With over 20K different balance exercises, each with different levels of difficulty, how do you determine the right time to progress a patient from one exercise to another? In previous posts, I’ve discussed criteria for determining an appropriate level of balance training intensity for a given exercise (see blog post 20:20 Clarity on Balance Intensity), but I have not covered when it appropriate to progress from one exercise to another.
In review, the “ideal” balance training intensity for a given exercise is a ratio of 20% steadiness to 20% unsteadiness. An individual should be steady at least 20% of the exercise time AND unsteady at least 20% of the exercise time. Steadiness is defined as the ability to stand or move without hesitation, holding, touching, slowness of movement, or presence of obvious balance reactions (ankle, hip, knee or stepping). Observations of steadiness are critical to setting balance exercise intensities at appropriate levels. Training at such levels is key to achieving positive outcomes and avoiding wasting time (if exercise is too easy) or frustrating patients (exercise is too hard).
Observations of steadiness are also essential to properly progressing balance exercises. When individuals are observed to be steady at least 50% of the exercise time, it is appropriate to progress to exercises that are more difficult. For example, if a patient is observed to be steady > 50% of the time while performing a stepping exercise forward of midline (Exercises 55 & 73 in the Haas Balance Book: 100+ Exercises for PTs and OTs), it is appropriate to then progress to stepping behind midline, which is a more difficult balance exercise.
The need for continually observing and monitoring patients during balance exercises cannot be overstated. Clinical observations are key to setting ideal training intensities (20:20 steadiness ratio), progressing patients at appropriate times (> 50% steady), spotting patients when needed for safety, and encouraging patients to push and expand their boundaries of balance. Balance training requires the unique skills of PTs and OTs to make these determinations. Use your skills to help keep balance progressive – particularly when steadiness is observed > 50% of the exercise time!