to control CoGstrategy to utilize in order to control CoG– Joint mechanoreceptors initiate automatic Joint mechanoreceptors initiate automatic

postural responsepostural response Selection of Movement StrategySelection of Movement Strategy

– Joints involved allow for a wide variety of Joints involved allow for a wide variety of postures that can be assumed in order to postures that can be assumed in order to maintain CoGmaintain CoG

Forces exerted by pairs of opposing muscles at a joint Forces exerted by pairs of opposing muscles at a joint to resist rotation (joint stiffness)to resist rotation (joint stiffness)

Resting position and joint stiffness are altered Resting position and joint stiffness are altered independently due to changes in muscle activationindependently due to changes in muscle activation


Ankle StrategyAnkle Strategy– Shifts CoG by maintaining feet and rotating Shifts CoG by maintaining feet and rotating

body as a rigid mass about the ankle jointsbody as a rigid mass about the ankle joints Gastrocnemius or tibialis anterior are responsible Gastrocnemius or tibialis anterior are responsible

for torque production about anklefor torque production about ankle Anterior/posterior sway is counteracted by Anterior/posterior sway is counteracted by

gastrocnemius and tibialis anterior, respectivelygastrocnemius and tibialis anterior, respectively

– Effective for slow CoG movements when Effective for slow CoG movements when base of support is firm and within LOSbase of support is firm and within LOS

– Also effective when CoG is offset from centerAlso effective when CoG is offset from center


Hip StrategyHip Strategy– Relied upon more heavily when somatosensory Relied upon more heavily when somatosensory

loss occurs and forward/backward loss occurs and forward/backward perturbations are imposed perturbations are imposed

– Aids in control of motion through initiation of Aids in control of motion through initiation of large and rapid motions at the hip large and rapid motions at the hip

– Effective when CoG is near LOS perimeter and Effective when CoG is near LOS perimeter and when LOS boundaries are contracted by when LOS boundaries are contracted by narrower base of supportnarrower base of support

Stepping StrategyStepping Strategy– Utilized when CoG is displaced beyond LOS Utilized when CoG is displaced beyond LOS – Step or stumble is utilized to prevent a fallStep or stumble is utilized to prevent a fall


Damaged tissue results in reduced joint Damaged tissue results in reduced joint ROM causing a decrease in the LOS ROM causing a decrease in the LOS – Greater risk for fallGreater risk for fall

Research indicates that sensory Research indicates that sensory proprioceptive function is affected when proprioceptive function is affected when athletes are injuredathletes are injured

Balance and InjuryBalance and Injury


Assessment of BalanceAssessment of Balance

Subjective AssessmentSubjective Assessment– Traditionally assessed via the Romberg TestTraditionally assessed via the Romberg Test

Feet together, arms at side, eyes closedFeet together, arms at side, eyes closed Loss of proprioception is indicated by a fall to one sideLoss of proprioception is indicated by a fall to one side

Balance Error Scoring System (BESS)Balance Error Scoring System (BESS)– Utilizes three stancesUtilizes three stances

Double, single, tandem on both firm and foam surfacesDouble, single, tandem on both firm and foam surfaces

– Athletes are instructed to remain motionless with Athletes are instructed to remain motionless with hands on hips for 20 secondshands on hips for 20 seconds

– Unnecessary movements and correction of body Unnecessary movements and correction of body position are counted as ‘errors’ (max score = 10)position are counted as ‘errors’ (max score = 10)

– Results are best utilized if compared to baseline Results are best utilized if compared to baseline datadata



Semi-dynamic and Dynamic Balance tests Semi-dynamic and Dynamic Balance tests – Functional reach testsFunctional reach tests– Timed agility testsTimed agility tests– Carioca Carioca – Hop testHop test– Timed T-band kicksTimed T-band kicks– Timed balance beam walks (eyes open and Timed balance beam walks (eyes open and

closed)closed)

Assessment of BalanceAssessment of Balance


Injury and BalanceInjury and Balance

Stretched/damaged ligaments fail to Stretched/damaged ligaments fail to provide adequate neural feedback, provide adequate neural feedback, contributing to decreased proprioception contributing to decreased proprioception and balanceand balance– May result in excessive joint loadingMay result in excessive joint loading– Could interfere with transmission of afferent Could interfere with transmission of afferent

impulsesimpulses– Alters afferent neural code conveyed to CNSAlters afferent neural code conveyed to CNS– Decreased reflex excitationDecreased reflex excitation

Caused via a decrease in proprioceptive CNS inputCaused via a decrease in proprioceptive CNS input


– Joint receptors damaged during injury to lateral Joint receptors damaged during injury to lateral ligamentsligaments

Results in Results in Articular Deafferentation Articular Deafferentation – Diminished signaling via afferent pathwaysDiminished signaling via afferent pathways– Reason behind balance training in rehabilitationReason behind balance training in rehabilitation

– Orthotic and bracing interventionOrthotic and bracing intervention Enhance joint mechanoreceptors to detect Enhance joint mechanoreceptors to detect

perturbations and provide structural support for perturbations and provide structural support for detecting and controlling swaydetecting and controlling sway

– Chronic ankle instabilityChronic ankle instability– Recovery of proprioceptive capabilitiesRecovery of proprioceptive capabilities

Instability vs. DeafferentationInstability vs. Deafferentation

Ankle InjuriesAnkle Injuries


– Ligamentous injury alters joint position detectionLigamentous injury alters joint position detection ACL deficient subjects with functional instability exhibit this ACL deficient subjects with functional instability exhibit this

deficit (persist to some degree after reconstruction)deficit (persist to some degree after reconstruction) May also impact ability to balance on ACL deficient legMay also impact ability to balance on ACL deficient leg

– Mixed results have been presented with static testingMixed results have been presented with static testing Isometric strength could compensate for somatosensory deficitsIsometric strength could compensate for somatosensory deficits Definition of Definition of functionally unstablefunctionally unstable may vary may vary

– Role of joint mechanoreceptors with respect to end range and the Role of joint mechanoreceptors with respect to end range and the far reaches of the LOSfar reaches of the LOS

– More dynamic testing may incorporate additional More dynamic testing may incorporate additional mechanoreceptor input mechanoreceptor input

Results may be more definitiveResults may be more definitive

Knee InjuriesKnee Injuries


– Balance has been utilized at a criterion variableBalance has been utilized at a criterion variable– Additional testing is necessary in addition to Additional testing is necessary in addition to

balance and sensory modalitiesbalance and sensory modalities– Postural stability deficitsPostural stability deficits

Deficits may last up to three days post-injuryDeficits may last up to three days post-injury Result of sensory interaction problem - visual system Result of sensory interaction problem - visual system

not used effectivelynot used effectively

– Objective balance scores can be utilized to Objective balance scores can be utilized to determine recovery curves for making return to determine recovery curves for making return to play decisionsplay decisions

Head InjuriesHead Injuries


Balance TrainingBalance Training

Vital for successful return to competition Vital for successful return to competition from lower leg injuryfrom lower leg injury– Possibility of compensatory weight shifts and Possibility of compensatory weight shifts and

gait changes result in balance deficitsgait changes result in balance deficits Functional rehabilitation should occur in Functional rehabilitation should occur in

the closed kinetic chain – nature of sportthe closed kinetic chain – nature of sport Adequate and safe function in the open Adequate and safe function in the open

chain is critical = first step in chain is critical = first step in rehabilitationrehabilitation


Rules of Balance TrainingRules of Balance Training– Exercise must be safe and challengingExercise must be safe and challenging– Stress multiple planes of motionStress multiple planes of motion– Incorporate a multisensory approachIncorporate a multisensory approach– Begin with static, bilateral, and stable surfaces Begin with static, bilateral, and stable surfaces

and progress to dynamic, unilateral, and and progress to dynamic, unilateral, and unstable surfacesunstable surfaces

– Progress towards sports specific exercisesProgress towards sports specific exercises Utilize open areasUtilize open areas Assistive devices should be within arms Assistive devices should be within arms

reach reach Sets and repetitionsSets and repetitions

– 2-3 sets, 15 sec. 2-3 sets, 15 sec. 30 sec. repetitions 30 sec. repetitions – 10 sets, 15 sec. 10 sets, 15 sec. 30 sec. repitions 30 sec. repitions


Classification of Balance Classification of Balance ExercisesExercises Static Static

– CoG maintained over fixed base of support on stable CoG maintained over fixed base of support on stable surfacesurface

Semi-dynamicSemi-dynamic– CoG maintained over fixed base of support while on a CoG maintained over fixed base of support while on a

moving surfacemoving surface– CoG transferred over fixed base of support in selected CoG transferred over fixed base of support in selected

ranges and/or directions within the LOS while on a ranges and/or directions within the LOS while on a stable surfacestable surface

DynamicDynamic– CoG maintained within LOS over a moving base of CoG maintained within LOS over a moving base of

support while on a stable surface (involve stepping support while on a stable surface (involve stepping strategy)strategy)

FunctionalFunctional– Same as dynamic with inclusion of sports specific taskSame as dynamic with inclusion of sports specific task


Phase IPhase I– Non-ballistic types of drillsNon-ballistic types of drills– Static balance trainingStatic balance training– Bilateral to unilateral Bilateral to unilateral – Utilize multiple surfaces to Utilize multiple surfaces to

safely challenge athletesafely challenge athlete– With and without With and without

arms/counterbalancearms/counterbalance– Eyes open and closedEyes open and closed– Alterations in various Alterations in various

sensory informationsensory information– ATC can add perturbationsATC can add perturbations– Incorporation of multiaxial Incorporation of multiaxial

devices devices


Bilateral Stance Bilateral Stance ExercisesExercises


Phase IIPhase II– Transition from static to dynamicTransition from static to dynamic– Running, jumping, and cutting Running, jumping, and cutting

Activities that require the athlete to repetitively Activities that require the athlete to repetitively lose and gain balance in order to perform activitylose and gain balance in order to perform activity

Incorporate only when sufficient healing has Incorporate only when sufficient healing has occurred occurred

– Semi-dynamic exercises should be Semi-dynamic exercises should be introduced in the transitionintroduced in the transition

Involve displacement or perturbation of CoGInvolve displacement or perturbation of CoG Bilateral, unilateral stances or weight transfers Bilateral, unilateral stances or weight transfers Sit-stand exercises, focus on postureSit-stand exercises, focus on posture


– Unilateral Semi-Unilateral Semi-dynamic exercisesdynamic exercises

Emphasize Emphasize controlled hip controlled hip flexion, smooth flexion, smooth controlled motioncontrolled motion

Single leg squats, Single leg squats, step ups (sagittal or step ups (sagittal or transverse plane)transverse plane)

Step-Up-And-Over Step-Up-And-Over activitiesactivities

Introduction to Introduction to Theraband kicksTheraband kicks

Balance BeamBalance Beam


Phase IIIPhase III– Dynamic and functional types of exerciseDynamic and functional types of exercise– Start with bilateral jumping drills (straight Start with bilateral jumping drills (straight

plane)plane) Advance to diagonal jumping patternsAdvance to diagonal jumping patterns Increase length and sequences of patternsIncrease length and sequences of patterns

– Progress to Progress to Unilateral drills, vertical drillsUnilateral drills, vertical drills Addition of implementsAddition of implements

– Tubing, foam roll, etc…Tubing, foam roll, etc…

– Final step = functional activity Final step = functional activity Subconscious dynamic control/balanceSubconscious dynamic control/balance


Phase III ExercisesPhase III Exercises

Documents

(c) 2004 The McGraw-Hill Companies, Inc. All rights reserved Chapter 8: Regaining Stability and Balance Jenna Doherty-Restrepo, MS, ATC, LAT Rehabilitation