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Balance Act: Converting the Berg Balance Test into an aquatic challenge

Byline: Andrea Salzman, MS, PT

For many people, natural movement has narrowed to a 3-foot by 2-foot area. Because of the fear of falling, there is no risk-taking behavior: no sudden lunges to grab the telephone on the fly, no casual forward leans to snag the dropped set of car keys, no plopping down in the favorite chair. Actually, there

is, as a matter of course, much plopping down. Most of it is unintentional. For these people, falls are a constant threat. This fear translates to an unwillingness to move without

external support. And while an external support, such as a walker or cane, may prevent a fall today, I'm starting to believe it can set up a tomorrow full of risk. My suggestion? Introduce the Berg Balance Test into your aquatic treatments. Make your entire session geared around these equilibrium tasks and you will convert a dry old test into a kick-tail aquatic treatment.

Sit Unsupported

Place a pool wheelchair (or any plastic chair) in the water in the shallow end of the pool. Make sure the chair is either stabilized on its own or with your external support. Keep in mind that the deeper you place the chair, the less it weighs and buoyancy will often lift it from the bottom of the pool and waft it gently into the deep end. Once the chair is secured, have your patient sit quietly. Can he sit with both legs touching the bottom? One leg only? No legs? How about with his arms lifted off the arm rests? While sitting on the edge? With his eyes closed? With external turbulence (which you apply by scullying your hands or pushing a kickboard)? With internal turbulence (with the patient performing a task while seated)? The simple act of sitting in an unstable chair may be challenge enough. If it is not, add variety.

Rise From a Chair

Now that you have exhausted all the sitting tasks you could conceive, move on to rising from that chair. Keep in mind the chair that appeared stable a minute ago will tend to drift once your patient is no longer providing a counterweight. Have your patient attempt to stand up from the chair using both arms. Then use one arm only. Then use no arms. How about sitting back "deep" in the chair instead of on the edge? Can he rise without using momentum? With only one try? With eyes closed? You get the idea. Now that your patient is standing, make sure his legs are not resting against the chair. Have him stand with weight equally distributed on both legs. Can he stand unsupported? Can he shift his weight from side to side without loss of balance? Can he do so with both still water and turbulent water? What happens if he lifts his arms up out of the water? Now repeat all these tasks without visual cues—can he perform as well with his eyes closed?

Transfer From Chair to Chair

Can your patient transfer from one chair to another? Or from a bench (with no arms) to a chair? Have him perform this task without your advice and watch how much he makes use of external props. Does he use excessive push-off with his hands? Does he lean his calves against the chair for balance? Does he plop down into the second chair instead of gracefully lowering himself? Does he lunge forward and make a

desperate grab for the second chair? Now move the chairs further apart. Can he perform a stand, pivot turn, and then sit, or does he have to perform a step or two to get to the chair? How many steps does it take for him to get to the other chair?

Repeat the standing unsupported drills, but this time, have your patient place his feet so close together that they are touching. This will narrow his base of support and dramatically decrease his balance reactions. This instability will be even more obvious in shallower water.

Reach Forward

From a standing position, with legs comfortably placed shoulder-width apart, have your patient reach forward as far as possible, maintaining his arm parallel to the surface of the pool. How far can he reach? With your cues, can he go further?

Place a kickboard outside his reach as a goal (but don't allow him to use it as a balance prop). Move the kickboard from directly in front of him to one side and then the other. Can your patient hold his extended position for 10 seconds? With his eyes closed? With his feet touching? With turbulent water? Now repeat the drills with both arms extending at the same time.

Pick Up an Object

Place a sinkable object on the bottom pool step or in shallow water (2 to 2.5 feet will work just fine). Have your patient sight the object and then pick it up with different lift techniques. Try a golfer's lift (one leg on the pool bottom and the other leg lifted up behind). Now try a squat lift. Next, place sinkable objects across the pool bottom and give your patient a timed trial on picking them up. Have him alternate the side he uses to pick-up the items (using the involved hand, then the uninvolved hand). Graduate to flatter items which are harder to pick up.

Look Behind Each Shoulder

With your patient standing with his legs comfortably apart, have him start to turn his head, shoulders and trunk toward the left. Have him sight on the pool wall throughout the turn and tell you what he sees as he turns his head. Ask him to tell you when he has turned the furthest he can manage. Now, what item can he just see out of the corner of his eye? How long can he hold this position? Five seconds? Ten? Repeat in the opposite direction. If your patient can master this task, have him place his legs so they are touching and repeat the drill. Try it in different depths of water and with more or less turbulence.

Turn in Full Circle

Have your patient perform a turn to the right. Without telling him, count how many steps it takes. Repeat to the left. Now tell him how many steps you counted and ask him to re-attempt the right turn with one fewer steps. Now the left. Progress to turns with two, three and four fewer steps. Can your patient keep his turning radius small or does he circumscribe a large area? Ask him to attempt to "pivot around a circle the size of a chair." Reduce or enlarge the circle to give new balance challenges.

Alternate Toe Touches

If you have a water-aerobics step available, place it in the pool. If you do not, you can perform this drill at the base of the steps entering the pool, but this is not ideal as the water depth is typically too shallow for safety. Either way, the goal is to have the patient lift one leg and tap the step (but not stand on it). Immediately, he should remove the foot from the step and place it back down and then repeat the process with the opposite foot. The goal is to see how rapidly your patient can perform this drill. Can he perform eight taps in 20 seconds? In 30 or 60 seconds? Does he sway and use his arms? Attempt the drill with his arms held stiffly by his sides. If your patient is a master at this task, repeat it with his eyes closed and with turbulence.

Maintain Tandem Stance

These final two tasks are ideal for water-based execution. They are very challenging on land, making it almost impossible for someone with severe balance complications to even attempt them. In the water, however, all things are possible. Have your patient place one foot directly in front of the toes of the other (like he is walking a tight-rope). Have him stand with weight equally distributed on both feet. Can he hold the position, and for how long? Does he flail his arms about? Can he hold them by his sides? Repeat with the other foot in front. It is actually harder to stand in a tandem stance than it is to "walk a line," but by all means, incorporate tandem walking into the program as well.

Stand on One Leg

Lastly, have your patient perform a stork position (standing on one leg). Time his efforts. Repeat on the other side. Add all the flourishes we've discussed to make it harder—closed eyes, still arms, turbulent water and so forth.


You've just mastered the Berg. With the Berg, patients may be challenged beyond their limits of stability in the water without the fear of consequences of falling which are often present with land-based balance training. The worst case result of an uncorrected loss of balance is a fall into a compliant fluid (water) and not a fall to a noncompliant solid (the ground). Thus, the patient may be challenged to move outside of his base of support without fear of traumatic consequences. This reduction in patient anxiety may encourage the patient to attempt tasks that he would not attempt on land. It becomes possible to elicit balance challenges that the patient has both the time and mental confidence to combat. Clearly, the water offers an excellent location for balance training. And by using the Berg as a training tool—and not just an assessment tool—you can make quick work of challenging every nuance of your patient's balance.


Bogle-Thorbahn, L., & Newton, R. (1996). Use of the Berg balance test to predict falls in elderly persons.Physical Therapy, 76, 576-585.

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