by Derek Benoit August 11th, 2021
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Balance in all things is a familiar concept for hunters, especially those out west. Those used to chasing mountain elk or mule deer, let alone the sheep guys and girls learn fast the importance of balance under heavy weight, and on steep terrain. However, anglers are not often as balance aware as they should be. Such is the same with the whitetail hunters in the east. Think about it:
- Getting pulled sideways around a pitching cockpit while fighting gamefish using standup gear
- Surfcasters on shifting sand while wading
- Surfcasters walking on craggy, less than flat jetty rocks, with yawning gaps
- Resisting the push and pull of wave action
- Carrying a bow or firearm to a stand with a backpack full of gear
Balance is far more critical to the average Jane or Joe outdoorsman than we realize. While working on my anterior pelvic tilt issues, I decided to pick the brain of my physical therapist, Katherine Bragg, Doctor of Physical Therapy at BIDMC Lexington here in Massachusetts. She’s a proven expert with all things motion and stability related.
1.) You’ve been a physical therapist in a hospital setting and now outpatient at BIDMC Lexington. You must have seen anything and everything related to balance. What is the most severe case you’ve ever had to treat?
Having experience as both an outpatient and inpatient physical therapist, I have seen many patients with various presentations in which balance was impaired. The most severe case was when I was working at BIDMC inpatient on the neurological floor. This specific patient had a large mass growing in their brain, pushing against the cerebellum. The cerebellum is responsible for controlling balance, posture, coordination, and speech. Because of this mass, and secondary surgery to remove the mass, the patient had part of the cerebellum removed.
The patient’s residual symptoms were the inability to control voluntary movements, he was unable to judge distance adequately, making stairs or turning corners very difficult. He had an unsteady gait which would present either wide based and lurching forward or as a scissoring pattern. Specifically, he would cross his legs over the other while walking forward, and on occasion he would have involuntary jerking of his arms or legs. This created difficulty maintaining his balance, whether sitting or standing.
He was in his mid 50’s. He required daily treatments for gait retraining, required a walker and contact guard assist to prevent falls. His independence was completely taken away from him. I worked with him only once, and required the assistance of an OT and rehab aide due to the significant balance impairments. He was eventually discharged from acute rehab and sent to Spaulding Rehabilitation for additional therapy.
2.) What are the major factors that affect a person’s balance?
Balance is affected by the patient’s vision, sensation and body awareness (proprioception), and the vestibular system
3.) How does the average person tell if they have a balance issue?
A quick test to determine whether or not you may have a balance issue is to perform a 4 step balance test. This includes:
1. Standing with your feet together and side-by-side,
2. Stand with one foot slightly above the other, so the mid foot is inline with your toes on the other foot (modified tandem stance),
3. Full tandem stance, which is heel to toe standing
4. Standing on one foot.
The goal is to stand for at least 10-20 seconds. Test both sides. If this appears easy, close your eyes, this will challenge your vestibular system and proprioceptive systems.
There are many different balance tests, however, this is a simple way to test in the home independently with no equipment needed.
4.) How often do you come across other issues when you evaluate patients for balance?
Often, most commonly we find patients with lower extremity and core weakness, postural restrictions, and sensation deficits of the feet and lower legs, to one of the main causes of balance restrictions.
(***Note: core weakness was an issue of mine in addressing my anter pelvic tilt through physical therapy***)
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5.) Is there a hierarchy for deciding which problem is most important?
As an orthopedic specialists physical therapist, I do not specialize in neurological diagnoses. I want to rule out any central cause of balance impairments. Those are symptoms related to the brain and/or spinal cord. Thus, if we feel those systems are being impaired, we will refer to the PCP, neurologist, and / or neuromuscular physical therapist.
6.) How do balance requirements change between, say hiking a steep slope, versus fighting a fish on a pitching boat deck?
This is a good example of how our proprioception and vestibular systems are affected. We rely on the sensation of our feet and legs, along with our sense to “know where we are in space” in order to maintain balance. When you are walking up a hill, we feel the gravel/dirt under our feet and we react by leaning forward. This is to maintain our base of support over our feet so we do not fall backward. When we are on a boat that is on water, we sense the waves under the boat, and our body constantly will be shifting through various positions to maintain and upright posture.
When you add the fish to the picture, you have another external source that is altering your sense of being upright. The second example is that where you require quick reactions and senses to be able to maintain your base of support.
7.) What are the impacts aging has on balance for the average person?
As we age we do lose the ability to maintain balance due to the loss of the sensory systems, the ability to integrate motor commands, and the loss of our musculoskeletal system. In layman’s terms as we age, we lose the sensation to our feet and lower extremity, we lose the ability to have quick reactions, and we lose strength and flexibility.
8.) Outdoorsmen and women often carry significant weight for some distance. How does one meld the weight aspect with balance training?
I often have patients train with external weight or perturbations. If someone was an outdoorsman/women and coming to me for balance impairments, I would have him or her hold the tool that they will use outdoors. For example, carrying the pack they would carry in the wild, start with no additional weight in the pack, and slowly add weight. Also, I have them carry/hold weight in a single upper extremity; this will require the patient to react to unilateral weight. When we are outdoors, the environment is constantly changing; therefore training for any unknown factors is key to quick balance reactions.
9.) What are five perfect exercises to improve balance at home? At what pace should people progress through them?
- The patient stands with feet together
- Standing with feet in modified tandem stance
- The patient stands in full tandem stance, bilaterally
- Standing in single leg stance bilaterally
- Tandem walking
If able to negotiate all of the above exercises with eyes open for 3×30 seconds, progress to 3×30 seconds with eyes closed. If this continues to become easy, I have the patient either changes the surface they are standing on or add resistance of some sort.
***I always recommend patient stand with support in front and behind and / or supervision for safety.***
10.) What are your favorite home therapy tools for working on balance?
Although you do not need any special tools to improve your balance as you can alter your vision/resistance easily in the home, I prefer to use airex balance pad, cones, and the bosu ball to challenge the balance systems.