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The biggest mistake in balance retraining

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Sometimes, doing so much is actually detrimental for our patients and I can think of one classic example being balance retraining. Too often I have seen balance retraining classes that lack specificity and clear clinical reasoning, and there are a multiple people standing at different stations doing what looks to be part strengthening, part balance and part leisure. Neither one of those activities seem particularly challenging or targeted to the person’s impairments.

Furthermore, the activities are hardly things we do at home or in the community. When do we ever stand on air or foam pads between parallel bars? Or stand and throw and catch balls?

Stripping down to the basics, the science of balance will tell you that we need 3 things: vision, sensory feedback and our vestibular system to work, and of course the brain’s ability to interpret those things in unison. Now most therapists can tell you that, but it’s how we train them that we go wrong.

Firstly, there is a hierarchy. The vestibular system rules the roost because it’s the fastest circuit to our sense of orientation to gravity, which is partly responsible for our reflexes to extend our limbs and modulate our muscle tone. Then we have sensory feedback that grounds us against the confines of our environment. And lastly, it’s vision.

No matter how much vision we have, we can never truly completely compensate for the vestibular or sensory system, which both process much more subliminal data at much faster rates.

If we want to regain this hierarchy, we need to train in that order, and really drive the neuroplasticity change in this system through intensity, repetition and progression of difficulty. All whilst reducing visual and sensory input.

So what does this mean?

It means that someone with a loss of balance needs to be thoroughly assessed, and if there is primary problem with their vestibular system we really should be spending the majority of time training this. This translates to starting in a dark room, and movement of the head in space in standing, free from too much distraction. In my humble opinion this is really balance retraining at its purest. Throwing balls and standing on balance pads only really encourage improving the compensation by vision or sensory feedback, as they work much harder to achieve the task, and most of the time patients will tighten up their head and neck because it’s so hard, and we don’t get the vestibular stimuli we need to make it work to its fullest potential.

Where do you ever see this being done?

Once you get this idea, you can reintegrate the patient back into the community, which is where advanced balance retraining begins. In my next post, I shall share with you my 6 novel ways to advance your balance retraining.


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