Integrated Neuromuscular Stabilization Training (NST) is simply defined as balance. Whether you are on a basketball court, stability ball or walking down stairs, maintaining your balance is the key to all functional movements. In functional activities, balance does not work in isolation. Therefore, it should not be thought of as an isolated component of function. Balance is a component of all movements, regardless if strength, speed, flexibility or endurance dominates the movement. We often tend to think of balance as a static process; however, functional balance is a dynamic process involving multiple neurological pathways. Maintenance of postural equilibrium is an integrated dynamic process requiring optimal muscular balance, joint dynamics and neuromuscular efficiency. The integrated performance paradigm tells us that adequate force reduction and stabilization is required for optimum force production. The ability to reduce force at the right joint, at the right time, in the right plane of motion and the right direction requires optimum levels of functional dynamic balance and neuromuscular efficiency. Integrated training should constantly stress an individual’s limits of stability (balance threshold). An individual's limits of stability are the distance outside of their base of support that they can go without losing control of their center of gravity. In order to improve dynamic balance and neuromuscular efficiency, an individual’s limits of stability must be constantly stressed in a multi-planar, proprioceptively enriched environment utilizing functional movement patterns. During functional movements, the kinetic chain undergoes deceleration at one joint, stabilization at another joint and acceleration at yet another joint. For example when we walk:
- The hip flexors initially accelerate the thigh to swing forward.
- The hamstrings and gluteus maximus decelerate extension of the knee and flexion of the hip, respectively.
- The gluteus medius and adductors stabilize the leg to guide the foot to a proper placement on the ground.
The kinetic chain works as an integrated functional unit to allow structural and functional efficiency. Structural efficiency is the alignment of the musculoskeletal system (myofascial and articular systems) that allows our center of gravity to be maintained over our base of support during movement. This signifies the importance of proper postural alignment before, during and after each exercise. Functional efficiency is the ability of the neuromuscular system to monitor and manipulate movement during functional tasks using the least amount of energy, creating the least amount of stress on the kinetic chain. This can only be accomplished by having proper structural efficiency. If the kinetic chain is not properly aligned, the muscles will be placed in altered length-tension relationships and cause altered force-couple relationships. In turn, the receptors located in the muscles, tendons, joints and ligaments will provide improper sensory feedback to the nervous system and result in the production of faulty movement patterns. The nervous system is organized in such a way as to optimize the selection of muscle synergies and not the selection of the individual muscles. The nervous system thinks in terms of movement patterns and not isolated muscle function. Isolation and training individual muscles over prolonged periods of time creates artificial sensory feedback, faulty sensorimotor integration and abnormal forces throughout the kinetic chain. This ultimately acts to confuse the nervous system as muscles are being asked to perform a function that the nervous system does not understand. In essence, the muscles are re-programmed to perform:
- …A different task – The hamstring performing knee flexion on a hamstring curl machine rather than decelerating knee extension, hip flexion and internal rotation of the tibia and femur.
- …At a different speed – Consistently at slow controlled speeds rather than progressing to functionally applicable speeds (power training).
- …With a different muscle action – Emphasizing concentric rather than eccentric muscle actions for the hamstrings or concentric rather than isometric (dynamic stabilization) for the hip abductors (outer thigh machines).
- …In a different plane of motion – Working in the frontal plane (inner thigh machines) rather than sagittal and/or transverse planes for the adductors.
However, training functional movements in a proprioceptively enriched environment (one leg, stability ball, balance boards, foam rolls, etc.) with correct execution (technique) at varying applicable speeds, facilitates the nervous system to achieve maximal sensorimotor integration, resulting in the selection of the proper movement pattern. The personal trainer must follow a progressive, systematic training program in order to develop consistent, long-term changes in each client. Traditional program design often results in an incomplete training program not challenging the proprioceptive mechanisms of the kinetic chain. Neuromuscular stabilization training fills the gap left by traditional training. It focuses on functional movement patterns in a multi-sensory environment. The design and implementation of balance into a program is critical for developing, improving and restoring the synergy and synchrony of muscle firing patterns required for dynamic joint stabilization and optimal neural muscular control.
Scientific Rationale for Integrated Neuromuscular Stabilization Training
Proprioceptive training has been shown to be particularly beneficial to improve dynamic joint stabilization. Dynamic joint stabilization refers to the ability of the kinetic chain to stabilize a joint during movement. An example is the rotator cuff stabilizing the head of the humerus on the glenoid fossa while throwing a ball or lifting weights. Balance and neuromuscular efficiency are improved through repetitive exposure to a variety of multi-sensory conditions. The main goal of balance training is to continually increase your client’s awareness of their balance threshold or limits of stability by creating controlled instability. Designing a functionally dynamic balance training progression requires creating a proprioceptively enriched environment and selecting the appropriate exercises for your client’s ability level.
Integrated Neuromuscular Stabilization Program
Implementing an Integrated Neuromuscular Stabilization Training Program requires the fitness professional to simply follow the progression of the Optimum Performance Training model. For example, if a client is in the Stabilization Level of training (Corrective Exercise, Phase 1 or Integrated Stabilization Training, Phase 2) then select Stabilization Balance exercises. However, a client in Phase 2 can perform some of the exercises in the Strength section. If a person is in the Strength Level of training (Stabilization Equivalent Training, Phase 3, Muscular Development Training, Phase 4 or Maximum Strength Training, Phase 5) then select Strength Balance exercises. If they are in the Power Level of training (Elastic equivalent Training, Phase 6 or Maximal Power Training, Phase 7) then select from Strength and Power exercises (Table 1).
|Table 1 - Integrated Neuromuscular Stabilization Program Design
||1-2 Stabilization and/or 1-2 Strength:
- Single-Leg Balance with Reach
- Single-Leg Windmill
- Single-Leg Squat
||3, 4, 5
- Single-Leg Squat Touchdown
- Single-Leg Romanian Deadlift
- Lunge to Balance
||1-2 Strength and/or 1-2 Power
- Lunge to Balance
- Multiplanar Hop with Stabilization
- Box Jump Up with Stabilization
||Included in Workout
- Clark MA. A scientific approach to understanding common kinetic chain dysfunction. Thousand Oaks, CA: National Academy of Sports Medicine; 2001.
- Brooks VB. The neural basis of motor control. New York: Oxford University Press; 1986.
- Kelso JAS. Dynamic patterns. The self-organization of brain and behavior. Cambridge, MA: The MIT Press; 1995.
- Newton RA. Neural systems underlying motor control. In Montgomery PC, Connoly BH editors. Motor control and physical therapy: Theoretical framework and practical applications. Hixson, TN: Chatanooga Group, Inc; 1991.
- Rose DJ. A multi level approach to the study of motor control and learning. Needham Heights, MA: Allyn & Bacon; 1997.
- Bullock-Saxton JE. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther 1994;74(1):17-23.
- Tippet S, Voight M. Functional progressions for sports rehabilitation. Champaign, IL: Human Kinetics; 1995.
- Voight M, Cook G. Clinical application of closed kinetic chain exercise. J Sport Rehab 1996;5(1):25-44.
- Lephart SM. Re-establishing proprioception, kinesthesia, joint position sense, and neuromuscular control in rehabilitation. In: Rehabilitation techniques in sports. Prentice WE (Second Edition). St. Louis, MO: Mosby Publishing, 1993.
- Voight M. Proprioceptive concerns in rehabilitation. In. Proceedings of the XXVth FIMS World Congress of Sports Medicine, Athens, Greece; 1994.
- Balogun JA, Adesinasi CO, Marzouk DK. The effects of wobble board exercise training program on static balance performance and strength of the lower extremity muscles. Physiother Can 1992;44:23-30.
- Barrack RL, Skinner HB. Proprioception in the ACL deficient knee. Am J Sports Med 1989;17:1-6.
- Barret D. Proprioception and function after ACL reconstruction. J Bone Joint Surg 1991;73:833-7.
- Blackburn TA. Rehabilitation of ACL injuries. Orthop Clin North Am 1985;16(2):241-69.
- Freeman MAR, Wyke B. Articular reflexes at the ankle joint: an EMG study of normal and abnormal influences of ankle joint mechanoreceptors upon reflex activity in the leg muscles. Br Journal of Surg 1967;54:990-1001.
- Freeman MAR. Coordination exercises in the treatment of functional instability of the foot. Phys Ther 1964;44:393-5.
- Hirokawa S, Solomonow M. Muscular co-contraction and control of knee stability. J Electromyogr Kinesiol 1991;1(3):199-208.
- Ihara H, Nakayama A. Dynamic joint control training for knee ligament injuries. Am J Sports Med 1986;14:309-14.