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CLINICAL OUTCOMES RESEARCH 

 

45 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020 
 

Functional Balance Assessment of Firefighters during Mass-Screening 
Examinations 
Rachel M. Eiler, DAT, LAT, ATC*; Zachary K. Winkelmann, PhD, SCAT, ATC†; and Kenneth E. Games PhD, 
LAT, ATC‡ 
*NovaCare Rehabilitation, Minneapolis, MN; †University of South Carolina, Columbia SC; ‡Indiana State University, Terre Haute, 
IN  
 

 
ABSTRACT 

Firefighters are tactical athletes who are required to 
complete rigorous tasks as part of their job functions. The 
focus of this clinical outcomes assessment was to assess 
functional balance assessment through the use of the anterior 
reach test with and without personal protective equipment 
(PPE) during a mass-screening examination. The screening 
was completed with 61 active firefighters in a local fire 
department with access to athletic training services. The 
results of the anterior reach assessment identified a 
significant difference of a firefighter’s anterior reach when 
donning and doffing PPE. Anterior reach distances were 
significantly reduced (P < 0.001) on the right leg with (mean 
= 55.78 cm ± 7.53 cm) and without PPE (mean = 58.92 cm 
± 6.47 cm). Similarly, significant decrements (P = 0.003) in 
left leg anterior reach distance in firefighters donning (mean 
= 57.67 cm ± 8.25 cm) and doffing (mean = 59.82 cm ± 
6.31 cm) PPE. Clinical application of these findings suggests 
that healthcare providers working with tactical athletes, 
specifically firefighters, should consider the risks associated 
with donning PPE such as functional balance deficits. 

Key Phrases 
Pre-participation exams and screenings, emerging settings 
 
Correspondence 
Dr. Zachary K Winkelmann, University of South Carolina, 
1300 Wheat Street, Columbia, SC 29208. 
E-mail: winkelz@mailbox.sc.edu 
Twitter: @zachwinkelmann   

Full Citation 
Eiler RM, Winkelmann ZK, Games KE. Functional Balance 
Assessment of Firefighters during Mass-Screening 
Examinations. Clin Pract Athl Train. 2020;3(2):45-49. 
https://doi.org/1031622/2020/0002.6.   
 
Submitted: December 19, 2019 Accepted: May 15, 2020 

PATIENTS 

Sixty-one firefighters from a Midwestern fire 

department were included in this mass-screening 
examination. All of the firefighters were 

considered career, full-time employees of the city 
municipality. Sixty firefighters identified as male 
and 1 firefighter identified as female. The 
firefighters ranged in age from 25 to 64 years of 
age (mean = 41.07 ± 9.23 years) and had 
between two and 34 years of experience (mean 
= 15.31 ± 9.41 years) in the fire service. The 
body composition of the firefighters was of 
average height (28.03 ± 1.08 cm) and above-
average mass (105.58 ± 20.87 kg). 

During the intake process, the firefighters 
completed a past medical history form. From this 
process, 12 firefighters (19.7%) reported having 
chronic pain, 16 firefighters (26.2%) reported a 
previous head/neurological injury, 42 firefighters 
(68.9%) reported having a previous surgery, and 
24 firefighters (39.3%) indicated an ongoing 
orthopedic injury at the time of the mass-screening 
examination. It is important to indicate here that 
while 39.3% of the firefighters reported an 
ongoing injury, none of these individuals were on 
restricted or light duty. Thus, they were required 
to execute and perform all job-related tasks.  

INTERVENTION 

The intervention was a three-day, mass-screening 
event at the fire department’s training center. The 
firefighters arrived at the firefighter training 
center during their shift in crews of three to seven 
people. Each firefighter completed a past medical 
history form and patient-reported outcome 
measures via an online survey (Qualtrics, Inc, 
Provo, UT). Once the patients completed the online 
survey, they proceeded to complete a series of 
functional screenings throughout the training 
center. Figure 1 outlines the flow chart of Mass-
Screening Intervention Process. 

mailto:winkelz@mailbox.sc.edu
https://doi.org/1031622/2020/0002.6


Functional Balance Assessment of Firefighters during Mass-Screening Examinations 
 

 

46 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

 

The first stage of the functional screening 
included patient intake (height, weight, leg 
length, tibial tuberosity height, and hand length), 
the weight bearing lunge test, and the closed 
kinetic chain upper extremity stability test. Once 
all patients completed these stations, they 
proceeded to the second stage of the function 
screenings that consisted of the anterior reach 
portion of the Y-Balance Test, the Landing Error 
Scoring System (LESS), and the Functional 
Movement Screen (FMS). The firefighters 
completed each of these tests while donning their 
station attire that included a t-shirt, athletic 
shorts/pants, and tennis shoes, or while donning 
their personal protective equipment (PPE) which 
included their jacket, pants, boots, helmet, mask, 
and condensed air tank. During the anterior 
reach, the firefighter’s mask was not connected 
to the condensed air tank during the completion 
of the anterior reach. The mask is the piece of 
equipment that covers the firefighter’s face into 
which the condensed air tank attaches to provide 
the firefighter with oxygen. Once the patient 
completed the tests while donning and doffing 
their PPE, their mass-screening examination was 
completed.  

OUTCOME MEASURES 

The focus of this clinical outcomes’ assessment was 
dynamic balance assessed using the anterior 
reach portion of the Y-Balance Test. The Y-
Balance Test measures dynamic balance using 
single limb stance excursion.1 Prior to the Y-
Balance Test, the Star Excursion Balance Test 
(SEBT) was used to identify chronic ankle 
instability, at-risk athletes for lower extremity 
injury, and assess overall physical performance.1 
The Y-Balance Test was developed to improve the 
repeatability of the SEBT.1 The anterior reach 

assessment was utilized because previous 
research suggests that asymmetries in the anterior 
direction indicated balance deficits that increased 
the risk for injury.2,3 Specifically, the anterior 
reach has high intrarater reliability at 0.91.1,2 To 
be mindful of time guided by the literature, we 
only assessed the anterior reach out of the three 
directions for the Y-Balance Test.  

Prior to the firefighter completing the assessment, 
the athletic trainer provided verbal and modeling 
instruction on how to complete the anterior reach 
assessment of the Y-Balance Test. During the 
anterior reach assessment, each firefighter 
successfully completed the test three times while 
donning  PPE (Figure 2) and three times doffing  
PPE (Figure 3) for a total of six trials of the 
anterior reach completed using an established 
protocol.1 The order was not controlled for the 
patients to start with or without their PPE. The 
anterior reach test was completed using the Y-
Balance Test Kit, which includes three pipes in the 
anterior, posteromedial, and posterolateral 
direction.1 For the mass-screening examination, 
only the anterior pipe was measured. The pipe 
was marked in 0.5 centimeters increments for 
measurements, where the firefighter pushes the 
reach indicator box along the pipe, marking the 
determination of the reach distance, and returning 

Patient 
Online 
Survey

Patient 
Intake

Functional 
Screening

Figure 1. Flow Chart of Mass-Screening Intervention Process 

Figure 2. Anterior Reach Assessment with Personal 
Protective Equipment 



Functional Balance Assessment of Firefighters during Mass-Screening Examinations 
 

 

47 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

to the starting point while maintaining their 
balance on their stance leg.1   

Once all patients completed the anterior reach 
assessment, the data were entered into a custom 
spreadsheet application and analyzed in a 
commercially available statistics package. First, 
the absolute reach distance was calculated by 
summing the three reach distances and dividing by 
three for the average on the right and left leg with 
and without PPE. Next, the data were normalized 
by dividing the maximum reach distance in each 
leg for each condition by the limb length of the 
patient. This number was multiplied by 100 to 
calculate the relative anterior reach distance.1  
Normalizing the data occurred to be able to 
compare the data among the individuals with 
different leg lengths.  

RESULTS  

The majority (54/61, 88.5%) of the firefighters 
were self-reported right leg dominant. Table 1 
provides the descriptive statistics for the anterior 
reach assessment. A paired sample t-test was 
utilized to analyze the data. Results of the data 
analysis identified a significant difference (P < 
0.000) for the right leg anterior reach distance 
when the firefighters were doffing their PPE (mean 

= 58.92 cm ± 6.47 cm) as compared to when they 
were donning their PPE (mean = 55.78 cm ± 7.53 
cm). Similar results were identified on the left leg 
with a significant difference (P = 0.003) for 
anterior reach distance donning and doffing PPE.  

Table 1. Anterior Reach Results  

Condition Mean 
(cm) 

Standard 
Deviation 

(cm) 

Standard 
Error 
(cm) 

Right Leg - 
PPE 55.78 7.53 0.96 

Right Leg - 
No PPE 58.92 6.47 0.83 

Left Leg - 
PEE 57.67 8.25 1.06 

Left Leg - 
No PPE 59.81 6.30 0.81 

PPE = Personal Protective Equipment 

After normalizing the measurements per patient, 
we identified a significant difference in relative 
anterior reach distance for the right (P < 0.01) 
and left (P = 0.026) leg when donning and 
doffing their PPE. Table 2 provides relative 
normalized reach distance descriptive measures 
per assessment condition. 

Table 2. Anterior Reach Normalized Results  

Condition Mean 
(cm) 

Standard 
Deviation 

(cm) 

Standard 
Error (cm) 

Right Leg - 
PPE 69.23 21.26 2.72 

Right Leg -  
No PPE 72.72 22.19 2.84 

Left Leg - 
PEE 71.31 22.79 2.92 

Left Leg - 
No PPE 73.49 22.76 2.91 

PPE = Personal Protective Equipment 

DISCUSSION 

In 2018, 58,835 firefighters were injured on the 
fireground.4 Strain or overexertion were the 
leading cause of fireground injuries.4 With the 
high rate and risk of injury during the job, 
firefighters are required to don PPE that limits 
smoke inhalation, chemical exposure, and fire 
contact resulting in burns.5  As a part of their PPE, 

Figure 3. Anterior Reach Assessment Without Personal 
Protective Equipment 



Functional Balance Assessment of Firefighters during Mass-Screening Examinations 
 

 

48 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

firefighters must also wear a compressed air tank 
which was identified in previous literature to have 
a negative effect on postural control and 
functional balance.6 There are various PPE designs 
that are worn by firefighters, but regardless of 
the design, PPE significantly impairs functional 
balance.7 When donning  PPE, firefighters had a 
decrease in movement speed by a 13% increase 
in performance time and made more errors on a 
balance exam.7 By knowing that the PPE could 
impair functional balance, it is vital to understand 
how decreases functional balance may 
predispose a firefighter to a musculoskeletal 
injury on the fireground. 

Results of this study found that there is a significant 
difference between the relative anterior reach 
distance for the right leg as compared to the left 
leg when patients are donning and doffing their 
PPE. Anterior reach decreased when donning PPE, 
due to the impairments of the functional balance. 
The anterior reach assessment was completed 
while donning and doffing firefighter PPE. 
Previous research has identified that the thermal 
layer (pants and jacket) alters a firefighter’s gait 
speed during balance testing. PPE negatively 
effects gait by decreasing step length thus slowing 
one’s speed.8 

Although we were not assessing gait, we did 
identify that wearing the PPE significantly altered 
the firefighter’s functional balance. Based on the 
literature, functional balance and gait are 
affected by donning PPE. This is of concern to the 
safety and wellness of the firefighters. The longer 
someone is in a live fire, the more functional 
balance is affected. If someone is moving slower 
and paired with balance decrements at the onset, 
there is a grave concern that exposure to heat 
while donning PPE may result in the trips and falls 
that contribute to the high statistics of sprains and 
strains in the United States fire service.  

One mechanism that may improve functional 
balance while donning PPE is by increasing 
resistance and aerobic training, as the literature 
supports that a more physically active firefighter 
has less physical impairment. 9 In regard to the 
limited anterior reach that was found in this study, 

one proposed mechanism for the decrements is 
limited dorsiflexion at the ankle. Ankle 
dorsiflexion for firefighters is impacted by their 
boots.10-12 The literature supports that boot type 
(rubber versus leather) influences a firefighter’s 
balance with rubber boots, increasing their risk for 
falls.10-12 Common tasks of firefighters include 
climbing ladders, emergency lifts to rescue victims 
in burning buildings, and assembling equipment to 
put out fires. As such, ankle dorsiflexion and 
functional balance are both required. Future 
research on PPE gear analysis would assist the 
industry in identifying how to create protective 
turnout gear that limits chemical exposure and 
exposure to fires that also allows for movement 
and range of motion. 

CLINICAL APPLICATION 

The data collected can assist in determining 
limitations that the patient’s experiences with their 
PPE. This allows clinicians to be able to understand 
the potential causes of the mechanism of injury 
and design rehabilitation plans to prevent the 
injury from reoccurring. By determining the 
limitations during the mass screening, the clinician 
can work with the patient on goal setting and 
injury prevention. Due to the equipment having a 
negative effect on the patient’s performance in 
the anterior reach, it may be beneficial to have 
the patient complete exercise, physical activity, 
and therapeutic rehabilitation with their PPE to 
train the body to replicate the conditions in which 
they are required to work. This change may result 
in more job-specific rehabilitation, with future 
investigations necessary to explore firefighters’ 
ability to complete movements. Clinicians are also 
able to develop resistance and aerobic training 
exercise plans to increase the firefighter’s overall 
physical fitness to reduce their physical 
impairments, which can result in improving their 
physical ability while donning PPE.   

REFERENCES 

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Functional Balance Assessment of Firefighters during Mass-Screening Examinations 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                              Volume 3 – Issue 2 – June 2020  

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