628616

research-article2016

CRE0010.1177/0269215516628616Clinical RehabilitationMik et al.

CLINICAL
REHABILITATION

Original Article

Effectiveness of balance
training programme in reducing
the frequency of falling in
established osteoporotic women:
A randomized controlled trial

Clinical Rehabilitation
18
The Author(s) 2016
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DOI: 10.1177/0269215516628616
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Ibolya Miko1, Imre Szerb2, Anna Szerb3 and Gyula Poor1

Abstract
Objective: To investigate the effect of a 12-month sensomotor balance exercise programme on postural
control and the frequency of falling in women with established osteoporosis.
Design: Randomized controlled trial where the intervention group was assigned the 12-month Balance Training
Programme and the control group did not undertake any intervention beyond regular osteoporosis treatment.
Subjects: A total of 100 osteoporotic women at least with one osteoporotic fracture aged 65years
old and above.
Main measures: Balance was assessed in static and dynamic posture both with performance-based
measures of balance, such as the Berg Balance Scale and the Timed Up and Go Test, and with a stabilometric
computerized platform.
Interventions: Patients in the intervention group completed the 12-month sensomotor Balance Training
Programme in an outpatient setting, guided by physical therapists, three times a week, for 30minutes.
Results: The Berg Balance Scale and the Timed Up and Go Test showed a statistically significant
improvement of balance in the intervention group (p=0.001 and p=0.005, respectively). Balance tests using
the stabilometer also showed a statistically significant improvement in static and dynamic postural balance
for osteoporotic women after the completion of the Balance Training Programme. As a consequence, the
one-year exercise programme significantly decreased the number of falls in the exercise group compared
with the control group.
Conclusion: The Balance Training Programme significantly improved the balance parameters and reduced
the number of falls in postmenopausal women who have already had at least one fracture in the past.
Keywords
Established osteoporosis, balance training programme, stabilometer, prevention of falls
Received: 7 February 2015; accepted: 1 January 2016
1National

Institute of Rheumatology and Physiotherapy,

Budapest, Hungary
2Uzsoki Hospital, Budapest, Hungary
3The London School of Economics and Political Science,
London, UK

Corresponding author:
Ibolya Mik, National Institute of Rheumatology and
Physiotherapy, Frankel Le t 62, 1023 Budapest, Hungary.
Email: miko.ibolya@orfi.hu

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Clinical Rehabilitation

Introduction
Osteoporosis is associated with an increased risk of
fracture, which is most commonly induced by falling. About 30% of people over 65years of age
experience a fall every year, almost 20% need
medical care following trauma and these falls are
often disabling or fatal.1 These consequences present a large public health burden.
Loss of balance can be one of the greatest risk
factors for falling in elderly, osteoporotic patients.2
Strengthening the balance and posture of elderly
osteoporotic patients can reduce the risk of falling,
thus preventing fatal events or hospitalization with
enormous healthcare costs. Therefore, exercise
programmes that aim to improve the balance of
patients need to address reduced proprioception
and strengthen sensomotor function as well.3 The
aim of our study was to investigate the effectiveness of a 12-month sensomotor Balance Training
Programme (BTP) on postural control, and the frequency of falling in women with established osteoporosis using both the performance tests and the
computerized stabilometer as well.

Data and method

Patients and study setting
All women aged 65 and over, who were examined
in the Osteoporosis Outpatient Clinic of the National
Institute of Rheumatology and Physiotherapy,
Budapest, one year before study were screened.
Demographic data and baseline characteristics were
collected using a questionnaire and have been summarized in Table 1.
Inclusion criteria were that only the patients
with osteoporosis, classified using the World
Health Organization diagnostic criteria for established osteoporosis in postmenopausal women,4
were used for the study. These patients had a bone
mineral density T-score lower than 2.5 in the lumbar spine, femoral neck or total femur region, and
in the history at least one osteoporotic fracture.
Exclusion criteria included visual deficiency,
severe auditive or vestibular deficiency, advanced
locomotor diseases, women who used assistive
walking devices or who were unable to walk

independently more than 10 metres, progressive

neurological or unstable cardiovascular diseases
and participation in a regular physical exercise programme in the past six months.
Eligible patients were randomized (using a
numbered series of prefilled envelopes specifying
the group) into two groups: The intervention group
who followed the BTP, and the control group who
only received osteoporosis treatment and had no
intervention. Given the large available database,
equal numbers of patients were selected for the
intervention and the control groups (Figure 1).
An informed consent form was obtained from all
participants prior to the study. The study was
approved by the regional ethics committee (Scientific
Research and Ethics Committee of Semmelweis
University). The study was carried out between 1
January 2011 and 31 March 2012.

Outcomes
Assessment of balance.Balance of all patients in
static and dynamic posture were measured at the
start, at three months and at the end of the trial by
an assessor physiotherapist who was blinded to
both groups. Performance-based measurements of
balance, such as the Berg Balance Scale and the
Timed Up and Go Test, were used to measure balance in the patient population.57 In addition to
these measurements, as a novelty in our study,
static and dynamic postural balance were also
assessed by the Bretz stabilometer,8 a computerized way of studying the balance of elderly patients.
The Bretz stabilometer, similar to other new
balance assessment tools,9 is proven to be a reliable
device for the quantitative assessment of postural
sway during stance, which allows static as well as
dynamic posturometric examinations.
Static postural balance was measured by two
tests, which were carried out while patients were
standing straight, feet together and arms extended
parallel to the ground for 20seconds with eyes
open (Romberg 1 position) and eyes closed
(Romberg 2 position).8 The movement of the
patients centre of pressure was visualized on a
monitor by individual dots forming a line on a
plane with X and Y coordinates. The main outcome

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Mik et al.
Table 1. Baseline characteristics of participants (n=100).
Group

Intervention group (n=50)

Control group (n=50)

Mean (SD)

Mean (SD)

Age (years)
BMI
Medical history
Hip osteoarthritis, number (%)
Knee osteoarthritis, number (%)
Diabetes mellitus, number (%)
Hypertension, number (%)
Pulmonary disease, number (%)

69.33 (4.56)
24.17

69.10 (5.3)
24.38

1 (2)
2 (4)
6 (12)
29 (58)
2 (4)

0 (0)
3 (6)
4 (8)
31(62)
1 (2)

P-value

0.926
0.947

0.327
0.655
0.511
0.514
0.568

Categorical data are presented as frequency and percentage, continuous data are presented as mean and standard deviation (for
normally distributed data).
BMI: body mass index.

variable of the tests was the radius of the circle that

captured 95% of these individual dots on the plane.
Dynamic postural balance was assessed using
Dynamic 1, 2 and 3 tests.8 During these tests the
patients moved the centre of pressure of their bodies on the stabilometers force platform, and movements away from the centre were visualized on the
monitor connected to the platform. The time
needed to carry out the three tasks was measured
and recorded.
Frequency of falling. During the study year, patients
in both the intervention and control groups kept a
fall diary, in which they recorded every fall and
its circumstances and the frequency of falling was
assessed based on this fall diary.

Interventions
Our BTP compiled by physiotherapists is a combination programme between conventional back, torso
and lower extremity muscle strengthening exercises10,11 and the proprioceptive dynamic posture
training,12 modified in its sensomotory elements in
order to improve balance control and reduce falling
in the study population. This exercise programme
follows a learning principle, which strengthens and
improves the function of the deep and postural muscles by making patients perform specific exercises.
There are three levels of progressivity within the
BTP, which are performed in a step-wise manner.

The first, static phase, where the focus is on stabilization, has to be completed for the patient to be able
to progress to the next, dynamic phase, which is
used to practise balancing, and additionally arm and
leg exercises. The final phase is the functional
phase. The goal of this phase is to achieve automatic stabilization of the torso when performing
different exercises and the activities of daily life.
The functional phase also assists patients in developing stabilization skills when changing position
and posture during sports and work activities.
Patients included in the intervention group did
the exercises twice a week in the outpatient setting,
guided by physiotherapists who compiled the BTP.
For the rest of the week, they continued exercises
60minutes a day based on an exercise booklet individually at home.

Statistical methods
A statistical analysis was carried out using SPSS
version 19.0 for Windows software. The baseline
characteristics of the patients were analysed using
descriptive statistic.
Independent-sample t-tests and MannWhitney
U-tests for continuous data and test for categorical
data were used to compare baseline values of the intervention and control groups and to determine whether
there was a statistically significant difference between
the outcomes of the intervention and control groups
postintervention (statistically significant difference

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Clinical Rehabilitation

Figure 1. Flow of participants through the study.

was considered at p<0.05). Relative risk was also calculated for falling.

Results
Performance-based measurements of
balance
The Berg Balance Scale and the Timed Up and Go
Tests showed a statistically significant improvement of balance and stability in the intervention
group after the completion of the one-year BTP
(Table 2).

Stabilometric balance tests

The static postural balance tests (Romberg 1,
Romberg 2) showed statistically significant
improvement in patients who completed the BTP,
compared with control patients receiving no intervention apart from osteoporosis treatment, at oneyear follow-up. Results were also significant at the
three-month follow-up for the closed but not the
open-eyed tests (Table 3).
The effect of the BTP on the dynamic postural
balance was confirmed by the dynamic balance
tests, which showed a significant improvement in

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Mik et al.
Table 2. Performance-based tests results at three-month and at one-year follow-up.

Intervention group
Mean time (seconds) at

Berg Balance
Scalea
Timed Up
and Go Testa

Control group
Mean time (seconds) at

P-value
(one year)

Baseline

3 months

1 year

Baseline

3 months

1 year

49.23
(46.6351.83)
8.89
(6.7711.01)

46.11
(45.5646.66)
7.27
(6.168.38)

42.27
(40.4744.07)
6.74
(5.847.64)

48.52
(38.7258.32)
9.95
(6.4613.44)

49.10
(38.3559.85
10.43
(5.9214.94)

50.15
0.001*
(44.9555.35)
10.64
0.005*
(6.6214.66)

aValues are presented as mean (SD).

*Significant result.

Table 3. Static postural balance tests results at three-month and one-year follow-up.

Romberg
1 (openeye)a
Romberg
2 (closedeye)a

Intervention group
Average radius (mm) of body centre
movement circle

Control group
Average radius (mm) of body centre
movement circle

Baseline

Baseline

3 months

1 year

3 months

P-value P-value
(at 3
(at 1
months) year)

1 year

14.25
12.05
10.47
13.73
14.83
14.50
0.09
(11.6516.85) (9.2514.85) (8.7712.17) (10.4916.97) (11.8517.81 (12.1216.88

0.001*

20.87
18.27
16.07
19.76
20.88
19.75
0.01
(18.1723.57) (16.3720.17) (13.8718.27) (16.1623.36) (18.4823.28) (17.1522.35)

0.001*

aValues are presented as mean (SD).

*Significant result.

the intervention group at one-year follow-up, but

the results were not statistically significant at threemonth follow-up. In the first two tests (Dynamic 1
and 2) and in the third dynamic tests (Dynamic 3)
patients completed the exercises in a significantly
shorter time in the intervention group at one-year
follow-up than the control group, proving the efficacy of the training programme in terms of the
patients improved postural balance and mobility
(Tables 45).

Frequency of falling
The number of falls was seven in the intervention group and 16 in the control group. The number of patients who fell in the study year was six
in the intervention group and 11 in the control
group.

The relative risk of falling in the intervention

group was 0.12 and 0.229 in the control group,
respectively (p<0.05).

Discussion
The first controlled, randomized study, which
examined the effects of physical activity in women
with decreased bone mineral density, was published in 1996.13 Therefore, a large range of literature is available for review. Several studies use
body balance and its changes to assess the results
of exercise programmes in osteoporotic patie
nts.1421 There were no systematic reviews or metaanalyses performed in this field for us to study.
Most previous researchers use performance tests,
such as the Timed Up and Go Test, standing on one
leg and the Berg Balance Scale, which evaluate

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Clinical Rehabilitation

Table 4. Dynamic postural balance test (12) results at three-month and one-year follow-up.
Intervention group
Mean time (seconds) to complete exercise at

Control group
Mean time (seconds) to complete exercise at

Baseline

3 months

1 year

Baseline

3 months

1 year

Dynamic
1a
Dynamic
2a

13.15
(8.6217.68
5.74
(0.4410.77)

13.05
(9.1517.85)
5.54
(0.6410.44)

11.05
(6.9416.06)
4.22
(0.428.02)

13.25
(7.7518.75)
5.80
(1.210.4)

13.10
(818.2)
5.65 (1.269.86)

14.00
(9.0618.94)
5.57
(0.8710.27)

P-valueb

0.001*
0.003*

aValues

are presented as mean (SD).

one-year follow-up.
*Significant result.
bAt

Table 5. Dynamic postural balance test (3) results at three-month and one-year follow-up.
Intervention group
% of assigned time spent within boundaries

Control group
% of assigned time spent within boundaries

Baseline

3 months

Baseline

Dynamic
3a

88.07
(79.297.57)

90.15
93.72
88.87
89.95
88.76
0.001*
(83.1197.19) (87.12100.32) (80.1397.61) (81.6198.29) (80.8696.66)

1 year

3 months

P-value

1 year

aValues

are presented as mean (SD).

one-year follow-up.
*Significant result.

At

balance in a functional approach. Madureira and

colleagues assessed the effect of a BTP on the
functional status of elderly osteoporotic women in
Brazil using such performance tests.3
In contrast, postural studies using a computerized method examine the swaying movement of the
body, which is a physiological test.
Our study is the first to our knowledge that
used both types of balance examinations to assess
the effectiveness of a 12-month sensomotor balance exercise programme on postural control and
the incidence of falling in women with established
osteoporosis.
The stabilometric measurements that were carried out in our study an example of a postural balance examination provided us with a more
objective and reliable measurement of improved
balance than using only performance-based tests.
Both static balance parameters showed a significant
improvement in the intervention group at one-year
follow-up; the closed-eye test (Romberg 2) was significant already at the three-month follow-up. The

dynamic balance data evaluation revealed an even

more interesting correlation. While the static balance results demonstrated significant improvement
already at the three-month follow-up in the intervention group, the dynamic balance test results did
not show significant improvement at three months.
However, the one-year test results did confirm significant improvement in the dynamic balance
parameters; a plausible explanation for this phenomenon is that the balance exercise programme
had to be completed for the dynamic balance
parameters to improve significantly compared with
patients not following the BTP.
The balance examinations of this study prove
that our new, complex BTP, which is a combination programme between conventional muscle
strengthening exercises and the proprioceptive
dynamic posture training, modified in its sensomotory elements, can improve the balance parameters of postmenopausal women who have
already suffered at least one previous osteoporotic fracture. According to the results of this study,

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Mik et al.
the one-year exercise programme also significantly
decreased the observed rate of falling in the intervention group compared with the control group.
Results confirm our hypothesis that exercise programmes, which aim to address reduced proprioception and strengthen sensomotor function in
addition to strengthening the muscles, are effective
in reducing the number of falls owing to balance
instability for established osteoporotic women.
The study has some limitations. Exercises conducted by patients at home were not supervised by a
physician, which could have had a negative impact
on the quality of the exercises performed. We did not
collect information about the fear of falling given
the lack of suitable questionnaires in Hungarian.
Our results are only generalizable to postmenopausal women with established osteoporosis.
Further research should be conducted on a larger
and international sample for a longer follow-up
period to assess the long-term effectiveness of the
complex BTP on the improvement of balance, and
consequently on reduction in the number of falls of
postmenopausal osteoporotic patients.
In conclusion, the 12-month exercise programme
significantly improved the balance parameters and
reduced the number of falls in postmenopausal
patients who had already suffered at least one fracture in the past. Therefore, we recommend the incorporation of the BTP in everyday rheumatological
practice exercise regimes to reduce the risk of further
fractures for postmenopausal osteoporotic women.
Clinical messages
The complex Balance Training
Programme described herein reduced
the frequency of falls in women with
established osteoporosis over a period
of one year.
The programme improved balance measured quantitatively by performance and
stabilometric tests.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publication of this article.

Funding
The author(s) received no financial support for the
research, authorship, and/or publication of this article.

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