Designing Balance Training Programs
The ACSM’s 2008 "Physical Activity Guidelines for Americans" suggests balance training at least 3 days a week for inactive and active older adults (\gte\65 yr). In a position statement on exercise for older adults (Chodzko-Zajko et al. 2009), the ACSM also recommended that older adults engage in balance activities at least two times week. Recently, the ACSM expanded its position statement to include not only balance but additional neuromotor skills - agility, gait, coordination, and proprioception (Garber et al. 2011). Neuromotor exercise training is specifically recommended for older adults who have poor mobility or who are at risk for falling. The ACSM (2014) recommends performing neuromotor exercises involving balance, agility, coordination, and gait at least 2 to 3 days/wk. Although the optimal duration and number of repetitions of these exercises is not known at this time, 20 to 30 min of neuromotor exercise per day is suggested.
Limited evidence exists to support definitive recommendations for younger and middle-aged adults with regard to the benefits of neuromotor training. For older clients with balance and mobility disorders, however, participating in a balance training program may be beneficial for increasing mobility, performing ADLs safely, and preventing falls (Garber 2011). Also, a review of balance training studies concluded that balance exercises are effective for reducing the risk of ankle sprains in athletes; 6 wk of balance training after an acute ankle sprain substantially reduces the risk of a recurrent sprain (McKeon and Hertel 2008). General recommendations for designing balance training programs are presented in the following:
Recommendations for Balance Training Programs (ACSM 2009b)
- Have clients engage in balance activities 2 or 3 days/wk.
- Progressively increase the difficulty of the balance exercises by using a narrower base of support such as two-leg stance, semitandem stance, tandem stance, and one-leg stance.
- Include dynamic movements that challenge the center of gravity such as tandem walking and circle turns.
- Displace the center of mass by stepping over obstacles and balancing on a rocker platform.
- Use exercises that stress postural muscles, such as heel stands and toe stands, and exercises that reduce visual or sensory input, such as standing with eyes closed or standing on a foam pad.
- Prescribe multifaceted activities such as tai chi and yoga.
Balance Training Exercise Prescription
Compared to the other physical fitness components, there is a lack of research dealing with balance training for athletes, children, and middle-aged and older adults. It is difficult to compare studies examining the effects of exercise on balance because of diversity in the populations (e.g., young athletes to frail older adults), as well as the lack of standardization in balance outcome measures and training regimens. Also, there is no gold standard measure of balance. The following questions address issues you should consider when prescribing balance training for your clients.
What types of physical activities may be used to improve balance?
Given that balance performance is affected by muscle strength, power, and flexibility, resistance training and stretching programs may be useful for maintaining and improving balance. In addition to increasing strength and range of motion, Pilates, yoga, tai chi, dance, walking, and combinations of exercise modes may be suitable activities for improving balance. Balance discs, foam pads and rollers, balance boards, stability balls, and computerized balance training systems are tools that may add variety and challenge to balance training programs.
In a review of exercise interventions to improve balance, Howe and colleagues (2007) analyzed results from 34 studies, with a total of 2883 participants. Recently, this review was updated and expanded to include 60 additional studies involving 7000 more participants (Howe et al. 2011). The researchers categorized the training interventions as follows: gait, balance, coordination, and functional tasks training; resistance training for strength and power; three-dimensional exercise including tai chi, yoga, dance, and qigong; general physical activity (walking or cycling); and computerized balance training, vibration platform training, and multimodal physical activity programs that used a combination of exercise modes. Table 12.5 summarizes the positive effects for some of these interventions on direct and indirect measures of balance. Evidence was insufficient to conclude that computerized balance training or vibration plate training improves balance.
What types of balance training activities can be used with older adults?
In addition to flexibility and resistance training, exercise programs that specifically improve the functional ability of the lower extremities may be effective for improving balance and preventing falls in older adults. Shigematsu and colleagues (2008) compared the effects of regular walking and square-stepping exercise on balance, leg power, agility, and reaction time of adults 65 to 74 yr. The participants exercised for 70 min, 2 times per week, for 12 wk. The square-stepping exercise program included forward, backward, lateral, and oblique stepping patterns performed on a felt mat (100 \x\ 250 cm) that was partitioned into 40 squares, 25 cm each. Each stepping pattern was repeated 4 to 10 times, and the patterns became progressively more complex, ranging from elementary forward-backward stepping to advanced lateral, oblique, and anterior-posterior patterns of stepping. Compared to the walking program, square-stepping exercise produced significantly greater improvements in leg extension power, forward-backward tandem walking, stepping with both feet, walking around two cones, and reaction time. Preliminary results suggest that square-stepping exercise is more effective than regular walking in reducing risk factors associated with falling.
In another study, proprioceptive balance training involved bilateral dorsiflexion/plantar flexion and supination/pronation of the ankle and bilateral squats during standing on semicompressible foam roller devices (Bellew et al. 2005). These devices are approximately 13 \x\ 6 in. (33 \x\ 15 cm) and resemble a football cut lengthwise. During each exercise session, subjects performed two 2 min bouts of bilateral supination/pronation and two 2 min bouts of bilateral plantar flexion/dorsiflexion. Each 2 min set of bilateral movements of the ankle was followed by partial squats (one set of 10 reps). This balance training protocol was performed 2 days/wk for 5 wk.
Compared to a sedentary control group, the training group showed significant improvements in functional reach test (25%) and a lower extremity reach test (16%).
Takeshima and associates (2007) compared the effects of aerobic, resistance, balance, flexibility, and tai chi training on the functional fitness of older adults. Exercise programs were performed for 12 wk, 2 days/wk, for each exercise training mode except for the aerobic training (3 days/wk for 90 min). While resistance training elicited the greatest improvement (31%) in upper body strength, balance training produced the greatest increase in lower body strength (40%). Resistance training, tai chi, and balance training each produced similar gains in balance and agility (10%).
Hill and colleagues (2007) examined the effects of physical activity that combined yoga, tai chi, and resistance training. At the end of this 6 mo program, strength, balance, and gait endurance of older adults were significantly improved. Those who attended classes 2 days/wk improved more than those averaging only once per week.
Does resistance training improve balance?
Improved balance is often mentioned as one of the benefits of resistance training. Muscle weakness is one intrinsic factor related to balance disorders and risk of falling. Reduced muscle strength, especially in the lower extremities, affects one’s ability to perform ADLs such as stair climbing or standing from a seated position. Orr and colleagues (2008) published the first systematic review of studies that assessed the effect of progressive resistance exercise training on balance of older adults. They noted that only a small percentage of balance outcome measures were significantly improved due to resistance training: static balance (26%), dynamic balance (14%), functional balance (57%), and computerized dynamic posturography (8%). Thus, resistance training as an isolated intervention does not consistently improve balance of older adults. Part of the discrepancy in results may be a function of the fact that in many of these studies, the researchers selected universal whole-body and lower body strength exercises for the resistance training programs instead of identifying key muscles used for balance. Also, machine-based resistance training may not be as effective as free-weight training for improving balance.
These results also suggest that strength alone is not the major underlying mechanism for poor balance. Muscle power (force \x\ velocity) may also be a limiting factor in balance control. Age-related decreases in neural processing may diminish the ability to develop force rapidly in response to postural challenges (Orr et al. 2008). In fact, power declines more rapidly than strength with advancing age (Granacher et al. 2012). Mayson and colleagues (2008) reported that leg press velocity was positively related to dynamic balance performance (i.e., Berg Balance Scale, POMA, and dynamic gait index), whereas greater leg strength was associated with better performance on static balance tests (e.g., unipedal stance test). In older men, power training with low loads (20% 1-RM) induced larger improvements in balance performance compared to moderate (50% 1-RM) or heavy (80% 1-RM) loads (Orr et al. 2006). More research is needed to determine the most effective resistance training loads, modes, and volume for improving balance.
In future studies addressing the use of progressive resistance training, it may be prudent to focus on the type of balance to be developed (i.e., static, dynamic, or functional), as well as specific muscle groups critical for balance such as the ankle dorsiflexors and plantar flexors, the knee extensors and flexors, and the hip abductors and adductors. Hess and Woollacott (2005) reported that a high-intensity strength training program targeting key lower extremity muscle groups (i.e., knee flexors and extensors and ankle plantar flexors and dorsiflexors) significantly improved the postural control in balance-impaired older adults.
Does balance training reduce the risk of ankle sprains?
Research demonstrates that balance training using balance boards, elastic tubing, ankle discs, and foam pads may reduce the risk of ankle injury and reinjury in physically active individuals (Han et al. 2009; Hoffman and Payne 1995; Verhagen et al. 2004). These programs use a combination of strengthening and coordination exercises to rehabilitate injured ankles and to improve balance. Han and colleagues (2009) reported that dynamic balance of healthy young adults with and without a history of ankle sprains was improved following a 4 wk elastic tubing exercise program with lower body resistance exercises performed in four directions (i.e., front pull, back pull, crossover, and reverse crossover). For this program, participants performed three sets of 15 repetitions, three times per week. Improvement in balance performance was retained up to 4 wk posttraining, suggesting that this form of balance training may improve ankle stability.
How effective is tai chi for improving balance and preventing falls in older adults?
Over the past few decades, tai chi has increased in popularity. Between 1992 and 2001, 11 randomized clinical trials were published in the tai chi literature, compared to 31 published from 2002 to 2007 (Li et al. 2009). The National Institute on Aging sponsored two studies on tai chi for older adults (Wolf et al. 1996; Wolfson et al. 1996). In the first study, the effects of tai chi on strength, flexibility, cardiorespiratory endurance, body composition, functional ability, and occurrence of falls were examined. Tai chi reduced falls and had a favorable impact on components of fitness and functional ability. The second study demonstrated that improvements in balance (measured by one-leg stance, limits of stability, sensory organization tests) and lower body strength resulting from a 3 mo balance training intervention could be sustained by participation in a low-intensity maintenance program of tai chi for 6 mo after the intervention (Wolfson et al. 1996).
Li and colleagues (2005) studied the effects of a 6 mo tai chi program (three times per week) on balance and number of falls in older men and women 70 to 92 yr. Compared to results for a control group that participated in a stretching program, the risk of multiple falls was 55% lower for the tai chi intervention. Tai chi participants showed significant improvements in all measures of balance including the Berg Balance Scale, Dynamic Gait Index, functional reach, and one-leg stance. Studies suggest that tai chi is an effective form of exercise for reducing falls and improving dynamic and functional balance performance of older adults (Kuramoto 2006; Maciaszek et al. 2007; Rogers, Larkey, and Keller 2009).
Wu (2002) reported that tai chi interventions improved one-leg stance with eyes open and Romberg test scores in 20 to 60 yr and older (>75 yr) adults. Tai chi training had only a limited effect on walking and timed get up and go scores.
What is the optimal style of tai chi for improving balance?
Tai chi is practiced in a variety of styles, for example Yang, Wu, and Tai Chi Chih. Each style has its own movements and traditional length of practice. The Yang style uses a wide stance and steady, slow speed of movement with constant knee flexion. Shifting body weight in this stance demands strength and flexibility. In contrast, the Wu style uses higher stances with a narrower stance width and slower movements, requiring more balance than strength compared to other styles. Therefore, the Wu style of tai chi may be more appropriate for balance training programs and interventions (Wu 2002).
How many tai chi sessions are needed to show improvement in balance?
The research clearly shows that the number of tai chi sessions makes a difference in terms of training effects on balance. Generally, 40 or more sessions are needed to show significant improvements in balance performance. To reduce risk of falls, tai chi training programs should last at least 15 wk. Due to age-related declines in physical abilities, the duration and frequency of tai chi programs for older adults may need to be increased to derive the degree of improvement seen in younger adults.
Is yoga an effective exercise mode for improving balance?
Despite the popularity of yoga, there are a limited number of randomized control studies assessing the effects of yoga on physical fitness and motor performance. Oken and colleagues (2006) reported that a 26 wk Hatha yoga intervention produced significant improvements in the timed one-leg stand with eyes open and chair sit-and-reach test scores of healthy older men and women 65 to 85 yr. The yoga training consisted of one 90 min session per week with unsupervised home practice during the week. During the training, participants were taught 18 poses; during the exercise sessions, 7 or 8 poses were held for 20 to 30 sec each.
Balance Training Programs
Balance training has been widely used in sports rehabilitation (injuries to ankle and knee joints) and in fall prevention programs for geriatric populations. Traditionally, these programs typically include static and dynamic exercises with eyes open and closed on stable and unstable surfaces. Although the training intensity, frequency, and volume varies greatly among studies using this approach, the results generally support the use of traditional balance training for inducing short- and long-term improvements in balance and postural control (Granacher et al. 2011). Recently, perturbation-based balance training has been promoted to reduce risk of falling, given that slipping and tripping account for 30% to 50% of falls in older adults. Using this approach, perturbation exercises that mimic real-life conditions are included.
Compared to the traditional approach, perturbation-based training appears to be more beneficial for improving reactive balance (i.e., recovery of equilibrium), demonstrating that the specificity principle also applies to balance training (Granacher et al. 2011).
In light of the complex nature of balance and the paucity of research studies dealing with balance assessment and training, it is not possible at this time to make firm recommendations for prescribing a balance training program for your clients. Use the general guidelines presented in this section as a starting point. Individualize programs to take into account your client’s needs, goals, age, and physical activity status. Keep in mind that balance training is task specific. Task-specific exercises that target a single, specific balance or gait impairment are more effective than generalized exercise for improving balance. Techniques from a variety of exercise modalities can be combined to form a comprehensive balance program that challenges your client. The "Sample Progressive Balance Program" illustrates how seated, standing, and movement balance activities may be adapted to increase the exercise challenge for further improvements in balance. In the "Sample Multimodal Program," exercises from tai chi, Pilates, agility training, and lunges are used to improve balance and mobility of an older adult.
Many excellent resources are available for designing an individualized balance training program for your clients. ABLE Bodies Balance Training (see Scott 2008) presents a 16 wk exercise program that safely takes older adults through the exercise progressions for improving balance and mobility, flexibility, posture and core stability, strength, and cardiorespiratory endurance. Resources for developing safe exercise programs for improving balance and functional fitness of older adults are available (see Rose 2003; Scott 2008). For ideas about incorporating Pilates and yoga workouts into balance training programs, see Isacowitz (2006) and Shaw (2009).
Sample Multimodal Balance Training Program
Age: 65 yr
Body weight: 145 lb
Program goal: Improve static and dynamic balance; prevent falls
Method: Tai chi, Pilates, lunges, and agility training
Frequency: 3 or more days/wk
Duration: 45 to 60 min per session
Guidelines for Designing Balance Training Programs for Older Adults (Granacher 2011)
- Mode: Tai chi; Pilates; yoga; static, dynamic, and reactive balance training exercises; resistance training for strength and power; or a combination of modes
- Equipment: Balance discs, foam pads and rollers, balance boards, stability balls, computerized balance systems, and force platforms to add variety and challenge to the program
- Frequency: Minimum of 2 days/wk
- Sets and Duration: 3 - 8 sets; 20 - 40 sec each set
- Time: 20 - 30 min per session; 2 hr/wk
- Length of program: 3 to 6 mo depending on exercise mode