Core Stability Training in Dynamic Balance
Testing Among Young, Healthy Adults
Nicole L. Kahle, BS; and Phillip A. Gribble, PhD, ATC
ABSTRACT
Dynamic balance is a key component of injury prevention and
rehabilitation in sports. Training the core muscles has been hy-
pothesized as an intervention for improving balance. However,
there is a lack of current scientific evidence to support this claim.
The purpose of this study was to compare the effects of a core
stability program on dynamic balance as measured with the
Star Excursion Balance Test (SEBT). Thirty healthy participants
were randomly divided into 2 groups: a control group and an
exercise group. All participants performed the SEBT before and
after a 6-week intervention period. During the 6-week period,
the exercise group performed a core stability program, whereas
the control group refrained from any new exercise. Maximum
excursion distances improved for the exercise group, compared
with the control group. This result justifies the hypothesis that
core strengthening can improve dynamic postural control dur-
ing treatment and rehabilitation of athletic injury.
B
alance is a key component of normal daily ac-
tivities, such as walking, running, and climb-
ing stairs. Maintaining balance is also vital in
the prevention of falls and resulting injury.1 Balance, or
postural control, can be described as either dynamic or
static.2 Static postural control is the attempt to maintain
a base of support while minimizing the movement of
body segments and the center of mass; dynamic postur-
al control involves the completion of a functional task
The authors are from the Department of Kinesiology, University of Toledo,
Toledo, Ohio.
Originally submitted December 11, 2008.
Accepted for publication January 30, 2009.
The authors have no financial or proprietary interest in the materials presented
herein.
Address correspondence to Phillip A. Gribble, PhD, ATC, Department of
Kinesiology, University of Toledo, 2801 West Bancroft Street, Mailstop #119, Toledo,
OH 43606; e-mail: phillip.gribble@utoledo.edu.
Athletic Training & Sports Health Care | Vol. 1 No. 2 2009
with purposeful movements without compromising an
established base of support.2,3 Dynamic activities can
also be described as those that cause the center of grav-
ity to move in response to muscular activity.4 Dynamic
control is important in many functional tasks because it
requires integration of appropriate levels of propriocep-
tion, range of motion, and strength. Because dynamic
balance is such an important aspect of everyday life, it
is imperative to find programs useful for measuring,
maintaining, and improving balance for injury preven-
tion and rehabilitation.
A useful method of measuring dynamic balance is the
Star Excursion Balance Test (SEBT). The test requires
individuals to maintain balance on a single limb (stance
leg) while manipulating the opposite limb. The SEBT is
a series of 8 unilateral balance tests. In the test, the indi-
vidual stands at the center of a grid laid on the floor with
8 lines extending at 45° increments from the center of the
grid.5 The stance leg operates in the closed kinetic chain,
with motion occurring at the ankle, knee, and hip joints
as the opposite leg reaches along a line in the specified
direction. The individual touches the line with the most
distal part of the foot and as lightly as possible to ensure
that the leg is not also being used for support. The reach
distance is measured and the individual returns to a bilat-
eral stance while maintaining balance. This test challenges
the postural control system as the body’s center of mass is
moved in relation to its base of support, making it a use-
ful clinical measure of functional performance following
injury.6,7
While demonstrating strong intratester reliability,4,7
the SEBT is sensitive for screening of musculoskeletal im-
pairments such as chronic ankle instability,3,8-10 anterior
cruciate ligament reconstruction,11 and fatigue.3,12 In addi-
tion, the SEBT may be used as an effective lower extrem-
ity injury screening tool.13 However, the SEBT has not
65
Kahle & Gribble
been used as an outcome tool in examining the effective-
ness of prophylactic training. Earl and Hertel14 indicated
that EMG activation of lower extremity muscles during
the SEBT was direction dependent, whereas others have
identified specific kinematic patterns that dictate perfor-
mance of this task,3,9,12,15,16 therefore providing clinicians
with knowledge about which directions are best suited
for isolating particular muscle recruitment patterns dur-
ing rehabilitation. The majority of information on SEBT
task performance has focused on lower extremity contri-
butions. It is not known whether the SEBT can be used
as an outcome tool for assessing the contributions from
outside the lower extremity, such as core stability.
Previous studies have demonstrated that intervention
protocols including coordination training and strength
exercises for the lower extremity are useful at improv-
ing balance in uninjured individuals,17-19 as well as indi-
viduals with ankle pathology.20-26 As knowledge about
the importance of core strength increases, clinicians are
beginning to incorporate more core strengthening tasks
into rehabilitation protocols and exercise prescriptions;
however, there is a lack of information that supports the
effectiveness of these exercises in improving balance. Ac-
cording to Kibler et al,27 core stability and strength is an
important component to maximize efficient balance and
athletic function in upper and lower extremity move-
ments. The authors also suggest that the core acts as a
base for motion of the distal segments, or “proximal sta-
bility for distal mobility.”27(p189) Core stability is a generic
description that describes the training of the muscles of
the abdominal and lumbopelvic region.28 A combina-
tion of global and local stability systems has been used
in an attempt to define core stability.28 The global stabil-
ity system refers to the larger, superficial muscles around
the abdominal and lumbar region, such as the rectus ab-
dominus, paraspinals, and external obliques. All of these
muscles are labeled as the prime movers for trunk or hip
flexion, extension, and rotation.28 Local stability then re-
fers to the deep muscles of the abdominal wall, such as
the transverse abdominus and multifundus. These inter-
nal muscles are then associated with stability of the lum-
bar spine during whole body movements when postural
adjustments are required.28
The involvement of the abdominal and lumbopelvic
muscles in trunk stability has been researched and proven
through multiple investigations.29-33 Logically, strength-
ening core muscles will improve stability of the lumbar
spine and would seem to be an important contributor to
66
balance; however, core stability training is not a common
component of intervention protocols for improving bal-
ance. Subsequently, there is a lack of devoted research to
the effects of core strengthening on tasks that encom-
pass whole body movement and dynamic postural con-
trol. Similarly, the SEBT has been verified as an effective
method of predicting initial injury, detecting pathologi-
cal differences, and representing the effects of fatigue, all
from lower extremity contributions; but the SEBT has
yet to be used as a measure of effectiveness of core stabil-
ity training. Therefore, the purpose of this study was to
verify the effects of a core stability program on dynamic
postural control using the SEBT.
Method
Participants
Thirty participants volunteered for the study and
signed a university-approved consent form. The
participants were assigned to either a control group
(8 men, 7 women; mean age = 21.160.5 years; mean
height = 1.7160.09 m; mean mass = 71.3611.9 kg) or
a core stability group (9 men, 6 women; mean age =
20.960.6 years; mean height = 1.7860.07 m; mean mass
= 74.868.2 kg) using a counter-balanced order, strati-
fying for gender. All participants were free of a history
of lower extremity musculoskeletal injuries (ie, any
injury requiring removal from physical activity for
.2 days in the past 12 months, any previous surgeries,
or any previous fractures) or any neurological deficits
or concussions that could have negatively affected their
dynamic balance. Participants were physically active,
defined as participating in >30 minutes of sustained
physical activity >3 times per week; however, they did
not have any experience with a formalized core stabil-
ity training program.
Protocol
All participants reported to the laboratory for 2 testing
sessions for pretest and posttest assessments of dynamic
postural control using the SEBT. During the pretesting
session, stance leg length was measured from the anter-
osuperior iliac spine to the middle of the medial malleo-
lus while the participant lay supine with a standard tape
measure. The stance leg was determined as the leg the
participant would use to stand on while kicking a ball.
The leg length measure was used to normalize reach dis-
tance data.34 After the pretest, the members of the core
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Figure 1. Star Excursion Balance Test reaching directions.
Figure 3. Medial reaching distance (left testing leg).
stability group reported to the laboratory for exercise
sessions 3 times per week for 6 weeks.
SEBT Performance
The SEBT testing grid consists of 8 tape measures secured
45° to each other from the center (Figure 1).5 During per-
formance of the SEBT, participants were asked to assume
a single-limb stance in the middle of the testing grid while
attempting to reach as far as possible in designated direc-
tions with the opposite limb without compromising the
base of support. Recent investigations suggested there is
redundancy among the 8 reaching directions and that the
Athletic Training & Sports Health Care | Vol. 1 No. 2
Core Stability Training
1
2
Figure 2. Anteromedial reaching distance (left testing leg).
3
4
Figure 4. Posteromedial reaching distance (left testing leg).
test can be paired down to fewer reaching directions.10,16
Specifically, the anteromedial, medial, and posteromedial
directions were selected for this investigation.10
Participants placed the foot of their stance leg in the
center of the grid, aligning the foot with the anterior and
2009 67
Kahle & Gribble

5
Week Week Week Week Week Week
1 2 3 4 5 6
Bridges 10 15 15 2 sets 2 sets 2 sets
with leg lifts of 10 of 15 of 15
Figure 5. Core stability exercise #1: Bridges with leg lifts.

6
Week Week Week Week Week Week
1 2 3 4 5 6
Static abs 20 sec 30 sec 2 sets, 2 sets, 2 sets, 2 sets,
20 sec 30 sec 45 sec 45 sec
Figure 6. Core stability exercise #2: Static abs.

completed 4 practice trials,16 followed by a brief 2-minute

rest period and then 3 test trials in each of the 3 direc-
7 tions (Figures 2-4). The order of the reach directions was
Week Week Week Week Week Week randomized. Reach distances were recorded by the inves-
1 2 3 4 5 6 tigator placing a mark on the tape measure that recorded
Lower trunk 53 53 103 103 153 153 the touchdown point. The same investigator performed
rotation all the measurements for all testing sessions.
Figure 7. Core stability exercise #3: Lower trunk rotation.
Core Stability Exercise Protocol
posterior reach direction lines. Participants were instruct- The exercise group participated in a steadily progressing
ed to use the opposite leg to make a maximum reach in supervised core strengthening program 3 times per week
a required direction while keeping the hands on the hips, for 6 weeks (Figures 5-14). The control group refrained
the stance foot in the original position, and the heel in from any form of core strengthening for a 6-week period.
contact with the floor. The participants were instructed After the 6 weeks, both groups returned to the labora-
to make a light touch on the floor on each of the 3 se- tory for posttesting identical to the pretesting.
lected arms of the SEBT grid with the distal most part of
the foot, and then to return to a double-leg stance in the Statistical Analysis
middle of the testing grid without changing the base of The reaching distances recorded in each direction were
support. If the participant failed to perform the reach in first normalized by dividing by the length of the stance
the required manner, the trial was discarded and the reach limb and reported as a percentage (MAXD).34 The means
was performed again. After instruction and demonstra- and standard deviations from the 3 trials were used to
tion of the test by the investigator (N.L.K.), participants create 3 dependent variables representing the normal-

68 atshc.com
 Core Stability Training

8A

9
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
Bicycles 153 203 253 2 sets, 2 sets, 2 sets,
203 203 253
Figure 9. Core stability exercise #5: Bicycles.

8B

8C
Week 1 Week 2 Week 3 Week 4 Week 5 Week 6
Planks 10 sec, 15 sec, 30 sec, 30 sec, 45 sec, 45 sec,
33 33 23 33 23 33
each each each each each each
Figure 8. Core stability exercise #4: Planks, in the prone (A), right (B),
and left (C) positions.

10
ized reaching distances (MAXD) in each of the 3 reach-
Week Week Week Week Week Week
ing directions. For each dependent variable (MAXD in
1 2 3 4 5 6
each reaching direction), a separate 2-between (Group:
Full vertical 103 153 203 253 2 sets, 2 sets,
Core, Control; Sex: Male, Female), 1-Within (Time: Pre, crunches 153 203
Post) repeated measure analysis of variance (ANOVAs)
Figure 10. Core stability exercise #6: Full vertical crunches.
was performed. A Newman-Keuls post hoc test was
used when a statistically significant interaction effect was P 5 .001). A Newman-Keuls post hoc test revealed
found. Effect sizes were calculated and interpreted for the that for the exercise group, MAXD was greater at the
statistically significant relationships using Cohen’s rec- posttest (89.0%66.6%), compared with the pretest
ommendations (0.20 5 small; 0.50 5 moderate; 0.80 5 (84.9%67.6%) (Table 1). A moderate effect size of 0.58
strong).35 In addition, the 95% confidence intervals of the was associated with this relationship.
effect size are reported. SPSS version 15.0 software (SPSS
Inc, Chicago, Ill) was used for all statistical analyses, with Medial
a significance level set a priori at P , .05. For the medial reach direction, there was a signifi-
cant group by time interaction (F1,26 5 19.969; P ,
Results .001). A Newman-Keuls post hoc test revealed that
for the exercise group, MAXD was greater at the
Anteromedial posttest (91.1%67.7%), compared with the pretest
For the anteromedial reach direction, there was a sig- (85.1%68.9%) (Table 2). A moderate to strong effect
nificant group by time interaction (F1,26 5 15.44; size of 0.72 was associated with this relationship. The

Athletic Training & Sports Health Care | Vol. 1 No. 2 2009 69

Kahle & Gribble

12
Week Week Week Week Week Week
1 2 3 4 5 6
11
Long arm 103 153 203 253 2 sets, 2 sets,
Week Week Week Week Week Week crunches 153 203
1 2 3 4 5 6
Figure 12. Core stability exercise #8: Long arm crunches.
Bridges with 103 153 153 2 sets, 2 sets, 2 sets,
marching 103 153 153
Figure 11. Core stability exercise #7: Bridges with marching.

14
Week Week Week Week Week Week
1 2 3 4 5 6
Bilateral leg 10 sec, 15 sec, 15 sec, 20 sec, 20 sec, 25 sec,
lowering 53 53 53 53 53 53
Figure 14. Core stability exercise #10: Bilateral leg lowering.

Newman-Keuls post hoc test also revealed that MAXD

for the exercise group at the posttest (91.1%67.7%)
was greater than that of the control group at the post-
test (84.3%66.9%) (Table 2). A strong effect size of
0.93 was associated with this relationship.

Posteromedial
For the posteromedial reach direction, there was a
significant group by time interaction (F1,26 5 7.193;
P 5 .013). A Newman-Keuls post hoc test revealed
that for the exercise group, MAXD was greater at the
posttest (92.5%66.9%), compared with the pretest
(85.5%69.6%) (Table 3). A strong effect size of 0.85 was
associated with this relationship. The Newman-Keuls
post hoc test also revealed that MAXD for the exercise
group at the posttest (92.5%66.9%) was greater than
that of the control group at the posttest (85.4%67.7%)
13
(Table 3). A strong effect size of 0.97 was associated
Week Week Week Week Week Week
with this relationship.
1 2 3 4 5 6
Trunk rotation 103 103 153 2 sets, 2 sets, 2 sets,
Discussion
with weight 103 153 153
For the 3 reach directions, normalized maximum ex-
Figure 13. Core stability exercise #9: Trunk rotation with weight.
cursion distances increased significantly from pretest

70 atshc.com
 Core Stability Training

Tab l e 1 Tab l e 2

Group by Time Interaction for Group by Time Interaction for

Anteromedial Reach MAXD Medial Reach MAXD
Group Mean6SD P Value Effect Size (95% CI) Group Mean6SD P Value Effect Size (95% CI)
Control Control
Pretest 87.5%68.8% .001 ExPre versus ExPost = 0.58 Pretest 85.2%68.7% , .001 ExPre versus ExPost 5 0.72
Posttest 87.1%67.4% (0.54-0.62)a Posttest 84.3%66.9% (0.68-0.77)a

Exercise Exercise
Pretest 84.9%67.6% Pretest 85.1%68.9% ExPost versus ConPost 5 0.93
Posttest 89.0%66.6%a Posttest 91.1%67.7%a,b (0.89-0.97)b
Abbreviations: MAXD, normalized reaching distance; Ex, exercise; Pre, pretest; Post, Abbreviations: MAXD, normalized reaching distance; Ex, exercise; Pre, pretest; Post,
posttest. posttest; Con, control.
a a
Exercise posttest . exercise pretest. Exercise posttest . exercise pretest.
b
Exercise posttest . control posttest.

to posttest for the exercise group. This improvement in

Tab l e 3
reach distance verifies that core strengthening does have
an effect on balance testing. As stated by Kibler et al,27 Group by Time Interaction for
the larger muscles of the core create a rigid cylinder and Posteromedial Reach MAXD
a greater moment of inertia against body perturbation Group Mean6SD P Value Effect Size (95% CI)
while allowing a stable base for mobility. The abdomi- Control
nal muscles consisting of the transverse abdominus, Pretest 84.6%610.0% .013 ExPre versus ExPost 5 0.85
internal and external obliques, and rectus abdominus Posttest 85.4%67.7% (0.81-0.90)a
all contract to provide stabilization for the spine and Exercise
therefore a stronger base of support for lower extremity Pretest 85.5%69.6% ExPost versus ConPost 5 0.97
movement.27 When the transverse abdominus contracts, (0.94-1.01)b
Posttest 92.5%66.9%a,b
the intra-abdominal pressure increases and tenses the Abbreviations: MAXD, normalized reaching distance; Ex, exercise; Pre, pretest; Post,
thoracolumbar fascia. These contractions occur before posttest; Con, control.
a
Exercise posttest . exercise pretest.
initiation of limb movement, allowing the limbs to have b
Exercise posttest . control posttest.
a stable base for motion and muscle activation. The rec-
tus abdominus and oblique abdominals are activated and recruitment of trunk musculature, which may help
in specific patterns regarding limb movement that also to explain the observed improvements in dynamic pos-
provides postural support.27 tural control. As Kibler et al27 described, the activation of
It appears from the limited number of studies that core musculature in patterns with extremity movements
core stability training regimens can improve the muscle helps to improve postural control—a phenomenon that
activation patterns of trunk musculature. Other studies may have been improved in the group that completed
have noted the importance of proper activation and sta- core stability exercises.
bility of the trunk during maintenance of static postural According to Kibler et al,27 the body uses core muscle
control.30,33 Our results demonstrate that implementing activation to generate the necessary rotational torques
a core stability training regiment to young, physically around the body and produce extremity motion. On the
active individuals can improve their dynamic postural basis of this suggestion, we theorized that in the SEBT, as
stability. Other studies have quantified and noted the the individual stands on the stance leg and uses the op-
importance of lower extremity muscle activation14 and posite limb to reach, the rectus abdominus muscles and
kinematic contributions3,9,16 to performance of the SEBT. obliques would fire before the movement occurs to per-
To our knowledge, there have not been previous inves- form trunk motion, allowing the individual to maintain
tigations of the activation patterns of trunk musculature balance. Also, the multifundi and transverse abdominus
during dynamic postural control tasks such as the SEBT. muscles would help to maintain dynamic balance during
However, our results do allow us to speculate that the lower extremity movement by providing support to the
introduced core stability exercises improved the strength lumbar spine. Similarly, Marshall and Murphy28 found

Athletic Training & Sports Health Care | Vol. 1 No. 2 2009 71

Kahle & Gribble
that exercising on a Swiss ball led to greater activation
levels of the muscles of the lumbopelvic region during
performance tasks. Exercising on the Swiss ball increased
activity for the rectus abdominus, transverse abdomi-
nus, and obliques during a press-up exercise, compared
with exercise on a stable surface. In our study, the par-
ticipants in the core stability group performed exercises
that included work on a Swiss ball, which may have cre-
ated similar improvements reported by Marshall and
Murphy.28 Although difficult to quantify, it is clear that
future investigation of trunk musculature activation pat-
terns during performance of the SEBT are needed to fully
address this theory. By applying theories regarding core
strength and extremity motion, we can suggest that par-
ticipating in core stability training effectively improves
dynamic postural control as measured by the SEBT.
There are mixed results in the literature about the in-
fluence of gender on SEBT performance. It is important
to note that although we included men and women in
our study, there was no significant influence of gender
on our measures. As reported by Gribble and Hertel,34
gender differences may be controlled by normalizing the
raw reaching distance to the leg length of the stance limb,
a procedure we followed in our study. Even with the leg
length normalization, some studies have reported a gen-
der difference. Subsequently, we elected to include as an
independent variable, but it was not part of our primary
purpose in this investigation. Because there was an exer-
cise group influence, but not a gender influence, it would
appear that the observed improvement on SEBT func-
tion with core stability training is not different between
men and women. We are not aware of previous investiga-
tions that have differentiated gender differences related to
core stability ability and function. Although our results
suggest there may not be a difference, future studies may
want to consider potential influences of gender on core
stability function.
For this study, only 3 of the possible 8 Star Excursion
directions were used for statistical analysis consisting of
the anteromedial, medial, and posteromedial directions.
These 3 were chosen based on recent work that has dem-
onstrated that the 8 directions of the SEBT may be pared
down for efficiency of task evaluation because of redun-
dancy across the reaching directions. As reported by
Hertel et al,10 all reach directions loaded on a single factor
and were significantly correlated. This led to the conclu-
sion of functional redundancy across the 8 directions and
a recommendation that the number of reach directions
72
administered could be decreased without compromising
the validity of the test. Robinson and Gribble16 further
demonstrated this concept by showing that not only the
reaching directions, but also the kinematic patterns of the
stance limb, were redundant across the 8 directions. In
our study, the 3 reaching directions all were sensitive at
demonstrating that core stability training could improve
performance. This allows a conclusion that from a reha-
bilitation outcomes approach, any of these 3 reaching di-
rections could be used to demonstrate the effectiveness of
core stability training.
Limitations and Future Investigations
There are several limitations that occurred in this study
that should be considered for improvement on fu-
ture investigations. A means for testing baseline core
strength using a curl or sit up endurance test should be
implemented to determine the actual level of improve-
ment in core stability strength. By doing so, the core ex-
ercise program may be tailored to fit individual strength
and the consequent exercise progression would create a
more demanding and individually specific exercise pro-
gression. Variation of the exercise progression according
to original strength could then provide more accurate
balance improvement results in each participant.
Our results can only lead to supposition about poten-
tial improvements in the core stability training group re-
lated to the level of activation in the targeted musculature.
Although we can conclude that participation in the core
stability training led to an improvement in dynamic pos-
tural control, we cannot conclude what, if any, changes
in muscle activation patterns were experienced. Although
difficult to perform, it will be important in the future to
quantify with electromyography the changes in core sta-
bility muscle activation patterns during performance of
the SEBT before and after the intervention program.
Conclusion
Dynamic postural control as measured by the SEBT
maximum excursion distances demonstrates a significant
increase across the 3 reach directions of anteromedial,
medial, and posteromedial for the core strengthening
group. The findings of the current study, coupled with
previous research, provide clinicians with a method of
improving dynamic balance by improving core strength
and implementing the SEBT. It is crucial that researchers
and clinicians be concerned about not only improving a
patient’s balance through rehabilitation after an injury,
atshc.com

but also strengthening their core to prevent an injury.
Our results suggest that core stability training could be
beneficial for improving balance by strengthening those
muscles most often associated with lumbar spine con-
trol. n
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