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Stability Ball Training - Part 4

One of the key components of training we always emphasize is proper progression of training. This basically refers to the "crawling before you walk" principle of teaching any skill. Stability Ball (SB) training is a skill. Thus, advancing a client through the proper progressions of an exercise not only ensures safety and effectiveness but also promotes "learning through success." This approach promotes program adherence, client retention and results.

One of the most common concerns I’m approached with about SB training is the fear that this type of training is too advanced for some populations (e.g., seniors). The progressions I have developed for each body part have a wide range of intensity. The beginning version of each exercise is appropriate for the geriatric population. These exercises typically involve the short lever made possible by executing exercise from a kneeling position (e.g., push ups) or with ball under the thighs or knees (e.g., push ups - hands on floor or supine bridges). As the progressions advance in difficulty, they can challenge the most accomplished athletes I have worked with. The advanced version of each exercise will usually involve a longer lever and minimum support contact. Let’s take a closer look at the lever system inherent to SB training and other methods used to vary the intensity of the exercises.

Prone Lever System

One of the advantages of SB training is that it uses the body’s lever system to allow variation in resistance. This inherent lever system can take into account not only the core stability of an individual, but it can also adjust the resistance applied to the prime movers at the extremities. The further the distance between the ball and the ground support (e.g., limbs), the greater the demand for core stabilization and the greater the resistance on the prime movers. For example, in the hands on floor push up, as the ball support goes further away from the arms, the demand for core stability is increased as well as the weight the arms must support. The longer the distance between the support points (in this instance, the ball and arms), the harder the exercises will be. The natural progression for the hands on floor push up is:

  1. Ball under the hips
  2. Ball under the knees
  3. Ball under the shins
  4. Ball under the feet

Repeating this sequence using a single leg support can further advance this progression.

Leg Position for Stabilization Progression

The width of the support at the legs can also provide adjustments in the demand of an exercise. A wide leg position offers more support than a narrow position, making the exercise easier with the wider support. As the legs get closer to each other, there is less of a ball support base, making the exercise harder. Ultimately, one leg supported exercises are the hardest due to the additional support demands. Careful attention should be paid to stabilizing the hips in a stable and leveled position, preventing lumbar hyperextension and core or hip rotation. Master an exercise using a wide base using a wide foot position. Then, narrow the base of support until one leg support can be executed. Abducting the free leg during the single leg version of any exercise (e.g., push up) really challenges the transverse plane stabilization on sagittal plane dominant exercises.

Reducing Contact Area of Support

Reducing the contact surface of any supporting limb can increase the load and neural demand of any exercise, especially where the hands or legs contact the ball. As mentioned earlier, two-leg support is easier than one-leg support. You can then proceed from thigh, shin or instep support, to the balls of the feet. Finally, the contact area on the stability ball can be further reduced by going to toe stabilization (i.e. 2 feet to single foot).

The same approach can be taken when support the upper body on the ball using the arms. Elbow stabilization (e.g. as rollouts) is easier than hand support. Two-hand stabilization (e.g. as in lockout stabilization and push-ups) can be made more challenging by going to a single hand progression. However, this is an extreme application and requires advance training.

Increased Flexibility Demand

Using various size stability balls allows one to vary the flexibility demands of many exercises. During one-leg exercises where the free leg is being supported by a ball, smaller balls require less flexibility from the adductors or hip flexors. Choose the smallest ball available to start. Then, progress to larger balls requiring the greatest amount of flexibility.

Consistent with the lever system, the closer the ball is to the mainline of the body during single leg exercises, the less flexibility and stabilization is needed. The further the ball is from the ground-support foot, the greater the requirement for stabilization and flexibility.

During one-leg exercises, start with "stationary"- free leg support. This requires less balance. Then, advance to dynamic movement, varying the distance between the support foot and the ball.

Once you have advanced to the dynamic, one-leg exercises, a "foot to mid-lower-leg role" adds a bit of stability in terms of ball position. The action and speed of the exercise will dominate the stability requirements. If you do not have perfect execution during this dynamic exercise the ball will role the "free leg" off. This "roll" again adds to the transverse plane stabilization requirements.

Ball size also affects flexibility in other exercises such as pike shoulder presses and some of the stretches. The larger the ball, the larger the support surface. Therefore, stretches like the supine abdominal stretch are supported to a greater extent by the larger size balls. Likewise, larger balls require less hip and hamstring flexibility during some core and upper body strength exercises (e.g. pike tucks and pike presses). However, these tucked positions provide greater vertical positions (e.g. more weight supported by the upper body) requiring more upper body strength for proper execution. This is one of the many reasons I recommend everyone use several size stability balls. It adds more versatility and range to your training.

 Notice the greater amount of extensor chain flexibility required by the smaller ball .  The larger ball requires less flexibility, but puts a greater amount of load on the upper body.

Complimentary Equipment

As versatile as the SB is, its versatility is further enhanced when it is incorporated with other training equipment. We have successfully incorporated the SB with rubber tubing, various medicine balls, dumbbells, side-angled boxes (i.e. "sidestrike"), and balance equipment, such as rocker boards.

Resistance Training in an Unstable Environment

Performing resistance training on the SB is a great way to work on stabilization and neural efficiency. The SB can be used in the same fashion as a bench. This application allows a series of squatting, lunging, pressing, and pulling exercises. The unstable environment created by the stability ball requires superior balance and stabilization on the part of the core and stabilizers of the extremities. Changing the contraction pattern will change the center of mass and increase the balance requirements of any exercise. Do to the increased balance requirement of this type of training, I do not recommend extremely heavy loads to failure or barbell work. Before embarking of this type of approach to stability ball training, the trainee should first be taught how to "miss a lift" and drop the weights to the side. This awareness creates a more confident training environment. I do recommend spotting with beginners until they have mastered the essence of this method of training. However, if the training has been progressed properly, little supervision is needed if starting loads are light and emphasis is on form rather than weight lifted.

Rubber Tubing

Rubber tubing can be used to create horizontal resistance for exercise such as rowing or resisted rotations. The SB can be used as a seat, or a supine support, during these types of exercises. This "unstable" exercise environment adds to the neurological demand of the activity. Geriatric clients are usually challenged by a two-leg ground support, while using a single leg ground support further challenges elite trainees. The line of pull can be changed, with or without notice to further challenge the stabilization and postural adjustments of the core. Altering band resistance from this position creates another stimulus to challenge the central nervous system.

Alternating pull while on single leg.

MB Training

Medicine balls can also be incorporated into your SB training. Medicine balls come in weights ranging from 2 to 40 pounds. They also have various gripping capabilities, such as handles and ropes. They come in different textures and bounce qualities. This makes them suitable for any population and creates a very safe environment.

Medicine balls can be used just like any other type of resistance and the stability can be incorporated just as you would a bench. Just about any exercise you can imagine with a barbell can be performed with a medicine ball. However, due to their rubber make-up, they can also be thrown (e.g. incorporating an overhead throw with an abdominal crunch, while sitting on the ball). This versatility allows one to address the dynamic nature of postural adjustments typical in speed and power dominated events, such as reactions to falls in the senior population and sport specific movements in athletes. The handles on "Power-Balls" allow these medicine balls to be used like dumbbells. The rope attachments on the "Converta-Balls" add a whole dimension to this training, allowing you to perform a variety of swinging exercises while sitting on the stability ball.

Sitting Med Ball throw

Balance Equipment

The stability ball can be seen as a piece of balance equipment, in itself. However, there are other pieces of balance equipment that can be incorporated with the stability ball to add diversity and fun to your training. For example, Biofoam rollers and rocker boards can be used at the opposite extremities of the stability ball to increase balance requirements during push-ups and sitting balance exercises. This application makes for a great "game-oriented environment" for youth as well as experienced trainees.

Now that we have developed an appreciation and fundamental knowledge of the stability ball - it’s time to get to work! The following three routines are examples of how the concepts discussed above can be applied in developing safe and progressive programs. These programs consist of 8 different movement components. Each movement component is associated with a major system of muscles. At the end we have a balance component that always adds a smile to the client’s face. The programs can be performed in succession (i.e. one exercise at a time), or as a sequenced circuit (i.e. all 8 exercises performed one after another). Performing 3 sets of each exercise for 5 - 15 reps can serve as a general guideline to volume. The number of reps will depend on the proficiency and technique of the trainee.

Rocker board push up

Warm-up before your workouts. Below are the list of biomotor skills we used as an active warm up in the ESBT. These drills are appropriate for healthy, asymptomatic individuals and illustrate some examples of what can be done in a small area. Taking about 15 to 20 seconds to perform each exercise will provide about two and a half minutes of an aerobic warm up. This should be sufficient to start elevating core temperature and prepares the body for a more specific warm up incorporating the stability ball.

  1. Running in place
  2. Butt kickers
  3. Jumping jacks (various)
  4. Stationary skips (various)
  5. Wood Chop
  6. Twists
  7. Diagonal wood chops
  8. Circles

Individuals with orthopaedic limitations can skip the ground-based, impact aerobic skills and try some light bouncing on the stability ball while in a sitting position. If orthopaedically tolerated, this gentle bouncing provides good balance and core training, while stimulating the cardiovascular system. It is a great warm up option for the geriatric population. Eventually the beginner program can serve as a great warm-up.

Remember these are just examples of programs and are not meant to be specific routines for your clients. Each of your clients will have a specific history and physiological profile that will require individual programming. Make sure you select an exercise with the client’s limitations in mind. Advance only through successful execution of an exercise and you will eliminate most of the carelessness in your training.

The next article will illustrate the 3Tier integration system of training. This is a system we designed to allow this eclectic approach to training to be combined with more traditional system of training. Until next time, stay on the ball and train smart.

Sample Workouts





  1. Anderson GBJ, Bogduk N, Deluca C, et al; Muscle: Clinical perspectives on Low Back Pain. New Perspectives on Low Back Pain. Edited by JW Frymoyer, SL Gordon. Park Ridge, IL, American Academy of Orthopedic Surgeons, pp. 293-334, 1989.
  2. Aosaki, T., et al. Responses of tonically active neurons in the primate’s striatum undergo systematic changes during behavioral sensorimotor conditioning. J Neuroscience, 14(6): 3969-3984, 1994.
  3. Blievernicht, J. Balance: Course Manual. Chicago, IL 1996.
  4. Boehme, Regi, OTR. Improving Upper Body Control. Tucson: Therapy Skill Builders, 1988.
  5. Bosco, C., Cardinale, M., Tsarpela, O., Colli, R., Tihanyi, J., Dullivard, S., Viru, A. The influence of whole body vibration on jumping performance. Biology of Sport. 15:157-164, 1998.
  6. Brody, Liz. “ The Axler: A Workout That’s Really on the Ball.” Shape. April 1993: 86-93.
  7. Carrie, Beate, P.T. “ Swiss Ball Exercises.” PT Magazine. September; 92-100. 1993.
  8. Carrie, Beate, P.T. and Linda Felix, P.T. “ In Consideration of Proportions.” PT Magazine. April 1993: 59.
  9. Carter AT: Piriformis syndrome: A hidden cause of sciatic pain. Athl Training 1988; 23(3):243-245. 1975
  10. Chek P. Scientific Back Training: Correspondence Course Manual. Paul Chek Seminars. LaJolla, CA 1994.
  11. Chek P. Swiss Ball Exercises for Athletes I-III. Paul Chek Seminars. Encenitas, CA 1997.
  12. Chek P. Scientific Abdominal Training. Correspondence Course Manual. Paul Chek Seminars. Lajolla, CA 1992.
  13. Chek P. Strong ‘N’ Stable Swiss Ball Weight Training Series, Vol. 1-3. Paul Chek Seminars. Encenitas, CA 1997.
  14. Clark, M. “Functional Leg Training”. NSCA Annual Conference, presentation. Kansa City, Missouri, 1999.
  15. Clark, M. “Foundations for Function”. Learn by Doing Seminar Series, Coral Gables, Florida, 1999.
  16. Cooper, Douglas. Dynamic Stabilization Exercises for the Lower Back. Portland: Douglas Cooper, 1992.
  17. Creager, Caroline C. Theraputic Exercises Using the Swiss Ball. Boulder: Executive Physical Therapy, 1994.
  18. Cresswell, A.G., Oddsson, L., Thorstensson, A. The influence of sudden perturbations on trunk muscle activity and intra-abdominal pressure while standing. Exp Brain Res, 98:336-341. 1994.
  19. Dominguez, Richard H, MD, Gajada Robert. Total Body Training. New York: Warner Books, 1982.
  20. Farfan HF. Effects of torsion on the intervertebral joints. Can J Surg 1969;12:336-341
  21. Farfan HF. Musculature mechanism of the lumbar spine and the position of power and efficiency. Orthop Clin North Am 1975; 6:135-144
  22. Farfan, H. F., Biomechanics of the Lumbar Spine in Managing Low Back Pain, Kirkaldy Willis, W.H., Ed. New York: Churchill-Livingston,1983.
  23. Foley, Erin. Personal Communication. Archivist, Robert L Parkinson and research Center. April 21, 2000.
  24. Fox, Charles P., ed. Old-Time Circus Cuts. New York: Dover Publications. 1979.
  25. Gambetta, V., "Building the Complete Athlete," (Course Manual), 1996.
  26. Gambetta, V., Clark, M., “ A formula for function”, Training and Conditioning, 8(4):24-29, 1998.
  27. Gambetta, V., Gary, G., “Following a functional path”, Training and Conditioning, 5(2):25-30, 1995.
  28. Gomez, Niska. Somarhythms: Developing Somatic Awareness with Large, Inflatable Balls.” Somatics. Spring/Summer, 1992. Pp12-18.
  29. Grabiner M. et al. Decoupling of bilateral paraspinal excitation in subjects with low back pain. Spine. 17(10):1219-1223. 1992.
  30. Granhed H, Jonson R and Hansson T. The loads on the lumbar spine during extreme weight lifting. Spine. 12(2): 146-149. 1987
  31. Gray, G.W., "Chain Reaction Festival," (Course Manual), Adrian, Michigan. Wynne Marketing.1996.
  32. Headley BJ: The “Play-Ball” Exercise Program. St. Paul. Minnesota, Pain Resources, Ltd., 1990.
  33. Hodges, P.W. , Richardson, C.A. Inefficient Muscular Stabilization of the Lumbar Spine Associated with Low Back Pain. Spine, 21(22):2640-2650, 1996.
  34. Hodges, P.W., Richardson, C.A., Jull, G. Contraction of the Abdominal Muscles Associated with Movement of the Lower Limb. Phys Ther, 77:132-14, 1997.
  35. Hypes, Barbara. Facilitating Development and Sensorimotor Function: Treatment with the Ball. Minnesota: P Press, 1991.
  36. Klien-Vogelbach, Suzanne. Theraputic Exercises in Functional Kinetics. Germany: Springer-Velag, 1991.
  37. Koes BW, Bouter LM, Beckerman H, et al. Physiotherapy exercises and back pain: a blinded review. BMJ. 1991; 302;1572-1576.
  38. Kucera, Maria. Gymnastik mit dem Hupfball (Exercise with the GymBall). 5Th Edition. Stuttgart: Gustav Fischer Verlag, 1993.
  39. Maurer, H. (no date) Gymnastik Ball. A Handout. 7112 Waldenburg zur Ausbildung von; Gymnastiklehrerinnen F.M.B.H.
  40. Miller DJ: Comparison of electromyographic activity in the lumbar paraspinal muscles of subjects with and without chronic low back pain. Phys Ther 65:1347-1354, 1985.
  41. Multiple Muscle Systems; Biomechanics and Movement Organization. Edited by Jack M. Winters and Savio L-Y Woo. pg 252-253
  42. Nachemson A, Morris JM. In vivo measurements of intradiscal pressure. J Bone Joint Surg Am.;46:1077-1080. 1964
  43. Nachemson AL: Disc Pressure measurements. Spine. 6;93-97, 1981.
  44. Nachemson, A. The load on the lumbar disks in different positions of the body. Clin Orthop.;45:107-112. 1966
  45. Nachemson, A.L., The Lumbar Spine, An Orthopedic Challenge. Spine 1:59, 1976.
  46. Necking, L., Dahlin, L., Friden, J., Lundborg, G., Thronell, L. Vibration-induced muscle injury: An experimental model and preliminary findings. J. Hand Surg. 17:270-274. 1992.
  47. Necking, L., Lundstrom, R., Lundborg, G., Thronell, L., Friden, J. Skeletal muscle changes of short term vibration. Scan. J. Plast. Reconstr. Surg. Hand Surg. 30:99-103. 1996.
  48. Pace JB: Commonly overlooked pain syndromes responsive to simple therapy. Postgrad Med; 58(4):107-113.
  49. Paruidge MJ, Walters CE. Participation of the abdominal muscles in various movements of the trunk in man, an EMG study. Physical Therapy Review;39;791-800. 1959
  50. Porterfield J.A. and DeRosa C. Mechanical Low Back Pain. Philadelphia: W.B.Saunders Co. 1991
  51. Posner-Mayer, J. Swiss Ball Applications for Orthopedic and Sports Medicine. Denver: Ball Dynamics International, Inc. 1995.
  52. Rathke, F., Knupfer, H. (no date) Exercise Ball: Exercising tool for child development. A handout. Stutttgart. Municipal Center.
  53. Robinson, R. The New Back School Prescription: Stabilization Training Part I. Occupt Med. 7(1):17-31. 1992.
  54. Saal J. Dynamic Muscular stabilization in the Nonoperative treatment of lumbar pain syndromes, in Orthopedic Review Vol. XlX No. 8 Aug 1990.
  55. Saal J. et al. Non operative management of herniated cervical intervertebral disc with radiculopathy. Spine,. 21(16). 1996
  56. Santana, JC. The Essence of Stability Ball Training, Vol I-II. Optimum Performance Systems, Boca Raton, Florida, 1999.
  57. Seroussi RE, Pope MH: The relationship between trunk muscle electromyography and lifting moments in the sagittal and frontal planes. J. Biomech . 20: 135-146, 1987.
  58. Sieg, K., Adams, S. Illustrated Essentials of Musculoskeletal Anatomy. Gainsville, Fl. Megabooks, Inc. 1985.
  59. Sweet, Waldo E. Sport and Recreation in Ancient Greece: A sourcebook with Translations. New York: Oxford University Press, 1987.
  60. Wirhed, R. Athletic ability and the anatomy of motion. Wolf Medical Publications. 1990.
  61. Wolpaw, J.R., Braitmman, D. J., Seegal. Adaptive plasticity in the primate spinal reflex: initital development. J Neurophysiology. 50:1296-1311, 1983.
  62. Wolpaw, J.R. Acquisition and maintenance of the simplest motor skill: investigation of CNS. Med. Sci. Sports Exerc. 26(12):1475-1479, 1994
  63. Zetterberg C, Andersson GBJ, Schultz AB: The activity of individual trunk muscles during heavy physical loading. Spine 12:1035-1040, 1987
  64. Ziethen, Karl-Heniz, Allen, Andrew. Juggling: The Art and Its Artists. Berliniwerner Rausch & Werner Luft. 1985.