Implementing Balance Training

Dr. Micah Kust DPT, ATC, CSCS

Now that we have assessed if athletes need balance training and determined what kind of balance training is indicated (unstable vs stable), what are ways we can implement balance training in the athlete population?

There are unlimited options for balance training but I will highlight some options. MOST of them will not include unstable surfaces, but there is SOME value to using these surfaces so I will briefly cover some examples.

Examples are included in this instagram post. Check it out

https://www.instagram.com/p/B0WukminKC-/?igshid=2rm9x4w7vvru

Unstable Surfaces

Tilt Board

I have personal experience with the tilt board after I tore my ACL for the second time. I decided to take myself through a non-operative protocol which included a lot of tilt board work. Ultimately, it came down to getting as strong as possible on that one leg but I will not discount the affect the tilt board had on my recovery.

Athletes who have sustained acute ankle or knee injury have shown to benefit from unstable surfaces. Much of this is due to the proprioceptive loss which occurs from a significant ligament or muscle injury. I prefer to use the tilt board he tilt board in early to mid stages of recovery for restoration of joint proprioception. This can be accomplished by having athletes find the balance point of the board, then tap an edge of the board and return to the original balance point.

Bosu Ball

The Bosu Ball…I would like to remove these from the physical therapy and performance profession but let’s discuss how they could be used. In the realm of UPPER EXTREMITY balance and stability they have a much greater benefit and application.

Load compromised athletes who benefit from this training tool the most. A load compromised athlete is unable to tolerate progressive loads in their current state due to pain, muscular inhibition or lack of force production. The bosu ball can be used to increase muscle activation without overloading the injured or painful joint due to the reduced forces produced while on an unstable surface. Additionally, unstable surfaces induce increased muscle co-activation which improves joint stability while reducing available range of motion. This can be beneficial for rehabilitating athletes who currently don’t possess the strength or ability to control a certain range of motion but still want to work on improving muscle activation.

The bosu ball fails as a pure balance tool as there are better ways to strictly train balance with the principle of specificity in mind.

Stable Surfaces

Now we get to the good stuff. Most athletes with the exception of those who experience unstable surfaces often in competition can benefit much more from stable surface training WITHOUT the potential negative consequences of reduced training affects. Most athletes interact with a stable surface during their competition so they should be performing most of if not all of their balance training in this manner. Many may think the ground does not provide enough of a challenge for the most talented and skilled athletes. This is a lazy excuse many sports physios use to justify their uses of unstable surfaces but you will see there are many ways to challenge athletes without a bosu.

Foot and Ankle Function

One of the most important aspects of balance training is foot function and strength. Below are some ways to training toe foot and ankle function in order to make sure it can support the body during balance training. Once we know the foot is ready to be challenged then we can add more layers to our balance training. Once the foot is prepared for balance training this can be implemented in a variety of different ways.

Half Kneeling

Even if the feet aren’t ready to be challenged yet there is a great alternative way to challenge balance. This will be accomplished from the half kneeling position. The half kneeling position takes out the ankle from the balance equation and puts emphasis on the hip and the trunk. You will be surprised at how many athletes of all levels will be unable to stabilize in this position especially in the aligned or narrow base position. It is important to note that in this position most of the weight should be distributed to the back thigh. It is helpful to cue patients to place 80% of their weight in the trial leg and 20% in the lead leg.

Single Leg Challenges

Check the Instagram post out for ways to challenge balance in single leg stance. There are unlimited opportunities for variation of stability challenges in this position with no need for unstable surfaces. As you will see, many of them are not easy and provide an adequate stimulus to improve balance.

Dual Task Challenges

Dual task challenges reduce an athletes reliance on vision in order to challenge balance. These tasks follow the principle of specificity as athletes are always performing dual tasks during competition and rarely are focused on a single point during athletic movement. No fancy glasses are needed to reduce an athletes use of vision. This can be accomplished by simply causing a change in head position while tracking a ball.

Ki-RO Core

The Kiro Core is a harness designed by Kika and Roberto Mela that can be used to train the trunk in multiple different planes of motion simultaneously.(https://www.kiroconcepts.com/)

The Kiro Core can also be implemented with balance training by creating multi-direction stability challenges on an individual during movement or in single leg stance. The rings on the harness can slide during movement constantly providing different stability challenges which don’t require the use of unstable surfaces and make it a very versatile device for balance training.

Unilateral Training

Balance training can also be challenged simply by unilateral training. Any strengthening movement performed on one leg or primarily one leg if in a supported position is balance training. All these positions provide a unique stability challenge while allowing progressive load. This can be the best of both worlds as we can provide a adequate stimulus for strength gains as we challenge balance with unilateral training.

Plyometric Training

Athletic movement provides significant stability challenges during jump landing tasks of jumping, bounding and hopping. These are conditions athletes experience during competition so principle of specificity applies extremity well with this type of balance training. Jump landing tasks can be done in all planes of movement in order to subject athletes to all stability challenges they will experience during competition.

These are only a few examples of how to implement balance training. The most important thing is to think critically when implementing these exercises, use the principle of specificity and don’t always look to an unstable surface to make a balance exercise more challenging.

https://www.instagram.com/p/B0WukminKC-/?igshid=2rm9x4w7vvru

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Educating the Athlete

Sports Physical Therapist has become a title many like to hang under their names in their Instagram bios. We should be using it as a skill to empower and educate athletes not our egos. In the area of Sports Physical Therapy, our job is to PREPARE and EDUCATE athletes on how to stay healthy and improve their performance.

There is so much information floating around on social media about sports performance and physical therapy. This makes it hard for any athlete or patient to make sense of. For as much that is quality and has solid scientific reasoning, just as much of it is misleading or unnecessary.

The goal of this project is to provide an evidenced-based, no BS resource for athletes of all levels from everyday to professional in order to educate them on how to stay healthy and improve their performance.

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Assessment: Do we need Balance Training?

Dr. Micah Kust DPT, ATC, CSCS

Stability and balance training is a currently a hot topic in sports medicine. Everyone wants to be doing it and everyone wants to be seen doing it. Before we get to this step, we must not skip a very important piece of the puzzle. Assessment. If we don’t assess an athletes ability to balance then we are just guessing if this type of training is needed. Spending valuable treatment time on interventions that aren’t necessary can take away from time devoted to relevant areas for injury prevention and performance.

Which athletes can benefit from balance training? Athletes who have sustained significant lower extremity injury, especially to the ankle or knee, can benefit from stability training. This information is gathered during a thorough subjective report of previous injury history. Other athletes who can benefit from stability training are ones who demonstrate deficiencies during an assessment. There are many different ways to assess for stability and balance deficits. I will highlight just one as it is my preferred and most regularly used method. No movement assessments are perfect but if they are used to gather relevant information to help guide treatment, then they can be useful.

Selective Functional Movement Assessment (SFMA)

Single Leg Stance, SFMA Top Tier

This post will only provide a brief overview of how I apply what I learned during the SFMA Level 1 course to single leg balance. If you want to learn and understand how the assessment truly functions, I highly suggest taking the course. The SFMA top tier has a specific test looking at single leg balance. The athlete is asked to stand on one leg and bring the opposite hip and knee to a 90-90 degree position (shown in picture above). They are asked to hold for 10 seconds with eyes open and eyes closed. During the test the clinician is looking for ability to maintain balance, loss of height (bending the knee to create stability), or asymmetry such as compensatory trunk lean. If an athlete is unable to perform this test proficiently there are two different breakouts used to identify potential issues contributing to the balance deficit.

Vestibular and Core Breakout

The first set of tests determines if the vestibular system or trunk are contributing single leg balance deficits.

  • Vestibular Test: CTSIB (Static and Dynamic)
    • This series of tests isolates the vestibular system by reducing visual and proprioceptive control during balance tasks
  • Half Kneeling Narrow Base Test
    • Takes the ankle out of the equation to isolate the stability of the weight bearing hip and trunk
  • Quadruped Diagonals Test
    • Further isolating the ability to balance on the weight bearing hip and trunk

Ankle Breakout

The next set of tests isolates the ankle. These tests are looking at active and passive capacity of the ankle joint to support the body during single leg stance tasks. If the ankle does not possess the capacity to produce and control these motions this must be treated first. If all of these tests are normal than there is a proprioceptive deficit and we can continue on to balance training.

  • Heel walk Test
  • Passive Prone Dorsiflexion Test: 20 degrees
  • Toe Walk Test
  • Passive Prone Plantarflexion Test: 40 degrees
  • Active Seated Inversion/Eversion Test: qualitative test to see if athlete is able to produce these motions
  • Passive Seated Inversion/Eversion Test: qualitative test does the ankle have the ability to move into these positions passively.

Additional Assessments

Foot Function

The SFMA breaks out the function of the ankle joint in relation to stability deficits but the foot is just as important.

Key Measures

  • 1st MTP (Big Toe) Extension: 70 degrees, 55 degrees need for proper walking mechanics
  • 1st MTP (Big Toe) Flexion: 45 degrees
  • Active Foot Function

Conclusion

If educating and preparing athletes to be successful is our primary goal as sports physios, a quality assessment is the first step. And while balance training always looks flashy, as sports physical therapists it’s our role to educate our athletes on if it is necessary. Then, once we know if an athlete can benefit from balance and stability training we can chose the appropriate type of training to match their needs. The next blog posts will look at unstable and stable surface training and implementation of proper balance and stability programs.

Blog videos powered by:

Dr. Micah Kust, Dr. Luis Fernandez and Dr. Mike Jones Force Physical Therapy

Balance and Stability Training

In the area of Sports Physical Therapy, our job is to PREPARE and EDUCATE athletes on how to stay healthy and improve their performance.

Stability training is a very trendy topic in Sports PT at the moment, but when you look at the evidence what do you find? Utilizing this evidence is how we can best educate our athletes and provide them with correct information on how to stay healthy.

Stability training is important because a it has been identified as a potential indicator of lower extremity injury. In addition, athletes who have sustained lower extremity injuries present with deficiencies in this area especially early in rehab.

Once we assess IF stability training is needed, then we can decide on how to best implement it. Without assessment we are just guessing and do not have the athlete’s best interest in mind.

Eric Cressey has a lot of great content on unstable surface training of all types including his “The Truth About Unstable Surface Training” resource. https://ericcressey.com/unstablesurfacetraininghtml This blog series will focus on lower extremity stability and balance training exclusively and its application to physical therapy and sports performance.

Blog Series

This series will include 3 installments to cover all the areas of lower extremity stability training.

  1. Assessment: Do we need stability training?
  2. Unstable vs Stable Surface Training
  3. Implementation of Lower Extremity Stability Training

Sources

Dingenen, Bart, et al. “Postural Stability During Single-Leg Stance: A Preliminary Evaluation of Noncontact Lower Extremity Injury Risk.” Journal of Orthopaedic & Sports Physical Therapy, vol. 46, no. 8, 2016, pp. 650–657., doi:10.2519/jospt.2016.6278.

Lehmann, Tim, et al. “Single-Leg Assessment of Postural Stability After Anterior Cruciate Ligament Injury: a Systematic Review and Meta-Analysis.” Sports Medicine – Open, vol. 3, no. 1, 2017, doi:10.1186/s40798-017-0100-5.

Trojian, T H. “Single Leg Balance Test to Identify Risk of Ankle Sprains * Commentary 1 * Commentary 2.” British Journal of Sports Medicine, vol. 40, no. 7, 2006, pp. 610–613., doi:10.1136/bjsm.2005.024356.

Article Links

https://www.jospt.org/do/abs/10.2519/jospt.2016.6278, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5574832/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564306/

Unstable vs Stable Balance Training

Once we determine which athletes require lower extremity (LE) balance training we must then determine what kind of training to implement. The two types of balance training that we will discuss in this post are Unstable Surface Training (UST) and Stable Surface Training (SST). Many other experienced professionals have discussed this topic previously (see below) but due to recent trends in sports physical therapy I believe it is an important topic to refresh.

Definitions

Definitions quoted from Kibele et al.

Balance: “a fundamental requirement for athletic performance and everyday activities. Balance can be considered as an (task-specific) ability of an individual to control either static or dynamic equilibrium while maintaining a stable position”

Stability: “the body’s resistance to being moved out of the present state of motion, linear or rotary, by external forces or torques.”

Stability is always changing based on what is going on around the athlete which affects an athlete’s ability to maintain balance.

Athletes who can benefit from UST

If you asked my opinion I would argue that UST is never truly needed and personally, I rarely use it. However, in order to be thorough it is important to determine which athletes can actually benefit from this type of training.

Athletes with Previous Injury

One of the greatest risk factors for injury is previous injury. Athletes who have sustained previous lower extremity injury are individuals who may benefit from unstable surface training. Verhagen et al. published a study looking at balance board training for the prevention of ankle sprains. The results showed that athletes who previously had sprained there ankle responded to the UST but healthy athletes with no previous injury showed no benefit. Athletes with previous injury will also greatly benefit from stable surface training, but especially during early stages of lower extremity injury UST can provide a stimulus to improve balance and proprioception on the injured limb.

Athletes Rehabbing from Lower Extremity Injury

The second group of athletes who can benefit from UST are athletes rehabbing from significant ankle, knee or hip injury during early to mid stage rehab. Training on unstable surfaces produces increased higher muscular activation including co-activation which increased the stiffness of a limb in order to protect it from excessive force output. These interventions are most useful in early stage rehab when the athletes may not be able to tolerate significant load and force output due to weakness and muscular inhibition.

“Physical therapists should consider IRT (instability resistance training) as a progressive component in the rehabilitation training program that may begin with solely balance training (no load), progressing to balance challenges with resistance (IRT) to traditional ground based RT with greater loads and intensities.” (Behm et al)

Once we build the athletes capacity to tolerate progressive load, UST needs to be replaced immediately. Unstable surface training not only reduces force output but also reduces range of motion due to co-contraction which are two extremely important, yet commonly overlooked areas when it comes to sport rehab. In my opinion, training rehabbing athletes on unstable surfaces throughout their recovery will produce a significantly under loaded athlete who is unprepared to generate the force output needed to return to sport safely.

When can UST be counter productive?

Trained Athletes

Prehab is also a very trendy topic in sports rehab and it involves the treatment of healthy athletes in order to reduce the chance of future injury. In this situation we run the risk of negatively affecting our athletes training and performance if we decide to use UST.

Cressey, West, Tiberio et al. investigated the potential effects of a 10 week lower body unstable surface training on athletic performance in healthy athletes. The athletes were tested on jump, sprint and agility performance measures.

“The primary findings of this study were that 10 weeks of lower-body UST attenuated improvements in both short- and long-lasting SSC jumping performance and 40- yard sprint time when compared with a stable surface program identical in all other programming variables.” (Cressey, West, Tiberio et al.)

This shows that utilizing unstable surface training in healthy athletes can actually have a negative effect on performance. Stable surface training can provide a similar benefit to unstable surface training for balance and proprioception and lacks the potential negative effects of instability training. Athletes have a very short window to recover and prepare during their off-season and as sports medicine professionals we must be making appropriate decisions for our athletes to maximize their efficiency in preparation.

The authors of this study also offer insight in to what program design should look like.

“Instead, program design with healthy athletes should adhere to the principle of specificity with respect to training surfaces just as it would for other characteristics of muscular actions” (Cressey, West, Tiberio et al.)

With that said, as physical therapists we must design our rehab programs to reflect this as well. A good rehab program should add on to the benefits of a training program and not take away from effects of training in healthy athletes.

My charge to sports medicine professionals is this: Always be wary of trends on social media, think critically about the times and situations in which you chose to implement UST, and always be prepared to back your decisions with evidence.

Sources

Behm, David G., et al. “Effects of Strength Training Using Unstable Surfaces on Strength, Power and Balance Performance Across the Lifespan: A Systematic Review and Meta-Analysis.” Sports Medicine, vol. 45, no. 12, 2015, pp. 1645–1669., doi:10.1007/s40279-015-0384-x.

Cressey, Eric M., et al. “The Effects Of Ten Weeks Of Lower-Body Unstable Surface Training On Markers Of Athletic Performance.” Journal of Strength and Conditioning Research, vol. 21, no. 2, 2007, pp. 561–567., doi:10.1519/00124278-200705000-00047.

Kibele, Armin, et al. “Stable, Unstable and Metastable States of Equilibrium: Definitions and Applications to Human Movement.” Journal of Sports Science and Medicine, Dec. 2015.

Lehmann, Tim, et al. “Single-Leg Assessment of Postural Stability After Anterior Cruciate Ligament Injury: a Systematic Review and Meta-Analysis.” Sports Medicine – Open, vol. 3, no. 1, 2017, doi:10.1186/s40798-017-0100-5.

Mcbride, Jeffrey M., et al. “Isometric Squat Force Output and Muscle Activity in Stable and Unstable Conditions.” The Journal of Strength and Conditioning Research, vol. 20, no. 4, 2006, p. 915., doi:10.1519/r-19305.1.

Verhagen, Evert, et al. “The Effect of a Proprioceptive Balance Board Training Program for the Prevention of Ankle Sprains.” The American Journal of Sports Medicine, vol. 32, no. 6, 2004, pp. 1385–1393., doi:10.1177/0363546503262177.