Viewing balance exercises with eyes closed

For a long time, I have questioned prescribing balance exercises with eyes closed to athletes in sport. Regular readers of the blog will know that I continuously explore the clinical reasoning behind treatments and interventions but have a particular interest in exercise prescription. I have to admit that single leg balance with eyes closed is an example of exercise prescription that just doesn’t make sense to me, how many athletes close their eyes to perform a sport related task? I’m regularly seeing discussions online about “what is functional?” and most of the debates are based around semantics without much weight behind them but provide a good opportunity for people to have a little disagreement about something. To avoid getting into a debate about “functional” I thought it best to better understand the concepts and demands behind “balance” to see if I can answer the “why” behind balance exercise progressions.

SLB
Now stay like that for 1 minute or until another player throws a ball at your face
One argument for closing eyes during balance exercises is to remove the visual stimulus and encourage the athlete to challenge vestibular and proprioceptive senses. Remove one thing and make others compensate for this deficit. In a study of track athletes, sway velocity (cm/s) increased two-fold when athletes closed their eyes during a static balance test (here) but the only significant finding in the study was the difference in centre of pressure displacement (cm) between non-dominant and dominant limb across the medial-lateral plane. So, no difference between male and female athletes and no difference between “eyes open” and “eyes closed”.

So how does this explain the increase in sway velocity? The sway velocity is the area covered in both the anterior-posterior and medial-lateral planes of the centre of pressure per second, indicating speed of correction. The fact that the displacement between “eyes open” and “eyes closed” was not meaningful suggests that the demand on the fine motor correction increases. A decent argument to include “eyes closed” in a balance program, if that is the aim.

Static balance in dynamic sports

Compared to dynamic balance tests, static tests do not allow re-positioning of the centre of mass within the base of support, so the athlete becomes more reliant on smaller corrections. Different sporting populations have demonstrated varying abilities in static and dynamic balance skills, with gymnasts outperforming in static balance but soccer players demonstrating better dynamic balance (here).

This may seem obvious given the control on the balance beam vs changing direction to avoid an opponent. But actually, perhaps where the argument becomes more broad and complex.

As with any exercise selection, it needs to be appropriate to the aims of the rehabilitation program and the demands of the sport, taking into consideration open and closed skills and linking these to fixed gaze drills vs dynamic gaze drills.

Have we gazed over “skill”?

In a given skill, experts can recognise which cues are relevant and avoid information overload (Martell & Vickers 2004). Below is a slide from my presentation “3 sets of when?” It explains the concept that following any injury, the athletes ability to perform a given skill returns (temporarily) to novice level.

skill level injury

Take a skill like walking. Immediately after an ankle sprain, your ability to perform that skill at an expert level is decreased. A skill that has taken years to perfect, to become automatic, now becomes a task which requires concentration. Thankfully, the return to expert level doesnt take years (hopefully!) and this is where our exercise selection becomes crucial to optimally load and sufficiently challenge. We can’t presume that the pre-injury skill level is the same post-injury. We should also consider experience of the balance task specifically. I can think of experiences where athletes are standing on one leg on a Bosu throwing a reaction ball at a 45 degree trampoline. “Oh you’re no good at that are you… we need to address your balance”

I’ve digressed slightly from single leg balance with eyes closed… and actually I still haven’t discussed “gaze control”.

off on a tangent

Gaze control links specifically to experience of a task. Comparing those skilled at orienteering to non-skilled (here) demonstrated an increased ability of the orienteering folk (what do you call people that go/do orienteering?!) to employ a wide focus of attention and to shift efficiently within a peripheral field. The test very cleverly measured gaze control to flashing images with varying degrees of relevant and irrelevant information. What is interesting from this study was that the control group where physically active and proficient in other sports, but the “skill” advantage lay with the orienteering-iers. [shrugs and thinks “sounds right”].

I did not know that about balance!…

Elite athletes have heightened spatial awareness and processing capabilities vs their non-elite counterparts, where gaze control is cool and calm, with long duration of fixation of specific locations. This results in better body positioning end efficient limb actions (here). What better example than ballet. When comparing professional dancers to controls walking along a thin taped line, it was observed that experienced dancers focus far into space, delivering effortless and accurate movements where as controls looked down and focused on the line, moving with greater speed and less control (here). Dancers shift their neural control from somatosensory inputs and to an increased use of visual feedback, via peripheral fields and focused gaze control. Interestingly, sub-maximal exercise has been shown to increase visual attentional performance (posh words for reaction time) and a decreased time need to zoom focus of attention (here). This is useful for prescription considerations.

This efficiency has been demonstrated in other studies also, where the addition of a 4-week balance training program to Physical Education classes in school resulted in increased CMJ, Squat Jump and Leg Extension Strength (here). A time period that can’t be associated with physiological adaptations to muscles (regardless of time, they did balance exercises!) and even when a balance training program has been compared to a plyometric strength program (here). It is thought that improved centre of pressure is linked to spinal and supraspinal adaptations, due to high inter-muscular activation and co-ordination.

My question for any budding researchers out there… if there is a spinal level involvement here, can we utilise the contralateral limb at the very early stages of injury to improve balance on the injured side?

Finally, I get to my argument… balance is the output. Balance and proprioception are different entities, as are gaze strategies and balance. But they may all be interlinked via “skill.”

In researching this blog, I’ve certainly become more accepting of “eyes closed” as an addition to balance programs. But also think I’ve gained more clarity on appropriate prescriptions and the suitable progressions for individuals.

Perhaps “eyes closed” is not a progression, but a starting point!

Immediately post injury, we are looking to internalise feedback (intrinsic) and focus on local, fine movements. There are plenty of regressions within “eyes closed” balance that we can make the athlete safe from secondary injury. Graded progressions from static to dynamic, trying to keep the demands appropriate to the skill required to return the athlete to “expert”.

From here, our progressions should not be the removal of a visual stimulus, but instead optimising and enhancing gaze control:

  • Focus on a stationary target –> moving target
  • Head still –> head moving (repeat stationary and moving target progressions within this)
  • Static balance –> dynamic balance (repeat progressions above)

Essentially, we progress through from intrinsic cues to extrinsic cues, where gradually the athlete is thinking less and less about the mechanics of balance and more about skill execution and performance. We know that gaze control components improve with sub-maximal exercise, so our ordering of our program can reflect this. It is commonplace for balance exercises to be at the beginning of the program, but if balance is our primary aim for rehabilitation, perhaps it should be later in the schedule.

I don’t think this is too dissimilar to how most people prescribe exercises, but for me at least it has given me a better thought process into the “why” which ultimately should make rehabilitation programming more effective and efficient and therefore more elite.

Yours in sport,

Sam

Compex doesn’t have to be complex

compex

I should probably start by acknowledging that there are other muscle stimulation devices available… but I’m not employed by Compex, I just have some very good experiences using their product. This blog was borne out of frustration of seeing Compex machines gathering dust in treatment rooms or being used ineffectively as passive, plinth based modalities. I think a lot of people are missing the trick, you need movement!

While I am an advocate of its use clinically, I  want to disclose that using a Compex will not make a bad exercise good. It is a bolt-on to a rehab program and is something that can make a good exercise great. That is key. The clinical reasoning, exercise selection and placement of the stimulation all underpins an effective application, so before rolling it out to all athletes or patients make sure you can reason why it has a place in your practice.

Its all about progress

Like with any intervention, the clinical reasoning behind the application of muscle stimulation can influence its use at different stages of injury and rehabilitation. In the acute stages, it is believed that muscle stimulation may modulate pain. For an interesting read on the use of electricity and pain throughout the centuries, click here. However, as we understand more about optimal loading and mechanotherapy, we probably need to limit the time an athlete sits on the plinth watching the latest Mannequin Challenge on their smart phone while their quad twitches. It is worth considering that a Compex placed on a dead body would still cause it to twitch. The key is to get them moving and use the Compex to either facilitate movement or provide an external load. Interesting that we can use the same machine and the same settings to either regress or progress an exercise… the key is in the exercise selection.

Consider the tissues

Muscle injury: It should be pretty obvious that placing a muscle stimulation device, designed to promote contraction of muscle, on a contractile tissue with a tear or micro-damage could have negative consequences. For a second, lets forget the Compex. Respect the pathology and consider if you really need to lengthen or contract that muscle to load it. Is there a way you can work that tissue as a synergist perhaps? If the hamstring was injured in the sagital plane, can we move through coronal (frontal) planes and still load the hamstring? This could possibly be a slight progression on an isometric exercise and shouldn’t change the length of the muscle that may cause pain or further damage. Certainly more beneficial than sitting on the treatment bed though. So now consider how muscle stim may benefit this stage of injury. It could possibly help with any inhibition due to swelling or pain, perhaps be used to add an increased load to unaffected tissues that you may not be able to load otherwise.

As the healing progresses and the level of activity increases, it is quite common that we see some deficits in muscle function, especially after a long acute phase (if that isn’t a paradox?! Think post surgery or fixation). A good example is post ankle reconstruction, where you have worked on regaining plantar / dorsi flexion but when you ask the athlete to do a heel raise, it’s quite an effort. It may be appropriate to use the Compex here as a little crutch to facilitate movement and contraction. But the key thing here is it is not our cadaver that we causing a contraction in, the athlete is consciously initiating the movement. (Previous blog on internal and external cues here).

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Now promise me if the Compex hurts, you will turn it down. OK?
Progressions by all definition, progress. So after working through isometric and concentric exercises, the program may require some eccentric load. This is worth trying yourself before asking a patient to do it, because a very simple exercise like a TRX squat that may have been cleared earlier in the program can dramatically increase in work with the addition of Compex. Consider a quad injury. The Compex has two phases of a cycle, a fasciculation phase that causes visible twitch and a long contraction phase (depending on the setting, the length and intensity of the contraction change). After one or two cycles for familiarisation, instruct the athlete to work against the contraction – so when the Compex wants to promote knee extension via a quad contraction, sit back and encourage knee flexion. Try this yourself for 6-8 reps and feel the fatigue induced, it usually surprises people. Again, make sure you can reason WHY you are doing this. This is usually a good bridge for someone who needs to step up their program but maybe can’t tolerate external load (confounding injuries, instability of joints, lack of technique etc etc.)

Joint Injuries: In comparison to a muscle injury, your application of Compex may be more aggressive. Because you are unlikely to affect a non-contractile tissue with the stimulation, you may use the eccentric reasoning to help reduce atrophy rates following a intracapsular injury like an ACL. Ensure you know the available range first of course.

With these injuries, the external stimulation may help with inhibition, improve proprioception lost by the ligament or capsule or it may provide stability to the joint by increasing the available contraction. Again, there will be a time and a place and it requires the clinician to reason through the application, but this may be a great addition to a program that is becoming stale.

Tendon injuries: The use of the Compex to enhance an isometric contraction or to create an eccentric contraction may be a great addition for an in-season tendinopathy as a way of managing load. The timed contraction allows clinicians to monitor Time Under Tension (TUT) which is essential for tendon management. If considering a High-Medium-Low frequency through the week, a pain free exercise that is used on a Medium day can become a High load exercise with the addition of an externally generated contraction. But consider the two things that aggravate a tendon, compression and shear. Appropriate exercise selection and range is going to be crucial, that being said, it may be that the addition of stimulation to the quads actually reduces shear through the patella tendon by changing the fulcrum of the patella (no research to back this up, just my musings).

musing
I really like Geckos. I found this Gecko a musing
Conclusion:

I think there are many options out there to enhance rehabilitation by considering the diversity of muscle stimulation. But I want to repeat for the hundredth time, it is the exercise selection that is key. The addition of a Compex will only amplify that choice.  For the patient, it adds a bit of variety to a rehabilitation program and for the clinician it is another tool to help with optimal loading of a healing tissue or structure. I am a big fan of weight training (don’t let my chicken legs fool you) but there are injuries or athletes that for one reason or another are unable to tolerate weights. This is one tool in a very large and overused metaphorical tool-box that may bridge that gap between body weight exercises and weighted exercises. I also believe there is great benefit when complimenting this with Blood-Flow Restriction Exercise or Occlusion training… but that’s another blog.

As always, thoughts and opinions are welcome.

 

Yours in sport,

Sam

“I’ve come here for an arguement”

I’ve recently made the move from the clinical environment into academia (despite the occasional clinical fix to satisfy my itchy feet). Part of this move was to set up some new MSc modules at the University of Brighton. The way I wanted this to run was based on me facilitating discussion rather than standing up and banging on about what I would do in different situations – no-one is going to enroll for that! But for this to work, it relies on people feeling comfortable talking about their own practice, something I’ve been surprised by the reluctance in doing so. People seem very uncomfortable disclosing what they do and how they do it.

A while back I read a blog re-tweeted by IFL Sciences (@IFLScience) about how a disagreement is different to an argument. Now rather than me eloquently blurring these definitions and confusing you more, why not allow the genius of  Monty Python to explain.. please watch this brief 3 min video (here).

The original clip goes on a bit longer and in true python fashion, gets stupider. But this clip can translate into our practice. It is perfectly reasonable and healthy to argue. We are not going to learn from each other by accepting that the other guy sat in the room, who has more experience than me, treated his ankle sprain using those exercises, so that’s what I should do.

No! Why? Why those exercises for that individual?

 

There are many roads to Derby:

imageCompletely random destination (just so happened to be one of the cities I can spell). But this image sums up what I think about clinical reasoning. It also demonstrates what I encourage our students, more so post-grad students with clinical experience, to accept when questioned about their practice.

Most of us have at some point ignored the sat-nav, right? Intentionally or not. But it simply re-routes and will eventually lead you to your destination. The same with rehab & treatment. We may all have the same goal & end point, but how we get there is different. The route we chose depends on many factors.

Letting the sat-nav make the decision:

For a relatively less experienced clinician, the situation may be this:

“I’ve only ever been to Derby once, but when I did go, that route worked pretty well for me, so I’m going for it again. Why risk otherwise?”

This is the equivalent of following a protocol or being led by a more experienced clinician. Perfectly legitimate but after a time the question will become, “have you tried other ways?” Yes that’s a pretty direct route, but sometimes it’s not about the speed you get there. An example I can think of was a player with a partial ACL injury that occurred just before christmas. We made the decision to prolong his rehab until the pre-season, despite realistically being able to get him fit for the last 2 games of the season. But there was no advantage to that, instead we were able to focus more on smaller details, enhance his “robustness” and ultimately, we had no re-injuries with him the following season. We decided to take the more scenic route and enjoy the drive. Sometimes, it shouldnt be other people asking why you have done something, but yourself. (Do this internally, arguing with yourself in a cubicle at work could have very different consequences to the intended career development).

Thanks Sat-Nav, but no thanks:

This option comes after you have driven to & from Derby a few times. Or if you insist on keeping it relevant to practice, an exposure to a certain injury with a set population. Experience may tell you that the route suggested by Sat-Nav has an average-speed check for 25 miles, so you may choose one of the alternate routes. This is the same as saying, “I wanted to use squats for his knee rehab, but it aggravates his hip so instead I used dead-lifts.” Someone has asked you why you went that route, the answer is reasoned and justified and neither party needs to be offended. But you have argued your point.

 

An argument is different to a disagreement:

An example of this not being constructive may be:

“I prefer this route because the services have Costa and not Starbucks. I hate Starbucks.” This opinion, without any justification may turn into a disagreement. “I don’t ever use a wobble cushion in my rehab, just don’t believe in them.” A genuine statement that I heard years back when I was studying myself. There was no rationale, every counter argument was met with “Nope. Dont buy it.”

opinions
This is a disagreement. Something I disagree with… Oh, balls.
Conclusion:

An argument doesn’t have to be raised voices or expletives (although people who swear more are shown to be more trustworthy and honest. If you belive that bullshit). It can be someone wanting to develop their own thinking and reasoning, therefore probing your experience – “But WHY did you chose that? (subtext = help me learn!)”

Equally it can be someone pushing you to develop. “You use that exercise for all of your patients.. why?”

I’ve started to do a little presentation at the start of our modules to explain this thinking, I will be asking “why?” A lot, but I don’t want people retreating or getting defensive. Asking Why is not a sign that I disagree with you. arguing is not a sign that I disagree with you. If you feel comfortable with those concepts, you have either done an MSc already, or you are ready to do one! For those not on twitter, firstly – how are you reading this blog? Secondly, get on there. Prime examples of arguments about clinical practice everyday and very quickly, normal jovial exchanges are resumed (I would highly commend Tom Goom (@tomgoom) for this attribute). But also, it is a good place to observe some people misunderstanding an argument and presuming it is a disagreement (I wont name people, don’t want to get in a disagreement).

 

Yours in sport,

Sam

Trying to simplify “Critiquing literature “

In order to effectively clinically reason, we need to be able to critique the evidence. I want to be clear from the start – I’m not here to sledge any authors or specific papers, so I’ll just use hypothetical examples throughout. But what I want to try and do is simplify the ability to critique research for those people who maybe aren’t comfortable doing so.

A few recent discussions with colleagues and MSc students at University prompted me to write this blog. I’m not a researcher and I’m certainly not a statistician. My wife just throws more than 3 sums at me to convince me I owe her money. Numbers fry my brain. But, that shouldn’t put me off being able to critique a paper in a constructive way.

criticalthinkingfit

Critical Comment #1: Can I understand why they’ve used this Methodology?

For an author to create a robust methodology, there has to be the existing literature available in the first place to support their design. We place a great deal of trust in authors that they have researched their methodology appropriately -the tests they use are validated, there’s evidence behind their outcomes, a clear rationale for their intervention. But have they made all of these clear? You can see already how we can create a peeled onion effect, whereby we could (if social lives weren’t an issue) trace back all of the references for outcomes measures and tests.

layeredonion
We can easily end up chasing references. Which like an onion, will probably make you cry.

I feel a great deal of sympathy for authors here, because in some cases they cant win. Authors are torn due to previously limited research, to which they need to reference their proposed methodology in order to be considered robust.

Lets use something that’s not contentious, I don’t know…? Massage. No one has established an appropriate and valid duration. Neither have they determined best technique, and so on – so a great deal of literature these days will standardise their methodology to an arbitrary figure, often 2 minutes per technique. Where has this come from? For those who do use massage as part of their practice – when do you time a duration for techniques? Surely its individual, dependent on the therapist, the treatment outcomes and goals etc – but any paper that justified their methodology on something that is extremely subjective like clinicians experience would get slated!

jackie_chan_meme_face_original
Why did you bring up massage again?!

I’m sure this will get shot down monumentally, but personally I would commend a study brave enough to use an experienced clinician and trust their clinical knowledge & autonomy. Let them use an intervention they use routinely and daily and allow for creative freedom and individual needs. We constantly bang on about treatments being individual, so lets put our money where our mouth is. I’ve used massage here, but the same could be applied for a lot of interventions – types, techniques, durations. If they haven’t been validated historically, how can we be assured about results from this current paper we’re critiquing?

It’s another argument for another time – but do we need to go back to basics with some interventions and learn more about them before we critique and dismiss them? Rather than compare intervention vs no intervention, should we compare the same intervention but with different goal posts first?

I’ve used massage here but that’s not my point, its the methodology I’m trying to emphasise.

  • Is it a fair comparison between interventions?
  • Does it even need a control?

 

Critical comment #2: Is there an appropriate population used for the research question?

We have to remember that any outcome or clinical relevance from a study can only be applied to the population that they used within that study. Can we assume that a new training program implemented with recreational athletes will have the same benefits with elite athletes? It’s impossible for authors to give us huge details about population because of their limited word count – but we need to make some educated guesses regarding the outcomes. The benefits of an eccentric intervention for an elite group of footballers doesn’t mean we can start Sunday league players or even semi-pro players on the same intervention at the same intensity or volume.

Take the findings and apply them to your clinical practice & patient exposure. Would this intervention fit with your athletes current schedule or level of conditioning?

Flip that around and consider that a study using a lay population may find huge benefits from an intervention – but is it just an accelerated learning curve that wouldn’t impact an elite athlete in the same way? Exposure to something completely new will have bigger consequences and effects.

Bolt%20V%20Blot%20Web_1

 

Critical comment #3: The dreaded stats! Or am I just being Mean? Probably (<0.05)

I’ve already said, I’m no statistician. The critique that can be applied with some understanding of these stats processes is incredible and I am in awe of people that can do this. But there are some simple points to consider when looking through analysis and results of papers. The first thing to consider, does the presented data tell you what you need to know? Go back to secondary school maths with Mean, Median (and Mode):

We want to investigate how many hops a subject can manage after ankle mobilisations (assuming we had no other variables like fatigue etc). Their pre-test scores are around 50. During assessment they record the following scores (40, 51, 45, 52, 100), one time they have blinder, recording 100 hops. A mean score would suggest that the effect of mobilisations increased their pre-intervention scores from 50 to 57.6, this sounds quite impressive. A median score used in this example would tell us that aside from one outlier, their post-intervention scores didn’t change too much (51). In this case, we want to know for definite whether or not our mobilisations have allowed this subject to hop better – they have a world championships in hopping coming up. If the data is clearly presented, we may be able to work this out ourselves. But I’m lazy – I’ve got 30minutes over coffee to read an article, I want to read their results and discussions and hope that this leg work has been done for me.

Now an author wanting to get a publication is always going to present the data with greatest impact – in this case the mean. That’s fine, but its worth checking the number of scores recorded. The greater the amount of data, the more accurate a mean will be. But less subjects or less tests would always be worth double checking the data.

 

If you can’t explain it simply, you don’t understand it” Albert Einstein

This brings us nicely onto probability. After writing this blog draft, I was shown this brilliant lecture by Rod Whiteley (Here) who understands this much more than me! (See above quote). It must be en vogue because the editorial in Physical Therapy in Sport this month disucsses P-Value also (Here). But what I do understand about P-Values is to always ask.. “So what?” So its statistically significant, but is it clinically relevant?

Again, another hypothetical study. We investigate the use of weighted squats to increase knee flexion. We find that by squat 1.5x body weight can significantly increase knee flexion (P<0.001). That significant difference is 3 degrees. Is that going to make your practice better?  In some cases it may do! Achieving a few degrees in smaller joints with less room to play with, or perhaps post-op TKR and we just need a few more degrees to allow this patient to safely negotiate stairs – if they cant do stairs I’m not sure I would get them doing 1.5x BW squats though, which takes us back to our population critique.

Hopefully you have watched the Rod Whiteley lecture by now, so you can see where non-significant data can be very clinically relevant. It does make me wonder how much we have thrown out or dismissed that could be very beneficial.

 

Critical Comment #4: The Conclusion

So we have 30 minutes to quickly search for a paper, read the abstract and decide to read the article. I’ll hold my hands up to skimming the vast majority of a paper just to get to the conclusion. Not good practice though. Its worth checking who the author is, have they published on this topic before? What is their motivation? Most people will publish something that they either strongly believe in, or don’t believe at all. We’ve already discussed how its easy to manipulate stats, so if I strongly want to prove something works, given enough data & appropriate stats I could probably could. This sounds incredibly synical, but it should be a question you ask. If the conclusion is strong despite some variable results, bear it in mind.

IMG_5941

Our Conclusion:

“Its actually quite exciting, what you know now will probably change”

So can we believe anything that’s published? Yes. We can & We need to. Otherwise we stand still. Being critical is not the same as disagreeing or dismissing something. It just shows us where there are gaps and where can start investigating next. It’s actually quite exciting, what you know now will probably change. Something you don’t understand now, we will probably find out in the future. But taking a single paper and changing our practice based on that is a bit drastic. We need to consider the body of literature, read articles that challenge accepted beliefs and make our own decision. The beauty of sports medicine is there are no recipes. Where possible the literature should challenge our thinking and keep us evolving, but it doesn’t always restrict us to guidelines and protocols. We are lucky enough to be autonomous in our treatment and our exercise prescription and we should celebrate that. Ask 3 respected conditioning coaches to create a program for one athlete with a specific goal and see how diverse they are. Thats what sets us apart from each other and makes us individual therapists and coaches.

Take home points:

  1. Check the methodology – are you happy with what they are investigating & how they do so? It is perfectly acceptable to disagree!
  2. Does the population used apply to what you’re looking to take from the paper? You are reading this paper for some reason – hopefully to re-inforce / change your practice. Do the female college basketball players used in this study apply to your clinical caseload?
  3. Don’t accept or dismiss a paper purely on its P-Value.
  4. Has the author based their opinion purely on the P-Value? Check! Don’t just accept their conclusion. This is their entitlement but its their interpretation of the stats.

#PrayForAuthors: They do face a fight between getting something published, and in doing so making their study conform to previously accepted literature but perhaps deviating away from what the masses actually practice in clinic. The lasting question I will leave you with; considering the points made in this blog and the discussion by Rod Whiteley – where does that leave systematic reviews? I have my own thoughts 😉 Let us know yours.

 

Yours in Sport

Sam