Kat Lay
Peta Bee
The Times
Gerry Gajadharsingh writes:
“Many clinicians in the musculoskeletal world will be very familiar with using balance tests on their patients. I think most people have a sense of how good or not so good their balance is, with those engaged in sports and exercise and movement activities such as dancing, tending to have better balance than those who don’t.
In their 12-year study examining the relationship between balance and mortality in a group of 1,702 people aged between 51 and 75, Dr Claudio Gil Araujo from Brazil and an international team including researchers from Bristol Medical School found that an inability to stand unsupported on one leg for ten seconds — to standardise the test they asked participants to rest their free foot on the back of the leg they were balancing on, and stare forwards — was associated with an 84 per cent raised risk of death from any cause.
Poor balance is a known side effect of underlying medical conditions including inner ear infections, hearing loss, Parkinson’s, Alzheimer’s and stroke. But, as the latest evidence shows, it can also be a warning sign for things to come. Even in otherwise healthy adults, an inability to balance on one leg for 20 seconds or longer has been associated with an increased risk of small blood vessel damage in the brain, reduced cognitive function and stroke, while some researchers have identified a strong correlation between poor balance and the incidence of dementia.
Some deterioration in balance is inevitable as we get older, trying to improve balance may have more positive effects than we previously imagined.
What I tend to advise for my patients:
Standing Tree Posture (STP)
If their balance is not great, and for many people their balance isn’t really that good, I tend to start with something called, Standing Tree Posture. The patient stands with their feet together, preferably in a doorway to keep them secure. Most people will wobble and that’s normal, the key is to minimise the wobbling, using small, corrected movements and try and stay there standing tall, looking ahead not at the floor focusing on your breathing and see if you can manage a minute or two.
Standing Tree Posture (eyes closed)
Once STP becomes easier, I will progress them to Standing Tree posture, eyes closed. By removing the sense of sight, it makes the other parts of our balance system work harder. Similar to before, standing tall looking ahead, but this time with eyes closed, focusing on your breathing and see if you can manage a minute or two.
Standing on one leg
Only when a patient becomes comfortable with STP, will I progress them to work on standing on one leg. Again, it’s useful standing in a doorway so that you have support if you need it. This time resting their free foot on the back of the leg they are balancing on, and stare forwards see if you could manage a minute or so. There is also evidence that standing on each leg for 60 seconds three times a day improves hip density of people in the 70s reducing the risk of fracture if they fall.
Standing on one leg (eyes closed)
Once you can manage this you can progress to standing on one leg this time with your eyes closed, see if you could manage a minute or so.
Walking along a line
Following a real or imaginary line trains vision and focus, which helps balance. Placing one foot in front of the other means you’re deliberately shifting a centre of gravity to maintain balance.
Slow Walking
Walking forwards and then backwards, as slowly as possible.
People are amazed at how difficult this can be, “surely it can’t be that difficult, it’s only walking and I do that every day!” Walking as slowly as possible is really good for balance and proprioception, try to make sure your feet are in line and you’re not walking with toes outwards or inwards. When going backwards making sure your feet aren’t crossing over.
Slow Walking (eyes closed)
When you get really good at slow walking, you can try this eyes closed walking forwards very slowly and then walking backwards very slowly.
Walking Meditation
Slow walking can also be turned into something called walking meditation I personally find this an unbelievably powerful tool for making our balance better and making us more mindful and shifting thoughts away from the external world into our internal world.
Wobble Board
These can be purchased online and again I tend to advise patients to place the water board in between a doorway stand on it with both feet and the idea is to keep their balance. This is particularly useful in lower extremity injury and pre-and post-operative rehabilitation especially in lower limb surgery.
What is striking about testing a patient’s balance, is it often quick to assess, doesn’t involve any high-tech equipment and often gives us very useful information. The research below suggests that clinicians, not just MSK clinicians, should now incorporate this as a routine part of clinical assessment, simply because poor balance does seem to be significantly associated to adverse health outcomes.
As with much research it’s observational and therefore it doesn’t really offer a mechanism as to why balance is important or indeed if you are found to have poor balance will trying to improve your balance help your health outcomes, I suspect that it will.
As we have described above poor balance is associated with quite negative health outcomes but one of the most obvious one is falling, which in itself has significant negative health outcomes especially in the elderly.
So how does our balance work?
Your brain coordinates the messages (sensory input) that it receives from your eyes (sight) your ears (including the inner ear which contains the vestibular system) and other body parts, such as muscles, joints and skin collectively known as proprioception. After processing that sensory input it essentially tells the muscles of the body how to react to maintain balance, motor output.
Humans possess three basic types of proprioceptors, muscle spindles which are in the skeletal muscles, Golgi tendon organs which lie at the junction of the muscles and tendons and mechanoreceptors, embedded in joint capsules of the joints, together called proprioception. The majority of this occurs within the lower extremities but also every other part of the body and also the skin. From an osteopathic perspective we also think that the upper neck in terms of how it functions is also critical for proprioception.
For completeness I give a more formal description of proprioception below, with thanks to physiopedia:
Proprioception (sense of proprioception) is an important bodily neuromuscular sense. It falls under our “sixth sense”, more commonly known as somatosensation. The term somatosensation (or somatosensory senses) is an all-encompassing term which includes the sub-categories of mechanoreception (vibration, pressure, discriminatory touch), thermoreception (temperature), nociception (pain), equilibrioception (balance) and proprioception (sense of positioning and movement). The feedback from all these different sensory components arise from our peripheral nervous system (PNS), and feed information to our central nervous system (CNS), both at the level of the spinal cord (reflexive) and sent to the cerebral cortex for higher processing.
Proprioception itself can be understood as including various sub-modalities:
Proprioception (Joint Position Sense): Proprioception is our sense of joint / limb positioning. It is often measured through joint position sense – active joint position sense (AJPS) and passive joint position sense (PJPS). Joint position sense determines the ability of a person to perceive a presented joint angle and then, after the limb has been moved, to actively or passively reproduces the same joint angle.
Kinaesthesia: Kinaesthesia (kinaesthesis) is the awareness of motion of the human body (motion sense). Sense of movement refers to the ability to appreciate joint movement, including the duration, direction, amplitude, speed, acceleration and timing of movements.
Sense of Force: Sense of Force (SoF) is also known as sense of effort / heaviness / tension or the force matching sense. It is the ability to reproduce (or match) a desired level of force one or more times. Sense of force is thought to stem from the afferent feedback of the Golgi Tendon Organs (GTOs) embedded within our tendons, the muscle spindles within our muscles and proprioceptors within our skin.
Sense of Change in Velocity (SoV): SoV is our ability to detect vibration, derived from oscillating objects placed against the skin. It is believed to travel through the same type of large afferent nerve fibers (Aαβ) as proprioception.
Proprioception is critical for meaningful interactions with our surrounding environment. Proprioception helps with the planning of movements, sport performance, playing a musical instrument and ultimately helping us avoid an injury and as the research below, reduces the risk of death.
Proprioception can be affected by the following factors:
Temporary impairment from a compromised state (for example the consumption of alcohol).
Age-related changes also affect proprioception. The risk of proprioception loss increases as we age due to a combination of natural age-related changes to the nerves, joints, and muscles.
Injuries or medical conditions that affect the neuromuscular system (muscles, nerves, and the cerebellum, CNS) which can cause long-term or permanent proprioception impairment.
Proprioception impairments have been noted among the following neurological conditions:
Brain injuries; multiple sclerosis (MS); stroke; Parkinson’s disease; Huntington’s disease; ALS (amyotrophic lateral sclerosis)
Also, health conditions: herniated disc, arthritis, autism spectrum disorder (ASD); diabetes, peripheral neuropathy
Post-surgery: joint replacement surgery, such as hip or knee replacement
MSK conditions: ankle sprains, ACL injuries, shoulder dislocations and tendinopathies, whiplash associated disorders (among others).
How do we clinically test for balance (a neurological perspective)
Romberg Test
The Romberg test is an appropriate tool to diagnose sensory ataxia, a gait disturbance caused by abnormal proprioception involving information about the location of the joints. It is also proven to be sensitive and accurate means of measuring the degree of disequilibrium caused by central vertigo, peripheral vertigo and head trauma. It has been used in clinic for 150 years.
It is a Tree Standing posture test already described, but with some modifications.
With shoes off the patient stands with their two feet together, initially quietly with eyes open and subsequently with eyes closed and the patient tries to maintain the balance. The clinician stands close to the patient just in case they begin to fall.
The Romberg test is sometimes scored by counting the seconds the patient is able to stand with eyes closed. Essentially a positive Romberg is when the patient can’t keep balance when their eyes are closed. Losing balance can be defined as increased body sway placing one foot in the direction of the fall or even falling if the clinician is not prepared (this has never happened to me in 35 years of clinical practice).
Sometimes the clinician can attempt to disturb the patient’s balance with a perturbation, essentially a gentle push on the torso of the patient either backwards or forwards or side to side via the arms.
Other tests that are sometimes used
Heel-Shin
The patient is asked to touch the heel of one foot to the opposite knee and then to drag their heel in a straight line all the way down the front of their shin and back up again. In order to eliminate the effect of gravity in moving the heel down the shin, this test should always be done in the supine position.
Ataxia
Best revealed if the examiner’s finger is held at the extreme of the patient’s reach, and if the examiner’s finger is occasionally moved suddenly to a different location. Ask the patient to touch the tip of their nose and your finger alternately with their index finger. This has to be done rapidly and repeatedly. The test should be performed with the patient’s eyes being open. Each arm should be tested separately.
Finger—nose—finger test. The patient is asked to alternately touch their nose and the examiner’s finger as quickly as possible, eyes open and eyes closed
Distal proprioception test. The tester will move the joints of the hip, knee ankle and big toe up and down while you watch. You then ask the client to repeat the same movement with your eyes closed.
A contralateral joint matching task. Asking the patient to match a demonstrated joint angle, and measuring the difference between the actual joint angle, and the reproduced joint angle (the difference representing the proprioception error).
Vibration Sense
During a neurological examination the clinician will place a vibrating tuning fork normally 128hz, at the medial malleolus of each leg. It is not uncommon for example with age related change the patients are unable to detect the vibration.”
People who cannot stand on one leg for ten seconds are almost twice as likely to die within the next decade, according to a study.
Researchers said the “simple and safe” balance test should be used in GP clinics during routine health checks for older adults, to pinpoint those with a shorter life expectancy.
They asked 1,702 middle-aged people to stand on one leg for ten seconds, placing the front of their free leg against the back of the leg that was touching the ground. Up to three attempts to hold the position for ten seconds were allowed.
Once age, sex and underlying conditions were taken into account, failing the test was linked with an 84 per cent increased risk of dying within ten years.
The study, published in the British Journal of Sports Medicine, was carried out by experts from universities and clinics in the UK, US, Finland, Australia and Brazil.
At present assessments of balance are not a routine part of health checks. Poorer balance has been shown to put people at increased risk of falls, but there is not much data that links it to wider health.
The researchers set out to examine whether it might be a reliable indicator of someone’s risk of dying.
They drew on data on participants in a long-running exercise study in Brazil. These were aged 61 on average when they underwent tests, and about two thirds were men.
Overall, 20.5 per cent of participants failed the test, with the likelihood of doing so increasing as they became older. The failure rate was about 5 per cent for those aged 51 to 55, 8 per cent among those aged 56 to 60, 18 per cent for those aged 61 to 65, and 37 per cent for those aged 66 to 70.
After age 70, participants were more likely than not to fail the test, with 54 per cent of those aged 71 to 75 unable to complete the challenge.
During on average seven years of follow-up, 123 of the participants died from causes including cancer, cardiovascular disease, respiratory disease and complications of COVID 19. Among those who failed the test, 17.5 per cent died, compared with 4.5 per cent of those who passed — a 288 per cent higher risk.
Overall, those who failed the test were in worse health. They were more likely to be obese, have heart disease, unhealthy levels of blood fats, high blood pressure, and type 2 diabetes.
The researchers said the increased risk held true even after taking those factors into account, calculating that it remained 84 per cent higher.
The study is observational and so cannot prove cause and effect. The researchers noted that they did not have information on some potentially influential factors, including recent history of falls, physical activity levels, diet, smoking and the use of drugs that may interfere with balance.
However, they concluded the ten second balance test “provides rapid and objective feedback for the patient and health professionals regarding static balance” beyond that provided by ordinary clinical data.