The key lumbar spine muscles include the transversospinalis group, erector spinae,
quadratus lumborum, and latissimus dorsi
The transversospinalis group includes the rotatores,interspinales, intertransversarii,
semispinalis, and multifidus. These muscles are small and have a poor mechanical advantage
for contributing to motion. They contain primarily type I muscle fibers and are therefore designed
mainly for stabilization.It has been established that this group is primarily responsible for
providing the CNS with proprioceptive information. This group is also responsible for inter or
intra segmental stabilization and segmental eccentric deceleration of flexion and rotation of the
spinal unit during functional movements.
The multifidus is the most important of the transversospinalis muscles. Ithas the ability to
provide intrasegmental stabilization to the lumbar spine in all positions. Wilke et al. found
increased segmental stiffness at L4-L5 with activation of the multifidus.
The quadratus lumborum functions primarily as a frontal plane stabilizer that works
synergistically with the gluteus medius and tensor fascia lata.
The latissimus dorsi has the largest moment arm of all back muscles and therefore has the
greatest effect on the lumbo-pelvic-hip complex. The latissimus dorsi is the bridge between the
upper extremity and the lumbo-pelvic-hip complex.
The abdominals are made up of four muscles: rectus abdominus, external oblique, internal
oblique, and most importantly, the transversus abdominus (TA).When working efficiently, the
abdominals offer sagittal,frontal, and transversus plane stabilization by controlling forces that
reach the lumbo-pelvic-hip complex.
The rectus abdominis eccentrically decelerates trunk extension and lateral flexion, as well as
providing dynamic stabilization during functional movements.
The key abdominal muscles include the rectus abdominus, external oblique, internal oblique,
and transversus abdominus (TA)
The key hip musculature includes the gluteus maximus, gluteus medius, and psoas
A gymnast has been having low back pain. She is otherwise a very fit and healthy athlete.
You suspect that her pain might be disc related. How might core weakness be
contributing to her problem, and how can core strengthening benefit her? 5.1
● Decreased stabilization endurance in individuals with low back pain with decreased firing
of the transversus abdominis, internal oblique, multifidus, and deep erector spinae.
Training without proper control of these muscles can lead to improper muscle
imbalances and force transmission. Poor core stability can lead to increased intradiscal
pressure. Core training will improve the gymnast’s posture, muscle balance,and static
and dynamic stabilization.
Last year a tennis player suffered a knee injury. She tore her ACL, MCL, and meniscus.
She is competing now but complains of recurrent back pain. She has rather poor posture
and significant postural sway. Could she benefit from core training, and how would you
go about selecting exercises for her? 5.2
● It could be that she has poor postural control because of a weak core. She probably
never regained neuromuscular control of her core following the knee injury. Tennis
requires a lot of upper-body movement, so she would probably benefit from core
strengthening that would allow her to control her lumbo-pelvic-hip complex while she
plays. In choosing her exercises, you should make sure that they are safe and
challenging and stress multiple planes that are functional as they are applied to tennis.
The exercises should also be proprioceptively enriched and activity-specific.
As part of a preparticipation screening you want to look for athletes who may be prone to
low back pain. What evaluative test can you use to do this? 5.3
● Individuals with poor core strength are likely to develop low back pain due to
improper muscle stability. The straight leg-lowering test is a good way to
assess core strength. The athlete should lie supine on a table with hips flexed
to 90 degrees and lower back completely flat against the table. To decrease the
lordotic curve, instruct the patient to perform a drawing-in maneuver. The patient
then lowers the legs slowly to the table. The test is over when the back starts to
arch off of the table. A blood pressure cuff can be used under the low back to
observe an increase in the lordotic curve. Someone with a weak core will not be
able to maintain the flattened posture for very long while lowering the legs.
You have had a track athlete on a core stabilization program for several weeks. She has
been progressing well but needs a different challenge. What can you do to change up her
program? 5.4
● Change her program frequently. Consider these variables as you plan changes: plane of
motion, range of motion, loading parameter (Physioballs, tubing, medicine balls, body
blades, etc.), body position (from supine to standing), speed of movement, amount of
control, duration (sets and reps), and frequency.
You have been training a softball player on a core strengthening program for a week. She
has been making improvements, and you think that it is time to progress her. What is
your goal, and what parameters should you consider when progressing her? 5.5
● Your ultimate goal with core strengthening is functional strength and dynamic
stability. As the athlete progresses, the emphasis should change in these ways: from
slow to fast, from simple to complex,from stable to unstable, from low force to high force,
from general to specific, and from correct execution to increased intensity. Once the
patient has gained awareness of proper muscle firing, encourage her to perform her
exercises in a more functional manner.Because activities in most sports require
multiplane movement, design her exercises to mimic those requirements.
A golfer has been out of activity for several weeks following a latissimus dorsi strain. As
part of his rehabilitation program, you have been progressing him through a core
strengthening program. Describe a level 4 exercise that would be ideal for him. 5.6
Dynamic PNF with a power ball would be ideal for him. The ball will provide a loading
parameter, and his range of motion will be functional for the demands of his sport. Adding a
twisting component is important so that he is not just training in a single plane of motion prior to
swinging his club.
SUBJECTIVE ASSESSMENT OF BALANCE
The assessment of static balance in athletes has traditionally been performed through the use
of the standing Romberg Test. This test is performed standing with feet together,arms at the
side, and eyes closed. Normally a person can stand motionless in this position, but the tendency
to sway or fall to one side is considered a positive Romberg’s sign indicating a loss of
proprioception.
The Romberg Test has, however, been criticized for its lack of sensitivity and objectivity. It is
considered to be a rather qualitative assessment of static balance because a considerable
amount of stress is required to make the subject sway enough for an
observer to characterize the sway. The use of a quantifiable clinical test battery called the
Balance Error Scoring System (BESS) is recommended over the standard Romberg test.
Three different stances (double, single, and tandem) are completed twice,once while on a firm
surface and once while on a piece of medium density foam (balance pad by Airex is
recommended) for a total of six trials. Patients are asked to assume the required stance by
placing their hands on the iliac crests and upon eye closure, the 20-second test begins. During
the single leg stances, subjects are asked to maintain the contralateral limb in 20–30 degrees of
hip flexion and 40–50 degrees of knee flexion.
Semidynamic and dynamic balance assessment can be performed through functional-reach
tests, timed agility tests such as the figure eight test,carioca, or hop test, Bass Test for Dynamic
Balance, timed “T-Band kicks,” and timed balance beam walking with the eyes open or closed.
The objective in most of these tests is to decrease the size of the base of support, in an attempt
to determine a patient’s ability to control upright posture while moving.
OBJECTIVE ASSESSMENT OF BALANCE
INJURY AND BALANCE
Research has revealed these impairments in individuals with ankle injury 23,31,69 and anterior
cruciate ligament (ACL) injury. The lack of proprioceptive feedback resulting from such injuries
may allow excessive or inappropriate loading of a joint. Furthermore, although the presence of a
capsular lesion may interfere with the transmission of afferent impulses from the joint, a more
important effect may be alteration of the afferent neural code that is conveyed to the CNS.
Decreased reflex excitation of motor neurons may result from either or both of the following
events: (a) a decrease in proprioceptive input to the CNS;and (b) an increase in the activation of
inhibitory interneurons within the spinal cord. All of these factors may lead to progressive
degeneration of the joint and continued deficits in joint dynamics, balance, and coordination.
BALANCE TRAINING
Developing a rehabilitation program that includes exercises for improving balance and
postural equilibrium is vital for a successful return to competition from a lower extremity injury.
Regardless of whether the patient has sustained a quadriceps strain or an ankle sprain, the
injury has caused a disruption at some point between the body’s COG and base of support. This
is likely to have caused compensatory weight shifts and gait changes along the kinetic chain
that have resulted in balance deficits. These deficits may be detected through the use of
functional assessment tests and/or computerized instrumentation previously
Because virtually all sport activities involve closed- chain lower extremity function, functional
rehabilitation should be performed in the closed kinetic chain. However, ROM, movement
speed, and additional resistance may be more easily controlled in the open chain initially. There-
fore, adequate, safe function in an open chain may be the first step in the rehabilitation process,
but should not be the focus of the rehabilitation plan.
The exercises must be safe, yet challenging.
• Stress multiple planes of motion.
• Incorporate a multisensory approach.
• Begin with static, bilateral, and stable surfaces and prog-
ress to dynamic, unilateral, and unstable surfaces.
• Progress toward sport-specific exercises.
There are several ways in which the athletic trainer can meet these goals. Balance exercises
should be performed in an open area, where the patient will not be injured in the event of a fall.
It is best to perform exercises with an assistive device within an arm’s reach (e.g., chair, railing,
table,wall), especially during the initial phase of rehabilitation.When considering exercise
duration for balance exercises,the athletic trainer can use either sets and repetitions or a
time-based protocol. The patient can perform 2–3 sets of 15 repetitions and progress to 30
repetitions as tolerated, or perform 10 of the exercises for a 15-second period and progress to
30-second periods later in the program.
PHASE 1
The progression of activities during this phase should include non-ballistic types of drills.
Training for static balance can be initiated once the patient is able to bear weight
on the extremity. The patient should first be asked to perform a bilateral 20-second
Romberg test on a variety of surfaces, beginning with a hard/firm surface.
Once a comfort zone is established, the patient should be progressed to performing
unilateral balance tasks on both the involved and uninvolved extremities on a stable
surface.The athletic trainer should make comparisons from these tests to determine the
patient’s ability to balance bilaterally and unilaterally.It should be noted that even though
this is termed static balance, the patient does not remain perfectly motionless. In order
to maintain static balance, the patient must make many small corrections at the ankle,
hip, trunk, arms, or head. If the patient is having difficulties performing these activities,
they should not be progressed to the next surface. Repetitions of modified Romberg
tests can be performed by first using the arms as a counterbalance, then attempting the
activity without using the arms.Static balance exercises should be used as a precursor
to more dynamic activities. The general progression of these exercises should be from
bilateral to unilateral, with eyes open to eyes closed. The exercises should attempt to
eliminate or alter the various sensory information (visual, vestibular, and
somatosensory) in order to challenge the other systems. In most orthopedic
rehabilitation situations, this is going to involve eye closure and changes in the support
surface so the somatosensory system can be overloaded or stressed.
Although static and semidynamic balance exercises may not be very functional for
most sport activities, they are the first step toward regaining proprioceptive
aware-
ness, reflex stabilization, and postural orientation. The patient should attempt to
assume a functional stance while performing static balance drills. Training in different
positions places a variety of demands on the musculotendinous structures about the
ankle, knee, and hip joints.For example, a gymnast should practice static balance
with the hip in neutral and external rotation, as well as during a tandem stance to mimic
performance on a balance beam. A basketball player should perform these drills
in the “ready position” on the balls of the feet with the hips and knees slightly flexed.
PHASE 2
This phase should be considered the transition phase from static to more dynamic
balance activities. Dynamic balance will be especially important for patients
who perform activities such as running, jumping, and cutting, which encompasses about
95 percent of all athletes. Such activities require the patient to repetitively lose and gain
balance to perform their sport without falling or becoming injured. Dynamic balance
activities should only be incorporated into the rehabilitation program once sufficient
healing has occurred and the patient has adequate ROM, muscle strength, and
endurance.This could be as early as a few days post-injury in the case of a grade 1
ankle sprain, or as late as 6 weeks post-surgery in the case of an anterior cruciate
reconstruction. Before the athletic trainer progresses the patient to challenging dynamic
and sport-specific balance drills, several semidynamic (intermediate) exercises should
be introduced.
PHASE 3
Ready to perform more dynamic and functional types of exercises. The general
progression for activities to develop dynamic balance and control is from slow-speed to
fast-speed activities, from low-force to high-force activities, and from controlled to
uncontrolled activities. In other words, the patient should be working toward
sport-specific drills that will allow for a safe return to their respective sport or activity.For
example drills to improve lateral weight shifting and sidestepping should be incorporated
into a program for a tennis player, while drills to improve jumping and landing are going
to be more important for a track athlete who performs the long jump. As previously
mentioned, the athletic trainer often needs to use his or her imagination to develop the
best protocol for their patient.Bilateral jumping drills are a good place to begin once the
patient has reached Phase III. The patient should begin with jumping or hopping onto a
step, or performing butt kicks or tuck jumps, and quickly establishing a stabilized
position.At this stage of the rehabilitation, pain and fatigue should not be as much of a
factor.All jumping drills performed bilaterally should now be performed unilaterally, by
practicing first on the uninvolved extremity. If additional challenges are needed, a
vertical component can be added by having the patient jump over an object such as a
box or other suitable object. Sonra da gözler kapalıya geçiş yapılabilir.
Another good exercise to introduce prior to advancing to Phase III is a balance beam
walk, which can be performed against resistance
DUAL-TASK BALANCE TRAINING AND ASSESSMENT
Therefore, a final progression for patients recovering from musculoskeletal injury or
neurological injury (i.e., concussion) could be the addition of competing
motor/coordination and cognitive tasks to assess the patient’s performance with these
challenges.
A gymnast recovering from a grade 1 MCL sprain to her right knee is ready to begin her
rehabilitation. What factors must first be considered prior to designing her balance
exercise program and progression? 7-2
The athletic trainer should first ensure that the patient has the necessary pain-free ROM and
muscular strength to complete the tasks that are being incorporated into the program.
Additionally, for exercises beyond the phase 1 static exercises, the patient must be beyond the
acute inflammatory phase of tissue response to injury. Once these factors have been
considered, the athletic trainer should focus on developing a protocol that is safe yet
challenging, stresses multiple planes of motion, and incorporates a multisensory approach.
How can the athletic trainer determine whether a patient is ready to progress to a more
challenging balance task and/or balance surface?
It should be explained to the patient, at the outset, that the goal is to challenge her or his motor
control system, to the point that the last two repetitions of each set of exercises should be
difficult to perform.When the last two repetitions no longer are challenging to the athlete, he or
she should be progressed to the next exercise. This can be determined through
subjective information reported from the athlete, as well as the athletic trainer’s objective
observations.It is very important to provide a variety of exercises.
A basketball player has been complaining of feeling pain and laxity upon landing from a
rebound. He has no swelling or other signs of an acute injury. What exercises
should be introduced to help improve the stability?
This patient most likely has a functionally unstable ankle. Research has shown that balance
exercises can help improve functional ankle instability. In this situation, the athletic trainer
probably can skip phase 1 exercises and move directly to phase 2 and 3 exercises. The athletic
trainer should design a program that incorporates challenging unilateral multidirectional
exercises involving a multisensory approach (eyes open and eyes closed). The progression
should include the progression suggested in this chapter that includes the foam, Bosu Balance
Trainer, Dynadisc, BAPS board, Extreme Balance Board, balance beam, and Balance Shoes.
Lateral and diagonal hopping exercises will also be a vital part of this protocol.
The goal should be to help strengthen the dynamic and static stabilizers surrounding the
ankle joint. This should result in rebuilding some of the afferent pathways and ultimately
improving ankle joint stability.
+Is the postural control affected by this situation? Which factors are related to the
postural control problem for the athlete in this situation????
Yes, the basketball player's postural control may be affected by the symptoms
described. When he complains of feeling pain and laxity upon landing from a rebound, it
indicates that his proprioception and neuromuscular control might be compromised.
Several factors related to postural control problems for the athlete in this situation could
be:
1. Ankle Stability: The athlete might be experiencing laxity due to weakened ankle
stabilizing muscles or ligament laxity, affecting his ability to maintain balance
upon landing.
2. Proprioception: Any pain or laxity upon landing suggests an impairment in
proprioception, which is the body's ability to sense the position, location,
orientation, and movement of the body and its parts. Impaired proprioception can
lead to instability and difficulty maintaining balance.
3. Muscle Strength and Control: Weakness or imbalance in the muscles around the
ankle, knee, or hip can affect the athlete's ability to stabilize himself upon landing.
4. Neuromuscular Control: Any pain experienced upon landing can disrupt the
neuromuscular control needed to maintain balance and stability.
5. Previous Injury: If the athlete has had previous ankle or knee injuries, it could
have left residual weakness or altered neuromuscular control, predisposing him
to further injury and affecting postural control.
What type of balance exercises would best meet the needs of a tennis player recovering
from a grade 2 anterior talo-fibular sprain?
It will be important for the athletic trainer to begin slowly with phase 1 and 2 balance exercises
to determine the patient’s readiness to move into more dynamic tasks as part of phase 3.
A tennis player competing at a high level will need to perform a lot of lateral movement along
the baseline, therefore necessitating the inclusion of dynamic balance exercises and weight
shifts in the frontal plane.
Why does an ankle injury affect balance? Why does a knee injury affect balance?
Does a shoulder injury affect balance?
1. Ankle Injury:
● Ankle injuries, such as sprains or strains, can affect balance because the
ankle plays a significant role in proprioception and stability.
● Proprioception is the body's ability to sense its position, motion, and
equilibrium. Ligaments, tendons, and muscles around the ankle joint
contribute to proprioception.
● When the ankle is injured, the proprioceptive feedback to the brain is
disrupted, leading to decreased balance and stability.
2. Knee Injury:
● Knee injuries, such as ligament tears or meniscus injuries, can also affect
balance.
● The knee joint plays a crucial role in weight-bearing and stability during
movements such as walking, running, and jumping.
● A knee injury can lead to weakness, pain, and instability, affecting the
athlete's ability to maintain balance and control body movements.
3. Shoulder Injury:
● While shoulder injuries may not directly affect balance to the same extent
as ankle or knee injuries, they can still impact overall stability and posture.
● The shoulder plays a role in overall body alignment and posture.
● Severe shoulder injuries or chronic shoulder pain can affect an athlete's
ability to maintain proper posture, which may indirectly affect balance.
ANKLE STRATEGY
Shifts CoG by maintaining feet & rotating body at a rigid mass about the ankle joints
Gastrocnemius or tibialis anterior are responsible for torque production in ankle
If the ankle strategy is not capable of controlling excessive sway the hip strategy is available to
control the motion of the COG and the initiation of significant and rapid motions at the hip joints
with anti-phase of the rotation.
HIP STRATEGY
Relied upon more heavily when a somatosensory loss occurs & forward/backward perturbations
are imposed or support surface lengths are altered.
Aids in control of motion through the initiation of large & rapid motions at the hip with anti-phase
rotation.
STEPPING STRATEGY
Utilized when CoG is displaced beyond * LOS (a position safer limit of stability)
Step or stumble/losing balance - is utilized to prevent a fall
