Stop Calling it ‘Balance Training‘ - You Are Applying ‘Neurological Torque‘ in Vestibular Rehabilitation

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The Wrong Lens

In the last article, we established why we use balance exercises to treat dizzy patients who are not fall risk of falls. We use them to find and fix ‘faulty sensory patterns‘.

Now, we must redefine the tool itself.

The biggest barrier to using this tool correctly is our own vocabulary. When we say ‘balance training‘, we instinctively think of ‘fall prevention‘. This is the wrong lens. It is a limiting and inaccurate description of what we are actually accomplishing. It misunderstands the goal and the mechanism.

The Orthopedic Analogy: Applying ‘Mechanical Torque‘

Let’s think in terms that we, as therapists, master every single day: orthopedics.

How do we strengthen the quadriceps muscle? We apply a ‘mechanical torque‘. We use a leg extension machine, a heavy squat, or a resistance band. We apply this load intentionally to ‘induce fatigue‘. We expect the muscle to even slightly burn. We may even push to the point of temporary failure.

That fatigue is not a ‘bad‘ thing; it is the sign that we have successfully challenged the musculoskeletal system. It is the necessary stimulus for adaptation and growth.

The Vestibular Analogy: Applying ‘Neurological Torque‘

This is ‘no different‘ from what we must do with our dizzy patients. The balance exercise is our tool to apply a ‘neurological torque‘.

How do we apply this torque? We ‘manipulate‘ the patient’s environment.

• We challenge somatosensory input: We put them on a foam pad and/or narrow their base of support. We can use vibration plates or Swiss Balls to bounce or counteract this input.

• We challenge visual input: We have them close their eyes, which seems simple, but this action isolates the somatosensory-vestibular systems. We can also use gaze stabilization exercises to create a visual disruption. Virtual Reality (VR) and simple optokinetics, like a disco-ball in a room, can produce a disruption and force CNS compensation.

• We challenge the vestibular system: We add head movements, changes in head positioning, and even full-body position changes.

• We challenge the musculoskeletal system: We narrow their base of support or apply external loads like therabands, tubing, weights, and even prolonged hold times. Remember, Musculoskeletal Balance Disorders (MSBD®) can be a consequence of the patient’s dizziness.

We do all of this intentionally to ‘induce conflict‘ in the brain.

What is the sign that this ‘neurological torque‘ is working? The ‘dizziness‘. This includes the unsteadiness that we can see and the symptoms that they feel—remember, dizziness has both signs and symptoms. This is the ‘sensory conflict‘.

The patient’s report of dizziness or their observable sway is the neurological equivalent of muscle fatigue. Again, it is a sign that we have successfully challenged the brain’s faulty sensory strategy. It is the necessary stimulus for neuroplastic adaptation.

Stop ‘Training‘, Start ‘Loading‘

We must stop seeing these exercises as simple ‘fall prevention tasks‘. They are precision instruments.

You are not ‘training‘ a patient to stand on foam. You are ‘loading‘ their central nervous system to force it to abandon a bad strategy and build a new, more efficient one. The tool (the exercise) is just the method we use to apply that specific ‘neurological load‘.

Brian Werner, PT, MPT, is a physical therapist who has been specializing in vestibular and balance disorders for over a quarter of a century. He is the founder of the FYZICAL Balance Paradigm and one of the co-founders of FYZICAL, LLC, Balance Center Division with Dr. Daniel Deems, MD, PhD, where he serves as the National Director of Vestibular Education & Training.