In Part 2 of this series, we looked at different type of reflexes that can be experienced during work, sport or any daily living activities, and we looked at how these reflexes relate to your balance training client. Here in Part 3, we will take a look at various control systems of the body and how they intimately relate to balance, yet are seldom looked at by fitness professionals in any of their clients.
Developing Balance and Troubleshooting the Balance Challenged Client
I routinely see clients from all over the world who suffer from a variety of ailments including unresolved orthopedic injury, neurological injury and overall ill health. Though many of these clients are working people, I also see quite a few elite athletes whose livelihood depends on their ability to develop and maintain exquisite balance skills. Some of the athletes who have consulted the C.H.E.K Institute for training and assistance in their sport are motocross racers, skate boarders, figure skaters, hockey players, track and field athletes, surfers, skiers, snow boarders, martial artists, gymnasts, cyclists, mountain bike racers, lugers and equestrian athletes.
In order for a client to acquire new balance skills, it is important to ensure optimal function of all the control centers in the body that affect balance. Some of the control centers affecting balance are not as obvious as others, which is why I’ve developed the Survival Totem Pole (below). Based on my clinical experience, the Survival Totem Pole is a representation of the order of developmental reflexes expressing their dominance over the motor system with regard to a hierarchical influence, based on survival of the organism. In other words, the further up the Survival Totem Pole you go, the more important that particular reflex is to survival.
While a full explanation of the Survival Totem Poll and how to analyze the functional capacity of each control center is far beyond the scope of this article, I would like to highlight how specific control centers influence our balance.
RESPIRATION and BALANCE
Respiration and all its related reflexes, reign supreme on the survival totem pole. If you stop breathing, you have about three minutes before your brain begins to die! Therefore, it is pretty safe to say that anything disrupting respiration will quickly cause postural alterations to facilitate improved ventilation, since breathing takes precedence over posture and posture may be altered to facilitate breathing.
One of the most common responses to obstructed respiration is forward head posture (below). In fact, the nervous system is so sensitive to respiratory obstruction that most people will begin developing forward head posture within as little as five minutes of acquiring a nasal airway obstruction. Such obstructed respiration could be caused by a number of factors including food allergy, growth and developmental disorders or structural aberrations such as a deviated septum from a broken nose.
As you can see below , as the head migrates forward, there will generally be a concomitant increase in thoracic kyphosis (B), which disrupts the balance of the spinal column. Because the body always wants the head over the pelvis for reasons of balance, where there is forward migration of the head, it is common to see forward migration of the pelvis (C) with hyperextension of the knees (D). This is a common postural and muscle imbalance syndrome seen in today’s gyms and physical therapy clinics worldwide.
Fitness professionals using any form of balance training with their clients must realize that a respiratory dysfunction (the most common of which is mouth breathing) may be the underlying factor of poor posture. Poor posture signifies altered static relationships of body segments, and as stated in Part 1, commonly lead to inability to maintain an OIAR during dynamic movements. While there are many people who can demonstrate some pretty impressive balance skills, they may also be predisposed to some pretty impressive bouts of chronic pain as a byproduct of not following proper exercise progression. That is, all clients should progress through their exercise program by first correcting length/tension imbalances and stability deficits, then focus on developing strength and finally focusing on power.
If any of your clients need to develop or improve balance skills for optimal performance or injury prevention in any environment, it is vital that you ensure they have the ability to breath normally through their nasal airways. While the topic of respiratory assessment is far too comprehensive for this article, I would like to point out some symptoms that may indicate a need for your client to be referred to a skilled doctor or physical therapist for respiratory assessment:
- Forward head carriage
- Inability to breath efficiently through the nasal airways
- A greater than 10 percent difference between nasal airway flow (check this at least five times a day because there is a natural difference between nasal airways that alternates throughout the day).
- Drool on the pillow when someone wakes up in the morning
- Bad breath
- Tempromandibular joint disorders
- Neck and/or low back pain
- Increased incidence of pronation related injuries of the lower extremities
- A tendency toward constipation
- Dehydration is more likely in someone with a respiratory dysfunction, particularly in those that don’t drink at least half their body weight (in pounds) in ounces of water daily.
Though each of these can have an etiology seemingly unrelated to respiration, I encourage you to keep the possibility of a respiratory dysfunction in the back of your mind. As I’ve shown using the Survival Totem Pole, respiration reigns supreme among control systems and can affect every other control system below it.
MASTICATION and BALANCE
Next in line on the Survival Totem Pole is the highly position-sensitive masticatory system. Between chewing our food, swallowing and other oro-functional activities associated with daily living, we may open and close our mouth as many as 4,000 times a day. If for any reason the teeth don’t fit perfectly in what is called centric occlusion, we default to a compensatory masticatory mechanism called the hit-and-slide mechanism. In order to guide the teeth into occlusion, the hit-and-slide mechanism results in a guiding of the teeth along the facets, which at a rate of ~4,000 times a day, could quickly wear your teeth out. Simply put, if you didn’t have teeth 10,000 years ago, you died! There are numerous reasons for a hit-and-slide mechanism including: growth and development disorders, malnutrition, trauma, forward head posture, dental disorders such as a cracked or rotten tooth or structural dysfunction such as subluxation of the upper cervical spine.
Because mastication is vital to survival, the body has developed an elaborate array of reflexes generated from the periodontal ligament and temporomandibular joint mechanoreceptors. These reflexes are used to influence subtle and gross motor responses of mastication to help adequately position the craniomandibular complex, such that hit-and-slide occlusal corrections are minimized in attempt to save the teeth. A simple example to demonstrate just how powerful these reflexes can be is to think of the last time you had a small sesame seed or piece of beef stuck in your teeth – you probably wore your tongue out trying to free it from your teeth!
Some of you may be wondering how malocclusion can affect balance. Developmentally speaking, because our teeth and ability to chew food was so vital to survival, the CNS learned to orchestrate any necessary repositioning of our body parts below our head in attempt to restore occlusion. In other words, if our teeth are out of alignment, our body will make whatever compensations are necessary from under the head to get our teeth lined up as straight as possible so we can continue to eat and survive.
Compensations for malocclusion commonly result in significant postural distortions. To illustrate my point, view Mr. B (below), a previous client who had a severe form of malocclusion called a cross bite. As you can see from the pictures, Mr. B’s body had made some significant postural alterations in attempt to normalize his bite, which resulted in a complex muscle imbalance syndrome called a layered syndrome.
Using the information I presented in the first two sections of this article series, it should be evident looking at Mr. B’s body alignment that teaching Mr. B balance exercises on a ProFitter, wobble board or even teaching him a complicated Swiss ball exercise could have proven futile until some serious corrective work was done!
Before we move on, last thing to consider when there is a masticatory disorder is the tremendous increase in the workload on the regional and global masticatory musculature, cervical and shoulder girdle musculature and all respiratory musculature, secondary to compensation. The result of this increased workload will commonly be trigger points in these muscles as they fatigue, which is problematic because some muscles, such as the sternocleidomastoid, can produce proprioceptive disorders, symptoms of vertigo and loss of balance. It is common for people to have difficulty balancing as a direct cause of postural or occlusal stressors who are prescribed balance exercises in an attempt to improve their balance. As I’ve shown, this presents a scenario in which the risk is far greater than the reward! The problem is often that exercise professionals don’t make the connection between chronic pain or seemingly unrelated musculoskeletal injury because the response to improper exercise selection is most often insidious.
VISION and BALANCE
The eyes are the chief exteroceptive organs. Your eyes function with two main systems to aid movement control, both of which are important to balance. Developmentally, if we lost our vision, there was a good chance we would not have survived very long. However, respiration and mastication are even more important to our survival, hence the eyes are ranked third on the Survival Totem Pole.
When it comes to balance, consider the following with regard to the function and impact of the eyes on balance:
The Focal System
The focal system is specialized for object identification. It is mainly concerned with objects in the central field of vision and serves to answer the question “What is it?” This recognition occurs so you will know how to respond to the challenge. For example, the way your body reacts to balancing on a bicycle and a balance beam are different, and therefore require different responses; the bicycle will create a much greater need for an integrated tilting response, while moving across a balance beam will primarily require a righting response (See Part 2 for more information about these reflexes). It is your focal visionthat provides the visual image that triggers the cognitive response to the balance challenge.
Focal vision is significantly influenced by illumination, which can also influence your ability to balance. For example, if you are walking outside on a dark winter night, you may not be able to see a patch of black ice. If you were to step on if without any focal visual input, your response will be completely reflexive – you will either have the appropriate reflex response or you won’t. If you step on black ice and have the correct software in place from previous training, but for any reason your body has become imbalanced (like Mr. B), even the correct response will not likely express itself and there will not be balanced recruitment around the involved joints. This is why some people can step off a curb they didn’t see and catch their balance without thinking about it, yet the person next to them steps off the same curb and gets hurt!
The Ambient System
The ambient system is specialized for movement control and involves the entire visual field, central and peripheral. The ambient system functions to detect motion and position of elements in the environment, and provides information about your own movements in relation to them. Thus, the ambient system provides answers to the questions “Where is it?” and “Where am I relative to it?” This is vital information with regard to maintaining your balance!
Optical flow is the term given to describe the light reflections passing through the eye from our environment. Optical flow provides numerous kinds of information about an individual’s movement in our environment, including the following:
- Stability and balance
- Velocity of movement through the environment
- Direction of movement relative to objects in the environment
- Movement of environmental objects relative to the performer
- Time before contact between the performer and an object
Using the example given to describe “focal vision,” ambient vision and optical flow will help you determine not only how fast your body is moving relative to the ground beneath you, it will assist you in knowing the angle you have relative to the surface of the earth and any other fixed objects they eye can use as a point of reference; ambient vision and optical flow will not tell you what you have slipped on.
When working with a client, if there is a chronic tendency toward forward head carriage, there may be problems with their focal vision; poor eyesight can be a cause of forward head posture. I have had many orthopedic clients who responded poorly to a postural correction program due to their nearsightedness. In such cases, all attempts to correct posture through stretching, exercise, and instruction have limited results because the client subconsciously adopts a forward head carriage to bring the eyes into focal distance, particularly when reading, using a computer or doing work that requires fine hand/eye coordination. When your client is repeatedly exposed to such postural programming, you will have a hard time reprogramming them through exercise. A client with poor focal vision in one eye will commonly show transverse plane postural dysfunction, which often presents as a scoliosis. They rotate their head and body to better position their good eye. The point of all this is, any visual disorder will diminish balance at the most fundamental level – segmental imbalances leading to gross imbalances and uncoordinated motor responses to any balance challenge.
In some cases, the motor commands associated with a given task (motor engram) will override those associated with focal problems. A quick way to determine the focal influence on your client’s training posture is simply to ask them to close their eyes while performing an exercise. For example, when asking your client to sit on a Swiss ball with good posture, if your client’s posture improves when they close their eyes, chances are they need to see an ophthalmologist. If their posture becomes worse with their eyes closed, it is likely that they have been using visual input to compensate for mal-alignment driven by other sources such as musculoskeletal, neurological or visceral.
Ambient vision can be enhanced by practice. For example, try holding your head and eyes still with a forward gaze and reach your arm out so that you are looking at the tip of your thumb. Now, without letting your eyes follow your thumb, begin taking your thumb laterally as you horizontally abduct your arm, paying close attention to how far back you can still see your thumb in your peripheral vision. This exercise can be performed by moving your thumb in any direction. Although this may not actually improve your peripheral vision, it will enhance your awareness of movement in the peripheral field. Activating ambient vision and optical flow with such exercises can easily improve balance, range of motion and alignment. In fact, I use the Neck – Trunk Trainer (below) routinely to improve a golfer’s readiness to play. I am sure you are aware that playing good golf requires exquisite static and dynamic balance skills.
Phase I: Trunk Rotation Test
Figure A. Golfer’s Neck/Trunk Trainer: Phase I
- Standing in a natural stance, raise your right arm so that it is reaching out in front of you, as though you were pointing at an object in the distance.
- Keep your feet firmly planted as you rotate your trunk, reaching around the body as though you were looking over your right shoulder to back your car up without using the rear view mirror (Figure A).
- Pay close attention to how far your trunk rotates and how far you can reach behind your body with your arm before you are restricted by spinal rotation. Do not allow the hips to rotate.
- Repeat this test on the other side. Once again, pay special attention to how far you can reach and rotate your trunk. Now, progress to Phase II.
Figure B. Golfer’s Neck/Trunk Trainer: Phase II
- Starting with your arm outstretched in front of you again, move your arm laterally, maintaining a horizontal plane.
- As you move your arm away from your body, hold your head still and follow your hand with your eyes (Figure B).
- Do not allow your torso to rotate.
- Repeat this ten times on each side and then progress to Phase III.
Figure C.Golfer’s Neck/Trunk Trainer: Phase III
- Performing the same movement as in Phase II, you now simultaneously rotate your head in the opposite direction while keeping the eyes on your hand as it moves away from your eyes. Initially, this may be a little challenging! (Figure C)
- Do this ten times on each side and then repeat the trunk rotation test (Phase I). You should now be able to rotate your trunk, shoulder, arm and neck much further!
- How did this happen? This phenomenon occurs as a result of a complex interplay between your eyes, the joints in your neck and the reflexes contained in the neck. It is very important to include Rubano’s Golfer’s Neck/Trunk Trainer warm-up exercise anytime you want to play your best golf!
The Ear (Audition and Vestibular Function)
The fourth spot on the Survival Totem Pole is held by the ear and the vestibular system. Ten thousand years ago, if you couldn’t hear out of one or both ears, you had a chance of survival but not nearly as great a chance as someone who had a well functioning audition and vestibular system.
The auditory portion of your ear consists of the outer auricle and the tympanic membrane (ear drum), which serves as the barrier between your outer and middle ear. The ear detects exteroceptive sound that is often useful to function and performance. Clinically, the client with deafness in one ear will have similar postural adaptation as the person with unilateral visual loss. He will rotate his body and/or head to position his most functional sense organ for optimal function of the organism. As described above, such aberrations of posture will ultimately reduce an individual's capacity to balance or learn balance skills.
The vestibular system senses motion and speed of movement of the head in all three planes of motion and is highly integrated with the cervical and ocular systems. The reflexes elicited by the vestibular organ principally serve two mechanisms:
- Maintenance of the equilibrium of the body (including postural responses)
- Keeping an eye on the surroundings independently of movements of the head and body (visual motor control)
It is apparent looking at these two mechanisms that hearing and the vestibular system are important to survival. For example, if developmental man could not see a predator approaching (i.e., during sleep or thick fog), he would have to rely on his hearing alert him of the oncoming danger. Also, our ancestors did not have the beautifully paved roads and sidewalks we do today and thus had to contend with relatively unpredictable terrain. If they did not have a properly functioning vestibular system, their chance of losing balance and injuring themselves was high. They didn’t have the modern medical technology that we have today and may have had a grim future after a major fall or accident.
Clients with a vestibular disorder may complain of vertigo or a sense of rotation of either the individual or the environment. Such clients may have a hard time sitting or lying on a Swiss ball or using any conventional balance apparatus requiring the client to right themselves. While serious vestibular pathology is not common among those attending gym-based exercise programs, it is more commonly seen among the physical therapy population. Clinically, I have seen a number of cases of positional vertigo secondary to whiplash accidents. It is not uncommon to have a client develop active trigger points in the anterior cervical musculature or ligaments and/or the head, neck or shoulder girdle after traumatic incidents. Due to the highly integrated neuroanatomy of all cranial nerves and the muscles and tissues innervated by C1-C3 and in some cases C4, trigger points anywhere in the zone of direct innervation of C1-4 may produce sensory bombardment at the spinal cord level, which can result in a spill-over effect that may result in pseudo-vestibular disorders and loss of balance.
Other commonly overlooked sources of vestibular dysfunction and related balance problems that your clients may well experience are dehydration, food allergy and food intolerance.
Dehydration affects the consistency of the lymph fluid in the container sac and it’s semicircular canal systems. The slower moving, concentrated lymph will not produce a true reading of the position and speed of movement of the head. What information is received from the vestibular system will not be synchronized with the information that is received from the eyes and the information coming from the spindle cells and mechanoreceptors of the muscles and joints of the cervical spine, particularly the upper cervical spine. The lack of synchronized information causes dizziness and vertigo that may occur when some dehydrated people move their head quickly.
At the C.H.E.K Institute, we have been very pleased with the positive responses to hydration received by following Dr. Batmanghedlidj’s hydration guidelines. He suggests that you drink a minimum of half your body weight (in pounds) in ounces of water daily. For example, a 200-pound man would need to drink 100 ounces of water daily.
While seldom appreciated as a possible causes of dizziness, vertigo or imbalance, I can assure you that having run tests for food allergies and intolerances in some of our clients, we have seen some astonishing cases of symptoms clearing up once the offending foods have been eliminated.
Today, many people could be displaying a reduced ability to balance as a byproduct of eating something that causes altered physiological responses in the body. This is in part due to incredibly high stress levels we encounter in today’s modern environment. Adding to the physiological load is work-related stress, relationship stress, environmental stress and consumption of medical drugs and alcohol, all of which are known to contribute to leaky gut syndrome. “Leaky gut” is a digestive disorder that results in the cell wall of the small intestine opening due to separation of what are called tight gap junctions, which then allows undigested food particles to pass through the gut wall. Once undigested food particles pass the gut wall, significant load is placed on the liver and the likelihood of undigested food particles, or food antigens, getting into the blood stream is significantly escalated.
While there are a plethora of possible symptoms that may result, consider that in food allergy and intolerance tests conducted on 690 patients by Lawrence Dickey, M.D., there were 2,989 positive responses. Of these responses, 406 were localized to the eyes, ears, nose or throat and a total of 771 responses in this area could be induced by exposure to the culprit substance during challenge tests. Among the symptoms experienced by ingesting foods people are allergic to are vertigo and dizziness.
For those of you thinking that none of this could be happening with your clients, I suggest you stop reading this article, walk over to the nearest juice bar or café and look at what is being sold to people in the name of health food! Where in nature do you find drinks loaded with sugar and neuro-stimulants? Where in nature do you find fluorescent orange, green, red and blue drinks? Where in nature did you ever find powdered protein that has been cooked, obliterated and is absent of necessary natural vitamins, minerals, trace minerals, enzymes, fats and carbohydrates? One of the first things I do for any client presenting with a balance disorder is to analyze their diet, hydration levels, what they are drinking and test them for food allergies and intolerances. In my opinion, most clients would be better off eating a Swiss ball or balance board than most of the garbage being pedaled in gyms as “health and performance foods!”
I can’t overemphasize enough that balance begins on the inside.
In Part 4 of this article series we will continue with the Survival Totem Pole but focus on one of it’s more complex segments: the upper cervical spine.