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Background Balance training (BT) has been used for the promotion of balance and sports-related skills as well as for prevention and rehabilitation of lower extremity sport injuries. However, evidence-based dose-response relationships in BT parameters have not yet been established.
Objective The objective of this systematic literature review and meta-analysis was to determine dose-response relationships in BT parameters that lead to improvements in balance in young healthy adults with different training status.
Data Sources A computerized systematic literature search was performed in the electronic databases PubMed, Web of Knowledge, and SPORTDiscus from January 1984 up to May 2014 to capture all articles related to BT in young healthy adults.
Study Eligibility Criteria A systematic approach was used to evaluate the 596 articles identified for initial review. Only randomized controlled studies were included if they investigated BT in young healthy adults (16-40 years) and tested at least one behavioral balance performance outcome. In total, 25 studies met the inclusion criteria for review.
Study Appraisal and Synthesis Methods Studies were evaluated using the physiotherapy evidence database (PEDro) scale. Within-subject effect sizes (ESdw) and between-subject effect sizes (ESdb) were calculated. The included studies were coded for the following criteria: training status (elite athletes, sub-elite athletes, recreational athletes, untrained subjects), training modalities (training period, frequency, volume, etc.), and balance outcome (test for the assessment of steady-state, proactive, and reactive balance).
Results Mean ESdb demonstrated that BT is an effective means to improve steady-state (ESdb = 0.73) and proactive balance (ESdb = 0.92) in healthy young adults. Studies including elite athletes showed the largest effects (ESdb = 1.29) on measures of steady-state balance as compared with studies analyzing sub-elite athletes (ESdb = 0.32), recreational athletes (ESdb = 0.69), and untrained subjects (ESdb = 0.82). Our analyses regarding dose-response relationships in BT revealed that a training period of 11-12 weeks (ESdb = 1.09), a training frequency of three (mean ESdb = 0.72) or six (single ESdb = 1.84) sessions per week, at least 16-19 training sessions in total (ESdb = 1.12), a duration of 11-15 min for a single training session (ESdb = 1.11), four exercises per training session (ESdb = 1.29), two sets per exercise (ESdb = 1.63), and a duration of 21-40 s for a single BT exercise (ESdb = 1.06) is most effective in improving measures of steady-state balance. Due to a small number of studies, dose-response relationships of BT for measures of proactive and reactive balance could not be qualified.
Limitations The present findings must be interpreted with caution because it is difficult to separate the impact of a single training modality (e.g., training frequency) from that of the others. Moreover, the quality of the included studies was rather limited, with a mean PEDro score of 5.
Conclusions Our detailed analyses revealed effective BT parameters for the improvement of steady-state balance. Thus, practitioners and coaches are advised to consult the identified dose-response relationships of this systematic literature review and meta-analysis to implement effective BT protocols in clinical and sports-related contexts. However, further research of high methodological quality is needed to (1) determine dose-response relationships of BT for measures of proactive and reactive balance, (2) define effective sequencing protocols in BT (e.g., BT before or after a regular training session), (3) discern the effects of detraining, and (4) develop a feasible and effective method to regulate training intensity in BT.
Background Effects and dose-response relationships of balance training on measures of balance are well-documented for healthy young and old adults. However, this has not been systematically studied in youth. Objectives The objectives of this systematic review and meta-analysis were to quantify effects of balance training (BT) on measures of static and dynamic balance in healthy children and adolescents. Additionally, dose-response relations for BT modalities (e.g. training period, frequency, volume) were quantified through the analysis of controlled trials. Data Sources A computerized systematic literature search was conducted in the electronic databases PubMed and Web of Science from January 1986 until June 2017 to identify articles related to BT in healthy trained and untrained children and adolescents. Study Eligibility Criteria A systematic approach was used to evaluate articles that examined the effects of BT on balance outcomes in youth. Controlled trials with pre- and post-measures were included if they examined healthy youth with a mean age of 6-19 years and assessed at least one measure of balance (i.e. static/dynamic steady-state balance, reactive balance, proactive balance) with behavioural (e.g. time during single-leg stance) or biomechanical (e.g. centre of pressure displacements during single-leg stance) test methods. Study Appraisal and Synthesis Methods The included studies were coded for the following criteria: training modalities (i.e. training period, frequency, volume), balance outcomes (i.e. static and dynamic balance) as well as chronological age, sex (male vs. female), training status (trained vs. untrained), setting (school vs. club), and testing method (biomechanical vs. physical fitness test). Weighted mean standardized mean differences (SMDwm) were calculated using a random-effects model to compute overall intervention effects relative to active and passive control groups. Between-study heterogeneity was assessed using I 2 and chi(2) statistics. A multivariate random effects meta-regression was computed to explain the influence of key training modalities (i.e. training period, training frequency, total number of training sessions, duration of training sessions, and total duration of training per week) on the effectiveness of BT on measures of balance performance. Further, subgroup univariate analyses were computed for each training modality. Additionally, dose-response relationships were characterized independently by interpreting the modality specific magnitude of effect sizes. Methodological quality of the included studies was rated with the help of the Physiotherapy Evidence Database (PEDro) Scale. Results Overall, our literature search revealed 198 hits of which 17 studies were eligible for inclusion in this systematic review and meta-analysis. Irrespective of age, sex, training status, sport discipline and training method, moderate to large BT-related effects were found for measures of static (SMDwm = 0.71) and dynamic (SMDwm = 1.03) balance in youth. However, our subgroup analyses did not reveal any statistically significant effects of the moderator variables age, sex, training status, setting and testing method on overall balance (i.e. aggregation of static and dynamic balance). BT-related effects in adolescents were moderate to large for measures of static (SMDwm = 0.61) and dynamic (SMDwm = 0.86) balance. With regard to the dose-response relationships, findings from the multivariate random effects meta-regression revealed that none of the examined training modalities predicted the effects of BT on balance performance in adolescents (R-2 = 0.00). In addition, results from univariate analysis have to be interpreted with caution because training modalities were computed as single factors irrespective of potential between-modality interactions. For training period, 12 weeks of training achieved the largest effect (SMDwm = 1.40). For training frequency, the largest effect was found for two sessions per week (SMDwm = 1.29). For total number of training sessions, the largest effect was observed for 24-36 sessions (SMDwm = 1.58). For the modality duration of a single training session, 4-15 min reached the largest effect (SMDwm = 1.03). Finally, for the modality training per week, a total duration of 31-60 min per week (SMDwm = 1.33) provided the largest effects on overall balance in adolescents. Methodological quality of the studies was rated as moderate with a median PEDro score of 6.0. Limitations Dose-response relationships were calculated independently for training modalities (i.e. modality specific) and not interdependently. Training intensity was not considered for the calculation of dose-response relationships because the included studies did not report this training modality. Further, the number of included studies allowed the characterization of dose-response relationships in adolescents for overall balance only. In addition, our analyses revealed a considerable between-study heterogeneity (I-2 = 66-83%). The results of this meta-analysis have to be interpreted with caution due to their preliminary status. Conclusions BT is a highly effective means to improve balance performance with moderate to large effects on static and dynamic balance in healthy youth irrespective of age, sex, training status, setting and testing method. The examined training modalities did not have a moderating effect on balance performance in healthy adolescents. Thus, we conclude that an additional but so far unidentified training modality may have a major effect on balance performance that was not assessed in our analysis. Training intensity could be a promising candidate. However, future studies are needed to find appropriate methods to assess BT intensity.