Journal of Aging and Physical Activity, 2012, 20, 442-1

© 2012 Human Kinetics, Inc. Official Journal of ICAPA

www.JAPA-Journal.com
ORIGINAL RESEARCH

The Dose-Response Relationship

of Balance Training
in Physically Active Older Adults
Kristen K. Maughan, Kristin A. Lowry,
Warren D. Franke, and Ann L. Smiley-Oyen

A 6-wk group balance-training program was conducted with physically active

older adults (based on American College of Sports Medicine requirements) to
investigate the effect of dose-related static and dynamic balance-specific training.
All participants, age 60–87 yr, continued their regular exercise program while
adding balance training in 1 of 3 doses: three 20-min sessions/wk (n = 20), one
20-min session/wk (n = 21), or no balance training (n = 19). Static balance (single-
leg-stance, tandem), dynamic balance (alternate stepping, limits of stability),
and balance confidence (ABC) were assessed pre- and posttraining. Significant
interactions were observed for time in single-leg stance, excursion in limits of
stability, and balance confidence, with the greatest increase observed in the group
that completed 3 training sessions/wk. The results demonstrate a dose-response
relationship indicating that those who are already physically active can improve
balance performance with the addition of balance-specific training.

Keywords: elderly, exercise prescription, one-leg standing, limits of stability

In 2007, the American College of Sports Medicine (ACSM) and the American
Heart Association (AHA) issued a statement on physical activity and public health
in older adults (Nelson et al., 2007). Along with specific recommendations for older
adults to engage in regular aerobic activity and strength training, balance training
was recommended for community-dwelling older adults at substantial risk of falls.
One question that emerges from these guidelines is whether balance training
is beneficial for older adults who are already participating in a regular program of
physical activity and are not at substantial risk for falls. Considerable evidence sug-
gests that regular physical activity in older adults has a positive impact on balance,
mobility, and the reduction of falls (Barnett, Smith, Lord, Williams, & Baumand,
2003; Bird, Hill, Ball, & Williams, 2009; Federici, Bellagamba, & Rocchi, 2005;
Gillespie et al., 2009; Lord et al., 2003; Perrin, Gauchard, Perrot, & Jeandel, 1999;
Province et al., 1995). Specific types of physical activity may further enhance bal-

The authors are with the Dept. of Kinesiology, Iowa State University, Ames, IA.

442
 Balance Training in Physically Active Older Adults   443

ance. These include proprioceptive activities such as Tai Chi and yoga (Cromwell,
Meyers, Meyers, & Newton, 2007; Federici et al., 2005; Gatts &Woollacott, 2006;
Gauchard, Gangloff, Jeandel, & Perrin, 2003; Gauchard, Jeandel, Tessier, & Perrin,
1999; Gillespie et al., 2009; Li et al., 2005; Province et al., 1995; Schmid, Van
Puymbroeck, & Koceja, 2010; Wolf et al., 1996) and balance-specific programs
that include such activities as standing on one leg, standing with eyes closed, and
standing or moving on unstable surfaces (Islam et al., 2004; Province et al., 1995;
Sakamoto et al., 2006; Toulotte, Thevenon, & Fabre, 2006).
Clinical balance trials in adults have been conducted over a wide range of
physical-performance capacities from frail, institutionalized adults (Sakamoto et al.,
2006) to independent, community-dwelling adults (Cromwell et al.,2007; Fu, Choy,
& Nitz, 2009; Islam et al., 2004; Li et al., 2005; Robitaille et al., 2005; Toulotte et
al., 2006). Although independent, community-dwelling adults are one subgroup of
the older adult population, there is a wide range of physical activity levels in this
group. This is reflected by the variability of pretrial physical activity levels among
subjects in different studies, from sedentary (Li et al., 2005), to variable (Robitaille
et al., 2005; Toulotte et al., 2006), to unknown or at least not reported (Cromwell
et al., 2007; Islam et al., 2004). Therefore, it is unclear whether older adults who
are already meeting current ACSM/AHA physical activity guidelines would derive
additional benefits from balance training.
A second question arising from the ACSM/AHA guidelines relates to exercise
prescription and addresses how often and how much balance training is needed to
observe a change in balance. The guidelines suggest frequency and duration for
both cardiovascular and resistance training, but there are no guidelines for either
the frequency or the duration of balance training. Previous investigations have used
varying frequency and duration of training, with extremes being 6 min of one-leg
standing per day for high-risk older adults (Sakamoto et al., 2006) to 90 min/day,
5 days/week (Gatts &Woollacott, 2006), both resulting in positive outcomes, but
none have compared varying doses in the same study.
In light of these questions, the purpose of this study was to examine improve-
ment in static and dynamic balance in physically active older adults given dose-
related practice. We hypothesized that physically active older adults would improve
in balance after a 6-week balance-training program and there would be a dose-
response relationship between the frequency of balance training and the level of
improvement in balance control.

Methods
Overall Design
This was a quasi-randomized control intervention, with the intervention being 6
weeks of group balance training that progressively increased in difficulty. There
were three groups: one that received 20 min of balance training three times per week,
one that received 20 min of balance training one time per week (same training, just
less frequently), and a control group that did not receive any balance training. All
participants were physically active and continued their regular physical activity
regimen throughout the study.
 444  Maughan et al.

Participants
Healthy, physically active, community-dwelling adults were recruited from two local
exercise facilities. To qualify for inclusion in the study, volunteers had to be 60 years
of age or older and be physically active based on self-report, that is, participating
in aerobic physical activity 3 days/week for at least 30 min and strength-training
exercises at least 2 days/week (based on ACSM exercise guidelines). Exclusion
criteria included known neurological problems, unstable cardiopulmonary condi-
tions, uncontrolled high or low blood pressure, use of lower limb orthotics or
walking aids, significant problems with joints or muscles that affected mobility, or
recent (within 6 months) lower body bone fracture or total knee or hip replacement.
Sixty-three people volunteered to participate in the study. Of those, 2 did not
meet the inclusion criteria; therefore, 61 people completed preintervention balance
testing. They were grouped by age (60–69, 70–79, and 80–89) and then randomly
numbered by 3s so that we had similar age variation between groups. Husbands and
wives were assigned as one so that they could participate as a couple. After initial
randomization, some adjustment was made so that groups were not statistically
different in baseline values. One-way ANOVAs were conducted to determine if
there were group differences (p < .05) in age, body-mass index, and pretest scores
on left-leg single-leg-stance and alternate stepping (see Table 1 for means and
standard deviations). One person in the 3-day intervention group discontinued
participation in the study during Week 2 for health reasons.
Twelve or thirteen participants in each of the three groups reported having been
physically active for 5 or more years. One participant in the control group and 2
in the 3-day intervention group had been active for only 2 years. Two participants
in the 1-day intervention group had been active for 6 months, 1 for 1 year, and
3 for 2 years. Most of our participants had not experienced falls in the previous
year. The following are those who did: In the 3-day group 6 reported one fall, 2
reported two falls, and 1 reported four falls; in the 1-day group 5 reported one fall;
in the control group 2 reported one fall, 1 reported two falls, and 1 reported four
falls. The participants were interviewed during the posttest session to determine if
their exercise activity had changed since pretest. One person in the control group
reported adding yoga to the exercise protocol; some participants reported increased
physical activity, and some decreased, but there was no systematic pattern across
groups, and all participants continued to meet the ACSM minimum physical activ-
ity inclusion criteria.

Table 1  Baseline Characteristics for Each Group

Control, n = 19 1-day, n = 21 3-day, n = 20 pa
Age, years, M (SD) 71.7 (7.7) 72.3 (7.7) 74.4 (6.8) .51
Men, n (%) 7 (37%) 8 (38%) 9 (45%)
Women, n 12 13 11
Body-mass index, M (SD) 25.9 (3.9) 27.2 (3.9) 25.5 (2.7) .31
Single-leg stance, s, M (SD) 24.9 (18) 20.9 (15) 19.5 (14) .55
Alternate stepping, s, M (SD) 7.4 (1.1) 7.9 (1.8) 8.2 (1.6) .42
ap values refer to the one-way ANOVAs conducted to examine pretest differences between groups.
 Balance Training in Physically Active Older Adults   445

All procedures were reviewed and approved by the institutional review board
of the university. All participants signed an informed consent and completed a
medical-history form before the start of the study.

Intervention
We developed a progressive balance-training program using components of
evidence-based protocols including the Fall Proof program developed by Rose
(2003) and the Tai Chi for Arthritis program developed by Lam (2004). Six sessions
were developed for group participation focusing on static and dynamic balance and
mobility in both single- and dual-task conditions (see Table 2). The same instructor
led all balance-training sessions. During each week of training, a new, progressively
more challenging 20-min session was presented. The 3-day intervention group
(referred to as 3-day) repeated the same session 3 days/week for a total of 60 min/
week. The 1-day intervention group (referred to as 1-day) participated in the same
balance sessions but only attended once per week for a total of 20 min, and this one
session was identical to the session in which the 3-day group engaged. Thus, the
intervention groups experienced the same balance exercises, but in varying doses.
The control group did not participate in any additional balance training.

Table 2  Six-Week Balance-Training Program

Week Activities included
1 Tai Chi for Arthritis (5 min); single-leg stance with eyes open/eyes closed/on foam;
tandem stance, static and with weight shifting; narrow stance on foam with smooth
pursuit eye movement/head movement; heel-to-toe walking; grapevine walking;
narrow-stance ankle strategy (weight shifting)
2 Tai Chi for Arthritis (5 min); single-leg stance with eyes open/eyes closed/while
moving towel with foot; tandem stance with head turns/on foam; ankle strategy (weight
shifting) with eyes closed; multidirectional reaching on foam (hip strategy); walking
with head turns/abrupt starts & stops/altered pace
3 Tai Chi for Arthritis (5 min); single-leg stance with eyes open/head turns/while moving
opposite leg/on foam; tandem stance with eyes closed/on foam with multidirectional
reaching; tossing a beanbag on foam; step strategy forward/backward; backward
walking on hard surface/foam
4 Tai Chi for Arthritis (5 min); single-leg stance with eyes focused forward as head turns/
while tossing a bean bag to partner; ankle strategy (weight shifting) on hard surface/
foam; tandem on foam with head turns; narrow stance on foam with eyes closed;
standing, walking, heel-to-toe, side stepping, and hip strategy on 1/2 foam roller;
walking and grapevine on heels/toes on hard surface and foam
5 Tai Chi for Arthritis (5 min); single-leg stance while reading/on foam while moving
alternate leg/without shoes; tandem standing without shoes; heel-to-toe walking with
head turns, direction changes, abrupt stops; ankle strategy (weight shifting) with eyes
closed; alternate stepping; obstacle course including stepping up and over obstacles on
both foam and hard surfaces and heel-to-toe walking on 1/2 foam roller
6 Tai Chi for Arthritis (5 min); single-leg stance with arms across chest/while moving a
ball with opposite leg; walking forward/backward/grapevine/heels & toes/varied speeds
while holding an egg on a spoon; hip circles while standing on foam with eyes open/
eyes closed; reaching with hands clasped on foam with eyes open/eyes closed; tandem
standing on foam with eyes closed; obstacle course (same as Week 5) while holding a
lunch tray
446  Maughan et al.

All participants were asked to continue their regular exercise routine and to
not engage in additional balance-training practice outside of scheduled training
sessions. Most participants completed the balance training immediately after their
regular workout session. Control and 1-day participants were offered the full 6-week
balance-training program at the conclusion of the study.
If participants were unable to attend one of the regularly scheduled sessions,
make-up sessions were arranged so that program adherence was maintained.
Adherence to the balance-training program was excellent (99.6%), with only 2
participants missing one session each.

Dependent Measures
Measurements were taken at two times: within 2 weeks before the start of the
intervention and 2–9 days after the conclusion of the last balance-training session,
with the average for both intervention groups being 5 days. Participants were asked
to engage in balance training only during formal sessions and, accordingly, were
asked to stop balance training after their last session. Five people conducted the
pretest and posttest, 4 of whom were blind to group assignment. Static balance
and dynamic balance were assessed, and balance confidence was measured with
the Activities-specific Balance Confidence Scale (ABC; Powell & Myers, 1995).

Static Balance
Single-leg-stance was measured on both the right (SLS-R) and left (SLS-L) leg
with eyes open. Participants were asked to focus the eyes forward, cross the arms
over the chest, and lift one leg off the floor to about ankle level without touching
the support leg. Data were recorded as the number of seconds they were able to
stand on one foot without putting their other foot down, touching the support leg,
or uncrossing the arms (up to a maximum of 45 s). Two trials were completed, and
the better trial was included in the analysis.
Tandem balance was measured with participants self-selecting position of their
feet (which foot was in front of the other) and with arms crossed over their chest.
Time in balance (up to a maximum of 45 s) was recorded as soon as the participant
reported being stable and the researcher removed her hand from helping the par-
ticipant gain a stable position. Two trials were completed, and the better trial was
included in the analysis. If the first trial was 45 s, a second trial was not conducted.

Dynamic Balance
Alternate stepping was administered as described by Berg, Wood-Dauphinee, Wil-
liams, and Gayton (1992). Participants stood unsupported and, moving as quickly
and safely as possible, placed each foot alternately on an 8-in.-high step. Times
were recorded as the number of seconds required to complete eight steps. Two trials
were completed, and the better trial was included in the analysis.
Limits of stability (LOS) were measured using a force platform (AMTI model
OR6–5, Advanced Mechanical Technology, Inc., Watertown, MA). Our LOS pro-
cedures were modified from the original eight-position protocol (Clark, Rose, &
Fujimoto, 1997) in a manner similar to that used by Brauer, Burns, and Galley (2000)
 Balance Training in Physically Active Older Adults   447

and Melzer, Benjuya, and Kaplanski (2004). Participants stood in a narrow stance
with shoes off, feet touching, and heels on a premarked line. Arms were crossed
over the chest with eyes focused on a fixed point. Participants were asked to lean
as far as they could in a specified direction, without bending at the waist, hips, or
knees or losing their balance and while keeping both feet with heels and toes on the
platform. On verbal command, participants were instructed to lean in the following
order: forward, backward, left, and right. After leaning in the specified direction,
they held the position for approximately 2 s and then, on command, returned their
weight to the center and waited for instructions to lean in the next direction. One
practice trial on the floor was allowed before trials on the force platform.
Variables measured included maximum excursion (cm) in both anteroposterior
(AP) and mediolateral (ML) directions. Two 30-s trials of each condition were
sampled at a frequency of 50 Hz. An average of the two trials was included in the
analysis. One participant in 1-day was unable to complete the leaning task on pre-
test; therefore, data for this participant were excluded from the LOS analysis. The
force-platform data were processed using custom MATLAB software (MathWorks,
Natick, MA) and were smoothed using a fourth-order low-pass Butterworth filter
with a cutoff frequency of 8 Hz. Center-of-pressure data were then computed from
the filtered data.

Statistical Analyses
Data for 60 participants age 60–87 were entered into the analyses. Hypotheses were
tested using a Group (control, 1-day, 3-day) × Session (pre–post) repeated-measures
ANOVA. A Bonferroni adjustment was applied to account for multiple variables, so
significance level was set at .008. Partial eta-squares were also reported for interac-
tions, with .01 indicating a small effect, .06 a medium effect, and .138 a large effect.
Because we were primarily interested in within-group changes in response to the
intervention, significant interactions were further tested using one-way ANOVAs
to test for changes from pre- to posttest within each group.

Results
Pre- and posttest values (means and standard deviations) for dependent measures
are listed in Table 3 along with p values for Group × Session interactions.

Static Balance
SLS-R and -L.  There was no main effect for SLS-R for group, F(2, 57) = 0.40, p =
.673, η2 = .014, but there was a main effect for session, F(1, 57) = 10.65, p = .002,
η2 = .157, with participants balancing longer at posttest. There was no interaction,
F(2, 57) = 2.95, p = .06, η2 = .094, although the 3-day group exhibited the greatest
increase (40%, 10%, and 8% for 3-day, 1-day, and control, respectively). Similarly,
there was no main effect for SLS-L for group, F(2, 57) = 0.23, p = .796, η2 = .008,
but there was for session, F(1, 57) = 18.97, p < .001, η2 = .25. The interaction
was also significant, F(2, 57) = 5.67, p = .006, η2 = .166, with 3-day exhibiting a
67% improvement, 1-day a 21% improvement, and control a 6% improvement.
Follow-up ANOVAs within group indicated that only the 3-day group exhibited a
448
Table 3  Changes in Dependent Measures With Frequency of Balance Training, M (SD)
Control 1-Day 3-Day
Variable Pretest Posttest Pretest Posttest Pretest Posttest pa
Static
  single-leg stance, left (s) 25 (18) 26 (15) 21 (15) 25 (18) 20 (14) 33 (16)* .006†
  single-leg stance, right (s) 27 (17) 29 (16) 25 (16) 27 (18) 25 (15) 35 (16) .060
  tandem (s) 43 (9) 45 (2) 34 (19) 39 (12) 41 (14) 43 (9) .520
Dynamic
  alternate stepping (s) 7.5 (1.1) 6.9 (0.9) 7.9 (0.4) 7.5 (0.3) 8.2 (1.6) 7 (1.2) .060
  limits of stability (cm) anteroposterior 12.7 (2.0) 13.8 (2.0)* 11.9 (2.0) 14.1 (2.0)* 11.3 (2.0) 14.2 (2.0)* .004†
  anteroposterior forward 7.0 (1.0) 7.4 (1.0) 6.6 (1.0) 7.6 (1.0)* 6.2 (2.0) 7.8 (1.0)* .003†
  anteroposterior backward 5.8 (1.0) 6.4 (1.0) 5.3 (1.0) 6.5 (1.0) 5.1 (1.0) 6.4 (1.0) .049
 mediolateral 9.9 (1.0) 10.9 (2.0) 9.5 (2.0) 11.5 (1.0) 9.8 (2.0) 11.3 (2.0) .093
Activities-Specific Balance Confidence 96.8 (3.0) 97.9 (2.0) 95.2 (5.0) 93.9 (7.0) 92.7 (7.0) 95 (4.0)* .001†
aFrom the Group × Session repeated-measures ANOVA for each variable. Included to provide a succinct summary of which analyses resulted in significant interactions.
*Significant pre–post within-group follow-up tests.
†Significant Group × Session interaction.
 Balance Training in Physically Active Older Adults   449

significant increase, F(1, 19) = 19.1, p < .001, η2 = .501; control F(1, 18) = 0.47,
p = .502, η2 = .025; 1-day F(1, 20) = 3.74, p = .067, η2 = .158.
Tandem Balance.  Almost everyone exhibited a ceiling effect; that is, they could
balance for 45 s. There were no main effects for group, F(2, 57) = 2.71, p = .075,
η2 = .087, or session, F(1, 57) = 3.92, p = .053, η2 = .064, and the interaction was
not significant, F(2, 57) = .52, p = .60, η2 = .018. These results indicate that tandem
balance is not a sensitive measure for physically active older adults.

Dynamic Balance
Alternate Stepping.  There was no main effect for group, F(2, 57) = 0.75, p = .477,
η2 = .026, but there was a main effect for session, F(1, 57) = 30.5, p < .001, η2 =
.348, with all groups improving from pre- to posttest. The 3-day group exhibited the
greatest increase, 15% compared with 5% for 1-day and 8% for control. However,
the interaction was not significant, F(2, 57) = 3.09, p = .053, η2 = .098.
LOS (ML and AP).  Examination of ML LOS maximum excursion revealed no
main effect for group, F(2, 56) = 0.14, p = .871, η2 = .005, but a main effect for
session, F(1, 56) = 62.94, p < .001, η2 = .529, with the posttest excursion greater
than pretest. The 1-day group increased by 21%, 3-day by 15%, and control by
10%. However, the interaction was not significant, F(2, 56) = 2.48, p = .093, η2
= .081. For AP LOS maximum excursion, there was no group effect, F(2, 56) =
0.37, p = .691, η2 = .013, although there was a main effect for session, F(1, 56) =
95.22, p < .001, η2 = .63. There was also an interaction, F(2, 56) = 6.26, p = .004,
η2 = .183, with the greatest increase in 3-day (26%), followed by 1-day (20%),
then control (9%). Follow-up ANOVAs revealed significant changes in all groups:
3-day F(1, 19) = 42.9, p < .001, η2 = .693; 1-day F(1, 19) = 60, p < .001, η2 = .76;
control F(1, 18) = 8.48, p = .009, η2 = .32.
On examination of the AP data, there appeared to be a difference between
forward and backward excursion. Thus, to better characterize the change in AP
excursion, we conducted several post hoc analyses to examine forward excursion
separately from backward excursion. For forward excursion there was no main effect
for group, F(2, 56) = 0.15, p = .858, η2 = .005, but there was for session, F(1, 56)
= 64.83, p = < .001, η2 = .537. There was also an interaction, F(2, 56) = 6.46, p =
.003, η2 = .187. The 3-day group exhibited the greatest change (27%), then 1-day
(16%), and the least change in the control group (9%). Follow-up one-way ANOVAs
indicated that 3-day and 1-day exhibited a significant increase, F(1, 19) = 31.51, p <
.001, η2 = .624, and F(1, 19) = 40.65, p < .001, η2 = .681, respectively. The control
group did not exhibit a significant increase, F(1, 18) = 4.61), p = .046, η2 = .204.
In backward excursion, there was no main effect for group, F(2, 56) = 0.58, p =
.565, η2 = .02, but there was a main effect for session, F(1, 56) = 76.15, p < .001,
η2 = .576, with a greater excursion at posttest. The 3-day group increased by 25%,
1-day by 24%, and control by 11%; however, the interaction was not significant,
F(2, 56) = 3.18, p = .049, η2 = .102.
450  Maughan et al.

Balance Confidence
Balance confidence was very high in this physically active group (see Table 3 for
means). There were no main effects for the ABC—group F(2, 57) = 2.85, p = .066,
η2 = .091; session F(1, 57) = 3.03, p = .087, η2 = .051— but there was an interac-
tion, F(2, 57) = 7.31, p = .001, η2 = .204. The 3-day group improved by 2.6% and
the control by 1.1%. The 1-day decreased by 1.4%. One-way ANOVAs showed a
significant increase in confidence in 3-day, F(1, 19) = 8.89, p = .008, η2 = .319,
but no session differences in the other groups: control F(1, 18) = 2.80, p = .111,
η2 = .135; 1-day F(1, 20) = 4.13, p = .056, η2 = .171.

Discussion
The underlying rationale for examining the effect of balance training in physically
active older adults was to address balance proactively. Clearly, our participants were
healthy and active, and according to current ACSM guidelines, balance training was
not indicated. However, the current balance literature focuses primarily on either
sedentary or at-risk populations—thus the need to examine the effect, and more
specifically the dose-related effect, of short-term static and dynamic balance training
in physically active older adults. We hypothesized that they would improve in bal-
ance after a 6-week balance-training program and there would be a dose-response
relationship between the frequency of balance training and improvement in balance
control. In general, the results from this study support these hypotheses. Older
adults who regularly engaged in physical exercise and then added balance-specific
training improved both static and dynamic balance; a dose-response relationship
was observed for SLS, LOS forward AP excursion, and balance confidence.
Previous research indicated that physical activity or balance-training interven-
tions improve SLS times for frail elderly and community-dwelling older adults, with
improvement ranging from 43% to 123% (Cromwell et al., 2007; Gatts &Wool-
lacott, 2006; Li et al., 2005; Nelson et al., 2004; Robitaille et al., 2005; Shimada,
Uchiyama, & Kakurai, 2003). Our study extends these findings to suggest that
healthy older adults who already meet the recommended physical activity guidelines
can improve SLS time with training (3-day improved by 67% and 1-day, 21%).
This increase occurred even though our sample exhibited higher pretest scores
than reported in many studies of older adults (Drusini et al., 2002; Li et al., 2005;
Nelson et al., 2004; Robitaille et al., 2005; Shimada et al., 2003). Group average
pretest scores from these studies ranged from 4 to 15 s, while our average pretest
time across groups was 23.1 s. Many balance-assessment tools use maximum SLS
cutoff times of 10 s or less (Berg et al., 1992; Province et al., 1995), suggesting
that these tools may not be sufficiently sensitive to evaluate balance in an active,
highly functioning older adult population.
A measurable decline in single-leg balance may occur as early as the fifth
decade of life (age 40–49; Isles et al., 2004; Nitz & Choy, 2004), with a marked
decline occurring between the ages of 70 and 80 (Era, Heikkinen, Gause-Nilsson,
& Schroll, 2002). The 3-day group increased their SLS-L and SLS-R times to an
average of 33 and 35 s, respectively, similar to average norms for 60-year-olds
(Vereeck, Wuyts, Truijen, & Van de Heyning, 2008). These findings are meaningful
in light of the known associations between decreased SLS time and falls, as well as
 Balance Training in Physically Active Older Adults   451

activities of daily living (Drusini et al., 2002; Hurvitz, Richardson, Werner, Rhul,
& Dixon, 2000; Vellas et al., 1997).
LOS also showed a dose-related effect specifically in forward AP excursion.
Previous studies relate AP excursion to falls. Melzer, Benjuya, and Kaplanski (2004)
measured LOS maximum AP excursion in community-dwelling older adults and
found significant differences between fallers (8.7 ± .08 cm) and nonfallers (10.4 ±
.04 cm). Wallmann (2001) compared performance of elderly fallers and nonfallers
in both reaching and leaning tasks and observed that poor performance in forward
leaning correlated with poor balance, whereas reaching tasks did not.
Many of the measures used in this study place demands on ML stability and
require lateral weight transference. Both SLS and alternate stepping additionally
require active movement of the center of mass laterally in anticipation of the tran-
sition from a two-leg to a one-leg position. In addition to adequate strength, these
tasks with ML stability demands require active, integrative central nervous system
control for successful execution (Horak & MacPherson, 1996). Previous work
indicates that impaired ML control is associated with increased risk of falling. A
prospective study found that measures of ML balance control (ML sway and one-
leg standing) best discriminated between fallers and nonfallers (Maki, Holliday, &
Topper, 1994). Using a reaction-time rapid step task, Brauer et al. (2000) found that
fallers had slower step times and delayed activation of the hip abductors, indicating
impaired lateral weight transference. Together, these data suggest that maintaining
or improving ML balance control may decrease the risk of falls.
Although our training activities incorporated the use of ML stability, we did
not find differences between training groups for LOS in the ML direction or in
alternate stepping. Similarly, Brauer et al. (2000) found no differences in either
the ML LOS or the clinical step-up test between fallers and nonfallers. In addi-
tion, Horak, Wrisley, and Frank (2009) found that the alternate stepping task was
one of the least difficult tasks performed by older adults with or without balance
problems and was a less sensitive test than other clinical tests. Therefore, if ML
LOS and alternative stepping did not differentiate between fallers and nonfallers,
it is not necessarily surprising that balance training in physical active adults was
less effective.
One overall observation is that the activities that were specifically and repeat-
edly practiced with increasing difficulty (leaning tasks 4 out of the 6 weeks and
SLS while engaged in tasks, such as turning the head or moving a towel, every
week for an average of 4–5 min/session) resulted in dose-related increases. In
contrast, alternate stepping, which was practiced only 1 week, showed only a trend
for the 3-day group to improve. These results support the position that specificity
of practice for changes in postural control in older adults is needed (Wolfson et
al., 1996). The dose-related response indicates that intensity is important, which is
also in agreement with Wolfson et al., who underlined the importance of intensity
for plasticity changes relative to postural control in older adults.
Balance-confidence scores improved in the 3-day group after training, with
average scores increasing for each of the 16 items included on the ABC. The items
that had a change of greater than 5% included Item 5, standing on tiptoes to reach;
Item 15, stepping onto or off of an escalator without the use of hands; and Item
16, walking on icy sidewalks. Unexpectedly, the 1-day group showed a trend for a
decrease in balance-confidence scores after training. Because our balance-training
452  Maughan et al.

program increased in difficulty each week, those in the 1-day group experienced
only one training session for each level of difficulty. Some 1-day participants
expressed frustration at not mastering some of the skills before trying the more
difficult tasks the next week, and others communicated that the balance-training
program increased their realization of their balance limitations. Thus, it is possible
the lower balance-confidence scores of the 1-day group reflect an increased aware-
ness of balance limitations because of training and, thus, are an indirect effect of
training. However, we did not equate the groups on balance confidence, making it
more difficult to determine the effect of the intervention on this measure.
We consider this study a first step in the process of examining balance training
in physically active older adults. As such, there were several limitations in the study.
Our sample size was small, and although we found significant effects and moder-
ate to large effect sizes for most interactions, a larger sample would provide better
representation and stronger statistical power. Since almost all variables showed an
improvement from pre- to posttesting, suggesting a learning effect regardless of
intervention group, an additional familiarization session should be provided before
pretesting. In addition, we did not provide a nonbalance alternative for the 1-day
and control groups, such as stretching or breathing exercises, thereby control-
ling for total time in exercise per week. However, given the practice-specific task
improvement in SLS and the relatively high levels of physical activity of all the
study participants, we do not think this influenced the group results. Finally, we
did not control exercise before and during the training period other than asking that
participants not change their exercise protocol or engage in balance tasks outside of
balance-training sessions. Participating in balance training could have systematically
influenced their exercise regimen and results. However, exercise changes based on
pre- and posttest self-report did not indicate any systematic changes across groups
in exercise regimens.
Further research needs to examine the effect of balance training in physically
active older adults on long-term functional outcomes such as mobility disability and
falls, as well as the intensity of practice necessary to maintain improved balance
skills. One study indicates that a less intense maintenance program is sufficient
once the initial, more intense program is completed (Wolfson et al., 1996). Another
important question is the degree to which these balance improvements transfer to
everyday tasks. To determine if improved balance in such healthy, highly active
older adults affects functional tasks, motor control of challenging tasks such as
stair climbing or descending without handrails or stepping over an obstacle must
be examined.

Conclusion
The data indicate that a dose-related response in SLS and LOS occurred with three
20-min sessions of balance-specific training per week in physically active older
adults. Furthermore, these results were obtained through an intervention that was
safely administered in a community setting. While the current ACSM/AHA recom-
mendations advocate balance training for older adults who are at substantial risk of
falls, this study provides a foundation for future longitudinal studies examining the
effects of balance training on functional outcomes for physically active older adults.
 Balance Training in Physically Active Older Adults   453

Acknowledgments
We thank the Iowa State University Adult Exercise Clinic in Ames, IA, and the Mary Greeley
Medical Center Lifetime Fitness Center in Story City, IA, for the use of their facilities and
equipment during the balance-training program. K. Lowry is currently supported by National
Institutes of Health T32 AG021885.

References
Barnett, A., Smith, B., Lord, S.R., Williams, M., & Baumand, A. (2003). Community-based
group exercise improves balance and reduces falls in at-risk older people: A randomised
controlled trial. Age and Ageing, 32, 407–414. PubMed doi:10.1093/ageing/32.4.407
Berg, K.O., Wood-Dauphinee, S.L., Williams, J.I., & Gayton, D. (1992). Measuring balance
in the elderly: Preliminary development of an instrument. Physiotherapy Canada, 41,
304–311. doi:10.3138/ptc.41.6.304
Bird, M.L., Hill, K., Ball, M., & Williams, A.D. (2009). Effects of resistance and flexibility
exercise interventions on balance and related measures in older adults. Journal of Aging
and Physical Activity, 17, 444–454. PubMed
Brauer, S.G., Burns, Y.R., & Galley, P. (2000). A prospective study of laboratory and clinical
measures of postural stability to predict community-dwelling fallers. Journals of Geron-
tology. Series A, Biological Sciences and Medical Sciences, 55, M469–M476. PubMed
Clark, S., Rose, D.J., & Fujimoto, K. (1997). Generalizability of the limits of stability test in
the evaluation of dynamic balance among older adults. Archives of Physical Medicine
and Rehabilitation, 78, 1078–1084. PubMed doi:10.1016/S0003-9993(97)90131-3
Cromwell, R.L., Meyers, P.M., Meyers, P.E., & Newton, R.A. (2007). Tae Kwon Do: An
effective exercise for improving balance and walking ability in older adults. The Jour-
nals of Gerontology. Series A, Biological Sciences and Medical Sciences, 62, 641–646.
PubMed doi:10.1093/gerona/62.6.641
Drusini, A.G., Eleazer, G.P., Caiazzo, M., Veronese, E., Carrara, N., Ranzato, F., & Wieland,
D. (2002). One-leg standing balance and functional status in an elderly community-
dwelling population in northeast Italy. Aging Clinical and Experimental Research,
14, 42–46. PubMed
Era, P., Heikkinen, E., Gause-Nilsson, I., & Schroll, M. (2002). Postural balance in elderly
people: Changes over a five-year follow-up and its predictive value for survival. Aging
Clinical and Experimental Research, 14(3, Suppl.) 37–46. PubMed
Federici, A., Bellagamba, S., & Rocchi, M.B.L. (2005). Does dance-based training improve
balance in adult and young old subjects? A pilot randomized controlled trial. Aging
Clinical and Experimental Research, 17, 385–389. PubMed
Fu, S., Choy, N.L., & Nitz, J. (2009). Controlling balance decline across the menopause
using a balance-strategy training program: A randomized, controlled trial. Climacteric,
12(2), 165–176. PubMed doi:10.1080/13697130802506614
Gatts, S.K., & Woollacott, M.H. (2006). Neural mechanisms underlying balance improve-
ment with short term Tai Chi training. Aging Clinical and Experimental Research, 18,
7–19. PubMed
Gauchard, G.C., Gangloff, P., Jeandel, C., & Perrin, P.P. (2003). Influence of regular pro-
prioceptive and bioenergetic physical activities on balance control in elderly women.
Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 58,
M846–M850. PubMed doi:10.1093/gerona/58.9.M846
Gauchard, G.C., Jeandel, C., Tessier, A., & Perrin, P.P. (1999). Beneficial effect of proprio-
ceptive physical activities on balance control in elderly human subjects. Neuroscience
Letters, 273, 81–84. PubMed doi:10.1016/S0304-3940(99)00615-1
454  Maughan et al.

Gillespie, L.D., Robertson, M.C., Gillespie, W.J., Lamb, S.E., Gates, S., Cumming, R.G.,
& Rowe, B.H. (2009). Interventions for preventing falls in older people living in the
community. Cochrane Database of Systematic Reviews, 15, CD0007146.
Horak, F.B., & MacPherson, J.M. (1996). Postural orientation and equilibrium. In J. Shepard
& L. Roell (Eds.), Handbook of physiology, section 12. Exercise: Regulation and inte-
gration of multiple systems (pp. 255–292). New York, NY: Oxford University Press.
Horak, F.B., Wrisley, D.M., & Frank, J. (2009). The Balance Evaluation Systems Test
(BESTest) to differentiate balance deficits. Physical Therapy, 89, 484–498. PubMed
doi:10.2522/ptj.20080071
Hurvitz, E.A., Richardson, J.K., Werner, R.A., Rhul, A.M., & Dixon, M.R. (2000). Uni-
pedal stance testing as an indicator of fall risk among older outpatients. Archives
of Physical Medicine and Rehabilitation, 81(5), 587–591. PubMed doi:10.1016/
S0003-9993(00)90039-X
Islam, M.M., Nasu, E., Rogers, M.E., Koizumi, D., Rogers, N., & Takeshima, N. (2004).
Effects of combined sensory and muscular training on balance in Japanese older adults.
Preventive Medicine, 39, 1148–1155. PubMed doi:10.1016/j.ypmed.2004.04.048
Isles, R.C., Low Chow, N.L., Phty, M., Steer, M., Phty, B., & Nitz, J.C. (2004). Normal values
of balance tests in women aged 20–80. Journal of the American Geriatrics Society, 52,
1367–1372. PubMed doi:10.1111/j.1532-5415.2004.52370.x
Lam, P. (2004) Tai Chi for arthritis handbook. Narwee, NSW, Australia: East Acton Pub-
lishing.
Li, F., Harmer, P., Fisher, K.J., McAuley, E., Chaumeton, N., Eckstrom, E., & Wilson, N.L.
(2005). Tai Chi and fall reductions in older adults: A randomized controlled trial. The
Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 60,
187–194. PubMed doi:10.1093/gerona/60.2.187
Lord, S.R., Castell, S., Corcoran, J., Dayhew, J., Matters, B., Shan, A., & Williams, P. (2003).
The effect of group exercise on physical functioning and falls in frail older people
living in retirement villages: A randomized, controlled trial. Journal of the American
Geriatrics Society, 51, 1685–1692. PubMed doi:10.1046/j.1532-5415.2003.51551.x
Maki, B.E., Holliday, P.J., & Topper, A.K. (1994). A prospective study of postural balance
and risk of falling in an ambulatory and independent elderly population. Journal of
Gerontology, 49, M72–M84. PubMed
Melzer, I., Benjuya, N., & Kaplanski, J. (2004). Postural stability in the elderly: A comparison
between fallers and non-fallers. Age and Ageing, 33, 602–607. PubMed doi:10.1093/
ageing/afh218
Nelson, M.E., Layne, J.E., Bernstein, M.J., Nuernberger, C.C., Kaliton, D., & Fiatarone-
Singh, M.A. (2004). The effects of multidimensional home-based exercise on functional
performance in elderly people. The Journals of Gerontology. Series A, Biological Sci-
ences and Medical Sciences, 59, M154–M160. PubMed doi:10.1093/gerona/59.2.M154
Nelson, M.E., Rejeski, J., Blair, S.N., Duncan, P.W., Judge, J.O., King, A.C., & Castaneda-
Sceppa, C. (2007). Physical activity and public health in older adults. Recommendation
from the American College of Sports Medicine and the American Heart Association.
Circulation, 116, 1094–1105. PubMed doi:10.1161/CirculationAHA.107.185650
Nitz, J.C., & Choy, N.L. (2004). The efficacy of a specific balance-strategy training pro-
gramme for preventing falls among older people: A pilot randomized controlled trial.
Age and Ageing, 33, 52–58. PubMed doi:10.1093/ageing/afh029
Perrin, P.P., Gauchard, G.C., Perrot, C., & Jeandel, C. (1999). Effects of physical and sport-
ing activities on balance control in elderly people. British Journal of Sports Medicine,
33, 121–126. PubMed doi:10.1136/bjsm.33.2.121
Powell, L.E., & Myers, A.M. (1995). The Activities-specific Balance Confidence (ABC)
Scale. The Journals of Gerontology. Series A, Biological Sciences and Medical Sci-
ences, 50A, M28–M34. PubMed doi:10.1093/gerona/50A.1.M28
 Balance Training in Physically Active Older Adults   455

Province, M.A., Hadle, E.C., Hornbrook, M.C., Lipsitz, L.A., Miller, J.P., Mulrow, C.D.,
& Wolf, S.L. (1995). The effects of exercise on falls in elderly patients. A preplanned
meta-analysis of the FICSIT Trials. Journal of the American Medical Association, 273,
1341–1347. PubMed doi:10.1001/jama.1995.03520410035023
Robitaille, Y., Laforest, S., Fournier, M., Gauvin, L., Panisien, M., Corriveau, H., & Damestoy,
N. (2005). Moving forward in fall prevention: An intervention to improve balance among
older adults in real-world settings. American Journal of Public Health, 95, 2049–2056.
PubMed doi:10.2105/AJPH.2004.057612
Rose, D.J. (2003). Fall proof: A comprehensive balance and mobility training program.
Champaign, IL: Human Kinetics.
Sakamoto, K., Nakamua, T., Hagino, H., Endo, N., Mori, S., Muto, Y., & Ochi, T. (2006).
Effects of unipedal standing balance exercise on the prevention of falls and hip fracture
among clinically defined high-risk elderly individuals: A randomized controlled trial.
Journal of Orthopaedic Science, 11, 467–472. PubMed doi:10.1007/s00776-006-1057-2
Schmid, A.A., Van Puymbroeck, M., & Koceja, D.M. (2010). Effect of a 12-week yoga inter-
vention on fear of falling and balance in older adults: A pilot study. Archives of Physical
Medicine and Rehabilitation, 91, 576–583. PubMed doi:10.1016/j.apmr.2009.12.018
Shimada, H., Uchiyama, Y., & Kakurai, S. (2003). Specific effects of balance and gait
exercises on physical function among the frail elderly. Clinical Rehabilitation, 17,
472–479. PubMed doi:10.1191/0269215503cr638oa
Toulotte, C., Thevenon, A., & Fabre, C. (2006). Effects of training and detraining on the
static and dynamic balance in elderly fallers and non-fallers: A pilot study. Disability
and Rehabilitation, 28, 125–133. PubMed doi:10.1080/09638280500163653
Vellas, B.J., Wayne, S.J., Romero, L., Baumgartner, R.N., Rubenstein, L.Z., & Garry, P.J.
(1997). One-leg balance is an important predictor of injurious falls in older persons.
Journal of the American Geriatrics Society, 45, 735–738. PubMed
Vereeck, L., Wuyts, F., Truijen, S., & Van de Heyning, P. (2008). Clinical assessment of bal-
ance: normative date, and gender and age effects. International Journal of Audiology,
47, 67–75. PubMed doi:10.1080/14992020701689688
Wallmann, H.W. (2001). Comparison of elderly nonfallers and fallers on performance mea-
sures of functional reach, sensory organization, and limits of stability. The Journals of
Gerontology. Series A, Biological Sciences and Medical Sciences, 56, M580–M583.
PubMed doi:10.1093/gerona/56.9.M580
Wolf, S.L., Barnhart, H.X., Kutner, N.G., McNeely, E., Googler, C., & Xu, T. (1996).
Reducing frailty and falls in older persons: An investigation of Tai Chi and computer-
ized balance training. Atlanta FICSIT Group. Frailty and injuries: Cooperative studies
of intervention techniques. Journal of the American Geriatrics Society, 44, 489–497.
PubMed
Wolfson, L., Whipple, R., Derbe, C., Judge, J., King, M., Amerman, P., . . . Smyers, D.
(1996). Balance and strength training in older adults: Intervention gains and Tai Chi
maintenance. Journal of the American Geriatrics Society, 44, 498–506. PubMed
Copyright of Journal of Aging & Physical Activity is the property of Human Kinetics Publishers, Inc. and its
content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for individual use.