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TerminologyBalance - Process of maintaining body’s CoG (Center of
Gravity) within base of supportAbility to align body segments against gravity to maintain or
move the body within the available base of support without falling .
Body’s CoG rests slightly above the pelvisStrength is emphasized before proprioception in rehab
because strength influences balance
Postural equilibrium - broader term that incorporates alignment of joint segmentsMaintaining CoG within the limits of stability (LOS)
TerminologyProprioception – body’s ability to transmit position sense,
interpret information & respond consciously/unconsciously to stimulation
Coordination – smooth pattern of activity is produced through a combo of muscles acting together with appropriate intensity & timing
Agility – ability to control the direction of a body or segment during rapid movement
Postural Control System
3 Components of the systemSensory detection of body motions
VisualVestibular Somatosensory inputs
Integration of sensorimotor information within the CNSExecution of musculoskeletal responses
Balance is both a static & dynamic process
Control of BalanceTall body vs. Small base of support
Balance relies on network of neural connectionsPostural control relies on feedback
CNS involvementSensory organization
Determines timing, direction & amplitude of correction based on input
System relies on one sense at a time for orientationMuscle coordination
Collection of processes that determine temporal sequencing & distribution of contractile activity
Sensory InputVision
Measures orientation of eyes & head in relation to surrounding objects
Helps maintain balance
VestibularProvides information dealing with gravitational, linear &
angular accelerations of the head with respect to inertial space
SomatosensoryProvides information concerning relative position of body
parts to support surface & each other
Somatosensation = Proprioceptive system
Specialized variation of the sensory modality of touch, encompassing joint sense (kinesthesia) & positionProcess•Input from mechanoreceptors•Stretch reflex triggers activation of muscles
Results in muscle response to compensate for imbalance and postural sway
•Muscle spindles sense stretch in agonist, relay information afferently to spinal cord•Information is sent back to fire muscle to maintain postural control
Body position in relation to gravity is detected by sensory input
Balance movements involve a number of joints Ankle Knee Hip Coordinated movement
along kinetic chain
Postural swayDeviation from Center of Pressure, Balance &
Vertical Force (CoP, CoB, or CoF)Determined using mean displacement, length of
sway path, length of sway area, amplitude, frequency and direction relative to CoP
Symmetry - Ability to distribute weight evenly between 2 feet in upright stance
Balance DisruptionBalance Deficiencies - Inappropriate interaction among 3
sensory inputs
2 Factors that Disrupt Balance Position of CoG relative to base of support is not accurately
sensed Automatic movements required to maintain the CoG are not
timely/effective
In the event of contact, the body must be able to determine what to do in order to control CoGJoint mechanoreceptors initiate automatic postural response
Selecting Movement Strategies during Balance Disruption
Joints (Ankle, Knee & Hip) involved allow for a wide variety of postures that can be assumed in order to maintain CoG
Instance of musculoskeletal abnormalityDamaged tissue result in reduced joint ROM
causing a decrease in the LOS & placing individual at a greater risk for fall
Research indicates that sensory proprioceptive function is affected when athletes are injured
Assessment of BalanceSubjective
AssessmentRomberg Test –
traditional assessment
Balance Error Scoring System (BESS)
Prentice, 2004, 4th ed.Google Images
Semi-dynamic & dynamic tests functional reach teststimed agility testscarioca hop testTimed T-band kicksTimed balance beam walks (eyes open &
closed)
Objective AssessmentBalance systems
Provide for quantitative assessment & training static & dynamic balanceEasy, practical & cost-effectiveUtilize to assess:
Possible abnormalities due to injury Isolate various systems that are affectedDevelop recovery curves based on quantitative measures in order to
determine readiness to returnTrain injured athlete
Computer interfaced force-plate technologyVertical position of CoG is calculatedVertical position of CoG movement = indirect measure of postural
sway
Prentice, 2004, 4th ed.
Force plate measuresAllows for static &
dynamic postural assessment
Single or double leg stance, eyes opened or closed
Dynamic stability - Ability to transfer vertical projection of CoG around a stationary supporting basePerception of safe limit of stability
Athlete should maintain their CoP near A-P and M-L midlines
Injury & BalanceStretched/damaged ligaments fail to provide adequate neural
feedback, contributing to decreased balance & proprioception May result in excessive joint loadingCould interfere with transmission of afferent impulsesAlters afferent neural code conveyed to CNSDecreased reflex excitation
Caused via a decrease in proprioceptive CNS input May be the result of increased activation of inhibitory interneurons within the
spinal cord
All of these factors may lead to progressive degeneration of joint & continued deficits in joint dynamics, balance & coordination
AnklesJoint receptors believed to be damaged during injury to lateral ligaments
Knee InjuriesLigamentous injury has been shown to alter joint position
detectionHead Injury
Balance Training
Vital for successful return to competition from lower leg injuryPossibility of compensatory weight shifts and gait changes
resulting in balance deficits
Functional rehabilitation should occur in the closed kinetic chain – nature of sport
Adequate AND safe function in the open chain is critical = first step in rehabilitation
Rules of Balance Training
Exercise must be safe & challengingStress multiple planes of motionIncorporate a multisensory approachBegin with static, bilateral & stable surfaces & progress to
dynamic, unilateral & unstable surfacesProgress towards sports specific exercisesUtilize open areasAssistive devices should be in arms reach early onSets and repetitions
2-3 sets, 15 → 30 repetitions or 10 of the exercise for 15 → 30 seconds later on in the program
Classification of Balance ExercisesStatic -
CoG is maintained over a fixed base of support, on a stable surface
Semi-dynamicPerson maintains CoG over a fixed base of support while
on a moving surfacePerson transfers CoG over a fixed base of support to
selected ranges and or directions within the LOS, while on a stable surface
DynamicMaintenance of CoG within LOS over a moving base of
support while on a stable surfaceFunctional
Same as dynamic with inclusion of sports specific task
Prentice, 2004, 4th ed.
Phase INon-ballistic types of drillsStatic balance trainingBilateral to unilateral on both
involved & uninvolved sidesUtilize multiple surfaces to
safely challenge athlete & maintaining motivation
With & without arms/counterbalance
Eyes open & closedAlterations in various sensory
informationIncorporation of multiaxial
devices Train reflex stabilization &
postural orientation
Phase IITransition from static to dynamicRunning, jumping and cutting – activities that require the
athlete to repetitively lose and gain balance in order to perform activity
Incorporate when sufficient healing has occurred Semi-dynamic exercised should be introduced in the
transitionInvolve displacement or perturbation of CoGBilateral, unilateral stances or weight transfers involvedSit-stand exercises, focus on postural
Prentice, 2004, 4th ed.
Unilateral Semi-dynamic exercisesEmphasize controlled hip
flexion, smooth controlled motion
Single leg squats, step ups (sagittal or transverse plane)
Step-Up-And-Over activities
Introduction to Theraband kicks
Balance BeamBalance Shoes
Phase IIIDynamic & functional types of exerciseSlow to fast, low to high force, controlled to uncontrolledDependent on sport athlete is involved inStart with bilateral jumping drills – straight plane jumping
patternsAdvance to diagonal jumping patterns
Increase length and sequences of patternsProgress to unilateral drills
Pain & fatigue should not be much of a factorCan also add a vertical component to the drillsAddition of implements
Tubing, foam rollFinal step = functional activity with subconscious dynamic
control/balance
The dynamic proprioceptive re-education consists of seven stages:-
1.Slow exercises followed by quicker movement
2.Exercise with limited effort followed by exercises requiring greater strength
3.Exercises requiring volition, followed by exercises done freely
4.Progress from walking to jogging
5.Running and sprinting
6.Jumping and changes of direction
7.Twirling and twisting around the injured or operated knee
Balance and control proprioceptive exercises
1.Stand on one leg.
2.Stand on one leg with eyes closed.
3.Stand on one leg – throw and catch a ball.
4.Stand on one leg – bend and straighten knee
5. Stand on one leg- pick up item from floor.6. Hold knee dip – throw and catch a ball. 7. Stand on one leg – move other leg to side,
front and back.8. Push up onto toes (2 legs) and hold. 9. Push up onto toes with eyes closed.10.Push back onto heels, balance and hold.11. Push up on toes on one leg.
Walking proprioceptive exercises
1.Walk forward along a straight line.
2.Walk on tip toes along straight line.
3.Walk backwards along straight line.
4.Side step along straight line.
5.Walk sideways crossing one foot over other (Cariocas).
6.Walk fast in one direction, quickly changing direction at intervals.
Running proprioceptive exercises
1.Run fast in one direction.
2.Run backwards and do sidesteps.
3.Fast crossovers (Cariocas).
4.Run in figure of eight – make it smaller and smaller.
5. Hopping on spot
6. Hop forwards and backwards – stop between hops.
7. Hop in zigzags.
8. Hop on and off step
9. Do triple jump - run, hop, jump and land.
• Balance and strength exercises are combined by incorporating light external forces and increasing the level of difficulty for balancing while strengthening the muscles required for dynamic stabilization
• Plyometrics begin with low-impact hopping, progressing to double-leg bounding, and finally single-leg hopping.
References
Prentice, W.E. (2004). Rehabilitation Techniques for Sports Medicine and Athletic Training, 4th ed., McGraw-Hill
Houglum, P.A. (2005). Therapeutic Exercise for Musculoskeletal Injuries, 2nd ed., Human Kinetics.
Kisner, C. & Colby, L. (2002). Therapeutic Exercise Foundations & Techniques, 4th ed., F.A. Davis.
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