Regaining Postural Stability and Balance

Muscular weakness, proprioceptive
deficits, and range of motion deficits
may challenge a persons ability to
maintain their center of gravity (COG)
› May lead to loss of balance
 Balance is the single most important
element dictating movement strategies
 Dynamic process involving multiple
neurological pathways
Joint position sense , proprioception, and
kinesthesia are vital to all athletic
performance requiring balance
Ability to balance and maintain postural
stability is essential to an athlete who is
acquiring or reacquiring complex motor
Complex process involving sensory and
motor components
Most daily activities such as, walking,
climbing stairs, throwing a ball, require
static foot placement with controlled
balance shifts
Balance should be considered both a
static and dynamic process
Impaired balance is a result of one or a
combination of two reasons
› Position of COG relative to base of support is
not accurately sensed
› Automatic movements required to bring
COG to a balanced position are not timely
or effectively coordinated
Position of the body in relation to gravity
and its surroundings is sensed by combining
visual, vestibular and somatosensory
 Balanced movements also involve motions
of the ankle, knee, and hip joints
› Primary mechanisms for controlling balance
occur in joints of the lower extremity
Postural control system operates as a
feedback control circuit between brain
and the musculoskeletal system
Mechanoreceptors transmit messages to
brain through sensory nerves in spinal
› Helps to control proprioception or body/joint
Provides information concerning the
orientation of body parts to one another
and to the support surface
Balance is the process of maintaining the
COG within the body's base of support
 Within kinetic chain each moving
segment transmits forces to every other
segment along chain
› Maintaining equilibrium or balance is
associated with injuries along the closed
kinetic chain
 Injuries to any one of the joints or corresponding
muscles along kinetic chain can result in loss of
appropriate feedback for maintaining balance
Human body is a tall structure on a
relatively small base
› COG is quite high, just above pelvis
Somatosensory input is preferred sense
for balance
› i.e. : feet in contact with support surface
and detection of joint movement
Visual input
› Measures orientation of the eyes and head in
relation to surrounding objects
› If eyes are closed balance becomes more
Vestibular input
› Sensory system that is leading contributor to
response to movement and sense of balance
› Sends signals, primarily to neural structures that
control our eye movement, and to muscles that
keep us upright
Proprioception: ability to determine the
position of a joint in space
Kinesthesia: ability to detect movement
› Mediated by mechanoreceptors found in
muscle and joints and by cutaneous, visual
and vestibular input
Joint mechanoreceptors
› Found in ligaments, capsules, menisci,
labra and fat pads
 Sensitive to change in shape of joint
structures and rate and direction of
movement of joint
 Most active at end ranges of motion
Muscle mechanoreceptors
› Found in muscles and tendons
 Muscle spindles and Golgi Tendon
 Muscle spindles sensitive to
changes in length of muscle
 Golgi tendon organs sensitive to
changes in tension
Subjective Assessments: Romberg's &
Balance Error Scoring System (BESS)
Romberg's test
› Feet together, arms out to side, and eyes
› Positive test: sway or fall to one side
› indicates loss of proprioception
Balance Error Scoring System (BESS)
› 3 stances: double , single, and tandem
 Completed 2 x each: Once on firm
surface and once on unstable surface
(Foam pad)
 Total of 6 trials
 Hands on iliac crest and eyes closed
 In SL ex. Non stance leg held at 20-30
degrees hip flexion and 40 to 50
degrees of knee flexion
BESS Assessment Continued
 20 second test begins when eyes close
 Single leg stance on non-dominant leg
(NDL) and NDL is in the rear for tandem
 Upon losing balance athlete returns to
testing position as quickly as possible
Balance Error Scoring System (BESS)
› Scoring
 1 point added for each error that occurs
Hands lifted off iliac crest
Opening eyes
Step, stumble or fall
Moving hip into > 30 degrees of flexion or Abduction
Lifting forefoot or heel
Remaining out of testing position >5 seconds
 Higher scores represent poor balance
Dynamic balance test include functional
reach test, timed agility, figure 8’s,
carioca, or hop test
› Ability to maintain upright posture while
Advancements in technology have
provided equipment to quantitatively
assess and train dynamic balance
› Mostly computer -interfaced force- plate
› Potential to assess possible abnormalities
that might be associated with injury and
help create appropriate training
Stretched or damaged ligaments may
fail to provide adequate neural
› May contribute to decreased proprioceptive
mechanisms, and thus decreased balance
› Increased postural sway and balance
instability contributed to neurological factors
and biomechanical factors after injury
Rehab program, especially for lower
extremities must include exercises to
improve balance and postural
› Any injury can cause disruption at some
point between COG and base of support
› If neglected can lead to reinjury, decreased
performance, or other injuries
5 general rules
› Safe, yet challenging
› Stress multiple planes of motion
› Incorporate multisensory approach
› Begin with static, bilateral stable surface and
progress to dynamic, unilateral, and
unstable surface
› Progress toward sport specific activity
Balance Exercises
› Static: COG maintained over fixed base of
support while on stable surface
› Semi-dynamic:
 Maintain COG over fixed base on moving
support or unstable surface
 Person transfers their COG over a fixed base of
support on stable surface through range
and/or directions
Balance Exercises
› Dynamic: maintenance of COG over
moving base of support
 Usually stable surface, but could be unstable
 Base of support always changing position so
COG is forced adjust with each movement
› Functional
 Same as dynamic, but add sport specific tasks
Phase I
› Can be initiated once athlete can bear weight
on the extremity
Static, non ballistic exercise
Hard firm surface
Bilateral to unilateral (double leg to single leg)
Eyes opened to eyes closed
Progress to unstable surface, perturbations (taps
or movement)
 Overload or stress somatosensory system
Phase II
› Transition of static to semi-dynamic & dynamic ex.
 Important for running, jumping, and cutting
 Progress only if sufficient healing has occurred
and ROM, muscle strength and endurance is
 Balance through movement
 Controlled hip and knee flexion and smooth
return to stabilization position
 Progress to added resistance and more
difficult movement patterns
Phase III
› Dynamic & Functional exercises
 Slow speed to fast speed
 Low force to high force
 Controlled to uncontrolled activities
› Jumping or hopping activities
 Bilateral to unilateral
 Single plane to multi-plane
 Exercises may differ between athletes
 Be sport specific
Balance and postural stability critical to
athletic performance and injury prevention
 A rehabilitation program must include
functional exercises that incorporate
balance and proprioceptive training
› Prepare athlete for return to activity
› Failure address balance problems may
predispose athlete to reinjury and injury
› Use imagination, be creative
› Use sport specific tasks