Pelvic neutral: Key to balance training

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Pelvic neutral: Key to balance training

http://www.ler.com April 2010

Research suggests that balance exercises, as part of a neuromuscular training

program, can help decrease injury risk and improve performance, particularly in

female athletes. But balance training technique can significantly influence

results.

by Gretchen D. Oliver, PhD, ATC, LAT

Unstable surface or balance training has become quite popular in all genres of

exercise from the elite athlete to the daily fitness advocate. Initially,

balance training was used solely in the rehabilitative setting in attempt to

restore the neuromuscular firing patterns that were disturbed in the injury

process. It is known that incorporating balance training improves proprioception

and kinesthetic awareness as well as developing more efficient neuromuscular

firing patterns. The importance of neuromuscular training has been discussed in

detail in the literature.1-7 Many have proposed protocols that incorporate

plyometrics, balance, and core stability training in an attempt to facilitate

neuromuscular changes as well as prevent injuries, particularly in female

athletes.1-7

When discussing balance or neuromuscular training, core muscle activation should

innately be included. Balance is the ability to maintain functional postural

control on an unstable surface. For postural control to be maintained,

appropriate activations and timing of these activations have to be achieved from

the core musculature. The core muscles must be engaged prior to any other muscle

activation for efficient segmented motions to occur.8

We often use the term core to refer to the trunk or more specifically the

lumbopelvic hip complex.9-14 It has been shown that the core musculature,

specifically the transverse abdominis, is the first to fire during unexpected or

trunk self-loading as well as during any upper or lower extremity movement,

regardless of the direction of movement.15 True core initiation begins in the

position of pelvic neutral. For the core to achieve full activation, the pelvis

must maintain a biomechanically neutral position. The muscles of the core either

originate or insert on the pelvis. To function efficiently, the muscles involved

need to be at their optimal length. When the pelvis is in neutral or its normal

anatomical position, the musculature is in its most efficient and functional

position.

Forward lunge balance exercise

As described by Willardson,16 core stability is dynamic and must continually

change in an attempt to respond to postural adjustments or external loads.

Response to postural adjustments can best be trained through the use of unstable

surface or balance training, also known as stability training. However, for

stability training to be effective, one must have core strength, lumbopelvic

stability, and dynamic stability, which are all achieved through performing core

stability exercises. Any type of dynamic activity, whether it is on an unstable

surface or through perturbations, that affects the body's center of gravity in

response to muscular activities is desirable for balance training. Postural

control or a position of pelvic neutral in controlled environments should be

achieved before one progresses to dynamic activities on unstable surfaces. An

example of a controlled environment would be maintaining pelvic neutral while

sitting or standing. During the initial stages of balance training, individuals

should be consciously aware of the activation of their core musculature, and

then through training, they should eventually become innately aware of their

core activation. When the individual can maintain postural control without

conscious effort, unstable surface training may progress to dynamic activities

on unstable surfaces.

Studies have shown that balance or unstable surface training effectively

increases lower extremity neuromuscular power and control, as well as increasing

postural stability in female athletes.5,17 In addition, it has been documented

that the rate of ankle sprains can be significantly reduced through a balance

training intervention.18-20 Also, sport specific balance training in female

soccer athletes has been shown to reduce noncontact hamstring and back

musculature injuries.21 Injury rates for the hamstrings, patellar

tendinopathies, gastrocnemius strains, and other common injuries have been

reduced when multiple balance training protocols are performed.19

Oliver and DiBrezzo22 found that implementing a sport specific balance training

intervention in female volleyball players resulted in no significant improvement

in their balance scores. They did, however, significantly improve their core

endurance scores, thus suggesting that balance training should be the focus of

any training program. If one can maintain postural control during exercise, then

the risk of non-contact injuries will decrease. Once postural control is

established, balance improvements may be developed.

Clinical Relevance

The importance of maintaining postural control and incorporating it with balance

training in attempt to decrease the rate of injury is evident. However the

question that remains unanswered is whether balance training can improve

athletic performance. Previous studies have reported relationships between

greater balance and performance.23-26 Ideally, one would think that if an

athlete could recover from being off balance, and thus maintain balance, he or

she would essentially have improved performance. Conversely, if an athlete were

unable to maintain balance, his or her performance would inevitably be decreased

due to an inability to stay upright. Either way, it is paramount that we focus

on balance training along with the incorporation of postural control.

It is known that female athletes are at greater risk of sustaining a non-contact

anterior cruciate ligament injury than their male counterparts.27-29 In

addition, it has been shown that when implementing ACL prevention programs for

female athletes, the incorporation of balance training has been associated with

improved lower extremity valgus (hip adduction, knee abduction, and ankle

eversion) when landing.30 Given the positive outcomes that balance training has

had on ACL injury prevention in female athletes,30 it is logical that balance

training for females should be a common denominator in all female strength and

conditioning programs.

Clinically, it is imperative that we concentrate on both postural control and

neuromuscular activations though balance training. In reference to injury

prevention, if one is not in a position of pelvic neutral then one is already

predisposed to injury. For example, exhibiting an anterior pelvic tilt (which

would not be indicative of pelvic neutral) would result in femoral internal

rotation, which would cause patellofemoral or iliotibial problems.31 The

quadriceps muscle group crosses the knee and inserts on the tibial tuberosity,

so if the femur is internally rotated, there will be additional stress on the

quadriceps/patellar tendon because the kinetic chain is no longer in anatomical

neutral. The same concept can be applied to the iliotibial band because it also

originates on the femur and inserts on the tibia.

To establish pelvic neutral, we should first focus on basic isometric exercises

that have the individual `hollowing in' her abdominal muscles and holding. The

exercise of abdominal hollowing activates the deep musculature of the core

including the multifidi, transverse abdominis, and other muscles that constitute

the core.14 It should be noted that the core encompasses all

musculature—anterior, posterior, medial and lateral. Muscles included are the

abdominals, obliques, gluteals, hamstrings, quadriceps, spinal stabilizers and

low back musculature. All of the core muscles have their origin or insertion on

the lumbo-pelvic hip complex. Thus when one is trying to hollow in the

abdominals, they are pulling the pelvis into neutral and all muscles are

activated. Therefore, in an attempt to maintain pelvic neutral, one has to

condition the core musculature. Isometric exercises such as front and side

planks, abdominal bridging, flying squirrels and Superman exercises have all

shown to increase abdominal endurance in fourth graders in less than a month.32

Thus, implementing isometric holds for 30 seconds a few times a day could

dramatically assist in gaining pelvic neutral.

Squat balance exercise

Once the individual has a cognitive and physical awareness of pelvic neutral,

she is ready to begin conditioning on an unstable surface. Cognitive awareness

is an important aspect, because when discussing pelvic neutral we are

essentially discussing posture. One must continue to practice proper posture,

particularly pelvic posturing, to understand innately what proper posture is and

what it is not. It has been shown that when one is cognitively aware of muscle

contraction and body position, one can achieve greater muscle activation.33 In

the current example, one could use a mirror as a simple biofeedback mechanism to

examine their posture while they are in pelvic neutral and essentially retrain

to be cognitively aware of what pelvic neutral is and what it feels like. If

they cannot maintain pelvic neutral while normal sitting or standing, then they

are not ready to begin training on unstable surfaces. Training on an unstable

surface without maintaining pelvic neutral will actually accentuate the

biomechanical abnormality that can predispose an athlete to injury.28

Once one can achieve pelvic neutral, the basics of stability training should

then be implemented. A basic stability training program should begin with double

leg support, progressing to single leg support, while maintaining pelvic

neutral. The progression should first begin on a stable surface before advancing

to an unstable surface. One should be able to maintain pelvic neutral while in

double leg support on a stable surface, then progress to single leg support

while maintaining pelvic neutral. When double and single leg support maintaining

pelvic neutral is achieved, then the same exercises should be repeated with eyes

closed.

Once the progression on the stable surface has been achieved, the individual can

then progress to an unstable surface following the same progression, from double

to single leg support with eyes open to double and single leg support with eyes

closed. Pelvic neutral needs to be maintained during all activities. Ball tosses

where the individual tries to throw and catch on an unstable surface can make

the exercises more sport specific. There are unlimited options for progression

of exercises while on an unstable surface. However, the ultimate goal should be

for the individual to maintain pelvic stability throughout the exercises.

Previously, the Indo Board has been used as a great tool for balance training.

Protocols as described by Oliver and DiBrezzo22 are great adjuncts to one's

exercise regimen. The important aspect when performing such balance protocols is

that pelvic neutral is maintained throughout.

Exercises on unstable surfaces where the athlete can perform sport specific

activities should be the preferred choice. These implements would include an

apparatus such as an Indo board or any other type of wobble board that would

allow him or her to maintain an athletic stance on the unstable surface. The

Indo board allows for a large surface area where one has the ability to

incorporate sport specific skills while trying to maintain pelvic neutral as

well as balance. The surface area and cost of the Indo board makes it a

functional apparatus for almost every sporting environment. Basic strength and

conditioning exercises can be performed on the Indo board. In addition, while

performing the basic strength and conditioning exercises, one can also address

the core musculature by maintaining pelvic neutral while performing the

exercises. The types of strength and conditioning activities that could be

performed are unlimited. Almost all body weight exercises could be performed on

the unstable surface, such as the lunge and squat. In addition, total body

exercises using free weights or body blades may be performed. For example, one

could perform a free weight shoulder press while balancing on an unstable

surface, in essence working both the upper and lower body. Balance training is

recommended as part of a thorough neuromuscular training program for all active

individuals, in an attempt to not only reduce the incidence of injury but also

to improve athletic performance.

It should be emphasized that sport specific training while on an unstable

surface is a paramount addition to any form of basic strength training, but

should only be performed once exercises on a stable surface have been mastered.

Balance on an unstable surface should be used as a more dynamic form of

training. A functional, dynamic form of training on an unstable surface will

allow for the development of functional postural activation. Very rarely, if

ever, is one simply trying to maintain a static balance position during

functions of daily living, much less athletic endeavors. If one cannot maintain

stability in an unstable environment, then injury is ultimately inevitable. If

one is training on an unstable surface, then one is simultaneously training the

core musculature by attempting to maintain pelvic neutral. The core conditioning

comes innately with the balance training because of the ultimate postural

control that one maintains through a stable core.

Gretchen D. Oliver is the clinical coordinator of the entry-level Graduate

Athletic Training Education Program and an assistant professor in the

department of health, kinesiology, recreation, and dance at the University of

Arkansas in Fayetteville, AR.

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