Posts tagged balance
Improved Glut Muscle Activation Noted with TRX Lunge vs. Traditional Lunge

Performing traditional strength training movements with an added component of instability has long been know to change the recruitment of muscles.  The unstable nature of the exercise enhances position sense (proprioception), balance, and joint stabilization during each repetition.  Previous research recommends using stable surfaces and exercises when the goal is optimal strength and power development.  In contrast, utilizing unstable surfaces is appropriate for joint stabilization, injury risk reduction, and more sport specific demands.

Krause and colleagues examined the muscle recruitment patterns between a traditional and suspension lunge exercise (Int J Sports Phys Ther. 2018).  The authors analyzed lower body muscle recruitment during the movements.  They found greater recruitment of the gluteus medius and maximum, as well as, hip adductors in the suspended lunge compared to the traditional lunge.  Surprisingly, they found no difference in quadriceps recruitment between the two conditions.  The increased hip recruitment demonstrates the increased stability requirements during the suspension lunge.  

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Slosh Tubes vs. Barbell Utilization During Back Squat

The back squat is one of the most efficient and effective exercises for lower quarter strength development.  This exercise can be performed with dumbbells, barbell, or a slosh tube.  Slosh tubes are a recent addition to resistance training equipment made up of a PVC pipe filled up to 1/4 to 1/2 with either water or sand.  The movement of the water or sand creates a higher demand on our core muscles and balance system.  A recent study highlights the benefits of using a slosh tube for weight training exercises.

Ditroilo studied elite Gaelic footballers under 4 squat conditions: barbell eyes open, barbell eyes closed, slosh tube eyes open, and slosh tube eyes closed (J Sports Sci. 2018).  Authors used EMG to study the activation levels of abdominal and low back musculature as well as a force platform during each trial.  The authors found increased oblique and multifidus recruitment under the slosh tube condition.  They concluded utilization of the slosh tube elicited greater levels of core muscle activation as well as a greater balance challenge to the squatting athletes enhancing proprioception.  

Increased Ankle Stiffness Reduces Proprioception and Balance

Injuries to our spinal and extremity joints can impact a variety of structures including muscle, ligament, and nervous system receptors.  The sensors or proprioceptors are critical in providing real time feedback to our spinal cord and brain on the positions of our limbs.  This feedback system is disrupted by injury leading to slower information processing and in turn a loss of balance.  Most commonly this cascade is seen in patients with ankle sprain.  Without balance training and physical therapy our proprioceptive system remains impaired.

A recent study in the Journal of Orthopedic and Sports Physical Therapy (Rocha Marinho, H. et al. 2017) examined the proprioceptive and balance abilities of patients complaining of ankle joint instability and their uninjured peers.  The authors also evaluated the passive movement in the subjects ankles.  Consistent with previous research the patients complaining of ankle instability demonstrated the worst proprioception or balance.  Those with limited ankle mobility and higher levels of stiffness demonstrated reduced balance or proprioceptive ability.  This research highlights the importance of retraining the nervous system after joint and muscle injury.  
For more information on proprioception training contact your local Physical Therapist.

Treatment and Prevention of Acute and Recurrent Ankle Sprains
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Ankle sprains remain one of the most common orthopedic injuries seen in both physician and Physical Therapy offices.  The majority of these injuries occur when the foot and ankle roll inward under the shin.  Previously, a program of P.R.I.C.E. (protection, rest, ice, compression, and elevation) was prescribed but new research has shown this strategy may help in the short term but may contribute to the high rates of chronic symptoms in this injury group.  The key missing component from the P.R.I.C.E. approach is the absence of manual therapy and focused exercise treatments designed to accelerate the healing progress and return of function.

Recently, a review article of the available evidence was published in the British Journal of Sports Medicine describing the most effective treatments and prevention strategies on ankle sprains (Doherty et al. 2017).  The authors compiled data from 46 previous research papers and found strong evidence supporting early mobilization with manual therapy and exercise after an ankle sprain injury.  Further, the authors reported strong evidence for bracing and moderate evidence for balance and proprioception training in the prevention of future injury.  Patients and athletes are advised to work with a local Physical Therapist to both accelerate their recovery from ankle sprains and reduce their risk of injury recurrence. 

Comparing Orthotics to Foot Strengthening Exercises
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In our previous posts, we have described the limitations of orthotics  to correct lower leg alignment and treat foot and leg conditions compared to Physical Therapy exercises.  In addition, long term orthotic users often show atrophy of the foot's core muscles which leads to further weakness and dysfunction.   Instead of orthotics, an active approach designed to strengthen the foot's core muscles has been shown to have a significant impact on both lower quarter pain and function.  A recent article compared orthotics and strengthening exercises to improve arch height, static and dynamic balance.

Kim and colleagues randomized healthy participants to either wear an orthotic or perform short foot/core strengthening exercises (J PT Science, 2016).  The exercise group performed strengthening exercises 30 minutes per day, 3 days a week, for 5 weeks.  Upon re assessment, the foot strengthening group was superior to the orthotic group on arch height, static and dynamic balance assessments.  This study adds to our existing research supporting the foot's need for both mobility and strength, not rigid orthotic supports.

Recurrent Ankle Sprains and Ligament Laxity

My approach to treating ankle sprains has changed dramatically since I began working with athletes in the late 1990s.  The PRICE (protection, rest, ice, compression, and elevation) approach has been replaced with a clinically superior movement approach designed to reduce pain and facilitate a return to an exercise program.  The PRICE approach was effective to control the inflammatory and pain processes but did little to reduce the recurrence of ankle injuries.  Research reports up to 70% of individuals who sustain an ankle sprain will have limited function and symptoms up to 6 months after their injury.  When these athletes would return to clinic with a subsequent ankle sprain the trend was to blame this recurrence on the loss of ligament strength secondary to the initial sprain.  This commonly held belief is being challenged by the most recent research on individuals with recurrent ankle sprains.

A recent article on 200 division I collegiate athletes examined the relationship between ligament laxity in the athlete's ankle and a history of ankle sprains (Liu et al. Clin J Sp Med. 2013).  The authors measured ankle displacement and movement to passive forces on an ankle arthrometer.  They reported no relationship between ligament laxity and the number of ankle sprains the athletes sustained.   Although some studies have linked laxity with recurrent sprains (Brown et al. 2015) this study and others indicate more factors are at play in these athletes other than ligament laxity.  

Our body regions gain stability through three areas:

1: Passive structures: joint anatomy, ligaments and other passive supports

2: Active structures: muscles and tendons

3: Neuromuscular structures: communication between the nervous system and the muscles noted in balance and proprioception

Depending on the severity of the injury, an injured ankle likely has an initial reduction in all 3 areas of stability.  An athlete who can "cope" with an ankle sprain and return to full sport activity likely is able to compensate when one of area of stability is compromised.  Unfortunately, many of these athletes with chronic complains demonstrate continued to loss of strength and balance in the lower quarter.  Interestingly, it is common to find bilateral balance impairments among individuals who have sustained a one sided ankle injury (Evans et al. 2004).  Impairments on the non involved side indicate impairments may have a central component due to changes the ability of the central nervous system to control posture on unstable or unpredictable surfaces.   It is currently not known if these changes were a cause or effect of the ankle sprain, but not rehabilitating the muscular and neuromuscular systems likely places the athletes at greater risk.

To reduce your risk of future injury after an ankle sprain work with a Physical Therapist to reduce lower quarter impairments and rehabilitate your proprioceptive control.