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Evidence Supporting Balance Training in Healthy Individuals: Asystemic Review

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Evidence Supporting Balance Training in Healthy Individuals: Asystemic Review BRIEF REVIEW EVIDENCE SUPPORTING BALANCE TRAINING IN HEALTHY INDIVIDUALS: ASYSTEMIC REVIEW 1 2 3 LINDSAY J. DISTEFANO, MICHEAL A. CLARK, AND DARIN A. PADUA 1Department of Kinesiology, University of Connecticut, Storrs, Connecticut; 2National Academy of Sports Medicine, Calabasas, California; and 3Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina ABSTRACT INTRODUCTION DiStefano, LJ, Clark, MA, and Padua, DA. Evidence supporting oor balance, or postural control, is associated balance training in healthy individuals: a brief review. J Strength with injury or falls in many populations and conse- Cond Res 23(9): 2718–2731, 2009—Balance is considered quently is considered to be a critical component of a risk factor for several injuries and consequently a focus of P common motor skills (2,8,18). Balance is generally defined as the ability to maintain the body’s center of gravity many strengthening, injury prevention, and rehabilitation pro- within its base of support and can be categorized by either grams. There are several studies that have evaluated the static or dynamic balance. Static balance is the ability to ability of balance training to improve balance ability in a healthy sustain the body in static equilibrium or within its base of population with no general consensus. We conducted support (10,24). Dynamic balance is believed to be more a systematic review to evaluate the body of evidence regarding challenging because it requires the ability to maintain the effectiveness of balance training on improving various equilibrium during a transition from a dynamic to a static forms of balance ability in a healthy population. Three electronic state (29). Both static and dynamic balance require effective databases and the reference lists of selected articles were integration of visual, vestibular, and proprioceptive inputs searched. Studies were included that evaluated balance to produce an efferent response to control the body within its ability before and after healthy subjects performed a multi- base of support (11,14). An interruption or deficit in any part session balance training program. Two individuals reviewed all of the sensorimotor system can result in a loss of balance, articles and agreed upon the selection criteria. Sixteen articles which can result in injury. Specifically, poor balance may result in lateral ankle sprains (18) and can explain differences were selected, abstracted, and reviewed. Means and measures between individuals with and without functional ankle of variability were recorded to calculate effect sizes, and study instability (29,30,36). Therefore, improving balance is a quality was assessed using the PEDro instrument. There is critical and frequent objective of rehabilitation and injury strong evidence to suggest that balance training can improve prevention programs. static balance ability on stable and unstable surfaces, as well Improving balance with training in a healthy population as dynamic balance ability. Elite athletes have the potential to has positive effects with reducing injury. Balance training has improve static balance on an unstable surface and dynamic decreased the rates of ankle sprains (19,34), as well as overall balance ability, but a ceiling effect appears to occur with stable lower extremity injury rates (25) in several types of athletes. balance ability on a stable surface. Balance training programs The balance training programs used in these studies vary performed at least 10 minutes per day, 3 days per week, for between using a simple ankle disc to including a balance com- 4 weeks that incorporate various methods of balance training ponent in a multifaceted exercise program that consists of appear to improve balance ability. Types of balance training strengthening, agility, plyometric, and balance exercises. included the use of tilt boards, unstable surfaces, and dynamic Despite this evidence suggesting that balance training de- body movements while maintaining a static stance. creases injuries, it is unknown if improvements in injury rates are actually associated with improvements in balance ability. KEY WORDS postural control, dynamic stabilization, injury There are several studies that have evaluated the effects of prevention balance training on static and dynamic balance abilities, but to our knowledge, there is no clear consensus available from this body of literature to help clinicians and fitness professionals Address correspondence to Darin A. Padua, [email protected]. make clinical decisions. Furthermore, the studies that exist 23(9)/2718–2731 have used a variety of different training methods, durations, Journal of Strength and Conditioning Research and outcome measures. This wide range of information can be Ó 2009 National Strength and Conditioning Association confusing for a clinician and needs to be consolidated to 2718 Journalthe of Strength and Conditioning ResearchTM the TM Journal of Strength and Conditioning Research | www.nsca-jscr.org provide clinicians with simple evidence-based guidelines to the reference lists from the 14 selected articles for any use with the design of a balance training program. Clinicians additional studies that met our criteria and selected 2 final and fitness professionals need to understand if there is articles giving us a total of 16 articles to review. sufficient evidence to support the use of balance training to We extracted specific details from each of the 16 articles to improve balance ability and if there are specific variables evaluate the body of literature on the ability of balance within a balance training program that influence the effects of training programs to improve balance in a healthy population. the program. Therefore, the purpose of this study was to Each of the 16 articles was reviewed and abstracted for this conduct a systematic review to determine if balance training information including the type and duration of the balance actually improves balance in a healthy population and training, whether or not the program was progressive evaluate the effects of the program variables. We specifically (exercise intensity increased or type of balance activity aimed to answer the following 3 questions: (a) Can balance changed in difficulty over time), and the population studied training improve static balance ability on a stable surface? (b) (Table 2). The data were extracted by one author and verified Can balance training improve static balance ability on an by the second author. unstable surface? and (c) Can balance training improve dynamic balance ability? Statistical Analyses We used the PEDro scale to evaluate the quality of each METHODS study’s design and methods. The PEDro scale is a reliable measurement tool that evaluates 11 specific items about study Experimental Approach to the Problem quality (17). These items assess some of the following issues: To address the 3 primary research questions of this systematic blinding, subject eligibility criteria, concealment of allocation, review, we searched the existing body of literature to select randomization, reporting measures of variability, and attri- articles that matched specific criteria and then critically tion. The scale ranges from zero to 10 points with the highest evaluated and compared these articles to reach consensus score indicating excellent design and methods quality. All 16 statements for each of the 3 objectives. We performed an articles were scored using the PEDro scale by both authors electronic literature search of the PubMed (maintained by the who were blinded to the other’s scores. The authors resolved National Library of Medicine), CINAHL, and SPORTDiscus any discrepancy in score through discussion and came to databases for articles matching our criteria between January a conclusion on a PEDro score for every study (Table 2). We 1988 and January 2008. The databases were searched using also calculated effect sizes from means and SDs, when variations of the terms listed in Table 1. A total of 310, 202, available, before and after the balance training programs and 270 articles were selected from PubMed, CINAHL, and (Tables 3–5). Effect sizes greater than 0.7 were considered SPORTDiscus, respectively, and their titles and abstracts strong, between 0.41 and 0.7 were moderate, and weak effect were reviewed to determine if they matched our selection sizes were less than 0.4 (3). criteria. Procedures RESULTS The selection criteria required the studies to be in English and Overall, the primary method of balance training in the 16 to primarily evaluate the effects of a balance training program articles meeting the inclusion criteria incorporated the use in modifying a balance outcome in healthy subjects. Nine of tilt boards (1,6,12,13,16,33) or other unstable surfaces articles from PubMed matched our criteria and were (4,7,9,28,31,32). For the purposes of this review, tilt boards reviewed. The CINAHL database search resulted in 4 will be inclusive of ankle discs, tilt boards, and wobble additional articles for review, and 1 additional article from boards because they all require individuals to move the board SPORTDiscus was reviewed. Finally, we manually reviewed in specified directions while balancing. The tilt boards are different from unstable surfaces because unstable surface training requires subjects to maintain a static stance while standing on an unstable surface compared with moving TABLE 1. Search terms used for literature review. the surface while balancing. Other methods of balance
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