Introduction to the exercises

In this section you can find examples of exercises in the STABLE approach.

The exercises are listed according to the balance domain which they are targeting. Please use the menu to find examples of exercises targeting each domain in the STABLE approach.

How to read the exercise descriptions 

For each domain you will find a short description of the overall goal of the exercises, the overall theme of the exercises and some additional considerations which can be important when designing or prescribing exercises for the domain in question. For each domain a number of key exercises are described. Each of the key exercises are provided with examples of how to progress or regress the exercise if the level need to be adjusted to the patient. 

Please notice that neither the key exercises or the examples of progressions and regressions are meant to be the only exercises which can be prescribed following the STABLE approach. The health professional treating the patient can freely modify the described exercises or design additional exercises, but following the STABLE approach it is always important to consider which domains do the exercises target. 

General considerations and recommendations

Safety

When prescribing exercises to be performed alone by the patient always consider safety first. Exercising to improve balance ability has no value if the patient experiences falls or even fractures during exercising. 

We recommend always instructing the patient to perform the exercises with the back close to a corner, when ever possible. Alternatively, the patient can be placed next to a (kitchen) table or other object which is stable enough that the patient can seek support if necessary.  

Further, it is important to help the patient finding the correct level of exercising. The inherit dilemma of practicing balance exercises is that exercises need to be enough challenging to promote a learning effect, but not that challenging so the patient loses control of the exercise. No exercises should be prescribed to any patient without seeing the patient performing the exercise and insuring that the level is appropriate. If any doubt is present about the patients' ability to perform an exercise safely, we recommend adjusting or changing the exercise. 

Please notice that some specific safety considerations are stated with some exercises.

Functionality

We recommend that exercises should preferable be functional. In the STABLE approach we define functional exercises as composed by tasks which has a clear purpose and are performed in normal activities of daily living. For example if a patient should practice free head movements while walking we do not recommend instructing the patient in "walking with head movements". Head movements without any purpose is not a task seen in daily living and will unlikely transfer optimally to improve tasks performed in daily living. Alternatively, the patient could be instructed in "walking while turning the head to spot blue objects, soft object, flying objects ect." In this way the same head movements are practiced, but with a clear functional purpose. 

Along these lines, we recommend practicing reaching for specific targets instead of "swaying", getting up from a seat or jumping instead of performing "lunges" etc.

Functional exercises will not always be the first choice of treatment. For instance, specific impairments of body structures like limited range of movement, pain or low strength in local muscles synergies may be targeted more effectively with exercises or other interventions with no direct functional purpose.

Dizziness

The STABLE approach is developed primarily to target balance impairments, but many of the key exercises described in this section are appropriate for improving dizziness as well. Patients with impairments in the vestibular function of the inner ear typically presents with both balance impairments and dizziness and prescribing exercises to patients with vestibular impairment can advantageously be based on the STABLE approach. It is our experience that the measures included in the STABLE approach are sensitive to dizziness as well because dizziness limits the patients performance within each domain. For instance will patients who have vestibular impairment and dizziness provoked by head movements or high degree of visual dependency often show low performance with anticipatory turning and sensory orientation and exercises targeting these domains can be appropriate.  

Training intervals 

To promote optimal consolidation in motor learning we recommend that exercises preferable are practiced in short training passes multiple times a day rather than in one (long) daily pass. As a rule of thump exercises should be practiced in intervals of 5-10 minutes 3-4 times a day.

Short brakes of 15-60 seconds can advantageously be incorporated after each set of repetitions. Incorporating short brakes is especially important when an exercise induces dizziness. For instance, one patient may be instructed to reach to the walls with the back to a corner with closed eyes, rest for 15-30 seconds and repeat reaching, continuing this pattern for 3-4 minutes. In continuation, the patient performs a second exercise following the same pattern of exercising and resting for another 3-4 minutes. This completes the training pass in 6-8 minutes. Following this approach, it is not recommendable to practice all prescribed exercises in each pass if more than two exercises are prescribed, but all exercises should preferable be practiced every day.

For some patients it is difficult exercising multiple times a day or it is preferable to complete all exercises in the same training pass. The approach of exercising should always be adapted to the patient rather than keeping with a rule of thump or a predefined concept!

Number of repetitions 

The number of repetitions in each set is dependent on the type of exercise and the patients' abilities. Typically exercises which induces dizziness or fatigue can be performed at less repetitions or shorter periods of time compared with exercises which challenge balance without producing other symptoms. The number of repetitions can be decided based on the patients' performance executing the exercise when instructed in the consultation. As a rule of thump, the number of repetitions in each set should not be higher than the patient can compensate for the fatigue or dizziness induced by the exercise within 30-60 seconds after completing the set.

One method to define a baseline for some exercises is instructing the patient to repeat a exercise until reaching the maximal capacity. For exercises inducing dizziness, this will be the number of repetitions which induces nausea and the need to sit down and rest (for several minutes). As a rule of thump, the number of repetitions should not exceed 30% of this maximal capacity. For example, a patient may be able to walk on the spot for maximal 12 seconds with eyes closed before feeling excessive dizziness and nausea. The patients is then instructed to close the eyes for only 3-4 seconds at the time while walking when executing this exercise.

For exercises inducing fatigue, the patients' maximal capacity will be the maximal number of repetitions the patient is able to execute without rest. If improving power is the primary purpose of the exercise the exercise should preferable be adjusted until the patient reaches maximal capacity within 12 repetitions or less. For example, a patient can maximum repeat 21 stands from a chair at high speed. The exercise is then adjusted by placing the chair in front of a staircase with the patients' feet on the first step (inducing a higher load in the extreme parts of the movement). Now, the patient can maximum complete 7 repetitions before fatigue and the patient is instructed to complete 3 sets of 7 repetitions incorporating 30-60 seconds rest between each set. Altenatively this exercise could be adjusted by increasing the speed or instructing the patient to carry a load while performing the task.

If adjusting an exercise to the decided number of repetions is not possible another exercise can be instructed instead.

Progression and regression

The examples of progressions and regressions given in this section are not listed in any specified order. It is very individual how the exercises can be adjusted to each patient. With some patients, the patients´ history and personal preferences guides how to adjust the exercises. With other patients it may be necessary to try multiple variations of an exercise to decide which adjustments are appropriate. 

When deciding if adjustments of an exercise is warranted the quality in the execution of the exercise should be considered. The patient might be able to execute an exercise with high speed and in multiple repetitions, but if the quality of the execution is low progression may not be advantageous. For instance, a patient can maybe move to touch the walls in a corner with high speed continuously for several minutes without dizziness or losing balance, but the task is performed with very limited head and upper body movements keeping the head fixed and straitening the knees. Rather than progressing the exercise, this patient should be instructed to improve the quality of the movement, by turning the head in the direction of the movement, relaxing the shoulders and knees to support a more flexible movement.

In the follow up consultations the exercises can be progressed. Simple progressions like increasing the speed or number of repetitions might be sufficient. Or more complex progressions like changing components of the exercise or changing the exercise may be relevant. We recommended awareness of not being too eiger of progressing or changing the exercises in each consultation. To promote comprehensive motor learning in balance it is preferable that the patient achieve some degree of "boredom" with the exercise before it is progressed or changed. Only when the patient is able to perform an exercise rather easily without dizziness it is insured that the exercised task is automated and progression is relevant.

When the patient is mastering the instructed exercises we recommend focusing on changing daily routines to incorporate learned abilities. For instance, if the patient has practiced free head movements standing in a corner tossing a ball and masters the exercise without noticeable balance impairment or dizziness, routines of incorporating free head movements in the patients' daily life can be discussed. We recommend awareness of not incorporating tasks which promotes dizziness or challenge the patients' balance excessively into daily routines before improvements has been achieved through exercising. For instance, if the patient is challenged by a high degree of visual dependency it is rarely recommendable instructing the patient to do daily routines with eyes closed or seek to ambulate in visually highly complex environments. This strategy could induce falls or worsen dizziness if the visual dependency is not primarily improved with exercises adjusted to the patients' functional level.

In the follow up consultations regression or other adjustments can be warranted as well. This can be the case if the instructed exercises were not adaptable to the patients' home environment or if the patient has experienced deterioration since last visit.

It is essential that the exercises are continuously adjusted to fit the patients' current state of function, the context wherein the exercises are performed and the patients' short term and long term goals.

 


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