Lower Extremity Perturbation Training
Perturbation training for the lower extremity involves controlled unpredictable forces directed to an unstable surface for improved efficiency of stabilizing muscular contractions during stance or gait. It is a type of neuromuscular training that refines neural pathways to promote effective muscular recruitment patterns and dynamic joint stability and Balance. Coupled with other neuromuscular techniques, perturbation training has been shown to be effective in pre-operative treatment of anterior cruciate ligament rupture and reconstruction even in all other ligament injuries of knee joint. The effects of training may also be beneficial in the prevention and rehabilitation of other athletic injuries like Micro Fractures, Ankle injuries and other Soft tissue injuries as well.
Perturbation exercises have recently been proven to enhance the ability of the proprioceptor signals to the muscle and prevent injuries and to enhance performance. Training on unstable environments would certainly not be the first choice to develop hypertrophy or explosiveness of muscles; there is nothing like high volume training, Olympic lifts and plyos for that. Having said that, would certainly incorporate a measured dose of stability training (i.e. using unstable training environment) within any hypertrophy or power program to help direct and control the size and power the program will surely provide. So, Perturbation exercises are performed on an unstable surface. It involved the use of roller boards and tilt boards to expose the individual to challenges in balance. Perturbation training can be successfully implemented in Knee Rehabilitation and Ankle Rehabilitation.
Common techniques which were practicing under Perturbation training are:
A) Multidirectional perturbations while the subjects were standing with One lower extremity on a Roller board and the other on a stationary platform,
2) A-P and M-L rotary perturbations on a Roller board,
3) Multidirectional perturbations while the subjects were standing only with One lower
extremity on a roller board and
4) Multidirectional perturbations while the subjects were standing in Single-limb support on a roller board.
One of the new methods of unstable training is vibration training. Multiple studies have now been conducted on the effects of vibration training on different parameters of performance and physiology (Bosco, Cardinale, Delecluse, Torvinen, Rittweger). The curiosity with vibration dates back to 1965 (Hagbarth) when the “Tonic Vibration Reflex (TVR)” was first described. This phenomenon described a reflex muscle contraction that ensued after mechanical vibrations were felt by muscles. It is believed that vibration training may enhance activation of the muscle spindles, leading to and enhancement of the “reflex loop.”
Furthermore, it is believed that the higher EMG readings illustrated during vibration training, when compared to voluntary contractions, could be related to an increase in motor unit synchronization. The reflex muscle activity noted in vibration training is thought to be a response of the central nervous system to strong perturbations (i.e. a disturbance of motion, course, arrangement, or state of equilibrium). Most of the vibration frequencies studied have been between 26Hz and 44Hz. Various implements have been researched, from vibrating dumbbells to total body platforms. The studies have shown some positive adaptations to vibration training, although the mechanism of action and the optimal protocol still evade scientists.
Other Equipments which are useful for Perturbation Training are:
Bosu Ball:
Standing on a BOSU ball can provide enormous Lower Limb stability due to the unstable training environment.
Body Blade:
The Bodyblade can easily provide active and dynamic perturbation in two planes of motions, simultaneously.
Shuttle Balance Platform:
Training on Shuttle Balance Platform is very efficient training programme where much vibration and Sharing forces will generate to improve the Proprioception of Lower Extremity Joints.
Balance Tutor Unit:
One of the fabulous Perturbation Training Platform where multidirectional and non-weight bearing and Partial weight bearing Gait Training Unit. Also very useful for AGILITY Training.
Research evidence on Knee - Specific Perturbation Training:
1. A study done by G Kelley Fitzgerald, et al. in 2000 which proven Perturbation training program appears to reduce the risk of continued episodes of giving way of the knee during athletic participation, and it allows subjects to maintain their functional status for longer periods after non-operative anterior cruciate ligament rehabilitation programs for physically active individuals1.
2. A study done by Rhon, Daniel; et al. in 2013 observed tolerance to perturbation exercises and the effect of a manual physical therapy approach with perturbation exercises on patients with Osteo Arthritis of Knee. Total of 15 patients were participated with follow up evaluation at 1, 3 and 6 months after beginning of program. And concluded that manual physical therapy approach that also included Perturbation exercises was well tolerated and resulted in improved outcome scores in patients with knee O.A2.
3. A study done in 2005 by Chmielewski TL, Hurd WJ, Rudolph KS, et al. to determine how perturbation training alters muscle co-contraction and knee kinematics in potential copers. 17 subjects without injuries were participated. Motion analysis and electromyographic data were collected as subjects walked across a stationary or moving platform (horizontal translation) before and after perturbation training. Findings from this study provide evidence for a mechanism by which perturbation training acts as an effective intervention for promoting coordinated muscle activity in a select population of people with ACL rupture (potential copers)3.
Research evidence on Ankle - Specific Perturbation Training:
1. Williams GN, et al. reported Perturbation training is one of the central components of rehabilitation phase in managing syndesmotic ankle sprains. They did a review on rehabilitation program of syndesmotic ankle sprains which gave clear view on acute phase rehabilitation, sub acute rehabilitation, Advanced rehabilitation phases. In advanced training phase focuses on preparing the patient for return to sports participation. Perturbation of support surfaces, agility drills, Plyometrics and sport – specific training are central components of this phase4.
2. In a text book “Clinical Orthopaedic Rehabilitation” by Michael Duke, PT, CSCS and S. Brent Brotzman, MD also discussed about perturbation training in ankle injuries as “those perturbation exercises described in relation to ACL rehabilitation are valid and effective ways to improve proprioception of the entire lower extremity. The addition of the following exercises will further improve stability of the ankle. Seated tilt board perturbations can be implemented early in the rehabilitation process with good patient tolerance5.
3. Also a research evidence giving a insight on importance of perturbation training in Dance education. This research was done by Batson G. in 2009 and stated that “Perturbation training is designed to evoke focal neuromuscular control at injured joint sites, as well as more global postural responses for overall balance and coordination”. So, this article provides an update on the science of proprioception within the framework of postural control and balance6.
References:
1) Fitzgerald GK, Axe MJ, Snyder-Mackler L. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physically active individuals. Phys Ther. 2000;80:128 –140.
2) Rhon, Daniel; Deyle, Gail; Gill, Norman; Rendeiro, Daniel “Manual Physical Therapy And Perturbation Exercises in Knee Osteoarthritis”. Journal of Manual & Manipulative Therapy; Nov 2013, vol 21, issue 4, p220-p228.
3) Chmielewski TL, Hurd WJ, Rudolph KS, et al. Perturbation training improves knee kinematics and reduces muscle co-contraction after complete unilateral anterior cruciate ligament injuries. Phys Ther. 2005;85:740–754.
4) Williams GN, et al. Rehabilitation of Syndesmotic (high) ankle sprains. Sports health. Nov 2010; 2(6): 460-470.
5) Text book of “Clinical Orthopaedic Rehabilitation” by Michael Duke, PT, CSCS and S. Brent Brotzman, MD.
6) Batson G. Update on proprioception: considerations for dance education. J Dance Med Sci. 2009; 13(2): 35-41.
Dr. Srinivas. P.T (Reg No. L-39682)
Head Of Department (Kaggadasapura branch)
Spectrum Physio Pvt Ltd
Bangalore.
