Improving Balance

How many of you currently train clients who struggle with their balance? Whether you are training the geriatric, athletic or general fitness client, balance is essential to improving performance, regardless of a client’s goals. The loss of balance is a key component to many falls and debilitating injuries in the elderly. It can also mean the difference between making a play or not making a play in sports. The previous article on improving hip rotation (see "related articles" at right) focused on improving activation of the low level fibers of the gluteus maximus and deep rotators of the hip. This article will discuss several components that relate to postural control and then provide strategies for improving strength and stability as it relates to balance.

Several systems in the body provide input critical to the body’s ability to maintain control in a variety of situations. Three of these components include the vestibular apparatus in addition to the visual and proprioceptive systems. 

• Vestibular Apparatus - The vestibular apparatus is an organ located in the inner ear that detects the awareness of balance. Two associated reflexes are responsible for detecting the body in space. These are described below: 
  • The system responds to changes in the center of gravity (COG) by anticipating and then initiating a reflexive contraction appropriate to maintain the individual’s balance.
  • If the head is rotated suddenly, the eyes will rotate in a direction equal and opposite of the head to help maintain the individual’s balance.
• Visual System - The eyes play an important role and can maintain balance even in the absence of input from the vestibular apparatus. Loss of vision may be one component of loss of balance in the elderly. The influence of the eyes on equilibrium can be easily demonstrated by standing on one leg. After maintaining the position, close your eyes. What did you notice? Most likely, you noticed it was more difficult to maintain balance with your eyes closed.
• Proprioceptors - These are specialized receptors that help to detect spatial awareness. There are several types located throughout the body including within muscles, skin, joints, joint capsules and ligaments. While each separate type plays an important role in the maintenance of balance, the neck and feet are two areas that tend to be the proprioceptively dense regions and are of particular importance.
  • Neck Proprioceptors - These are joint receptors located in the neck that detect motion of the head in relation to the body. The signal from the neck proprioceptors oppose the signals of the vestibular response to allow for maintenance of a sense of equilibrium.
  • Foot Proprioceptors - The feet are rich in proprioceptors that supply the central nervous system with information vital in activating muscular responses of balance. For example, activation of the interossei muscles (muscles located between the metatarsals) of the foot are essential for creating a rigid foot lever necessary for proper mid-stance support and the toe-off phases of gait. However, contraction of the interossei also sends a reflexive signal to the extensor chain to contract. Lack of foot stability may help explain postural inhibitions and difficulties activating the extensor chain (gastrocnemius, hamstrings, gluteals, erector spinae).

With a variety of influences affecting balance, determining where to begin helping your client can be quite challenging. Many individuals experiencing challenges with their balance often demonstrate muscle inhibition and resultant imbalances. For the fitness professional, improving balance becomes a question of doing what you do best: improve a client’s strength, especially stabilization strength.

Stabilization strength is based upon activation of the low level type I fibers. Recall from the previous article on hip rotation that the type I fibers tend to be inhibited by trauma, over-use, dis-use and pain leading to an increased activation of type II fibers. Over time, this imbalance becomes exaggerated as the individual develops more compensatory patterns. Although this article will often make reference to the importance of type I fibers in joint stabilization, it is important to note that all muscles are vital in maintaining joint control. Weakness in any muscle will lead to substitution and/or over-use syndromes.

So what is the most effective way to improve balance? Improving balance begins with developing stability in a variety of static postures such as kneeling, quadruped, seated and standing. Maintaining these positions requires stabilization strength and cooperation between the stabilization (type I fibers) and movement (type II fibers) muscle systems. In addition to achieving balance of the two muscle systems, the individual should be able to maintain proper respiratory function (diaphragmatic breathing) throughout any of these positions. Once an individual can maintain these postures with little effort (no bracing or gripping type strategies) and without any substitutions, he or she is then progressed to stepping or lunging patterns. Note: The following progressions are utilized regardless of the client’s beginning conditioning level or goals. The only variable that changes between clients is how rapidly they are moved through the progressions.

Step Out to Lunge Progression

The client begins in a neutral stance with activation of the core (1a). The client then steps out with one leg and decelerates into position (1b). There should be no deviations of the trunk or lower extremity as the person plants his foot, and there should be relatively equal contribution in movement (flexion) from the hip, knee and ankle. The client maintains this position for one to two seconds and then pushes back, returning to the starting position. Again, there should be no deviations in the trunk position, and there should be equal contribution in movement (extension) from the hip, knee and ankle. After proving efficiency in the basic step out, the client is progressed to a lunge (2a-b), which is basically a longer and deeper version of the step out. Trunk and lower extremity alignment should be maintained throughout the movement (see parallel lines).

As the individual masters the basic step out and lunge patterns, multi-directional lunges can be added to further develop trunk and lower extremity stability. Dumbbells can be added for increased challenge (3a-c).

Keys to Performance

During each of the step out or lunge progressions, the hips should remain inside the lower extremity during all movement patterns (4a and 5a). The weight should be maintained on the inside of the plant foot. More specifically, the weight should be on the first metatarsal-phalangeal joint (big toe) and medial aspect of the calcaneus (heel). Common substitution patterns include allowing the weight to land on the outside of the foot (ankle inversion), for the hip to “kick” out beyond the lower extremity or the knee to rotate in towards midline (4b and 5b). This is typically caused by weakness in the hip abductors and/or muscles controlling pronation of the lower extremity. However, any noted movement disorders should be confirmed by range of motion assessment and muscle testing. 

Advanced Progressions

Single leg patterns are an advanced progression once the client demonstrates mastery of the lunge patterns. Once again, the individual must be able to maintain stability with no trunk or lower extremity compensations before being progressed (6a). Movement of the head, closing the eyes or any number of pulling or pushing patterns performed while maintaining a stable stance position (dumbbell curls, overhead presses, cable pulls, anterior reaches, medicine ball partner tosses) are just a few of the progressions that can be utilized by advanced clients.

In Figure 6b, there is a compensated Trendelenburg’s position. Note the trunk lean towards the side of the stance leg. Figure 6c demonstrates an uncompensated Trendelenburg’s stance. Note the inferior shift of the pelvis on the side away from the stance leg. Clients should not be allowed to perform any exercises in a single leg stance if they demonstrate either of these patterns or a general sense of instability.

Balance Apparatus

In our profession, there is preponderance towards using balance boards, discs and a variety of labile equipment to improve balance. While there may be some limited benefit to using these tools with certain clientele, there lies an inherent risk of developing compensatory and/or over-use syndromes. If clients cannot adequately stabilize themselves in a variety of positions (seated, standing and moving), then there is little benefit to be gained by putting them on an unstable surface. There is no way to ensure that using unstable surfaces will improve a client’s balance. However, placing an individual who cannot stabilize his body weight on a flat surface onto an unstable surface is likely to ensure compensatory and altered movement and stabilization patterns.

Conclusion

Balance is the key component to living a full and productive life. It is also a vital part of developing and maintaining structural integrity of the neuro-musculo-skeletal system. Input from a variety of sources including the central nervous and proprioceptive systems is required to perform at an optimal level. By developing the appropriate stabilization strength necessary for optimal balance, the fitness professional plays a key role in helping clients achieve their goals, whether they are injury prevention, improved performance or simply performing activities of daily living. 

References

1. Guyton AC. Textbook of Medical Physiology- 8th Edition, Saunders Company. Philadelphia PA, 1991.
2. Michaud TC. Foot Orthoses, Thomas Michaud, Newton MA, 1997.
3. Osar EM. Complete Program Design, Fitness Education Seminars, Chicago, 2006. 
4. Osar EM. Complete Hip and Lower Extremity Conditioning, Fitness Education Seminars, Chicago, 2005.

Previously Published on PtontheNet