The Effects of Balance Exercises on Lower Extremity Injury Prevention: A Systematic Review
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20 Comments on “The Effects of Balance Exercises on Lower Extremity Injury Prevention: A Systematic Review”
HANNAH CASS (2 days ago): This is a topic that I find really interesting, especially with having torn my acl three times. I worked on implementing an injury prevention program at the high school in Custer, SD this summer for some of the athletes but found myself unable to determine how often and how many days a week they should be doing it. Do you have any insight after completing this on how often an injury prevention program should be done a week? And does it differ based on if the athletes are in season or out of season? Great job!
Hi Hannah, great question! From the studies we looked at it seemed that the athletes who completed the prevention programs 3+ times a week had a decreased injury rate. One of the main conclusive findings of our review was that the higher the compliance, the lower the injury rates. So, based on the research we found, it would seem that athletes should be participating in at least 3 sessions a week. As for the in season or out of season, there were no specifics, but that would be an interesting topic.
JAMIE SCHWEISS (3 days ago): Of the 5 articles you included in your systematic review, I noticed in the outcome column of
Table 1 that only one of the articles mentioned a reduction in specific LE injuries. Did any of the other articles mention specific LE injuries? Also, the last article by Halvarsson et al. mentioned substantial injuries. Were these injuries defined in the article?
A substantial injury was defined as “any physical complaint resulting in moderate or severe reductions in training volume, or moderate or severe reduction in performance, or complete inability to participate in sports”. In this article done by Halvarsson et al. injuries were self-reported through a series of questionnaires and text alerts. Each study went about defining injuries and collecting data on them in different ways. For example, in the article by Owen et al., it was considered an injury if it prevented the players from participation in normal training/competition for 48 hours and injuries were assessed by qualified physiotherapists. Injuries were further broken down into 11 different categories. Examples of categories included muscle strain, ligament tear, tendonitis, impingement, back/neck, etc. That article also excluded the injury if it did not occur during training or competition. In conclusion, each study had its own way of quantifying injuries. Some of the articles were more in-depth with their qualifications while others were more vague on their definitions.
TIEGEN LINDNER (3 days ago): Very cool! While analyzing this systematic review, I notice that dynamic single leg balance and adherence to an injury prevention program were found to be most important for injury prevention in addition to the fact that firm surface training had a negative effect on injury prevention. I also noticed, with regard to the above conclusions, that of the 5 studies that were included, 4 of them are performed on uneven surfaces (only one that is not is basketball). Do you believe the “successful” outcomes of the dynamic SLB was found due to the specificity of the sport (not firm rehabilitation is better for not firm playing surfaces once recovered)? Do you think that basketball, as it is not played on uneven surfaces, could potentially benefit more from firm surface (in addition to dynamic surface) than soccer/rugby/orienteering which is played on uneven/grass/dirt? TL
BAILEY NEISES reply (18 hours ago): I do believe that sports-specific injury prevention programs and balance exercises are important. However, I do not believe that the only reason that dynamic SLB exercises were found to be successful was just due to the fact that the sports included (besides one) in our systematic review were played on an uneven surface. I believe this is evident in the study completed by Bonato et al. That study consisted of women’s basketball players completing dynamic balance exercises with moving BOS. Even though basketball is played on a firm surface, these women had amazing rates with far fewer injuries when completing dynamic SLB exercises.
Dynamic SLB requires much more input and effort in regard to our neural and body systems as compared to SLB on firm surfaces. The addition of the extra inputs and efforts cause for dynamic SLB to be more difficult to complete and better prepares athletes for the demands they may encounter.
ERIN LUKEN (4 days ago): Very nice work! This is a topic that really interests me, especially because a couple of the patients I have right now are focusing on injury prevention. I am not surprised that there was a found benefit with single leg dynamic balance training, because more often than not, non-contact injuries occur during dynamic movement. It is unfortunate that studies are lacking in this area because it could potentially be very beneficial for clinicians and coaches. How do you think a general strengthening program would compare to one focused solely on dynamic balance in terms of injury prevention? Obviously an ideal training program would include both. However, I am wondering if a general LE strengthening program would be comparable to a balance protocol in terms of injury prevention.
RYAN HANKS reply (2 days ago): Thanks Erin!
Good question. Ideally, yes, there would be both a strengthening and dynamic balance component to a training program, especially when it pertains to injury prevention in sport. As far as which would be more beneficial, I think it may be more contextual to the sport. For endurance athletes in which there is more of a sustained speed for long durations of time, I could definitely see where a dynamic balance program would be sufficiently beneficial for those athletes. In sport that requires more anaerobic activity and expression of power, I don’t think either simply a strengthening or dynamic balance program would benefit the athlete (although, it would matter the context of exercise selection in the programs) because of the demands of the sport and the expression of athleticism that is required of the athletes.
TORI (5 days ago): You found that firm surface training had a negative impact on lower extremity balance training, do you think that athletes competing on firm surface sports like basketball are at
higher risk for injury when compared to football players on surfaces such as grass or turf?
Do you think you would see different/more results if you widen your search to injury prevention training on all individuals who exercise rather than just sports related/athletes?
ZACH SEBERN reply (a day ago): Good questions Tori, I don’t think there is anything out there regarding safety on firm surface (gym court) vs. unfirm surfaces (grass or turf). However, we could make conclusions based on injury rates specific to the surfaces and understanding that firm surfaces are going to give more accurate signaling to our somatosensory system compared to grass and turf. The other variable needing to be considered is natural (grass) vs. artificial (turf), which we know artificial surfaces have seen higher non-contact injury rates in athletes. I think this issue is multifactorial in nature but without looking at playing surface injury rates it’s tough to say which surface presents a higher risk.
Yes, I believe we would see more results, but the results would probably be less specific to athletes and the population we were trying to address. I don’t know if we would see many studies looking at injury prevention with a general population who are just exercising to staying active, but it is definitely worth a quick literature search to check!
Nice job on your research findings! I thought it was very interesting how limited this topic was on research. My first question is do you feel that was the most limiting factor, just not having access to enough information? Otherwise in your opinion, do you think the results of significant findings could more be contributed to the frequency (3+ per week) for reducing LE injuries, or the actual exercises that were being performed? I agree that more research in general needs to be done with better PEDro scores to help increase the generalizability.
We were also somewhat surprised at how little research was out there. The biggest issue with our research topic was definitely the lack of studies that focused solely on static or dynamic balance exercises as a method for injury prevention. Most of the studies implemented injury prevention programs that were multi-faceted which included strength/power training, dynamic stretching, mobility/agility drills, and balance. This makes it hard to determine which is most important to injury prevention, but it also tells us they all play an important part with those that show consistency in completing at least 2+x week. From what we were able to find, adherence and consistency of their programs was the most important factor in injury reduction. The exercises were shown to not be as important as long as the exercises were specific to the athlete and what they’ll be required to do for performance as well as challenging them appropriately with time, intensity, and frequency.
Great job, definitely an important topic! In the outcome column of the studies you cited, they mention finding decreases to LE injury risk. How exactly were they measuring ones risk of injury? Was this based on performance measures, like a functional movement screen, or just the occurrence of injury throughout the duration of the program?
Hey Cody,
The risk of injury was based on the occurrence of an injury during the specific study. Each study had their own definition of what would classify as an “injury”. For example, in the study looking at elite professional soccer players, the injuries were broken down into 11 different categories. The categories included things such as ligament tear, muscle strain, tendonitis, impingement, back/neck, etc. The injury was only included if it occurred during training/competition. This is just the example for that one specific study. Overall, the studies looked at occurrence of injury in some capacity.
Great job on the poster, guys! I have a similar question to Tiegen’s above, so forgive me if this is redundant but I think it is different enough. I saw that a conclusion from the systematic review is that firm surface balance training had a negative effect on injury prevention. I would think that at the very least it would have no effect or maybe even a slightly positive, even if a particular athlete’s sport was played on an uneven surface. From your study, why do you think that firm surface balance training had a negative effect on injury prevention?
Great question Michael, I’ll try to answer the best I can. While we did find that firm surface training had a negative effect, none of the findings were significant. Also, the three studies looking at firm surface training were performed by athletes who play their sport on an uneven surface. The lack of specificity of their program could’ve impacted the injury rate, but at the same time those studies were also including other forms of SLB and not solely firm surface training.
Good work on the poster, very relevant issue being addressed. When do you think it would be appropriate to begin these injury prevention programs? Frequently it seems we hear of athletes younger and younger that are having LE injuries such as ACL, so I was just curious on your thoughts of the appropriate age range to begin these prevention measures.
Personally, injury prevention programs can be held earlier than most actually are. Obviously, all of this is going to be individually based and sport-specific. One of my favorite forms of “injury prevention programs”, as a means of strength, balance, and coordination training is gymnastics. Simply placing young kids in sports like that which will challenge all of these aspects can be extremely beneficial in injury prevention. So, in short, you can start implementing injury prevention programs for young children who are old enough to begin sports.
Great work! Overall, this poster is organized well with beneficial information to share. I believe this topic will continue to influence therapists, trainers, and athletes on physical activity and game preparation. Especially as there seems to be many possible influences contributing to LE injuries. Looking through the articles used, I noticed the sports are considered non-contact LE, yet included soccer. My first question would be regarding what makes a sport LE non-contact?
Another question of mine would be considering the age difference in athletes along with skill level. I see there are high school level athletes compared to professionals. Would the impact of practice training (coaching, conditioning, etc.) influence their outcomes. Lastly, would you see a difference in athletes who are injury prevention training in off season compared to in season? Overall, great job sharing your findings!
So, to answer your first question the sports injuries we were looking for in our literature search were non-contact injuries, not necessarily saying the sport doesn’t include contact just that the injuries we looked at were sustained with a non-contact mechanism. Secondly, I think the age of the athlete does impact injury rates as different ages have different developmental statuses and prior training experience can influence the chance of injury. With your last question I think better results would be seen if athletes completed these programs on a year-round basis as the results have shown decreased injury rates with adherence rates. So, I think the best option would be to really prioritize injury prevention in the off-season along with other forms of training and find time to continue injury prevention a couple times a week during the season. I don’t think it’s something you would want to do just do during the season or just in the off season but year-round in a perfect world.
Hey guys! It’s crazy that there is such a lack of research regarding balance training and its effect on injury prevention. A few questions – Why do you think there is such a significant gap in research in this area? Do you feel that your inclusion/exclusion criteria were a main player in the lack of research? Would you say that a limitation is the fact that most coaches probably wouldn’t opt for a “balance only” injury prevention program and would more likely choose a more “comprehensive” program? Thanks and great job with this project!
Hey Spencer,
Great questions! I do not believe that our inclusion/exclusion criteria were the main players for lack of research. We as a group tried a wide range of search criteria and key words to try and find research for our systematic review. The main reason we found for the gap in research is because most studies focused on comprehensive injury prevention programs when looking into injury prevention. I think you hit the nail on the head with coaches and others wanting to implement comprehensive programs instead of balance only injury prevention. Factors such as strength, mechanics, and many others play a role in injuries along with balance. However, we as a profession would benefit from learning what exact balance exercises would be most beneficial for injury prevention.
USD PT Research 
HANNAH CASS (2 days ago): This is a topic that I find really interesting, especially with having torn my acl three times. I worked on implementing an injury prevention program at the high school in Custer, SD this summer for some of the athletes but found myself unable to determine how often and how many days a week they should be doing it. Do you have any insight after completing this on how often an injury prevention program should be done a week? And does it differ based on if the athletes are in season or out of season? Great job!
LikeLike
Hi Hannah, great question! From the studies we looked at it seemed that the athletes who completed the prevention programs 3+ times a week had a decreased injury rate. One of the main conclusive findings of our review was that the higher the compliance, the lower the injury rates. So, based on the research we found, it would seem that athletes should be participating in at least 3 sessions a week. As for the in season or out of season, there were no specifics, but that would be an interesting topic.
LikeLike
JAMIE SCHWEISS (3 days ago): Of the 5 articles you included in your systematic review, I noticed in the outcome column of
Table 1 that only one of the articles mentioned a reduction in specific LE injuries. Did any of the other articles mention specific LE injuries? Also, the last article by Halvarsson et al. mentioned substantial injuries. Were these injuries defined in the article?
LikeLike
Hey Jamie,
A substantial injury was defined as “any physical complaint resulting in moderate or severe reductions in training volume, or moderate or severe reduction in performance, or complete inability to participate in sports”. In this article done by Halvarsson et al. injuries were self-reported through a series of questionnaires and text alerts. Each study went about defining injuries and collecting data on them in different ways. For example, in the article by Owen et al., it was considered an injury if it prevented the players from participation in normal training/competition for 48 hours and injuries were assessed by qualified physiotherapists. Injuries were further broken down into 11 different categories. Examples of categories included muscle strain, ligament tear, tendonitis, impingement, back/neck, etc. That article also excluded the injury if it did not occur during training or competition. In conclusion, each study had its own way of quantifying injuries. Some of the articles were more in-depth with their qualifications while others were more vague on their definitions.
LikeLike
TIEGEN LINDNER (3 days ago): Very cool! While analyzing this systematic review, I notice that dynamic single leg balance and adherence to an injury prevention program were found to be most important for injury prevention in addition to the fact that firm surface training had a negative effect on injury prevention. I also noticed, with regard to the above conclusions, that of the 5 studies that were included, 4 of them are performed on uneven surfaces (only one that is not is basketball). Do you believe the “successful” outcomes of the dynamic SLB was found due to the specificity of the sport (not firm rehabilitation is better for not firm playing surfaces once recovered)? Do you think that basketball, as it is not played on uneven surfaces, could potentially benefit more from firm surface (in addition to dynamic surface) than soccer/rugby/orienteering which is played on uneven/grass/dirt? TL
BAILEY NEISES reply (18 hours ago): I do believe that sports-specific injury prevention programs and balance exercises are important. However, I do not believe that the only reason that dynamic SLB exercises were found to be successful was just due to the fact that the sports included (besides one) in our systematic review were played on an uneven surface. I believe this is evident in the study completed by Bonato et al. That study consisted of women’s basketball players completing dynamic balance exercises with moving BOS. Even though basketball is played on a firm surface, these women had amazing rates with far fewer injuries when completing dynamic SLB exercises.
Dynamic SLB requires much more input and effort in regard to our neural and body systems as compared to SLB on firm surfaces. The addition of the extra inputs and efforts cause for dynamic SLB to be more difficult to complete and better prepares athletes for the demands they may encounter.
LikeLike
ERIN LUKEN (4 days ago): Very nice work! This is a topic that really interests me, especially because a couple of the patients I have right now are focusing on injury prevention. I am not surprised that there was a found benefit with single leg dynamic balance training, because more often than not, non-contact injuries occur during dynamic movement. It is unfortunate that studies are lacking in this area because it could potentially be very beneficial for clinicians and coaches. How do you think a general strengthening program would compare to one focused solely on dynamic balance in terms of injury prevention? Obviously an ideal training program would include both. However, I am wondering if a general LE strengthening program would be comparable to a balance protocol in terms of injury prevention.
RYAN HANKS reply (2 days ago): Thanks Erin!
Good question. Ideally, yes, there would be both a strengthening and dynamic balance component to a training program, especially when it pertains to injury prevention in sport. As far as which would be more beneficial, I think it may be more contextual to the sport. For endurance athletes in which there is more of a sustained speed for long durations of time, I could definitely see where a dynamic balance program would be sufficiently beneficial for those athletes. In sport that requires more anaerobic activity and expression of power, I don’t think either simply a strengthening or dynamic balance program would benefit the athlete (although, it would matter the context of exercise selection in the programs) because of the demands of the sport and the expression of athleticism that is required of the athletes.
LikeLike
TORI (5 days ago): You found that firm surface training had a negative impact on lower extremity balance training, do you think that athletes competing on firm surface sports like basketball are at
higher risk for injury when compared to football players on surfaces such as grass or turf?
Do you think you would see different/more results if you widen your search to injury prevention training on all individuals who exercise rather than just sports related/athletes?
ZACH SEBERN reply (a day ago): Good questions Tori, I don’t think there is anything out there regarding safety on firm surface (gym court) vs. unfirm surfaces (grass or turf). However, we could make conclusions based on injury rates specific to the surfaces and understanding that firm surfaces are going to give more accurate signaling to our somatosensory system compared to grass and turf. The other variable needing to be considered is natural (grass) vs. artificial (turf), which we know artificial surfaces have seen higher non-contact injury rates in athletes. I think this issue is multifactorial in nature but without looking at playing surface injury rates it’s tough to say which surface presents a higher risk.
Yes, I believe we would see more results, but the results would probably be less specific to athletes and the population we were trying to address. I don’t know if we would see many studies looking at injury prevention with a general population who are just exercising to staying active, but it is definitely worth a quick literature search to check!
LikeLike
Nice job on your research findings! I thought it was very interesting how limited this topic was on research. My first question is do you feel that was the most limiting factor, just not having access to enough information? Otherwise in your opinion, do you think the results of significant findings could more be contributed to the frequency (3+ per week) for reducing LE injuries, or the actual exercises that were being performed? I agree that more research in general needs to be done with better PEDro scores to help increase the generalizability.
LikeLike
We were also somewhat surprised at how little research was out there. The biggest issue with our research topic was definitely the lack of studies that focused solely on static or dynamic balance exercises as a method for injury prevention. Most of the studies implemented injury prevention programs that were multi-faceted which included strength/power training, dynamic stretching, mobility/agility drills, and balance. This makes it hard to determine which is most important to injury prevention, but it also tells us they all play an important part with those that show consistency in completing at least 2+x week. From what we were able to find, adherence and consistency of their programs was the most important factor in injury reduction. The exercises were shown to not be as important as long as the exercises were specific to the athlete and what they’ll be required to do for performance as well as challenging them appropriately with time, intensity, and frequency.
LikeLike
Great job, definitely an important topic! In the outcome column of the studies you cited, they mention finding decreases to LE injury risk. How exactly were they measuring ones risk of injury? Was this based on performance measures, like a functional movement screen, or just the occurrence of injury throughout the duration of the program?
LikeLike
Hey Cody,
The risk of injury was based on the occurrence of an injury during the specific study. Each study had their own definition of what would classify as an “injury”. For example, in the study looking at elite professional soccer players, the injuries were broken down into 11 different categories. The categories included things such as ligament tear, muscle strain, tendonitis, impingement, back/neck, etc. The injury was only included if it occurred during training/competition. This is just the example for that one specific study. Overall, the studies looked at occurrence of injury in some capacity.
LikeLike
Great job on the poster, guys! I have a similar question to Tiegen’s above, so forgive me if this is redundant but I think it is different enough. I saw that a conclusion from the systematic review is that firm surface balance training had a negative effect on injury prevention. I would think that at the very least it would have no effect or maybe even a slightly positive, even if a particular athlete’s sport was played on an uneven surface. From your study, why do you think that firm surface balance training had a negative effect on injury prevention?
LikeLike
Great question Michael, I’ll try to answer the best I can. While we did find that firm surface training had a negative effect, none of the findings were significant. Also, the three studies looking at firm surface training were performed by athletes who play their sport on an uneven surface. The lack of specificity of their program could’ve impacted the injury rate, but at the same time those studies were also including other forms of SLB and not solely firm surface training.
LikeLike
Good work on the poster, very relevant issue being addressed. When do you think it would be appropriate to begin these injury prevention programs? Frequently it seems we hear of athletes younger and younger that are having LE injuries such as ACL, so I was just curious on your thoughts of the appropriate age range to begin these prevention measures.
LikeLike
Thank Logan.
Personally, injury prevention programs can be held earlier than most actually are. Obviously, all of this is going to be individually based and sport-specific. One of my favorite forms of “injury prevention programs”, as a means of strength, balance, and coordination training is gymnastics. Simply placing young kids in sports like that which will challenge all of these aspects can be extremely beneficial in injury prevention. So, in short, you can start implementing injury prevention programs for young children who are old enough to begin sports.
LikeLike
Great work! Overall, this poster is organized well with beneficial information to share. I believe this topic will continue to influence therapists, trainers, and athletes on physical activity and game preparation. Especially as there seems to be many possible influences contributing to LE injuries. Looking through the articles used, I noticed the sports are considered non-contact LE, yet included soccer. My first question would be regarding what makes a sport LE non-contact?
Another question of mine would be considering the age difference in athletes along with skill level. I see there are high school level athletes compared to professionals. Would the impact of practice training (coaching, conditioning, etc.) influence their outcomes. Lastly, would you see a difference in athletes who are injury prevention training in off season compared to in season? Overall, great job sharing your findings!
LikeLike
Hi Makaela,
So, to answer your first question the sports injuries we were looking for in our literature search were non-contact injuries, not necessarily saying the sport doesn’t include contact just that the injuries we looked at were sustained with a non-contact mechanism. Secondly, I think the age of the athlete does impact injury rates as different ages have different developmental statuses and prior training experience can influence the chance of injury. With your last question I think better results would be seen if athletes completed these programs on a year-round basis as the results have shown decreased injury rates with adherence rates. So, I think the best option would be to really prioritize injury prevention in the off-season along with other forms of training and find time to continue injury prevention a couple times a week during the season. I don’t think it’s something you would want to do just do during the season or just in the off season but year-round in a perfect world.
LikeLike
Mikaela** sorry
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Hey guys! It’s crazy that there is such a lack of research regarding balance training and its effect on injury prevention. A few questions – Why do you think there is such a significant gap in research in this area? Do you feel that your inclusion/exclusion criteria were a main player in the lack of research? Would you say that a limitation is the fact that most coaches probably wouldn’t opt for a “balance only” injury prevention program and would more likely choose a more “comprehensive” program? Thanks and great job with this project!
LikeLike
Hey Spencer,
Great questions! I do not believe that our inclusion/exclusion criteria were the main players for lack of research. We as a group tried a wide range of search criteria and key words to try and find research for our systematic review. The main reason we found for the gap in research is because most studies focused on comprehensive injury prevention programs when looking into injury prevention. I think you hit the nail on the head with coaches and others wanting to implement comprehensive programs instead of balance only injury prevention. Factors such as strength, mechanics, and many others play a role in injuries along with balance. However, we as a profession would benefit from learning what exact balance exercises would be most beneficial for injury prevention.
LikeLike