PT on the Net Research

Scientific Balance Training - Part 6

If you’ve been following this article series from the beginning, hopefully you’re aware of how the exercise industry currently operates within the scope of many dangerous illusions and misperceptions. Some of these include:

As a conclusion to this series, I will be shedding some light on some of the “gray areas” that exist in the exercise and rehabilitation industries with regard to how we can provide a safer and more effective approach to balance training. Specifically, I will cover four necessary steps to prescribing an effective balance training program for your clients. These steps are:

Step 1: Clear the Runway

When designing and/or implementing a balance training program for any client, we must begin by clearing the relevant survival reflex mechanism in accordance with the C.H.E.K Survival Totem Pole (Figure1). Such factors as respiration, mastication, vision, vestibular, auditory, upper cervical, visceral, emotions and the intimate link between the central nervous system and the sacrum (pelvic girdle) can all negatively affect how the slave joints (C3-L5 and extremity joints) will be utilized by the body. Thus, any dysfunction in superincumbent systems results in a buffering effect in one or more of the inferior systems as a means of maintaining functional stability (balance) in the body. In other words, if any of the survival systems are not functioning properly, a client’s balance may be seriously compromised, and administering inappropriate balance exercises may do them more harm than good!

If you don’t have the appropriate training to assess each of the individual survival systems, it is best to acquire the assistance of a Level 3 or 4 C.H.E.K Practitioner, or a skilled medical professional. Correcting survival system deficits is the only way to assure long-term results and influence the therapeutic approach.

Step 2: Identify and Remove Potential Roadblocks

Once you have completed the appropriate assessments in Step 1, you must determine which survival system deficits (if any) are correctable and then focus on developing a multidisciplinary approach to treatment. Where serious deficits in one or more control systems are identified, work with the appropriate health professional(s) to develop a sound compensation plan. For example, if a client has a craniofacial growth and development disorder that has resulted in restricted nasal air-flow, you may want to look at such options as:

Regardless of the survival system that is disrupted, I strongly encourage you to work with a qualified health care professional that will help determine the cause of the disruption and that will ultimately assist in it’s correction. It is always best to consult health care professionals that embrace holistic treatment models.

Step3: Program for Improved Flexibility, Balance and Stability

Now that you have first cleared the relevant survival systems in Step 1 and sought outside help to correct any deficits in Step 2, it’s time to move on to Step 3 and focus on correcting any aberrant muscle imbalances as well as start working on increasing static postural stability.

If your client is experiencing any musculoskeletal pain, you must first identify any source of nociceptive (pain) input to the CNS. These findings can be correlated with any noted symptoms (Table 1 below, Column 1), related functions (Table 1, Column 4) and tracked to the appropriate spinal segment, plexus and gland (Table 1, Column 3). In concert with the multidisciplinary approach suggested above in Step 2, any sources of nociception must be addressed in order to achieve lasting stability in any and all working joints controlled by muscles innervated by nerve roots sharing a sensory/motor relationship with the source of nociception.

Table 1

Performing a length/tension assessment, with particular emphasis on those muscles recognized as tonic (see Part 1 of this series) will be essential to developing a corrective stretching program. Stretching tonic muscles prior to exercise has been shown to decrease their facilitation, thus encouraging normal motor sequencing, muscle recruitment and joint stability - all prerequisites to developing a balanced body! By carefully allotting time to restore intrinsic muscle balance and stability through joint mobilizations, stretching exercises and stabilization exercises, the practitioner will be facilitating more rapid acquisition of task specific balance skills and long term stability in his/her client.

At this point, select exercises may be used to improve the bioenergetics and physiological systems of the body as indicated by your assessment of physiological functions, such as digestion, elimination, sleep and hormonal rhythms. For example, the individual with reflex sciatic pain secondary to constipation may benefit greatly from BreathingSquats. Breathing squats (below) are full squats performed at the pace you naturally breathe. As you exhale, lower yourself until your torso rests on your thighs, which results in compression of the cecum and sigmoid by the respective thighs, move feces through large intestine. Using such exercises to normalize or balancethe system may eliminating unwanted reflex inhibition or visceromotor influences on joints and muscles who’s function may be critical to any task specific balancing challenge your client may be faced with.

By improving segmental stability in regions of the body that are linked directly to primal functions such as sex/procreation (below and Table 1, Columns 3 and 4), function may be restored, which can greatly reduce the emotional charge. Any means of stabilizing and improving musculoskeletal function in areas linked to one’s survival, sustenance or procreative functions, will often alleviate an emotional overtone or undertone in the body. Because emotions have the potential to play havoc with all control systems of the body, early administration of corrective exercises that serve to restore both musculoskeletal and emotional stability will also balance subtle energy flow in the body, the overall effect of which can not be objectively quantified, but is often easily determined using qualitative measures.

While my approach may seem complex compared to typical balance training exercises or programs, please consider that stress summates in the body (below). By exposing already stressed clients to the latest trendy exercises that require advanced motor and balance skills, we are merely facilitating substitution patterns, increasing the chances of injury (or reinjury) and ultimately decreasing client retention! Currently, the exercise industry is adding non-physiological stress to an already stressed out body, rather than applying the proper types of stress to restore health and balance! We can and must change that!

Static Postural Stability

Should you have adequate time in your program after designing an initial program designed to restore segmental stability and physiological function as described above, you can initially integrate exercises targeting static postural stability. However, if correcting muscle imbalances takes the majority of the time, you can begin static postural stability training at the beginning of the next conditioning phase. These are exercises that strengthen the postural muscles and improve postural awareness. An example of the many ways to begin static postural training is the Seated Posture Trainer, during which your client learns to sit with good posture on a Swiss ball. As the client’s postural endurance, control and awareness improve, they can be challenged by lifting a foot off the floor and attempting to hold good spinal alignment and balance. A head weight may be used to increase spinal proprioception (below). This class of posture and balance training exercise subserves the development of task specific balance.

What is of great importance during the static postural phase is that the client learns an awareness of their body segments and how to balance them in good alignment. To accomplish this requires more than simply standing there while being prodded by an instructor to “hold good posture.” Proof of the inefficiency of this method can be seen in military men who were forced to stand bolt-upright for many years, yet develop back pain, neck pain, interscapular pain and even pass out in the process! It is the initial phase of corrective stretching and joint mobilization along with specific segmental stability exercises that affords adequate elasticity and structural patency to learn to stand efficientlyin the gravitational field.

To exemplify how developing static postural competency is critical to long-term efficiency in the use of your motor system, consider that “posture is the position from which movement begins and ends.” If you begin in poor posture, you will not only end in poor posture, you will be less energy efficient (less skillful!) and more likely to acquire unnecessary structural stress and strain, often leading to injury. A great example of this very situation can be seen in golf. The first thing you must do to be successful as a golfer is address the ball (below). Addressing the ball is very much a postural event.

To achieve an optimal swing, you must begin with an optimal address, which requires optimal balance of the body segments to produce optimal balance of the body in an athletic stance. To place someone on an unstable apparatus to teach this particular postural skill would be a mistake. A mobile surface will demand reflex acquisition of dynamic postural abilities and skills, which cannot be accomplished if the prerequisite postural building blocks are not in place. For example, you can see my assistant Janet Alexander correcting the address alignment of a golf pro during an instructional phase. A test to determine the static postural capacity of an athlete in such an instance is to simply time their ability to hold optimal posture statically. Using this example, we would time the golfer to see how long he can address the ball before experiencing postural fatigue or loss of the ability to control body segments. In many cases, we’ve found players that could hold an address posture for as little as ten seconds, yet when we timed their average time to address the ball, it was as high as sixty seconds.

With this in mind, it becomes clear that the player doesn’t have the static postural foundation to support the dynamic phases of movement – the swing in this particular example. Thus, it should be obvious that using unstable apparatus with such a player only serves to fortify a static postural deficit because the static postural ability and skills of the individual are a key component, or subsystem, of the dynamic postural control systems. Additionally, because the use of a mobile surface results in constantly changing the body position, there will not be adequate loading of weak postural muscles to acquire a conditioning effect, resulting in strengthening of the deficits. In my lectures, I exemplify this with the statement, “The body always moves toward the position of strength.” To do anything else would increase the likelihood of injury since weakness in movement translates to instability and thus, reduced balance!

So here in Step 3, identify and correct any muscle imbalances that may impede on a balance training program and time permitting, begin on a static postural stability program implementing principles outlined in this series.

Step 4: Developing Dynamic Posture & Stability

Now that your client has achieved optimal length/tension relationships, joint mobility, static postural awareness and endurance to facilitate dynamic posture and stabilityin their chosen work or sports environment, they can safely progress to more dynamic stability challenges.

In Part 2 of this series, I discussed the importance of choosing the right exercises to develop the correct reflex profile, specifically the righting or equilibrium reflexes. In it, I used an example of a motocross racer and how you would select given exercises based on the needs of the athlete, not on what was trendy at the time. What we must do now is utilize our knowledge of the fact that our neuromuscular system reacts differently to environments where the surface is fixed than it does when the surface isn’t fixed and, integrate this knowledge with an understanding of the specific movement demands of your client.

While there are many theories today with regard to how the sensory-motor system learns to move and generate movement, I have found the concept of the generalized motor program put forth by Richard A. Schmidt to be the most easily recognizable and transferable to a clinical practice. Schmidt classifies movements into generalized motor movements by the criteria that movements within a class share the same relative timing. For example, if you assess the rate of ankle dorsiflexion, knee flexion and hip/trunk flexion during a squat and compare it to a vertical jump, the relative timing of the joint movements are comparatively similar even though the amplitude and velocity of the movements differs.

Through my own research, I have developed a system of Primal Pattern Training to address those generalized motor patterns that I feel underlie most movements needed for general survival both developmentally and currently. The seven primal pattern movements, all of which are performed standing:

This information becomes highly valuable and practical when you consider, for example, that many people (particularly the elderly) have poor balance when squatting. In fact, hip fractures commonly result in the elderly when they fall trying to squat to get on and off the toilet, to get into and out of cars and to lower their body into the bath water. Generally, squatting movements are performed on the ground, which is an environment that favors the use of a righting dominant reflex profile, and thus we should seek to progress the client who has achieved static stability into squat-specific dynamic stability by educating and conditioning them in this very environment (below).

Above, you can see a 57-year-old client learning squat-specific balance in a righting-dominant reflex environment while simultaneously developing strength and confidence in a movement pattern that challenges her. While I could easily have her doing any number of ball or board exercises that would challenge her, I have found that dynamic stability,or balance, is “pattern specific.” Therefore, I am of the opinion that we must emphasize developing balance in the movement patterns that are most specific and most challenging to the client’s environment. In this case, I can use an apparatus such as the Swiss ball as supplementary, assisting in an improvement of her general reflex capacity while expanding motor vocabulary (below).

Once the client has mastered dynamic stability, or balance and orientation of the body segments while performing the movements most challenging to them and specific to their environment, we can begin to make the movements more challenging by decreasing base of support or increasing the complexity of an exercise. For example, a squat can be progressed to squat with a weight shift, as necessary to get into and out of a car. Next we can move to single leg squats.

While we are focusing on our primary objective, we can incorporate the use of apparatus to challenge the neuromuscular system on a more global level. For example, we can use the Swiss ball, which is a mobile structure with a small base of support that moves very quickly in response to any change in the position of your center of gravity. To stay on top of the ball will by default, necessitate an increase in the speed at which your central nervous system generates the appropriate righting/equilibrium response. The very fact that people can learn and progress to more demanding versions of the same exercise on such apparatus is a good indicator that the ability to respond, and speed of the response are improving. By adding a load to the body or by moving, accelerating or decelerating a load, such as a medicine ball, we both speed the rate at which the center of gravity is displaced and the rate at which the body must respond (below).

To illustrate how the entire approach outlined here can differ, we must consider that generalize motor programs exist for specialized environments, outside the survival patterns described above, which are mainly used in a righting dominant environment. For example, if we look at the water-skier below, you could speculate that learning to perform a bend pattern in an unstable environment with one foot in front of the other may be more applicable as a generalized motor pattern for water skiing than performing a bent over row in a gym.

With this in mind, we may need to develop exercises that challenge the body in a similar way in the gym, allowing us the opportunity to control the necessary variables to encourage the appropriate training adaptations (below).


Balance training, when performed with the intent of long-term success must be viewed holistically. As I have attempted to demonstrate in this series, it is very likely that many of your clients will require a multidisciplinary approach to normalize the control systems that govern the slave joints as outlined on the C.H.E.K Survival Totem Pole.

In this article series, I have attempted to demonstrate through anatomy, physiology, and scientific and empirical evidence that we must be careful not to fall into the trap of being trendy with the use of balance training apparatus. The principles I have outlined in this article series are based on my belief that the treatment is often the best prevention and that prevention is the best treatment! I have had athletes ask, “How come no body ever taught me this before I got injured?” In fact, I’ve been asked more times than I can count, which is the reason I’m a big believer in a comprehensive assessment as a necessary prerequisite to beginning any kind of training.

Most of the training administered in the gyms today is stressful to the body, and most of the people working out today are already stressed psychologically, hormonally and are nursing one or more musculoskeletal aches and pains – in other words, they are in a catabolic state. Balance training is demanding of the nervous system and when used with resistance, such as adding weights to the Swiss ball, serves only to add to the catabolic environment we should move away from in most instances. Good balance training can be very technical, as I have demonstrated in this series, and just because someone can stand on three balance boards at once, does not mean they are doing themselves any favors. In my opinion, true balance equates to balance skills acquired by a balanced body, a body that demonstrates segmental stability, good static and dynamic posture and adequate strength to learn balance skills that will reduce chances of injury and improve performance in the chosen environment. It is my hope that the exercise industry will mature beyond marketing hype, aesthetic-driven exercise selection and mass-market seduction to become an industry of skilled professionals - professionals that accurately prescribe exercise based on the psychological, physiological and musculoskeletal needs of their clients. I hope this series has contributed to that endeavor.