Maureen Dwight Registered Physiotherapist, Clinical Musculoskeletal Specialist, Advanced Spinal Practitioner ISAEC

4th in a series on causes of low back pain 

Many of my clients tell me they have poor balance.  They find it difficult to stand on one foot.  They trip and stumble over almost imperceptible unevenness in the ground.  In therapy this topic frequently comes up when I ask you to walk slowly.  You may have no issue walking quickly but as soon as you slow down you totter off to one side and/or lose your balance. Poor Balance Srategies Video

In addition to looking old, this tottering is problematic for injuries.  It contributes to falls, hip and knee osteoarthritis and causes low back pain. Whether you are born with poor balance or develop it after an injury there is no doubt that more efficient balance strategies is something worth spending time on.  Not only can improving balance reduce the likelihood of back pain it may also help to prevent catastrophic falls later in life.

Causes of poor balance

After an episode of low back pain, poor balance is quite common.  Weakness and compensatory strategies following nerve impingements predict these issues[1] and providing your spine therapist knows where to look for the cause they often easily corrected.  What is more interesting to me as a therapist is that many people have issues with balance long before they ever hurt their back and these poor balance strategies are now known to be a cause of low back pain.

Most of my clients are well aware of whether their balance issues preceded or followed their back pain.  Some remember being in military training at age 20 and noticing everyone else marching forward while they broke formation by rocking from side to side.  Others describe themselves as the kid everyone thought was clumsy, falling just a bit easier than the rest of their peers.

Testing for poor balance strategies

Even if you don’t tend to trip, fall or totter you may still be using inefficient balance strategies.  People can still find a way to balance even when they are using the wrong muscles. The stronger and more athletic you are the more I find you can look balanced even when you are using these less efficient muscle patterns. To determine whether you are using inefficient balance strategies try the following tests:

Test 1: The Toddler

Stand in front of a mirror with someone standing directly behind you.  Have them position their head directly behind your head.  You shouldn’t see any part of their face.  As you stand on one leg you will naturally shift to one side however if you have good balance you should only see about ½ their face.  An adult shifts about 6” to stand on one leg, rather than toddling from side to side. If you are shifting excessively it would be wise to begin to work out a program to address this shift.  Even if you passed the 1st test you may still be faking balance.  Go through test 2 and 3 to be sure. Toddler balance video

Test 2: The Salsa Dancer

Thread a light, long stick into the front two belt loops of your pants i.e. paint stick. Stand in front of a mirror and position the stick until it is level with the ground.  Stand on one leg and watch to see if the stick moves. If you are using your hip muscles properly the stick will stay level or slightly drop on the leg you are standing on. If it goes up this means your hip muscles are not supporting your body weight correctly.  This movement looks like the hip drop seen in latin dancing i.e. salsa or rhumba. Salsa support video

This lack of support is not a healthy pattern to be using in everyday life activities i.e. walking, standing.  If you see this pattern you should discuss it with your therapist as it is most likely caused by weak or poorly coordinated hip abductor muscles (gluteus medius/minimus).

Test 3: The Masterful Faker

The final test requires you to feel which muscles are working when you balance.  Even when my clients perform the first two tests correctly I sometimes find they are able to coordinate a compensatory pattern that makes it look like they are doing everything right – no excess shift, no hip drop.  Only when I ask them to tell me which muscles they are using to balance do I get any insight that they are faking me with their balance strategies. As you stand on one leg note which muscles you tend to dominantly use:

  • Toe and feet muscles
  • Calves
  • Muscles at the front of your ankle
  • Muscles at the front of thigh (Quadriceps)
  • Inner thigh or groin muscles (Adductors, hip flexors)
  • Muscles at the back of thigh (Hamstrings)
  • Back muscles
  • Buttocks (gluteus maximus)
  • Outer hip muscles (gluteus medius/minimus)
  • Abdominal muscles

Healthy Balance Patterns

Balance is best coordinated using the large muscles of the hips and torso.  In a recent study[2] electrodes were placed on several muscles around the feet, ankles and hips.  They found that people with more difficulty balancing initiated the correction for a loss of balance with their feet whereas the healthier patterns began with the hip and pelvis muscles.

I often see this pattern in my back patients.  Many use balance strategies involving the muscles in their feet and toes. Although this may work for a while, the problem is that these muscles are small and must work hard to balance our entire body weight.  These muscles fatigue and/or have difficulty creating enough power to correct for larger losses in balance.

Involving your gluteus medius and minimus muscles is crucial to healthy balance strategies.  The problem is that these muscles often weaken after injuries to the spine and pinched nerves.  This pattern is also an issue in hip arthritis and knee injuries as excess side to side “toddling” increases the strain on these joints.

Correcting balance issues

If you had difficulties passing any of these three tests I would recommend seeing a registered physiotherapist or registered kinesiologist.  Work to improve these patterns, preferably before you are having issues. To effectively correct balance you need to get to the source of the issue.  Your therapist should look for weakness and poor muscle coordination patterns.

Balance is complex and it is also important to rule out other causes such as inner ear imbalances, etc. Once you determine the source is from the muscles, a program including both strengthening and muscle coordination exercises will help to correct the underlying issues.  The final step is to ensure that you rapidly activate your hip muscles for balance when you are doing stairs, walking, sports or practicing “tree” in Yoga class. A salsa hip may be a great pattern for dance but should be saved for the dance floor.   With just a few minutes of effort every day it’s amazing how much improvement can be made, even if you have had poor balance all of your life.

The next topic:  Compensatory patterns and low back pain. 

Maureen Dwight is a registered physiotherapist practicing in downtown Toronto at the Orthopaedic Therapy Clinic. For more information on treatment options for prevention and alleviation of low back pain please contact us at physio@orthophysio.com or drop by our Toronto Clinic.

The advice in this article is not meant to replace advice from your health care professional.

[1] Compensatory strategies and balance will be addressed in a future blog
[2] http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2527415/?tool=pmcentrez