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20:20 Clarity on Balance Intensity

In order to get the most of balance training, the intensity of the exercise needs to be “just right.” Too much support (holding, touching, spotting, bracing, etc.) or too little of challenge (hard/stable surfaces, wide stances, minimal head or body movements, etc.) can make balance exercises too easy. Exercises that are too easy hurt potential balance gains. On the other hand, if too little of support is given, or if challenges are too hard, patients will develop feelings of fear, frustration, and vulnerability. Determining the ideal level of intensity for balance training takes skill (which is why balance training is the domain of PT's and OT's). Below is a quick guide to finding balance intensities that are "just right:"

  1. Exercise is Too Easy – As a guide, patients need to be “unsteady” at least 20% of exercise time. Unsteadiness is defined as the presence of postural reactions (ankle, hip, stepping, etc.), slowness of movements (slow reach, pauses in head turns, etc.), and/or use of support (gait belt help, hand support, etc.). If balance exercise is too easy, the patient can complete over 80% of the exercise time without evidence of postural reactions, slowness of movement, or support. Exercises that are too easy waste time and limit positive training effects. Easy exercises are not good.
  2. Exercise is Too Hard – On the opposite end of the spectrum, patients need to be “steady” at least 20% of the time. Steadiness is being able to maintain a posture, or perform an exercise, without obvious use of postural reactions, slow movements, or need for supports. If this is noted > 80% of exercise time, then the balance exercise is considered too hard. Exercises that are too hard, lead to feeling of vulnerability, frustration, and lost confidence – the opposite of what we are trying to do in rehab. Exercises that are too hare are not good.
  3. Exercise is Just Right – For exercise intensity to be “just right,” patients should be able to work in and out of periods of steadiness and unsteadiness. As a guide, postural reactions, slow movements, and/or need for support should range from 20% to 80% of the exercise time. Patients need to use balance reactions (ankle, hip, arm, stepping, etc.) while exercising – they are indicators that an exercise is challenging. The use of hand support (quick touches on bars, tactile cues at hips, slight correction on gait belts, etc.) is also okay, as long as, patients still feel safe and in control when exercising. Patients need to feel challenged, but not frustrated. Exercise shouldn’t be too easy or too hard. Exercises that are "just right" are good. 

It is clear that balance exercises need to be just right to facilitate positive improvements in steadiness without patients feeling frustrated, unsafe, or losing confidence. Use this 20:20 guide to help properly challenge your patients with the right balance intensity.   

For more on balance training exercises, check out Balance Training: 5 Laws & 100+ Exercises.

For even more information on balance training intensity please check out previous posts: 4 Ways to Overload Balance Training, How Patients Say Balance Exercises are Hard (Verbal and Non-Verbal), and 3 Factors to Balance When Prescribing Balance Exercises.