Sometimes we can anticipate a balance challenge, other times we get caught by surprise. Anticipation is seeing someone walking your way with their head down (texting on their phone), noticing that they are heading straight for you, and bracing yourself for impact to prevent getting knocked over. Surprise is catching your toe on the ridge of an uneven sidewalk, suddenly careening forward, and tossing everything in your arms to prevent face planting on the ground. Surprise reactions are also known as reactionary balance strategies. Because reactionary balance is part of life, it should be part of balance training as well.
Reactionary balance comes largely out of surprise events, and lower-level balance strategies are passed over – ankle, hip, and knee strategies. As such, stepping and arm strategies remain to correct for the sudden, and sometimes large, disruptions to balance. Stepping movements are needed to reset the base of support and center the body’s center of pressure back in a steady state. Arm reactions are needed to help decelerate the movement of the body toward the ground, e.g., the arms quickly move up to slow the overall momentum of the body going down. In addition, stepping and arm strategies must happen quickly, with proper coordination, and with strong enough muscle responses to overcome the slip, trip, bump, push, etc. Otherwise, a fall will occur.
As noted previously, balance training needs to include reactionary balance. Below are 3 suggestions for incorporating reactionary balance into your treatments.
- Perturbations are outside forces that cause a change in normal standing state. Pushes, nudges, losses of support are all examples of perturbations. For perturbations to be reactionary, they must not be easily anticipated. Examples of such perturbations include the following:
- Nudges that occur randomly from different sides, amplitudes, and times.
- Tilting of a water-filled tube while standing or walking.
- Pulls from a belt attached to a pulley, when slack is taken up and suddenly let go.
- Losses of support, when hand is released suddenly after asking patient to pull or push against a supporting hand.
- Taps or tilts to wobble board (from therapist) as patient attempts to keep it flat and still.
- Clocking is the use of randomized stepping to improve reaction speed and muscle strength in standing. As the name suggests, the use of a clock face is central to the exercise. The exercise begins with the patient standing in the middle of the clock face. As a number is called out (1-12), the patient steps on that number and returns to the starting point – like the lunging motions seen in reactionary stepping strategies. For more information on clocking visit http://clockyourself.com.au/.
- Catching can elicit quick changes in body position. Stretching and reaching to catch a “wild” ball, e.g., one far away from the body, can create a loss of balance and an immediate need for reactionary balance strategies. As such, use a gait belt and spot your patient properly as they throw and catch a ball against a wall. Below are a few suggestions for grading catching:
- Heavier balls are harder to catch (weighted balls).
- Extremely light balls are harder to catch (balloons).
- Smaller balls are harder to catch.
- Balls thrown in random ways are harder to catch (high, low, away, bounced, etc.).
Balance training always involves an element of risk, and reactionary balance exercises can be even more dangerous. As such, spot your patients appropriately and keep them safe as they learn and improve their balance skills. The world is full of unexpected balance challenges. Incorporating reactionary balance exercises into your treatments will better prepare your patients for the next unexpected bump, trip, slip, or nudge that comes their way.