The present systematic review and meta-analysis quantified dose–response relationships of balance training (BT) modalities (i.e., training period, training frequency, training volume) to maximize improvements in balance performance in healthy adults aged 65 years and older. |
Our analyses revealed that an effective BT protocol is characterized by the following independently considered training modalities to improve balance performance in healthy older adults: a training period of 11–12 weeks, a frequency of three sessions per week, a total number of 36–40 training sessions, a duration of 31–45 min of a single training session, and a total duration of 91–120 min of BT per week. |
Our study provides preliminary evidence-based guidelines on dose–response relationships for practitioners and therapists to increase the efficacy of their BT protocols and to highlight the necessity of studies that incorporate systematically structured BT programs. |
1 Introduction
2 Methods
2.1 Literature Search
2.2 Selection Criteria
2.3 Coding of Studies
2.4 Assessment of Methodological Quality and Statistical Analyses
3 Results
3.1 Study Characteristics
References | Subjects | Balance training modalities | ||||||
---|---|---|---|---|---|---|---|---|
N (M/F) | Age (years) |
P
| TF |
S
|
D
|
T
|
E
| |
Arampatzis et al. [50] | 38 (13/25) | BT: 67 ± 2 BT + ST: 68 ± 3 CG: 68 ± 3 | 14 | 2 | 28 | 90 | 180 | N/A |
Beling et al. [32] | 23 (12/11) | BT: 79 ± 7 CG: 81 ± 5 | 12 | 3 | 36 | 60 | 180 | 5 |
Bierbaum et al. [51] | 38 (13/25) | 69 ± 3 | 14 | 2 | 28 | 90 | 180 | N/A |
Franco et al. [54] | 32 (7/25) | 78 ± 6 | 3 | 2 | 6 | 30–45 | 60–90 | N/A |
Granacher et al. [44] | 40 (N/A) | BT: 66 ± 5 CG: 67 ± 4 | 13 | 3 | 36 | 60 | 180 | N/A |
Granacher et al. [45] | 20 (6/14) | BT: 72 ± 5 CG: 75 ± 6 | 6 | 3 | 18 | 60 | 180 | N/A |
Gusi et al. [33] | 40 (11/29) | 76 ± 8 | 12 | 2 | 24 | 15 | 30 | 3 |
Jacobson et al. [47] | 25 (N/A) | 63 ± 6 | 12 | 3 | 36 | N/A | N/A | N/A |
Judge et al. [46] | 110 (64/46) | BT: 79 ± 3 ST: 80 ± 4 BT+ ST: 80 ± 4 CG: 81 ± 5 | 12 | 3 | 36 | 45 | 135 | N/A |
Kronhed et al. [34] | 30 (14/16) | 73 ± 2 | 9 | 2 | 18 | 60 | 120 | N/A |
Leiros-Rodriguez et al. [48] | 28 (0/28) | 69 ± 3 | 6 | 2 | 12 | 50 | 100 | 12 |
Maughan et al. [35] | 60 (24/36) | BT I: 72 ± 8 BT II: 74 ± 7 | 6 | 1 | 6 | 20 | 20 | N/A |
CG: 72 ± 8 | 6 | 3 | 18 | 20 | 60 | N/A | ||
Melzer et al. [36] | 66 (17/49) | 77 ± 7 | 12 | 2 | 24 | N/A | N/A | N/A |
Nagai et al. [37] | 48 (6/42) | BT: 81 ± 7 CG: 82 ± 6 | 8 | 2 | 16 | 40 | 80 | 8 |
Pfeifer et al. [38] | 33 (4/29) | 78 ± 8 | 4 | 3 | 12 | 60 | 180 | N/A |
Piao et al. [39] | 30 (16/14) | BT: 68 ± 2 CG: 70 ± 4 | 8 | 3 | 24 | 60 | 180 | N/A |
Rossi et al. [52] | 41 (0/41) | BT: 67 ± 2 CG: 68 ± 3 | 6 | 3 | 18 | 40 | 120 | 6 |
Thiamwong et al. [49] | 104 (40/64) | 71 ± 8 | 12 | 7 | 84 | 30 | 210 | 6 |
Weerdesteyn et al. [40] | 107 (23/84) | BT: 74 ± 6 CG: 75 ± 7 | 5 | 2 | 10 | 90 | 180 | N/A |
Weerdesteyn et al. [53] | 95 | BT: 74 ± 6 CG: 75 ± 7 | 5 | 2 | 10 | 90 | 180 | N/A |
Wolf et al. [41] | 72 (60/12) | BT: 78 ± 7 Tai Chi: 78 ± 6 CG: 75 ± 5 | 15 | 1 | 15 | 60 | 60 | N/A |
Wolfson et al. [42] | 110 (64/46) | 79 ± 5 | 12 | 3 | 36 | 45 | 135 | N/A |
Yu et al. [43] | 30 (16/14) | BT: 68 ± 2 CG: 70 ± 4 | 8 | 3 | 24 | 60 | 180 | N/A |
References | Subjects | Balance training modalities | Type of balance test | % (pre-post); SMDws
| SMDbs (BT vs. control) | |||
---|---|---|---|---|---|---|---|---|
N (M/F) | Age (years) |
S/R
| DE | |||||
Arampatzis et al. [50] | 38 (13/25) | BT: 67 ± 2 BT + ST: 68 ± 3 CG: 68 ± 3 | N/A | N/A | RB (simulation of forward falls; horizontal velocity of the center of mass) | BT: +3.6 % (↑); 0.21 | −0.31 | |
Beling et al. [32] | 23 (12/11) | BT:79 ± 7 CG: 81 ± 5 | N/A | N/A | sSSB (sensory organization test, composite score) | BT: +20.3 % (↑); 0.96 | 0.55 | |
PB (TUG; time) | BT: −9.3 % (↑); 0.34 | 0.59 | ||||||
TB (BBS; score) | BT: +10.0 % (↑); 0.62 | 1.76 | ||||||
Bierbaum et al. [51] | 38 (13/25) | 69 ± 3 | N/A | 30–40 | RB (gait perturbation test; base of support, mean distance) | BT: +1.9 % (↑); 1.11 | −0.17 | |
Franco et al. [54] | 32 (7/25) | 78 ± 6 | N/A | N/A | TB (BBS; degree) | BT: +10.6 % (↑); 0.59 | 0.12 | |
Granacher et al. [44] | 40 (N/A) | BT: 66 ± 5 CG: 67 ± 4 | 4 | 20 | PB (FR; maximal reach distance) | BT: +8.5 % (↑); 0.80 | 1.00 | |
RB (perturbation on Posturomed; sway path) | BT: −60.7 % (↑); 2.19 | 2.08 | ||||||
dSSB (tandem walking; number of successful steps out of 10) | BT: +52.5 % (↑); 0.95 | 1.47 | ||||||
Granacher et al. [45] | 20 (6/14) | BT: 72 ± 5 CG: 75 ± 6 | 1/4 | 20 | dSSB (10-m walking test; stride time) | BT: 1.5 % (↑); 0.10 | 0.83 | |
Gusi et al. [33] | 40 (11/29) | 76 ± 8 | 2–3 | 10–40 | sSSB (20-s bipedal stance on Biodex Balance System; degree) | BT: −48.9 % (↑); 0.96 | 0.97 | |
Jacobson et al. [47] | 25 (N/A) | 63 ± 6 | N/A | 30–60 | PB (TUG; time) | BT: −25.1 % (↑); 0.76 | 1.33 | |
TB (BBS; score) | BT: +51.1 % (↑); 3.77 | 2.28 | ||||||
Judge et al. [46] | 110 (64/46) | BT: 79 ± 3 ST: 80 ± 4 BT+ ST: 80 ± 4 CG: 81 ± 5 | N/A | N/A | dSSB (8-m walking test; usual gait speed) | BT: −2.7 % (↓);−0.14 | −0.31 | |
Kronhed et al. [34] | 30 (14/16) | 73 ± 2 | N/A | N/A | sSSB (right leg stance with eyes opened; time to stand) | BT: −9.5 % (↓); 0.20 | 0.56 | |
dSSB (30-m walking test, usual gait speed) | BT: +11.3 % (↑); 1.13 | 0.12 | ||||||
Leiros-Rodriguez et al. [48] | 28 (0/28) | 69 ± 3 | 5–60 | 60 | PB (TUG; time) | BT: −39.0 % (↑); 3.30 | 3.49 | |
TB (BBS; score) | BT: 17.9 % (↑); 2.82 | 2.49 | ||||||
Maughan et al. [35] | 60 (24/36) | BT I: 72 ± 8 BT II: 74 ± 7 | N/A | N/A | sSSB (right leg stance with eyes opened; time to stand) | BT: +8.0 % (↑); 0.13 | −0.11 | |
dSSB (alternating stepping; time) | BT: −5.1 % (↑); 0.75 | −0.90 | ||||||
CG: 72 ± 8 | N/A | N/A | sSSB (right leg stance with eyes opened; time to stand) | BT: +40.0 % (↑); 0.67 | 0.37 | |||
dSSB (alternating stepping; time) | BT: −14.6 % (↑); 1.00 | −0.09 | ||||||
Melzer et al. [36] | 66 (17/49) | 77 ± 7 | N/A | N/A | sSSB (30-s bipedal stance with eyes opened; displacements) | BT: −17.2 % (↑); 0.68 | 1.55 | |
Nagai et al. [37] | 48 (6/42) | BT: 81 ± 7 CG: 82 ± 6 | 3 | >5 | sSSB (10-s bipedal stance with eyes opened; postural sway) | BT: −23.5 % (↑); 0.44 | 0.14 | |
PB (FR; maximal reach distance) | BT: +18.3 % (↑); 0.85 | 1.08 | ||||||
Pfeifer et al. [38] | 33 (4/29) | 78 ± 8 | N/A | N/A | sSSB (30-s bipedal stance with eyes opened; postural sway path) | BT: −1.3 % (↑); 0.09 | −0.45 | |
TB (BBS; score) | BT: +14.6 % (↑); 1.64 | 1.13 | ||||||
Piao et al. [39] | 30 (16/14) | BT: 68 ± 2 CG: 70 ± 4 | N/A | N/A | sSSB (30-s bipedal stance with eyes opened; CoP displacements) | BT: −3.5 % (↑); 0.49 | 0.96 | |
Rossi et al. [52] | 41 (0/41) | BT: 67 ± 2 CG: 68 ± 3 | 4 | 60 | RB (perturbation test; CoP displacements) | BT: −8.7 % (↑); 2.95 | 3.26 | |
Thiamwong et al. [49] | 104 (40/64) | 71 ± 8 | 1/20 | N/A | PB (FR; maximal reach distance) | BT: +13.0 % (↑); 1.07 | 1.03 | |
Weerdesteyn et al. [40] | 107 (23/84) | BT: 74 ± 6 CG: 75 ± 7 | N/A | N/A | sSSB (single leg stance with eyes opened; time to stand) | BT: +12.2 % (↑); 0.26 | 0.07 | |
Weerdesteyn et al. [53] | 95 | BT: 74 ± 6 CG: 75 ± 7 | N/A | N/A | RB (obstacle avoidance; time) | BT: −2.4 % (↑); 0.23 | 0.31 | |
Wolf et al. [41] | 72 (60/12) | BT: 78 ± 7 Tai Chi: 78 ± 6 CG: 75 ± 5 | N/A | 10–130 | sSSB (single leg stance with eyes opened; postural sway) | BT: −20.6 % (↑); 0.58 | −0.08 | |
0.72 | ||||||||
Wolfson et al. [42] | 110 (64/46) | 79 ± 5 | N/A | N/A | sSSB (single leg stance with eyes opened; time to stand on a narrow area) | BT: +36.1 % (↑); 1.63 | 3.19 | |
PB (maximal posterior and lateral inclination; inclination angle) | BT: +18.2 % (↑); 2.67 | 4.68 | ||||||
dSSB (8-m walking test, usual gait speed) | BT: +6.3 % (↑); 1.75 | 1.95 | ||||||
Yu et al. [43] | 30 (16/14) | BT: 68 ± 2 CG: 70 ± 4 | N/A | N/A | sSSB (30-s bipedal stance with eyes opened; CoP displacements) | BT: −4.4 % (↑); 0.38 | 0.42 |
3.2 Methodological Quality of the Included Trials
References | Eligi-bility criteria | Rando-mization | Concealed allocation | Similar group baselines | Blinding of all subjects | Blinding of all therapists | Blinding of all assessors | Dropout <15 % | Intention-to-treat method | Statistical between-group comparisons | Point measures and measures of variability | Score |
---|---|---|---|---|---|---|---|---|---|---|---|---|
Arampatzis et al. [50] | − | + | − | + | − | − | − | − | − | + | + | 4 |
Beling et al. [32] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Bierbaum et al. [51] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Franco et al. [54] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Granacher et al. [44] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Granacher et al. [45] | + | + | − | + | − | − | − | + | − | + | + | 5 |
Gusi et al. [33] | + | + | + | + | − | − | + | + | + | + | + | 8 |
Jacobson et al. [47] | − | + | − | + | − | − | − | − | − | + | + | 4 |
Judge et al. [46] | + | + | − | + | − | − | + | + | + | + | + | 7 |
Kronhed et al. [34] | + | + | − | − | − | − | − | + | − | + | + | 4 |
Leiros−Rodriguez et al. [48] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Maughan et al. [35] | + | + | − | + | − | − | − | + | + | + | + | 6 |
Melzer et al. [36] | + | + | + | + | − | − | + | + | + | + | + | 8 |
Nagai et al.[37] | + | + | − | + | − | − | − | − | + | + | + | 5 |
Pfeifer et al. [38] | + | + | − | − | − | − | − | − | − | + | + | 3 |
Piao et al. [39] | − | + | − | − | − | − | − | − | − | + | + | 3 |
Rossi et al. [52] | + | + | − | + | − | − | − | + | − | + | + | 5 |
Thiamwong et al. [49] | + | + | − | + | − | − | − | + | − | + | + | 5 |
Weerdesteyn et al. [40] | + | + | − | + | − | − | − | + | + | + | + | 6 |
Weerdesteyn et al. [53] | + | + | − | + | − | − | − | − | − | + | + | 4 |
Wolf et al. [41] | + | + | − | − | − | − | − | − | − | + | + | 3 |
Wolfson et al. [42] | + | + | − | + | − | − | + | + | − | + | + | 6 |
Yu et al. [43] | − | + | − | − | − | − | − | − | − | + | + | 3 |
3.3 Effectiveness of BT
3.4 Dose–response relationships
Training modalities | Results/most effective dose | ||
---|---|---|---|
Healthy older adults | Healthy young adults [17] | ||
Overall balance | Static steady-state balance | Static steady-state balance | |
Training period (weeks) | 11–12 | 11–12 | 11–12 |
Training frequency (times per week) | 3 | 3 | 3 |
Number of training sessions | 36–40 | 36–40 | 16–19; 36–39a
|
Duration of a single training session (min) | 31–45 | 31–45 | 11–15b
|
Total duration of BT per week (min) | 91–120 | 121–150 (only one study) | N/A |
Number of exercises per training session | N/A | N/A | 4 |
Number of sets/reps per exercise | N/A | N/A | 2/N/A |
Duration of a single balance exercise (s) | N/A | N/A | 21–40 |