https://orcid.org/0000-0002-9206-7725
Figures
Abstract
Background
Although a lot of attention is paid to the flaws of balance training research in older adults, the low methodological quality and incomplete reporting of studies still limit the knowledge transfer between research and practice. These known shortcomings are considered also as barriers for creating recommendations for balance training in older adults. Despite the considerable efforts to improve the scientific quality of studies, such recommendations have not yet been formulated to date. Therefore, this scoping review aims (1) to analyze the literature that addresses balance training in older adults, (2) to identify and summarize gaps in the existing literature, and (3) to propose future research on this topic.
Methods
We focused on studies that evaluated the effect of balance training on balance control in apparently healthy older adults over 60 years of age.
Results
Out of 6910 potentially relevant studies, only 26 met the eligibility criteria. The identified shortcomings were as follows: missing a priori criteria for training session attendance and leisure-time physical activities, insufficiently described exercises and training load, and inappropriately chosen tests.
Conclusions
Among the shortcomings of the balance training research, the insufficiently described balance training program and inappropriately chosen tests can be considered the most important. For this reason, even with an excellently designed experiment, it is almost impossible for practitioners to apply the results of such studies into practice. Therefore, researchers should pay more attention to possible users of the acquired knowledge, which is more than desirable in the case of exercise programs for older adults.
Citation: Kováčiková Z, Cimboláková I, Čurgali M, Labudová J, Zemková E (2025) What are the hidden shortcomings of balance training research in older adults that prevent its transfer into practice? Scoping review. PLoS ONE 20(1): e0308752. https://doi.org/10.1371/journal.pone.0308752
Editor: Pengpeng Ye, National center for chronic and non-communicable diesease prevention and control, CHINA
Received: April 17, 2024; Accepted: July 30, 2024; Published: January 2, 2025
Copyright: © 2025 Kováčiková et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The research reported in this manuscript has been supported by the Scientific Grant Agency of the Ministry of Education, Science, Research and Sport of the Slovak Republic and the Slovak Academy of Sciences (No. 1/0725/23). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Even though balance training is highly recommended to older adults for improving balance control [1, 2], reducing the risk and occurrence of falls [3], improving physical functions [4] and independence in performing activities of daily living [5], consensually accepted training guidelines are still not available. We register individual efforts to propose some kind of universal recommendations for the balance training of older adults. These are usually limited to the duration of the intervention, training frequency and volume. Moreover, the recommendations are often contradictory. For instance, Lesinski et al. [6] found that effective balance training in relatively healthy older adults is characterized by training period of 11–12 weeks, with a frequency of 3 training sessions/week and a length of 31–45 min. However, the desired training effect can be achieved even in a shorter period, with a lower frequency of training units and training duration (6 weeks, 2 training sessions/week for 30 minutes) [7]. To determine which study is more believable, it is necessary to consider other aspects such as its methodological and reporting quality.
Reliable tools that facilitate a comprehensive review of exercise training trials such as TESTEX [8] or PEDro scale [9] have been proposed to address common shortcomings in study design, quality, and reporting in the intervention studies. However, none of the available tools include detailed evaluation of training protocol. This is perhaps due to the assumption that the training protocol as the cornerstone of intervention studies must be always well described.
Methodological quality of balance training studies is usually moderate to weak [6]. Within the training protocol, deficiencies are most often attributed to training modalities, such as the number of training exercises, dosage, and duration. Despite these known shortcomings of individual studies, guidelines for balance training in older adults have still not been formulated. Therefore, we assume that there are also other, and so far, undescribed shortcomings of balance training studies that can be considered as barriers for implementing evidence-based findings into clinical and training practice.
Therefore, the aim of this scoping review is to identify the shortcomings of balance training studies related primarily to the description of training protocol. We focused on studies conducted in apparently healthy older adults. The reason is that various comorbidities and disease severity may require different approaches to creating protocols, which is then reflected in the high methodological diversity between studies. The very high methodological diversity of studies is an obstacle to reaching a scientific consensus on recommendations regarding balance training for older adults [10].
Methods
Research question
What are the methodological gaps of balance training studies in apparently healthy older adults?
Design
Scoping review.
A scoping review can be used as a standalone project or as a preliminary step to a systematic review to identify studies shortcomings and research gaps on the specific topic in the existing scientific literature [11]. The methodological framework JBI Manual for Evidence Synthesis was used (Chapter 11) [12]. This review was reported according to the PRISMA Extension for Scoping Reviews reporting guidelines [13].
Inclusion and exclusion criteria
A PCC framework was used to guide the eligibility criteria for this scoping review [14]. Inclusion and exclusion criteria are listed in Table 1.
Search strategy
A literature search was conducted through the electronic databases Web of Science (all databases) and Scopus. The search strategy included the following combination of terms: ’balance training’ OR ’balance intervention’ AND ’balance’ OR ’balance control’ AND ’older adults’. Only articles published in a peer-reviewed journals in the period January 2019—August 2023, full-text articles written in English, and articles published under an open access license were included. We focused on the recent articles to reflect more up-to-date shortcomings in the field of balance training research in older adults. See Fig 1 for a PRISMA flow diagram.
* It was not possible to determine the exact number of excluded studies within each category. This was because some studies could be excluded for several reasons at the same time. For example, the effect of balance training was assessed in young adults with chronic disease.
Source of evidence selection
A pilot evaluation was conducted on 20 randomly selected articles dealing with balance training in older adults. Google Scholar was used to search for articles. Three reviewers analyzed them according to the pre-defined criteria within the protocol. The aim was to verify the consensus of all reviewers in the data coding. If there were disagreements in the coding between the reviews, areas of disagreement were discussed until 100% agreement was achieved between reviewers. Identified studies were exported to an MS Excel document in the form of study title, author(s), publication year and source.
Data extraction
Study protocol included information about author(s) and year of publication; number of participants (including gender statistics); balance training type; training characteristics such as frequency of training units and duration; type of trained balance; training protocol description; additional physical activity; a priori criteria for session attendance; control group; diagnostic tools; and the outcome (Supplementary file 1).
Results
A total of 6910 potentially relevant studies were identified based on the key terms. Of these, 26 studies met the eligibility criteria and were included in this scoping review. The most studies were published in 2021 (12 out of 26). All included studies are processed according to outcome categories in Table 2.
Discussion
We found a greater number of women participating in the balance training studies than men (462 vs 300). One of the explanations could be that women in general are more physically active than men [48]. Moreover, they are more willing to participate in the research and undergo physical interventions [49].
Another finding is that studies varied widely in the length of the intervention, number of training sessions and their duration. A dose-response analysis of Gebel et al. [50] revealed that the frequency and duration of balance training are not the modalities that would strongly affect postural balance control in young healthy individuals. Whether this also applies to healthy older adults is unknown. In this context, it is also difficult to draw any comprehensive conclusions regarding the effectiveness of the intervention on balance. Namely, statistically significant improvement did not always occur in all included balance tests. Since the tests used did not always reflect the type of balance being trained, any attempt to draw conclusions about effectiveness would be considerably complicated.
Entry criteria
We have identified two significant shortcomings of the studies related to the entry criteria. The first one concerned missing a priori criteria for training session attendance. Only 2 out of 26 studies specified requirements for the minimum number of completed training units in their protocols [23, 35]. Six studies reported training adherence [16, 28, 30, 43, 44, 46]. It ranged from 75 to 100%, depending on the study. Low attendance rate could affect exercise dose and consequent training outcomes. According to Williams et al. [21], if training session attendance rates and study outcomes are reported, it should be possible to calculate dose-response characteristics and determine whether an optimal criterion level for training attendance exists. Explicit reporting requirements for the minimum number of completed training units within protocols could help in decision about the level and value of a priori criteria for training session attendance [21].
According to Huang & Yamamoto [51], the weekly training frequency is an important modality of balance control in healthy adults. Authors DiStefano, Clark & Padua [52] found that subjects with more training sessions achieved greater improvements in balance than the subjects who attended less sessions.
The second shortcoming is the missing criterion for additional physical activity in most studies. Only five studies prohibited or restricted the performance of any physical activity during the duration of the intervention [23, 31, 32, 41, 45] and three studies excluded physical activities that explicitly included balance components within the entry criteria [41, 43, 44]. On the contrary, we have identified 1 study where older adults performed physical therapy along with balance training [16]. Therapy was on the voluntary basis and included strength exercises, mobility exercises and/or balance exercises.
According to Taube et al., [53], the neuromuscular adaptation is unique to training level and experience. If we consider that training level and experience are related to the frequency of training units and the number of training stimuli, then additional physical activities that include balance components performed along with the balance intervention could have an impact on training outcome. Physical activity or therapy in general can complicate the response to a balance intervention or conversely, it can interact with the intervention. From the outcome perspective, the intervention can be uniquely effective, but also ineffective [22]. It has been previously observed that even ordinary walking (aerobic activity) significantly improves static and dynamic balance in older adults [54]. Therefore, each physical activity performed along with the intervention should be strictly monitored. Otherwise, it can lead to difficulty in drawing conclusions about the potential utility of the intervention.
Control group
Five studies did not use a control group [26, 36, 46, 40, 41], but only 3 of them considered this a limitation [36, 40, 41]. A control group is important in increasing confidence in causal inferences by reducing the plausibility of alternative explanations [55, 56].
Three studies used a passive control group that did not receive any intervention or was not allowed to perform or start any physical activity during the study [28, 30, 35]. Using of no-intervention or passive controls in the training studies is increasingly discussed. According to Malay & Chung [57], control group should be free of exposure/intervention under study. On the other hand, there are also opinions that it is not ethical to deny participants an intervention that could benefit them. Louro et al. [58] points out that the use of a no-intervention control group is ethically acceptable if the intervention has not yet been shown to be more beneficial than the no-intervention alternative. However, the possibility that the intervention would be offered to the control group after the end of the study is less discussed. Problem may arise when physical activity is restricted for long time, especially in apparently healthy and physically active older adults. Restriction could lead to a wide array of deleterious social, emotional, and physical changes that can be describe as a downward spiral of health [59]. However, in the case of healthy individuals, temporary restriction of physical activity might not represent a significant problem.
Training protocol
Detailed description of training protocol should be an integral part of every training study. It means more than providing an intervention length, training frequency and duration. More than half of all studies identified in our review have insufficiently described training protocols [16, 23, 28, 30–32, 34, 36, 39, 42–46]. The most common was missing information about the number of repetitions, sets, and/or rest interval of individual exercises. Description of training exercises and the process of increasing difficulty were also missing. Very few studies specified the type of balance that training was aimed at. Balance training is effective in improving balance tasks that are trained, with limited transfer to non-trained balance tasks [10]. If we were to go into more detail, none of the studies emphasized quality of movement execution. It is one of the biggest keys to great results in all exercise endeavors, especially in the older adults.
A specific balance training studies identified within our review were exergame studies. Some of them lacked game description to be able to identify what type of balance is game aimed at [27, 32, 35, 36]. It was also not stated the duration of the game, number of attempts that were given to participants and rest interval between individual trials/games.
Key training features such as description of individual exercises, number of repetitions and sets, intensity, rest interval, and process of increasing the difficulty can all influence efficacy and reproducibility of the intervention. Even though exercise intensity is the major training stimulus that affects adaptation and overall performance, there is still no methodological approach for its determining in the case of balance exercises [60]. Therefore, we did not consider missing information on exercise intensity as a shortcoming. Indication of exercise dosage is necessary for the sustainability of the training effect and elimination of potential adverse effect of the training intervention [61]. Only by describing the interventions and protocols in detail can other researchers replicate the research or build on the research findings.
Tests
We have investigated what type of balance the intervention was aimed at, and what diagnostic tools were used to evaluate it. We wanted to know whether the same type of balance that was trained was evaluated. It is known, balance training is effective in improving balance tasks that are trained, with limited transfer on non-trained balance tasks [10]. Therefore, the use of tests that do not reflect the trained type of balance reduces the relevance of the results.
Not all studies used tests that accounted trained type of balance [16, 28, 30, 31, 39]. In four studies, it was not possible to determine the appropriateness of the tests used, due to the lack of training exercises description [32, 35, 36, 43]. One study assessed narrow base walking, while training included proactive and reactive static balance exercises [41]. However, the aim of the study was to evaluate the training transfer from one type of balance to another. In the study of Allin et al. [24], training was aimed to improve reactive balance following perturbations such as slipping and tripping. Body kinematics during perturbed walk, POMA, TUG and OLS were used to evaluate balance control. Three out of four tests used in the mentioned study did not reflect the trained ability. TUG is considered as a test to measure proactive, not reactive balance control [62, 63]. Single leg stance test is used as a test to measure static balance [15, 64]. POMA include tasks to measure static balance and gait [65]. None of the tests involved a reactive component. The goal of the study was not to evaluate the transfer from one type of balance to another. Rezaei et al. [34] used standing on rotating platform as a test to measure dynamic balance. On the contrary, Gerards et al. [66] consider standing on the platform inducing multidirectional shifts or tilts as a test of static reactive balance.
The selection of tests should consider also the physical and functional status of the population involved. Not all tests are suitable for physically active older adults. For instance, OLS has pronounced ceiling effect and, therefore, should not be used as measures of physical performance in high-functioning older adults [67]. However, the physical activity level of older adults was not described in any of the included studies, so it is not possible to determine the appropriateness of the tests used.
The identified shortcomings of the included studies and suggestions for future research are summarized in Table 3.
Limitations
Our study has several limitations that should be addressed. First, the design of the studies within the inclusion criteria was not specified. Although scoping review allows to include a wide range of study designs [8], it would be appropriate to specify them in the case of future research. Second, review studies were excluded to avoid duplication of literature. On the other hand, this type of study design can serve as a source for identifying potentially relevant studies. Third, methodological quality of individual studies was not examined. Fourth, some exergame interventions could be multicomponent. Since the games were often not (well) described, we cannot rule it out. Fifth, important works may have been omitted due to the inclusion of only papers available on open access publication.
Conclusions
Insufficiently described protocol and inappropriately chosen tests to be the most serious shortcomings of identified studies. For this reason, even with an excellently conducted experiment, it is almost impossible for practitioners to apply the results of such studies into practice. Therefore, researchers should pay more attention to possible users of the acquired knowledge, which is more than desirable in the case of exercise programs for older adults.
Supporting information
S1 Checklist. Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist.
https://doi.org/10.1371/journal.pone.0308752.s002
(PDF)
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