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CHAPTER NINE

BalanceTrainingConcepts

MODULE 9-1:

Concepts in Balance Training

The Importance of Balance

Whether on a basketball court, stability ball or walking down stairs,

maintaining balance is key to all functional movements. In functional

activities, balance does not work in isolation. Therefore, it should

not be thought of as an isolated component of function. Balance is a component

of all movements, regardless of whether strength, speed, flexibility or endurance

dominates the movement.1,2

Balance is often thought of as a static process. However, functional balance is

a dynamic process involving multiple neurological pathways. Maintenance ofpostural equilibrium (or balance) is an integrated process requiring optimal

muscular balance (or length-tension relationships and force-couple relationships),

joint dynamics (or arthrokinematics) and neuromuscular efficiency.1,2

The integrated performance paradigm (Figure 9-1) shows that adequate force

reduction and stabilization are required for optimum force production.The ability

to reduce force at the right joint, at the right time and in the right plane of motion

requires optimum levels of functional dynamic balance and neuromuscular

efficiency.1,2

ObjectivesAfter studying this chapter, you will be able to:

Describe balance and its purpose.

Rationalize the importance of balance training.

Design a balance-training program for clients in any level of training.

Perform, describe and instruct various balance-training exercises.

Key Terms

Dynamic joint stabilization

Multisensory condition

Controlled instability

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Importance of Properly Training the Balance Mechanism

Balance training should constantly stress an individuals limits of stability

(or balance threshold). An individuals limit of stability is the distance outside

of the base of support that he/she can go without losing control of his/her

center of gravity.This threshold must be constantly stressed in a multiplanar,

proprioceptively enriched environment, utilizing functional movement patterns

to improve dynamic balance and neuromuscular efficiency.1,2

Training functional movements in a proprioceptively enriched environment

(unstable, yet controllable) with appropriate progressions (floor, balance beam,

half foam roll,Airex pad, Dyna Disc), correct technique and at varying speeds,

facilitates maximal sensory input to the central nervous system,resulting in the

selection of the proper movement pattern.1,2

Fitness professionals must implement progressive, systematic training

programs in order to develop consistent, long-term changes in each client.

Traditional program design often results in an incomplete training program,

which does not challenge the proprioceptive mechanisms of the kinetic chain.

Balance training fills the gap left by traditional training. It focuses on

functional movement patterns in a multisensory, unstable environment.3,4 The

design and implementation of balance into a program is critical for developing,

improving and restoring the synergy and synchronicity of muscle-firing patterns

required for dynamic joint stabilization and optimal neural muscular control.3-6

Optimum Performance Training for the Health and Fitness Professional

Figure 9-1: Integrated Performance Paradigm

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MODULE 9-1: Summary

Balance is key to all functional movement. However, it does not work in

isolation and is not static. Maintenance of postural equilibrium is an integrated,

dynamic process requiring optimal muscular balance, joint dynamics and

neuromuscular efficiency. Balance training should challenge an individuals ability

to stabilize outside their normal base of support. By training in a multisensory

environment, there will be more of a demand on the nervous systems ability

to activate the right muscles at the right time in the right plane of motion.

MODULE 9-1: Quiz

1. The limit of stability is the distance a person can go outside of his base

of support, without losing control of his ___________________.

2. The integrated performance paradigm demonstrates that adequate force

reduction and stabilization are required for optimum force production.

True False

3. What type of environment is created by training with any of the following

implements: floor, balance beam, half foam roll,Airex pad, Dyna Disc?

4. Balance is an isolated activity.

True False

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Balance TrainingConcepts

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MODULE 9-2:

Scientific Rationale for Balance Training

Benefits of Balance Training

Balance training has been shown to be particularly beneficial to improve

dynamic joint stabilization.7-14 Dynamic joint stabilization refers to the

ability of the kinetic chain to stabilize a joint during movement. Some examples

of this include:

The rotator cuff stabilizing the head of the humerus on the glenoid

fossa while performing a push-up

The gluteus medius and adductor complex stabilizing the hip when

performing a squat

The posterior tibialis and peroneus longus stabilizing the foot andankle complex when performing a calf raise.

Balance and neuromuscular efficiency are improved through repetitive

exposure to a variety of multisensory conditions.5,6 An example of this

would be having a client balance on one foot on a half foam roll,while squatting

down and reaching across the body, toward the floor.This helps facilitate the

nervous system to achieve maximal sensorimotor integration, resulting in the

selection of the proper movement pattern.

The main goal of balance training is to continually increase the clients

awareness of his/her limit of stability (or kinesthetic awareness) by creating

controlled instability.1 An example of this could range from having a 65-year-

old client balance on one foot, to having a 25-year-old client balance on one

foot on a half foam roll or Dyna Disc.

Balance and Joint Dysfunctions

Research has demonstrated that specific kinetic chain imbalances (such as

altered length-tension relationships, force-couple relationships and

arthrokinematics) in individuals leads to altered balance and neuromuscular

efficiency.15-24

Alterations in the kinetic chain before, during or after exercises further

affect the quality of movement and perpetuate faulty movement patterns.The

faulty movement patterns alter the firing order of the muscles involved,

disturbing specific functional movement patterns and decreasing

neuromuscular efficiency.15,25,26 Prime movers may be slow to activate, while

synergists, stabilizers and neutralizers substitute and become overactive

(synergistic dominance). This leads to abnormal joint stress, which affects the

structural integrity of the kinetic chain.This may lead to pain, joint dysfunction


DYNAMIC JOINTSTABILIZATION:The ability of thekinetic chain tostabilize a joint

during movement.

MULTISENSORYCONDITION:

Trainingenvironment that

provides heightenedstimulation to

proprioceptors andmechanoreceptors.

CONTROLLEDINSTABILITY:

Trainingenvironment that isas unstable as can

safely be controlledby an individual.

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and further decrease neuromuscular efficiency.17

Research has demonstrated that joint dysfunction creates muscle

inhibition.17,27,28 Joint injury results in joint swelling, which results in the

interruption of sensory input from articular, ligamentous and muscular

mechanoreceptors to the central nervous system (Figure 9-2).29 This results in

a clinically evident disturbance in proprioception. It has been demonstrated

that sensory feedback to the central nervous system is altered, following ankle

sprains, ligamentous injuries to the knee and low back pain.17,19,20,30-34 This is

critical for the fitness professional to understand because 85 percent of the

adult U.S. population experiences low back pain and an estimated 80,000 to

100,000 anterior cruciate ligament (ACL) injuries and two million ankle sprains

occur annually.

Thus, muscle imbalances, joint dysfunctions, pain and swelling can lead to

altered balance.Therefore, the majority of the clients that fitness professionals

work with may have decreased neuromuscular efficiency. It is imperative to

understand balance and how to design a balance routine that caters to the

needs of todays client.

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Figure 9-2: Effects of Joint Dysfunction

Joint Dysfunction

Muscle Inhibition

Joint Injury

Swelling

Altered Proprioception

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MODULE 9-2 Summary

Balance training benefits dynamic joint stabilization. Its main goal is to

continually increase awareness of limits of stability. Repetitive exposure to

varied multisensory conditions can improve balance and neuromuscular

efficiency. Training should occur in an unstable environment in which an

individual can still safely control movements.

Individuals with altered neuromuscular control likely have specific kinetic

chain imbalances.These affect the quality of movement, create faulty movement

patterns and lead to lowered neuromuscular efficiency.This may contribute to

synergistic dominance, which can cause joint dysfunction and pain elsewhere.

Joint dysfunction creates muscle inhibition, which alters balance and leads to

tissue overload and injury.

The majority of fitness clients have decreased neuromuscular efficiency

and problems with balance.

MODULE 9-2 Quiz

1. Joint dysfunctions, pain and swelling can lead to altered balance.

True False

2. When the body stabilizes a joint during movement, it is known as what?

3. Joint dysfunction may lead to:

Synergistic dominance

Muscle inhibition

Decreased neuromuscular control

All of the above

4. A training environment should be as unstable as possible.True False


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MODULE 9-3:

Designing a Balance Training Program

Balance Training Design Parameters

A balance-training program is a vital component of any integrated training

program. It ensures optimum neuromuscular efficiency of the entire kinetic

chain.The program must be systematic and progressive.1,2 Fitness professionals

must follow specific program guidelines, proper exercise selection criteria and

detailed program variables (Figure 9-3).1,2

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Exercise Selection

Safe

Progressive

Easy to hard Simple to complex Known to unknown Stable to unstable Static to dynamic Slow to fast Two-arm/leg to

single-arm/leg Eyes open to eyes closed

Systematic Stabilization Strength Power

Proprioceptivelychallenging

Floor Balance beam Half foam roll Airex pad

Dyna Disc

Variables

Plane of motion Sagittal Frontal Transverse

Range of motion

Full Partial End-range

Multisensory Half foam roll Reebok Core Board Airex pad Dyna Disc BOSU

Type of resistance

Body position

Two-leg Staggered-stance Single-leg Multiposition

Upright

30

45

75

90

Speed of motion

Duration

Frequency

Amount of feedback

Figure 9-3: Program Design Parameters for Balance Training

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Levels of Balance Training

There are three levels of training within the OPT model: stabilization,

strength and power (Figure 9-5).A proper balance-training program follows the

same systematic progression.

Stabilization Level

In balance-stabilization training, exercises involve little joint motion.They

are designed to improve reflexive joint stabilization contractions to increase

joint stability.1,2 This means that when the body is placed in unstable

environments, it must react by contracting the right muscles at the right time

to maintain balance. Exercises in this level include:

Single-leg Balance

Single-leg Hip Internal and External Rotation

Single-leg Hip Flexion and Extension

Single-leg Balance Reach

Single-leg Rotation

Single-leg Lift and Chop


Figure 9-4: The OPTTM Model

Phase 1

Phase 2

Phase 3

Phase 4

Phase 5

Phase 6

Phase 7

STABILIZATION

STRENGTH

POWER

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Single-leg Balance

Preparation

1. Stand with feet shoulder-width apart and pointedstraight ahead. Hips should be in a neutral position.

2. Lift chest, retract shoulders slightly and tuck chin.

Movement3. Draw abs in and activate glutes.

4. Lift one leg directly beside balance leg.Dorsiflex toe,

flex hip at a 90-degree angle and slightly flex knee.

Maintain optimal alignment, including level hips and

shoulders.

5. Hold for five to 20 seconds.

6. Slowly return to original position.

7. Switch legs and repeat as instructed.

Single-leg Hip Flexion and Extension

Preparation1. Stand with feet shoulder-width apart and pointed

straight ahead. Hips should be in a neutral position.






shoulders.

5. Slowly flex and extend hip of lifted leg,holding each

end position for two seconds.



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Start

Finish

Start

Finish

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Single-leg Balance Reach (Sagittal, Frontal and Transverse)

Preparation

1. Stand with feet shoulder-width apart and pointed straight ahead. Hips should be in aneutral position.



4. Lift one leg directly beside balance leg. Dorsiflex toe, flex hip at a 90-degree angle and

slightly flex knee.Maintain optimal alignment, including level hips and shoulders.

5. Move lifted leg to the front of the body (sagittal).Hold for two seconds.


7. Move lifted leg to the side of the body (frontal).Hold for two seconds.


9. Externally rotate balance hip and move lifted leg to the rear of the body (transverse).

Hold for two seconds.

10.Slowly return to original position.

11.Switch legs and repeat as instructed.


Sagittal Start

Frontal Start

Transverse Start

Sagittal Finish

Frontal Finish

Transverse Finish

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Single-leg Lift and Chop

Preparation


2. Hold medicine ball (between five and 10 percent of

body weight) in extended hands.






shoulders.

6. Extend arms so that hands are at the outside of the

balance leg.

7. Lift medicine ball in a diagonal pattern, rotating the

body using hips, abs and glutes until medicine ball is

overhead.Hold for two seconds.



Start

Movement

Finish

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Strength Level

In balance-strength training, exercises involve more dynamic eccentric and

concentric movement of the balance leg,through a full range of motion.Movements

require dynamic control in mid-range of motion,with isometric stabilization at the

end-range of motion.The specificity, speed and neural demand are progressed in

this level.These exercises are designed to improve the neuromuscular efficiency of

the entire kinetic chain.1,2 Exercises in this level include:

Single-leg Squat

Single-leg Squat Touchdown

Single-leg Romanian Deadlift

Lunge to Balance

Step-up to Balance


Single-leg Squat



2. Lift chest, retract shoulders slightly, tuck chin and

place hands on hips.


4. Lift one leg directly beside balance leg. Dorsiflex toe,

flex hip at a 90-degree angle and slightly flex knee.Maintain optimal alignment, including level hips and

shoulders.

5. Slowly squat as if sitting in a chair. Lower to first

point of compensation. Hold for two seconds.

6. Slowly stand upright but pushing through heel, using

abs and glutes.


Start

Movement

Finish

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Single-leg Squat Touchdown

Preparation








shoulders.

5. Slowly squat as if sitting in a chair, reaching hand

opposite of balance leg toward lower foot and

keeping chest lifted.

6. Lower to first point of compensation.Hold for two

seconds.

7. Slowly stand upright but pushing through heel, using

abs and glutes.


Single-leg Romanian Deadlift









shoulders.

5. Slowly reach hand toward stabilizing foot.

6. Lower to first point of compensation.Hold for two

seconds.7. Slowly stand upright,using abs and glutes.


Start

Finish

Start

Finish

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Lunge to Balance


straight ahead. Hips should be in a neutral position.2. Lift chest, retract shoulders slightly, tuck chin and



4. Lunge forward, landing on the heel of lunge foot with

toes pointed straight ahead and knee directly over

the toes.Both knees should be bent at 90-degree

angles. The front foot should be flat and the back

heel should be lifted.

5. Stabilize.

6. Push off of front foot through heel onto back leg,

straightening balance leg and lifting opposite leg so

that hip and knee are flexed at 90-degree angles with

foot dorsiflexed.

7. Switch sides and repeat as instructed.

Start

Movement

Finish

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Step-up to Balance

Preparation1. Stand in front of a box or platform (between six and

18 inches) with feet shoulder-width apart and pointedstraight ahead. Hips should be in a neutral position.



4. Step onto box with one leg, keeping toes pointed

straight ahead and knee directly over the toes.

5. Push through front heel and stand upright, balancing

on one leg, lifting opposite leg so that hip and knee

are flexed at 90-degree angles with foot dorsiflexed.

6. Stabilize.

7. Return lifted leg to the ground, keeping toes and

knees aligned.


Power Level

Start

Finish

In balance-power training, exercises are designed to develop high levels of

eccentric strength, dynamic neuromuscular efficiency and reactive joint

stabilization.1,2 Exercises in this level include:

Multiplanar Hop with Stabilization

Sagittal Plane Hop with Stabilization

Frontal Plane Hop with Stabilization

Transverse Plane Hop with Stabilization

Single-leg Box Hop-up with Stabilization

Single-leg Box Hop-down with Stabilization

Single-leg Hop with Stabilization

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Multiplanar Hop with Stabilization

(Sagittal, Frontal and Transverse)

Preparation

1. Stand with feet shoulder-width apart and pointed straight ahead. Hips should be in aneutral position.



4. Lift one leg directly beside balance leg. Dorsiflex toe, flex hip at a 90-degree angle and

slightly flex knee.Maintain optimal alignment, including level hips and shoulders.

5. Hop forward (sagittal), landing on opposite foot. Stabilize and hold for two to four seconds.

6. Hop backward (sagittal), landing on opposite foot in starting position.Stabilize and hold

for two to four seconds.


8. Use the same format to move in frontal and transverse planes,hopping in a side-to-side

or turning manner.

Sagittal Start

Frontal Start

Transverse Start

Sagittal Finish

Frontal Finish

Transverse Finish

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Single-leg Box Hop-up with Stabilization

Preparation1. Stand in front of a box or platform (between six and

18 inches) with feet shoulder-width apart and pointedstraight ahead. Hips should be in a neutral position.






shoulders.

5. Using arms, jump up and land on top of box, keeping


the toes.Stablize.Hold for two to four seconds.

6. Step off box, keeping toes and knees aligned.


8. Use the same format to hop in the frontal and

transverse planes.

Single-leg Box Hop-down with Stabilization

Preparation1. Stand on a box or platform (between six and 18

inches) with feet shoulder-width apart and pointed

straight ahead. Hips should be in a neutral position.2. Lift chest, retract shoulders slightly and tuck chin.





shoulders.

5. Using arms, jump off box and land on ground,keeping


the toes.Stablize.Hold for two to four seconds.

6. Step onto box, keeping toes and knees aligned.7. Switch sides and repeat as instructed.

8. Use the same format to hop in the frontal and

transverse planes.

Start

Finish

Start

Finish

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Single-leg Hop with Stabilization


straight ahead. Hips should be in a neutral position.2. Lift chest, retract shoulders slightly and tuck chin.


4. Lift one leg directly beside balance leg. Dorsiflex toe,



shoulders.

5. Squat slightly as if sitting in a chair.

6. Jump up, extending arms overhead.

7. Land softly, maintaining optimal alignment and

returning arms to sides. Stabilize and hold for two

to four seconds.


Start

Finish

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MODULE 9-3 Summary

A balance-training program is designed to ensure optimum neuromuscular

efficiency of the entire kinetic chain. Balance training programs must be

systematic and progressive, following specific program guidelines, proper

exercise selection criteria and detailed program variables.

A proper balance-training program follows the same systematic

progression as the OPT model: stabilization, strength and power levels of

training. Exercises in the stabilization level of balance training do not involve

much joint motion and improve joint stability. In the strength level of balance

training, the balancing leg moves dynamically through a full range of motion,

with exercises that require greater specificity, speed and neural demand.These

movements require isometric stabilization at the end-range of motion. They

improve neuromuscular efficiency of the entire kinetic chain. Exercises in the

power level of balance training improve high levels of eccentric strength,

dynamic neuromuscular efficiency and reactive joint stabilization.

MODULE 9-3 Quiz

1. Which guidelines must be taken into consideration when designing

a balance training program?

Proprioceptively challenging

Isolated

Systematic

Unrelated to activities

Creative

Progressive

2. In the stabilization level of balance training, exercises involve little joint

motion to _____________ joint stability.

Increase

Decrease

3. Match the exercises to either stabilization, strength or power levels

of training:

Single-leg Balance:_____________________

Single-leg Hop with Stabilization:_____________________

Single-leg Squat:_____________________

Lunge to Balance:_____________________

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MODULE 9-4:

Implementing a Balance Training Program

Balance Training Design Parameters

Implementing a balance-training program requires that fitness

professionals follow the progression of the OPT model. For example, if a

client is in the stabilization level of training (Phase 1 or 2), select balance-

stabilization exercises. For a client in the strength level of training (Phase 3, 4

or 5), the fitness professional should select balance-strength exercises. For an

advanced client in the power level of training (Phase 6 or 7), select balance-

power exercises (Table 9-2).

Filling in the Template

To fill in the program template, go to the section labeled Core and Balance.You will then refer to Table 9-2 for the appropriate type of balance exercise

(stabilization, strength or power), the appropriate number of balance exercises

OPT Number of Level Phase(s) Exercise Exercises Sets Reps Tempo Rest

Stabilization 1 Balance 1-4 1-3 10-20 3-10 sec 0-902 Stabilization (or single-leg hold sec.

6-10 each)

Strength 3 Balance 0-4 2-4 8-12 3/2/1 - 0-604 Strength 1/1/1 sec.5

Power 6 Balance 0-3 2-4 8-12 Controlled. 0-90

Power Hold sec.stabilizationposition for3-5 seconds.

7 Included in resistance-training portion of workout.

Table 9-2: Balance Training Program Design

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Figure 9-5: OPTTM Template

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and the appropriate acute variables specific to the phase of training your client

will be working in (1-7).

MODULE 9-4 Summary

To choose the right exercises when designing a program, follow the

progression of the OPT model. In the stabilization level, choose one to four

balance-stabilization exercises. In the strength level,select zero to four balance-

strength exercises (optional in Phases 4 and 5). In the power level, pick from

zero to three balance-power exercises.

MODULE 9-4 Quiz

1. What kind of exercises would you choose for a client in Phase 3 of the

OPTTM model?

2. What is the optimal tempo for a single-leg balance reach?

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