Michael Martin Cohen, M.D. — Balance on the Water: “One Hand For Yourself, One Hand For the Ship”

Because sailors spend much of their life on the water – which is constantly shifting beneath their feet – balance on the water is an everpresent problem. Ergo, “One Hand For Yourself, One Hand For the Ship.” But when most sailors consider balance on the water they may think of sail balance, or hiking balance, or even cargo balance; but only when they become older do they begin to worry about their personal balance. They may feel less sure footed on deck or perhaps they or a friend of theirs has had a nasty fall. In fact as we will see below, balance training is increasingly recognized as an important component of a complete exercise program for adults. Late in coming but better late than never!

Balance training was discussed in Chapter 10 [1] but since it is increasingly emphasized by health organisations around the world it is worth taking another look. I previously stated that,

“Balance training has been the stepchild of the fitness world. The concept of training or even just improving your balance has been relegated to the realms of rehabilitation and fall prevention in the elderly. That is unfortunate because on the water our balance system is constantly being tested, since our center of gravity is constantly shifting beneath us.”

The main emphasis of health care institutions in the 21st century is to convince their citizens to get moving. “Sitting is the new smoking” is a current meme. And so the emphasis is on first getting people out of their chairs and moving (walking, bicycle riding, etc.). “You gotta move”. However if you look at the discussion in my recent blog entitled “Some Other Important Numbers…” you will see that all three of the publications cited discuss not only aerobic exercise but the need to add resistance training (weights or calesthenics):

Physical Activity Guidelines for Americans, 2nd edition
UK Chief Medical Officers Physical Activity Guidelines
World Health Organization 2020 Guidelines On Physical Activity and Sedentary Behavior

All three also refer to flexibility (stretching) and balance training as important components of an exercise program – the latter especially when referencing “older” adults. The UK guidelines contain a helpful graphic that is explicit in its recommendation for balance training 2 times a week. (Figure 1).

Earlier this year the National Institute on Aging (part of the NIH) made the most explicit statement yet: [2] “Four Types of Exercise Can Improve Your Health and Physical Ability” –

1. Endurance (Aerobics)

2. Strength (Resistance)

3. Balance Training

4. Flexibility or Stretching

Figure 1: UK Chief Medical Officers Physical Activity Guidelines. Notice the lower right quadrant, “Improve balance”

I believe that every sailor over the age of perhaps 35-40 should think of their exercise regimen as containing those 4 components.

Buckle up, sailor, or put on your PFD as we embark on a journey though the world of “balance.”

Developing Our Sense of Balance the Hard Way – Trial and Error

Let’s go back to when it all began – childhood. We all started walking at about a year of age and slowly developed our sense of balance throughout the remainder of childhood – without even thinking about it! As our senses developed we learned how to integrate them.

For balance on or off the water, we depend on the interaction of three sensory systems to signal when we are upright and prevent us from falling: vision, vestibular (inner ear balance mechanism), and proprioception (position information coming from our muscles, joints, and tendons which also tell us about our position in space). If this seems familiar, it should, as it was discussed in depth in Chapter 1, “Seasickness.” [3]

These 3 systems are represented in the following illustration:

Seasickness occurs when these three systems are providing conflicting information. For example in Figure 3B there is a conflict between the information supplied by the eyes (nothing moving) and that supplied by the inner ear vestibular system (which is signalling a rotation to starboard)

What does this have to do with balance? Well, in order to function normally we need these systems to be working together in harmony. In seasickness there is disharmony. The inner ear is telling the brain one thing, the vision another, and the joints something entirely different. That sensory mismatch is at the heart of seasickness.

For balance we need all three of these systems working together and that’s what our brain “learns” in childhood. The child’s brain learns how to integrate the information and make sense of it. It’s a learning process. At what age is there reasonable balance? You can find gymnastics classes for children as young as 2!, although most coaches suggest starting at 5 years of age or older. By 5 years of age, 50% of kids can hold a single leg balance for 10 seconds on each leg with less than 20 degrees of trunk movement side to side.

Ok, so if these 3 systems are the sensory input for balance, with which decisions are made, what about the output? You need to have strong muscles and stable joints to have good balance. This is generally not a problem in childhood.

Teenage and Twenties

I played sports with the other kids in the neighborhood and was always physically active. I engaged in weight lifting and endurance training (running and swimming) but never gave a thought to balance. It was just there, a fact of life. My brain (and yours) had accomplished the coordination of vision, inner ear, and proprioception senses and integrated the input with the out put – our muscles.If our senses ascertained that we we tilting to the left a series of signals is sent to muscle groups in the back and leg to prevent the fall. It is a feedback system that usually works. We make whatever corrections are necessary to keep us upright. Of course when we drink or do other “anti-social” things like drugs, we pay the price and might lose our balance or worse.

For those who were in the military or played contact sports, balance issues arose after a head injury, even a minor concussion. In the US, the BESS (The Balance Error Scoring System) has been used to assess return-to-play status and return to active duty.[4]

Figure 4: The BESS Test for balance assessment

The test consists of three stances (double leg, single leg, and tandem) and two surfaces (firm and foam). Each stance is performed with the eyes closed and a stopwatch is employed. The subject (usually a student) is expected to keep their balance for 20 seconds in each position. A scoring system is employed, and a perfect score is “0” with no errors. [5]

By closing the eyes you are removing the contribution of one sensory system – vision and forcing the student or cadet to try to get by on the other two. By using the single leg you are removing 50% of the proprioception from the feet and the tandem stance also reduces the stability.

Repeating the procedure on a foam surface, makes maintaining your balance much harder. [6]

For young people whose proprioception and vision are probably normal the BESS is testing the inner ear balance mechanism – and the rest of the brain too. It turns out that balance is not as simple as just the three inputs and the feedback to the muscles. The rest of the brain especially a portion called the cerebellum is also involved. [7]

And yes, variations of of the BESS test are often included in the DUI testing by your local police.[8]

Neurology Training

In my mid 20s, once I started my neurology career, balance was always on my mind. Clinically speaking, that is.

As part of the standard Neurologic Examination every patient has his or her balance and gait tested. The balance test which is now standard was devised by Dr. Moritz Romberg a 19th century German neurologist who developed the test as a way to diagnose a form of tertiary syphylis (which was rampant in Europe) called tabes dorsalis. [9] It is still referred to as a Romberg Test (Figure 5) and is performed many thousand times every day by neurologists and other physicians testing balance in patients all around the world.

It is basically the first part of the BESS. Once you close your eyes, if you begin to sway and especially if you lose your balance there is likely to be a defect in your inner ear balnace mechanism or your proprioception (sensation from the feet). The neurologist can usually figure out where the problem is located.

The Invincible Years 30-40

In my late 20s-early30s when I started sailing small boats and then keel boats I never gave it a thought. No one does at this age unless they sustain a concussion. [10] It’s not that everything is fine, it’s just that the deterioration in some of these systems is subtle. By the time you are in your late 30s and early 40s your nerves (especially the long ones from your feet) are just beginning to slow. At this age if you perform the Romberg on foam you can feel your feet and toes struggling to keep your balance.

50 and above:

By your 50s you begin to notice that your balance is not quite the same. Falls are more likely and you feel less safe climbing ladders. With age, the quality of the information provided by your eyesight, inner ear, and position sense declines. These age related changes are compounded by the fact that your brain – which is putting all this information together in split-second time – isn’t getting any younger.

It’s time to fight back!

I started to work on my balance 5 years ago in my late 60s. I decided to buy a Balance Board with a hard rubber round bottom which is fairly standard on such boards (Figure 6) and incorporated it into my workouts. I was surprised to find that with practice you can teach an old dog new tricks. I didn’t really exercise on it (as some of the younger folk do) I was just pleased that I could increase my balance time on the board without tilting and touching the edge (or falling).

My wife wanted to start working on balance and I decided to start her out with a foam balance pad – the type frequently used by physical therapists. (Figure 7).

Just for kicks, I decided to try it with the BESS postures. Fortunately, no one was scoring my performance! Despite my years on the balance board as soon as I closed my eyes I could feel my feet dancing in place trying to keep me upright. I never realized just how much a role vision was playing.

Remember, your muscles ultimately hold you up and if they are weak from disuse or any other cause your balance will suffer. For sailors, the important point is that muscular fatigue will also impair balance. So after a long greuling task you should expect a temporary impairment of balance. This is definitely a time for “One Hand For Yourself, One Hand For the Ship.”

What to Do

The first thing to do is evaluate (or have a physical therapist evaluate) your ability. If you go the physical therapy route they can work with you and provide a guide as to what to do post therapy.

On the other hand, if you are confident in your balance, have not had any unexplained falls but wish to work on it (and that is certainly a good idea) there are a number of options, and they are all good. But first, there is one more concept that is critical for sailors to understand.

Static Versus Dynamic Balance

There are two types of balance—static and dynamic—and they are both important on the water. Static balance is what we have been discussing so far.

Dynamic balance is more difficult to define. Basically, it is the ability to maintain postural stability and orientation while the body is in motion. (Figure 8) Examples would include forward or backward stepping with a brief stop to maintain alternate leg balance, side-to-side stepping also with a stop to maintain alternate leg balance, the grapevine walk, lunges, many of the Tai Chi moves, and basically any disco move (for those of you of a certain age).

Figure 8: Dynamic balance - heel to toe walking

Most of the yoga poses represent static balance although by emphasizing the transitions between poses you can increase the dynamic quality of the Yoga exercise. Hatha yoga is practiced at a slower pace and emphasizes the breath, controlled movements, and stretching. Vinyasa Yoga is more dynamic and there is a constant flow between poses.

What about Tai Chi? Studies have shown Tai Chi can reduce falls in seniors by up to 45%. It can also improve balance in people with neurological problems including improving balance in people with Parkinson’s disease.

Figure 10: Tai Chi is designed for slow dynamic balance

In addition to physical therapy, Yoga, and Tai Chi, there are countless videos available to help you work on your balance. The most important thing is to make it part of your routine workout, at least a couple of times per week.

Now, speaking to those of a certain age: if you can’t perform even the basic static and dynamic balance exercises then I would favor cruise ships for your nautical experience (Harsh advice, I know, but with your best interest in mind).

It has been said that balance training is not necessary because at sea the perturbations of a moving boat cannot be replicated by any balance training. Theoretically, that is true, but I can vouch from personal experience that the type of side-to-side and fore and aft movements that we experience at sea are fairly close to what I experience on my balance board, and as I have stated, I have definitely improved my balance over time.

[1] Healthy Boating and Sailing (author)

[2] https://www.nia.nih.gov/health/four-types-exercise-can-improve-your-health-and-physical-ability

[3] See Chapter 1 for a discussion of all aspects of Seasickness

[4] Of course, now everything is automated – no more scoring the errors by hand.

[5] “Don’t try this at home” unless you have a spotter or something adjacent like a table or chair that you can grab onto. It is much more difficult than it appears!

[6] I can do all 3 of the firm surface stances, but let’s say I might have “a few” errors on the foam. To be honest, I struggle on the foam. More on this later when we discuss us “mature” individuals.

[7] For you neurogeeks, here is a graph of the distribution of all the regions which have been documented to be involved at least to some degree in balance. It is basically the whole brain!

[8] At least that’s what I’m told!

[9] For those of you who enjoy imaginary time travel, close your eyes and imagine you are in mid-nineteenth century London or another European city. Down the street you should picture a man or a group of men walking with an unusual slapping gait and at the same time tapping with their canes.

They are stomping or slapping down the cobble stone streets of old London Town in order to get every ounce of sensation from their feet since the conduction of the sensory information is being blocked in their spinal cord by a syphilis lesion. The cane helps to steady their gait but also supplies more sensory input to their spinal cord and brain via their arm.

[10] For those of you paying attention, yes, I did sustain a sailing related concussion, but it was mild, I did not lose consciousness, and in those days unless you were knocked out no one paid much attention to you!