Balance Training and Rehabilitation With Closed Kinetic Chain Exercises

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Abstract Balance is a crucial component of daily d aily activity. It is a simplistic concept but the mechanisms involved in monitoring, adjusting and percieving balance are highly complex. The three systems associated with balance with balance work together to maintain the body’s centre of mass over the base of support. This report will discuss the physiolog y and responsibilities of the vestibular, visual and the somatosensory systems and their role in balance. This report will also discuss closed kinetic chain exercises and their progressions to retrain balance in individuals with lower extremity injuries. The visual system is responsible for percieving movement, locating obje cts in space and differentiating between exafferent and reafferent information. The vestibular system is responsible for monitoring gravity changes and acceleration associated with head movement. The somatosensory system monitors many bodily changes, but this report will focus on proprioception. Proprioception is the ability to monitor and percieve the location of body parts in space with the feedback of muscle spindles and golgi tendon organs. It is concluded that closed kinetic chain exercises that progress to cha llenge the visual and somatosensory systems are successful in retraining balance. It is recommended that the vestibular system be challenged with rotational and lateral head movements to incorporate all three balance systems.

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Table of Contents .......................................................................... .................... 1 1.0 Introduction ................................................. ...................................................... 1.1. Balance ................................ .................................................... .......................................................................................... ...................................... 1 1.1.1. Visual and Vestibular Systems .......................................................................... ... 2 1.1.2. Somatosensory S ystem ......................................................................................... 4 1.2. Open vs. Closed Kinetic Chain Exercises ........................................ ............................. 6 2.0 Methods and Findings .................................................... ........................................................................................................ ....................................................... ... 7 2.1. Physical Therapy for the Vestibular System ............................................. .................... 7

S ystem ............................................................................ ... 8 2.2. Rehabiliation of the Visual System 2.3. Balance Exercises and the Somatosensory System .................................................... . 10

........................................................................ .................. 11 3.0 Conclusion .................................................. ...................................................... ............................................................... .......... 12 4.0 Recommendations ................................................ ..................................................... ............................................................... ........ 13 5.0 Glossary ............................................................... ....................................................... ........................................................................ .................. 15 6.0 References ................................................... ...................................................... ........................................................................................................... ........................................................................ .................. 17 7.0 Appendix ..................................................... ............................................................... ........ 19 8.0 Evaluation ............................................................ .......................................................









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List of Tables and Figures Figure 1.0. Anatomical structures of the vestibular labyrinth lab yrinth .................................................... 2 Figure 2.0. Diagram of the th e ampulla within semicircular canals ................................................. 2 Figure 3.0. Otolith organs organ s at rest and displaced.................................... ...................................... 3 Figure 4.0. GTO response to over contraction co ntraction of bicep muscle ................................................. 4 Figure 5.0. Patellar reflex depicting muscle spindle activity ................................................... ... 5 Figure 6.0. OKC lat pull down vs. CKC pull up...................................................................... up.................. ....................................................... ... 6 Figure 7.0. Ankle strategy (left) vs. Hip strategy (right) ............................................................ 9 Table 1.0. Level progression for 26 participants at the end of a 6-week test period ................ 10









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1.0 Introduction [name of clinic here] is a multi-disciplinary clinic that deals with a wide range of personal and motor vehicle injuries to help promote and increase the rate of recovery. recover y. The role of the kinesiology department is to implement the correct stretches and ex ercises for each individual and progress accordingly based on therapists’ therapists’ guidelines and assessment of injuries. A wide range of injuries are present throughout the clinic, however, those involving the lower extremities are often associated with one’s inability to maintain one’s balance. There are many factors that can affect one’s balance, balance, these include tramautic brain injuries, muscle or nerve damage, concussions, age or visual acuity. 1.1 Balance

It is now understood that balance is maintained b y three sensory systems, the vestibular, visual and somatosensory system (Mohapatra, Krishnan & Aruin, 2011). The stimulation of either of these systems evokes a deviation in balance and increases body sway. We are able to depress or remove the systems while training for balance b y closing the eyes to remove vision, v ision, standing on a foam pad, one leg or uneven surface to hinder the somatosensory and vestibular system. Proprioception* can be altered in man y ways. Vibration introduced to the muscle tendons will activate muscle spindles, producing a feeling of instability causing postural tilt in the direction of the muscle vibrated, also known kn own as vibration-induced falling (Van Ooteghem, 2010). This phenomena only occurs when the individual is not looking at the vibrated limb. When vision is introduced, the sensation ceases an d negates the vibrating effect (Van Ooteghem, 2010). This reflects how much one relies on the visual system system for proprioceptive feedback. feedback. The vestibular system is a highly complex system that monitors head move ment through a labyrinth of organs in the inner ear (Gray, n.d.). It works together with the visual system to differentiate objects moving in our visual space and the movement of one’s one’s own head. When working optimally, the three components of balance work collectively to produce a stable body, minimizing deviations from the central base of support b y postural sway and reducing the risk of









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1.1.1 Vestibular and Visual Systems

One cannot describe the visual system and vestibular system individually without referencing the other. This section will discuss the vestibulo-ocular pathway and its relationship with balance. The vestibular system

Figure 1.0. Anatomical structures of the vestibular labyrinth.

is located in the inner ear and is made of 3 semicircular canals (SCCs) and 2 otolith organs, the saccule and utricle, making up a structure called the vestibular labyrinth, shown in Figure 1.0 (Gray, n.d.). The semicircular canals are responsible for detecting angular acceleration and are oriented 90° to each other (Gray, n.d.). Their orientation allows angular acceleration of the head to be detected in the roll*, pitch* and yaw* directions, corresponding to the x,y,z axes (Gray, n.d.). See Appendix A for a diagramatic view of each direction. Otolith organs oriented 90° from one another detect linear changes in head movement, the utricles measure mostly horizontal acceleration (ie. deceleration) while the saccules respond s primarily to vertical acceleration (ie. gravity) (Gray, n.d.). All 3 SCCs and both otolith organs innervate the vestibulocochlear nerve (VIIIth CN) (Gray, n.d.). At the entrance (ampulla) of each semicircular canal there is a gelatinous liquid called cupula (Rutka, n.d.). Embedded in the cupula are stereocilia, tiny hairs that extend out from the vestibulocochlear nerve that respond to mechanical shearing* in different directions causing a chemical depolarization* or hyperpolarization* of the nerve (Rutka,









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the head has moved (Rutka, n.d.). In relation to vision, each SCC innervates two ipsi-lateral* and two contra-lateral* muscles of each eye, with six extraocular muscles in each eye, corresponding to each of the three SCCs SCC s there is an innervation ratio of 2:1 (Rutka, n.d.). This level of control allows for a fine response in eye movement, keeping a stable retina image (Rutka, n.d.). Importantly, this allows us to differentiate between subjective and objective mov ements. This phenomena can be demonstrated by placing your finger infront of your face and shaking your head up and down, and left and right while fixing your gaze upon your finger (Clopton, 2007). Your finger stays stationary while your head moves, but by shaking your finger while your head is fixed, the finger appears blurry (Clopton, 2007). This is an example of the SCC portion of the vestibulo-ocular pathway (Clopton, 2007). Otolith organs lie between the semicircular canals and the coch lea within the vestibular labyrinth (Rutka, n.d.). Responsible for gravitational movement, the saccule and utricle are oriented at 90° from each other, detecting d etecting linear changes in the horizontal horizon tal and vertical directions (Rutka, n.d.). Otolith organs contain a gelatinous matrix* with cilia* projecting from the afferent afferent nerve endings, similar to the SCCs (Rutka, n.d.). However, the surface of the gelatinous matrix contains a membrane with a layer of calcium carbonate crystals ontop, increasing the weight of the membrane membrane (Rutka, n.d.). n.d.). Otolith Otolith mean’s “ear stones” in Greek (Rutka, Greek (Rutka, n.d.). This blanket of crystals causes drag on the top of the gelatinous matrix when the head is moved causing a displacement of the matrix resulting in the hairs within the matrix to bend, similar to the function of the SCCs (Rutka, n.d.). In turn, the otolith organs also stimulate the vestibulocochlear nerve (Rutka, n.d.).











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1.1.2 Somatosensory System

The somatosensory* system is a collection of unnamed senses which includes vibration, temperature, pain and proprioception (Arezzo, Schaumburg & Spencer, 1982). This report will focus on proprioception and its involvement in balance and reafferent sensory feedback. Proprioception is termed as the ability to perceive the location of our own body bod y in space (Van Ooteghem, 2010). It is part of the somatic division, or voluntary division, of the peripheral nervous system, which includes the sensory neuron s of the skin, joints, tendons and muscles (Van Ooteghem, 2010). During balance balanc e rehabilitation there are two structures that are being targeted and are responsible for fall prevention and limiting postural sway. These are golgi tendon organs (GTOs) and muscle spindle fibers (Van Ooteghem, 2 010). Golgi tendon organs are innervated by encapsulated 1B nerve endings located at the muscletendon junction and are arranged a rranged in series with the muscle and its tendon (Van Ooteghem, 2010). Since muscles contract towards the muscles belly, the most tension occurs at the tendons thus stimulating the GTOs (Van Ooteghem, 2010). Response to tension prevents the muscle from over contraction and overexertion that could cause muscular damage at its origin and insertion points as well as the muscle itself (Van Ooteghem, 2010) . GTOs are associated with a negative feedback loop where an









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2010). Intrafusal fibers are not to be confused with extrafusal* fibers which are innervated by alpha motor neurons, as they are both arranged in parallel to each other within the muscle belly (Van Ooteghem, 2010). Muscle spindle fibers contain 2 sensory components, primary (annulospiral) endings and the secondary (flower spray) endings (Van Ooteghem, 2010). Primary endings output signals to the spinal cord via v ia 1A afferent neurons, secondary endings via Group II afferent neurons (Van Ooteghem, 2010). These Th ese components respond to stretching of the muscle, which is dependent on sarcomere* length. Muscle spindles are involved in a feedback loop, also known as the “stretch reflex” (Van Ooteghem, 2010). The stretch reflex is activated when the muscle spindle fibers have been stretched quickl y in a short period of time (Van Ooteghem, Oote ghem, 2010). This elicits a response of the intrafusal fibers signalling via 1A and Group II afferent neurons to the spinal cord where they the y synapse with alpha motor neurons of o f the agonist and antagonist muscles (Van Ooteghem, 2010). The “stretch reflex” reflex” elicits a contraction of the stretched agonist muscle and a relaxation of the antagonist muscle. A prime example is the patellar reflex. The patellar tendon is struck with a reflex hammer, causing a stretch in the muscle. This sudden stretch in the muscle causes the spindle fibers to respond. Information is sent to through the stretch reflex loop and the quadriceps contract causing the th e leg to rise.









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1.2 Open vs. Closed Kinetic Chain Exercises

Exercises can be broken down into two components, open kinetic chain (OKC) and closed kinetic chain (CKC) exercises. OKC exercises are d efined as an exercise where the distal* d istal* segment of a limb (ie. hands, feet) is moving freely (Hooper, Morrissey, Morrissey & King, 2001). Straight leg raise, leg press, lat pull down and knee extension are examples of OKC exercises. During CKC exercises, the distal end of the segment is fixed throughout the exercise (Hooper, Morrissey, Morrissey & King, 2001). Isometric shoulder exercises, squats, pull-ups and push ups are examples of CKC exercises. Studies have shown that CKC exercises ex ercises may be more beneficial in the early rehabilitation stages because of its involvement in activating more muscle groups in a more functional fun ctional way rather than isolating a single muscle group with OKC ex ercises (Hooper, Morrissey, Morrissey & King, 2001). CKC exercises Figure 6.0. OKC lat pull down vs CKC pull up

are also conceived at better enhancing functional performance, more than OKC excercises (Hooper, Morrissey, Morrissey &

King, 2001). For example, a CKC exercise such as a squat recruits twice as much hamstring activity, greatest activation of quadriceps at full knee flexion as well as more vasti muscle activation than an OKC leg press p ress exercise (Escamilla, Fleisig, Zheng, Barrentine, Wilk & Andrews, 1998). However, proper discretion must be taken into consideration when implementing primarily CKC or OKC exercises to an individual’s individual’s routine. For anterior cruciate









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many rehabilitation techniques and modalities to promote the healing of musculoskeletal structures and systems. The role as a kinesiologist is to prescribe ex ercises and stretches based on the clinician’ clinician’s program requests and make changes if necessary. Many individuals at the clinic experience issues with balance, whether from muscular or neural issues. This report will discuss the utilization of CKC exercises and other method s to challenge the three balance b alance systems. This is a non-empirical report where formal reasoning and research of implemented CKC exercises and rehabilitation methods for balance will be discussed and supplemented with critical analysis.

2.0 Methods and Findings Balance rehabilitation must incorporate many areas of expertise and treatment to be able to fully diagnose the root cause of an individual’ individual’s balance disorder. At [nonames] Physiotherapy and Rehabilitation Centre there are a large majority of individuals with balance disorders stemming from musculoskeletal issues such as lower extremity fractures*, ligament* and muscular tendon* tears. Therefore, there is greater app lication of proprioceptive balance training. This section will discuss methods of vestibular, visual and proprioceptive rehabilitation for balance with most emphasis on proprioception through CKC exercises. 2.1 Physical Therapy for the Vestibular System

There are two branches of the vestibular system, central and peripheral. Physical therapy is one method for treating vestibular system dysfunctions. Other forms of intervention include pharmacological therapy and surgical intervention. This section will discuss the physical therapy methods for treating the vestibular system. Imbalance in the p eripheral vestibular system, which









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walking, walking at varying speeds, walking with head movements in the yaw and pitch directions, walking over and around objects, p ivoting and stair climbing (Brown, Whitney, Marchetti, Wristley & Furman, 2006). TUG is a timed sitting, walking and standing examination where the patient is asked to stand up from a chair, walk 3 metres and an d return back to their chair and sit down (Brown, Whitney, Marchetti, Wristley & Furman, 2006) . The FTSTS test measures balance and lower extremity strength and it requires individuals to rise from a seated position position and sit back down without the aid of their arms (Brown, Whitney, Marchetti, Wristley & Furman, 2006). The tests cause angular and linear accelerations of the head, exposing the individual to movements that may cause discomfort and rehabilitating the issue. Significant improvements in gait and balance were present at patient discharge after vestibular physical therapy (Brown, Whitney, Marchetti, Wristley & Furman, 2006). Benign paroxysmal positional vertigo (BPPV) is a common issue in vestibular dysfunctions and can be treated more intensively with positional exercises and liberatory maneuvers proposed by Semont et al and Epley (Brandt, 2000). This physical therapy treatment involves rapid lateral head and trunk tilts to induce the feeling of vertigo. The T he patient is to remain in the tilted position until vertigo subsides or duration of 3 0 seconds (Brandt, 2000). This process can be repeated in different planes of the head and trunk to stimulate the different SSCs. The purpose of these maneuvers is to loosen and break down clots that have accumulated in the endolymph* of the inner ear (Brandt, 2000). The clot decreases the fluidity of the gelatinous matrix, which lags behind causing nystagmus* and vertigo (Brandt, 2000). These maneuvers can be performed in home without assistance from a clinician (Brandt, 2000). See Appendix B for a











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the acuity of their eye sight, therefore must compensate with greater demand on the vestibular and somatosensory systems (Lord, 2003). Those who are visually impaired put more emphasis on vestibular and somatosensory information to adjust and monitor balance (Ray, Horvat, Croce, Mason & Wolf, 2008). Older adults with adverse vestibular affects and lessened visual acuity place more priority on their proprioception (Ray, Horvat, Croce, Mason & Wolf, 2008). It is reported that both

Figure 7.0. Ankle strategy (left) vs. Hip strategy (right)

adolescent children and adults who are blind exhibit fear of falling and have decreased postural stability (Ray, Horvat, Croce, Mason & Wolf, 2008). In a mixed trial where individuals with full vision closed their eyes and balanced, and blind individuals closed their eyes, e yes, imbalance was similar (Ray, Horvat, Croce, Mason & Wolf, 2008). Howev er, with eyes open, blind individuals demonstrated similar amounts of imbalance (Ray, Horvat, Croce, Mason & Wolf, 2008). This









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2.3 Balance Exercises and the Somatosensory System

Postural control can be described as the attempt to maintain coordination of body segments without loss of balance for the facilitation of other actions (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Postural sway is the co ntinuous movement the body undergoes to maintain this control (Strang, Haworth, Hieron ymus, Walsh & Smart, 2010). Thus, it can be interpreted that minimum postural po stural sway is required to achieve significant postural control. Balance can be improved in all demographics by training with balance-specific exercises. Balance exercises have been shown to strengthen the lower extremities as well as reduce recurring injuries (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). Holistic and progressive balance exercises can be prescribed in the clinical and rehabilitative setting to improve postural control of individuals with balance issues (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). It has be en noted by researchers that a healthy h ealthy postural sway reflects the individual’ individual’s flexibility, adaptability and automaticity of postural control(Strang, Haworth, Hieronymus, Walsh & Smart, 2010). A limited, rigid postural sway indicates a less-adaptable, attention-demanding control of posture (Strang, Haworth,









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tested in each of the trials by b y progression of exercises from a hard surface to foam surfaces, inflatable discs, BOSU balls and Bongo Boards (Strang, Haworth, Hieronymus, Walsh & Smart, 2010). There were improvements in balance for each of the balance trials for each individual. Table 1.0 illustrates the progression of each of the 26 individuals, and the number of successful individuals to complete each task at the end of the trial period (Strang, Haworth, H aworth, Hieronymus, Walsh & Smart, 2010). Findings lead to the understanding that by training with restricted vision and diminished proprioceptive feedback, a change in postural sway in the normal stance position and improved postural control was observed (Strang, H aworth, Hieronymus, Walsh & Smart, 2010).

3.0 Conclusions In a physical rehabilitation setting balance is a featured component in most injuries, especially those regarding the lower extremities. Composed of an elaborate system of interconnected feedback pathways, balance is a complex but crucial component in everyday life. The vestibular labyrinth within the inner ear is continuo usly monitoring head movement









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re-establishing balance such as falls, wobble board training, BOSU stance and forward and lateral hops.

4.0 Recommendations Recommendations With extensive research of the physiology of each system and their corresponding methods of training, [The Cool People Rehab Clinic] should implement a balance training protocol that incorporates the vestibular as a major component of training. Removal of vision by performing exercises with eyes closed and the addition of an unstable surface to challenge the proprioceptive system is commonplace in a rehabilitative setting. However, vestibular training can be implemented to further challenge vision and the somatosensory system. By having individuals stand on one leg with eyes closed on an unstable surface while moving their head in the yaw and pitch directions, all systems are included in one exercise. ex ercise. There are a lot of clinical based exercises for balance focused on proprioception, by introducing a wobble board, foam mat or BOSU ball and progressing to eyes closed but few have considered introducing head movement to stimulate the vestibular system in addition to the other components. Begin with vestibular movements similar to those mentioned in Section 2 .1 and progress to standing and on









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– minute hairlike organelles lining the surface of cells Cilia – minute Contra-lateral – pertaining – pertaining to the opposite side

– the influx of sodium ions across a membrane, causing an action potential Depolarization – the stimulating the nerve Distal – situated – situated away from the point of origin Endolymph – fluid – fluid within the labyrinth of the inner ear Extrafusal – situated – situated outside of a muscle spindle

– a break in the continuity of the bone Fracture – a – a pattern of movements for walking or moving on foot Gait – a Hyperpolarization – efflux – efflux of potassium ions across a membrane preventing or inhibiting an

action potential











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– sensations pertaining to the skin and deep tissues of the body Somatosensory – sensations Tendon – fibrous – fibrous tissue that connects muscle to bone

– a moment of force to produce rotation about an axis Torque – a Vertigo – a – a feeling of motion, dizziness or confusion Yaw – rotational – rotational movement of the head side to side on the z-axis









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1. Arezzo, J. C., Schaumburg, H. H., & Spencer, P. S. (1982). Structure and function of the somatosensory system: A neurotoxicological perspective. Environmental Health Perspective, 44, 23-30. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1568957/pdf/envhper00461-0029.pdf 2. Brown, K. E., Whitney, S. L., Marchetti, G. F., Wrisley, D. M., & Furman, J. M. (2006). Physical therapy for central vestibular dysfunction. American dysfunction. American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation, Rehabilitation, 87 (87), (87), 76-81. doi: 10.1016/j.apmr.2005.08.003 3. Brandt, T. (2000). Management of vestibular disorders. 491-499. 4. Clopton, J. (2007). Balanced (2007). Balanced vision: How the visual and vestibular system interact . Unpublished manuscript, Retrieved from http://www.sifocus.com/files/Balanced Vision- How the Visual and Vestibular Systems Int….pdf









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14. Rutka, J. A. (n.d.). Physiology (n.d.). Physiology of the vestibular system. system. Informally published manuscript, Retrieved from http://www.bcdecker.com/SampleOfChapter/1550092634.pdf 15. Strang, A. J., Haworth, J., Hieronymus, M., Walsh, M., & Smart Jr, L. J. (2010). Structural changes in postural sway lend insight into effects of balance training, vision, and support surface on postural control in a healthy population. 1485-1495. doi: 10.1007/s00421-010-1770-6 16. Van Ooteghem, K. (2010). An Introduction to Psychomotor Behaviour. University of Waterloo. 17. Vestibular exercises. exercises. Unpublished raw data, University of Mississippi, Jackson, MS, Retrieved from http://www.umc.edu/uploadedfiles/umcedu/content/education/schools/medicine/clinical_science/ otolaryngology__communicative_sciences/handouts/vestibularexercise.pdf









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B. Schematic of the Semont maneuvers









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Balance Training and Rehabilitation With Closed Kinetic Chain Exercises

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