Exercise for improving balance in older people

Balance is staying upright and steady when stationary, such as when standing or sitting, or during movement. The loss of ability to balance may be linked with a higher risk of falling, increased dependency, illness and sometimes early death. However, it is unclear which types of exercise are best at improving balance in older people (aged 60 years and over) living at home or in residential care. 

This updated review includes 94 (62 new to this update) randomised controlled trials involving 9821 participants. Most participants were women living in their own home. Some studies included frail people residing in hospital or residential facilities.

Many of the trials had flawed or poorly described methods that meant that their findings could be biased. Most studies only reported outcome up to the end of the exercise programme. Thus they did not check to see if there were any lasting effects.

We chose to report on measures of balance that relate to everyday activities such as time taken to stand up, walk three metres, turn and return to sitting (Timed Up & Go test); ability to stand on one leg (necessary for safe walking in well lit and dark conditions), walking speed (better balance allows faster walking), and activities of daily living (Berg Balance Scale, comprising 14 items). These were our primary outcomes.

There were eight categories of exercise programmes. These are listed below together with those measures of balance for which there was some evidence of a positive (statistically significant) effect from the specific type of exercise at the end of the exercise programme. Some trials tested more than one type of exercise. It is important to note that the evidence for each outcome was generally from only a few of the trials for each exercise category.

1. Gait, balance, co-ordination and functional tasks (19 studies of which 10 provided data for one or more primary outcomes). Positive effects of exercise were found for the Timed Up & Go test, walking speed, and the Berg Balance Scale.

2. Strengthening exercise (including resistance or power training) (21 studies of which 11 provided data for one or more primary outcomes). Positive effects were found for the Timed Up & Go Test; standing on one leg for as long as possible with eyes closed; and walking speed.

3. 3D (3 dimensional) exercise (including Tai Chi, qi gong, dance, yoga) (15 studies of which seven provided data for one or more primary outcomes). Positive effects were found for the Timed Up & Go Test; standing on one leg for as long as possible with eyes open, and with eyes closed; and the Berg Balance Scale.

4. General physical activity (walking) (seven studies of which five provided data for one or more primary outcomes).

5. General physical activity (cycling) (one study which provided data for walking speed).

6. Computerised balance training using visual feedback (two studies, neither of which provided data for any primary outcome).

7. Vibration platform used as intervention (three studies of which one provided data for the Timed Up & Go Test).

8. Multiple exercise types (combinations of the above) (43 studies of which 29 provided data for one or more primary outcomes). Positive effects were found for the Timed Up & Go Test; standing on one leg for as long as possible with eyes open, and with eyes closed; and the Berg Balance Scale.

In general, effective programmes ran three times a week for three months and involved dynamic exercise in standing. Few adverse events were reported.

The review concluded that there was weak evidence that some exercise types are moderately effective, immediately post intervention, in improving balance in older people. However, the missing data and compromised methods of many included trials meant that further high quality research is required.

Authors' conclusions: 

There is weak evidence that some types of exercise (gait, balance, co-ordination and functional tasks; strengthening exercise; 3D exercise and multiple exercise types) are moderately effective, immediately post intervention, in improving clinical balance outcomes in older people. Such interventions are probably safe. There is either no or insufficient evidence to draw any conclusions for general physical activity (walking or cycling) and exercise involving computerised balance programmes or vibration plates. Further high methodological quality research using core outcome measures and adequate surveillance is required.

Read the full abstract...
Background: 

In older adults, diminished balance is associated with reduced physical functioning and an increased risk of falling. This is an update of a Cochrane review first published in 2007.

Objectives: 

To examine the effects of exercise interventions on balance in older people, aged 60 and over, living in the community or in institutional care.

Search strategy: 

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register, CENTRAL (The Cochrane Library 2011, Issue 1), MEDLINE and EMBASE (to February 2011).

Selection criteria: 

Randomised controlled studies testing the effects of exercise interventions on balance in older people. The primary outcomes of the review were clinical measures of balance.

Data collection and analysis: 

Pairs of review authors independently assessed risk of bias and extracted data from studies. Data were pooled where appropriate.

Main results: 

This update included 94 studies (62 new) with 9,821 participants. Most participants were women living in their own home.

Most trials were judged at unclear risk of selection bias, generally reflecting inadequate reporting of the randomisation methods, but at high risk of performance bias relating to lack of participant blinding, which is largely unavoidable for these trials. Most studies only reported outcome up to the end of the exercise programme.

There were eight categories of exercise programmes. These are listed below together with primary measures of balance for which there was some evidence of a statistically significant effect at the end of the exercise programme. Some trials tested more than one type of exercise. Crucially, the evidence for each outcome was generally from only a few of the trials for each exercise category.

1. Gait, balance, co-ordination and functional tasks (19 studies of which 10 provided primary outcome data): Timed Up & Go test (mean difference (MD) -0.82 s; 95% CI -1.56 to -0.08 s, 114 participants, 4 studies); walking speed (standardised mean difference (SMD) 0.43; 95% CI 0.11 to 0.75, 156 participants, 4 studies), and the Berg Balance Scale (MD 3.48 points; 95% CI 2.01 to 4.95 points, 145 participants, 4 studies).

2. Strengthening exercise (including resistance or power training) (21 studies of which 11 provided primary outcome data): Timed Up & Go Test (MD -4.30 s; 95% CI -7.60 to -1.00 s, 71 participants, 3 studies); standing on one leg for as long as possible with eyes closed (MD 1.64 s; 95% CI 0.97 to 2.31 s, 120 participants, 3 studies); and walking speed (SMD 0.25; 95% CI 0.05 to 0.46, 375 participants, 8 studies).

3. 3D (3 dimensional) exercise (including Tai Chi, qi gong, dance, yoga) (15 studies of which seven provided primary outcome data): Timed Up & Go Test (MD -1.30 s; 95% CI -2.40 to -0.20 s, 44 participants, 1 study); standing on one leg for as long as possible with eyes open (MD 9.60 s; 95% CI 6.64 to 12.56 s, 47 participants, 1 study), and with eyes closed (MD 2.21 s; 95% CI 0.69 to 3.73 s, 48 participants, 1 study); and the Berg Balance Scale (MD 1.06 points; 95% CI 0.37 to 1.76 points, 150 participants, 2 studies).

4. General physical activity (walking) (seven studies of which five provided primary outcome data).

5. General physical activity (cycling) (one study which provided data for walking speed).

6. Computerised balance training using visual feedback (two studies, neither of which provided primary outcome data).

7. Vibration platform used as intervention (three studies of which one provided primary outcome data).

8. Multiple exercise types (combinations of the above) (43 studies of which 29 provided data for one or more primary outcomes): Timed Up & Go Test (MD -1.63 s; 95% CI -2.28 to -0.98 s, 635 participants, 12 studies); standing on one leg for as long as possible with eyes open (MD 5.03 s; 95% CI 1.19 to 8.87 s, 545 participants, 9 studies), and with eyes closed ((MD 1.60 s; 95% CI -0.01 to 3.20 s, 176 participants, 2 studies); and the Berg Balance Scale ((MD 1.84 points; 95% CI 0.71 to 2.97 points, 80 participants, 2 studies).

Few adverse events were reported but most studies did not monitor or report adverse events.

In general, the more effective programmes ran three times a week for three months and involved dynamic exercise in standing.

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