RESEARCH ARTICLES
Sensory-Challenge Balance Exercises Improve
Multisensory Reweighting in Fall-Prone Older Adults
Leslie K. Allison, PT, PhD, Tim Kiemel, PhD, and John J. Jeka, PhD
Background and Purpose: Multisensory reweighting (MSR)
deficits in older adults contribute to fall risk. Sensory-challenge bal-
ance exercises may have value for addressing the MSR deficits in
fall-prone older adults. The purpose of this study was to examine the
effect of sensory-challenge balance exercises on MSR and clinical
balance measures in fall-prone older adults.
Methods: We used a quasi-experimental, repeated-measures, within-
subjects design. Older adults with a history of falls underwent an
8-week baseline (control) period. This was followed by an 8-week
intervention period that included 16 sensory-challenge balance exer-
cise sessions performed with computerized balance training equip-
ment. Measurements, taken twice before and once after interven-
tion, included laboratory measures of MSR (center of mass gain and
phase, position, and velocity variability) and clinical tests (Activities-
specific Balance Confidence Scale, Berg Balance Scale, Sensory Or-
ganization Test, Limits of Stability test, and lower extremity strength
and range of motion).
Results: Twenty adults 70 years of age and older with a history
of falls completed all 16 sessions. Significant improvements were
observed in laboratory-based MSR measures of touch gain (P =
0.006) and phase (P = 0.05), Berg Balance Scale (P = 0.002), Sensory
Organization Test (P = 0.002), Limits of Stability Test (P = 0.001),
and lower extremity strength scores (P = 0.005). Mean values of
vision gain increased more than those for touch gain, but did not
reach significance.
Discussion and Conclusions: A balance exercise program specifi-
cally targeting multisensory integration mechanisms improved MSR,
balance, and lower extremity strength in this mechanistic study.
These valuable findings provide the scientific rationale for sensory-
Department of Physical Therapy, Winston-Salem State University, Winston-
Salem, North Carolina (L.K.A.); Department of Kinesiology, University
of Maryland, College Park (T.K.); and Department of Kinesiology and
Applied Physiology, University of Delaware, Newark, Delaware (J.J.J.).
Preliminary findings were presented at the Combined Sections Meeting of the
American Physical Therapy Association in Tampa, Florida, February 2003.
This research was supported by a grant from The Erickson Foundation.
The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions
of this article on the journal’s Web site (www.jnpt.org).
Correspondence: Leslie K. Allison, PT, PhD, Department of Physical Ther-
apy, School of Health Sciences, Winston-Salem State University, 342 FL
Atkins Bldg, 601 S. Martin Luther King Jr Dr, Winston-Salem, NC 27110
(allisonlk@wssu.edu).
Copyright  C 2018 Academy of Neurologic Physical Therapy, APTA.
ISSN: 1557-0576/18/4202-0084
DOI: 10.1097/NPT.0000000000000214
84
Copyright © 2018 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
challenge balance exercise to improve perception of body position
and motion in space and potential reduction in fall risk.
Key words: exercise, falls, multisensory reweighting, postural
control
(JNPT 2018;42: 84–93)
INTRODUCTION
F all-prone older adults have multiple risk factors, particu-
larly imbalance.1,2 Horak et al3,4 described a postural con-
trol model indicating how age- and disease-related changes in
postural control system components lead to balance deficits
and falls. One critical component is multisensory reweighting
(MSR), an adaptive central nervous system process to estimate
body position and motion in space.5-7 Multisensory reweight-
ing of visual, vestibular, and somatosensory inputs allows us
to maintain balance as environmental conditions change.8-11
Multisensory reweighting is impaired in healthy older adults
and more so in the fall-prone elderly.3,12,13 Healthy older adults
rapidly adapt to changing environments; fall-prone older adults
do not.3,13-22 Impaired MSR may, therefore, be associated with
increased fall risk.
Balance exercise interventions reduce fall risk.23-26
However, it is not known which types of balance exercises best
remediate specific balance impairments, nor do we understand
the mechanisms by which exercise might mediate changes in
one or more components of the postural control system.27 This
gap in our knowledge hampers clinical decision making.28
Sensory-challenge balance exercises contribute to im-
proved balance and reduced fall risk.29,30 Whipple27 system-
atically reviewed 25 balance training studies performed with
older adults. He found that successful exercise interventions in-
corporate sensory challenge activities. However, to our knowl-
edge, no previous balance exercise intervention studies have
restricted the intervention only to sensory-challenge balance
exercises, excluding dynamic balance exercises, functional
balance activities, or other forms of exercise.
Because prior studies used various types of balance ex-
ercises and other forms of exercise (eg, strengthening, stretch-
ing, aerobics) in addition to sensory-challenge exercises, it
is not possible to separately assess the potential effects of
the sensory challenge exercises. Furthermore, previous stud-
ies did not use discriminatory measures of MSR, nor examine
whether changes in balance and fall risk occurred concurrently
with changes in MSR. These studies used overall postural sway
JNPT r Volume 42, April 2018
JNPT r Volume 42, April 2018 Sensory-Challenge Balance Exercises

measures that do not discriminate changes in sensory reweight-

ing from other postural control processes that affect sway.31
We explored MSR as a specific adaptive balance con-
trol mechanism using methods that permitted MSR changes
to be explicitly determined.31,32 Exercises challenged sensory
reweighting abilities by manipulating surface and visual con-
ditions such that MSR would benefit postural stability. The
purposes of this study were to (1) measure whether sensory-
challenge exercises influenced MSR and (2) determine
whether MSR changes were associated with improvements
in clinical measures of balance and fall risk. Other influential
postural control system components were also measured to
isolate MSR contributions to changes in balance and fall risk.

METHODS
Design
We used a quasi-experimental, repeated-measures,
within-subjects design in which participants served as their
own controls. All tests were performed 3 times: pretest 1,
pretest 2, and posttest. One 8-week no-training control period
(between pretests 1 and 2) and one 8-week training period
(between pretest 2 and posttest) were provided.

Participants
Adults 70 years of age and older with a history of falls
in the prior year were recruited from a congregate retirement
community. A fall was defined as an event resulting in a
person coming to rest inadvertently on the ground, floor, or
other lower level.33 Volunteers were screened via an eligibil-
ity questionnaire, telephone screening, and clinical screening
by an experienced physical therapist (for exclusion criteria and
screening tests, see Supplemental Digital Content 1, Appendix
1, http://links.lww.com/JNPT/A202) The participant recruit-
ment, screening, testing, and attrition process is illustrated in
Figure 1.
This study was approved by the Institutional Review
Board at the University of Maryland, College Park. Written
consent was obtained from all participants according to the
guidelines proscribed by the Institutional Review Board at the
University.
Outcome Measures
Laboratory MSR Assessment
The MSR experimental paradigm (Figure 2) has been
previously described.31,34 Briefly, participants stood in front of
a large rear-projection screen on a force plate (Kistler Instru-
ment Corp, Amherst, New York) in a modified tandem stance.
The narrowed stance induced mild instability to heighten the
need for attention to sensory inputs. They wore goggles limit-
ing their peripheral vision. Participants lightly touched a fin-
gertip force plate, located at hip height on the right side. This
force plate sounded an alarm if the touch force exceeded 1 N.
Both visual and touch motion stimuli oscillated mediolaterally.
Medial-lateral center of mass (COM) motion was
approximated using an ultrasound position tracking system
(Logitech, Inc, Fremont, California). A posterior tracking
sensor was attached to a waist belt. Participants wore a harness
attached to the ceiling with slack straps to permit postural
Figure 1. Flowchart of participant recruitment, testing, and
attrition.
sway but prevent a fall. An assistant stood close behind each
participant. Data were sampled at 50 Hz.
Postural sway measures in the time domain (Figure 3)
were converted to the frequency domain (Figure 4) to allow
the discrimination of postural response adaptations to separate
visual and touch stimuli. Each sensory motion input stimulus
was provided at a different frequency. The visual display and
fingertip touch plate were simultaneously oscillated mediolat-
erally at 0.20 and 0.28Hz, respectively. The peak amplitudes of
the 2 stimuli were varied such that across 5 conditions, touch
motion amplitude declined while visual motion amplitude in-
creased (see Table 1).
Participants performed 3 trials in each of the 5 con-
ditions (15 total). Trial duration was 120 s, with the order
of trials pseudorandomized within 5-trial blocks. Seated rests
were taken between trials.
Clinical Assessment
To determine whether improvements in MSR were as-
sociated with improvements in balance measures associated


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Allison et al JNPT r Volume 42, April 2018

Figure 3. Time series. Three exemplar time series are shown

from 1 fall-prone older adult at pretest 1 (top), pretest 2
(center), and posttest (bottom). A 125-s segment of data
from each test session shows the time series of visual display
motion at 0.2 Hz (upper trace), mediolateral center of mass
displacement (middle trace), and touch surface motion at
0.28 Hz (lower trace). In these exemplars, visual motion
amplitude is 4 mm and touch surface motion amplitude is
2 mm.
Figure 2. Experimental setup. A participant is illustrated in a
modified tandem stance facing the computer-generated
visual display while lightly contacting the touch surface with ronments (see Supplemental Digital Content 1, Appendix
her right fingertip. Markers on the occiput and lower lumbar 1, http://links.lww.com/JNPT/A202). All exercises were
region tracked the trajectories of the head and estimated performed on a SMART Balance Master (NeuroCom Inter-
center of mass, respectively. national, Inc, Clackamas, Oregon; now Natus Medical, Inc,
Pleasanton, California), a computerized balance testing and
training device. We chose to use this equipment because it pro-
with fall risk, the Berg Balance Scale (BBS) was used as a
vides operator-controlled surface and/or visual environment
global balance and fall-risk measure.35-39 Multiple impairment
motion that can be finely graded up or down in small, quantifi-
outcome measures associated with fall risk were also used, in-
able increments that are precisely repeatable between sessions
cluding the Activities-specific Balance Confidence Scale,38,40
and participants and closely matched to participant ability lev-
composite bilateral lower extremity range of motion (goniome-
els. If desired, the equipment also provides visual feedback
try) and strength (hand-held dynamometer; Chatillon CSD100,
AMETEK, Inc, Largo, Florida),41-44 the Sensory Organiza-
tion Test (NeuroCom International, Inc, Clackamas, Oregon,
now Natus Medical, Inc, Pleasanton, California),10-13,32,45-47
and Limits of Stability Test (NeuroCom International, Inc,
Clackamas, Oregon, now Natus Medical, Inc, Pleasanton,
California).30,48 Each of these tests has been shown to be
reliable with older adults. Appendix 2 describes these tests
(see Supplemental Digital Content 2, Appendix 2, http://links.
lww.com/JNPT/A202). All clinical testing was performed by
an experienced PT prior to laboratory testing.

Intervention
Sensory Challenge Balance Exercise Program
Participants attended two, 45-minute exercise sessions
each week for 8 weeks. All sessions occurred in an outpatient
physical therapy clinic in the congregate retirement commu-
nity. One-on-one sessions were provided by trainers (1 physical
therapist and 2 physical therapist assistants) who were blinded
to test results and trained in the exercise protocol by 1 author
who is a physical therapist.
The exercise program was designed (by author LKA)
to improve (1) estimation of body position and motion
in space and (2) adaptation to changing sensory envi-
Figure 4. A-E. Amplitude spectra. Five exemplar amplitude
spectra are shown for visual display motion (A), touch surface
motion (B), and center of mass displacements from the same
fall-prone older adult in Figure 3 at pretest 1 (C), pretest 2
(D), and posttest (E). In these exemplars, visual motion
amplitude is 4 mm and touch surface motion amplitude is
2 mm. Note the lower posttest center of mass response
amplitudes to the dynamic vision and touch stimuli.

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JNPT r Volume 42, April 2018
Table 1. Sensory Stimulus Motion Amplitudes Across Conditions
Sensory Stimulus
Motion Amplitudes Condition 1 Condition 2
Touch, mm 8 4
Vision, mm 2 2
Postural stability Upweight vision; Upweight vision;
benefits from Downweight touch Downweight touch
about center-of-gravity position and motion to promote early
motor learning. Participants stood quietly, with instructions to
avoid “standing too stiffly, like a soldier”, to achieve maxi-
mum stability in each exercise. Stability was challenged by
progressively reducing base-of-support size, reducing target
size to increase the control demand, and making the motion
of the support surface and visual surround larger and less
predictable.
All participants followed the same standardized balance
exercise progression, with the initial exercise difficulty level
adjusted for each participant. Balance exercises became pro-
gressively more difficult over the 16 sessions. Visual center
of gravity feedback was provided during and weaned over
the first 8 training sessions to facilitate the development of
correct spatial orientation. Supplemental Digital Content 1,
Appendix 3, http://links.lww.com/JNPT/A202, describes the
progression of balance exercise tasks and environmental mo-
tion conditions and the reduction in visual center of gravity
feedback.
Data Analysis
Conversion of Data From Time Series to Frequency
Domain
A sample time series of the medial-lateral COM postural
sway data and the visual and touch motion stimuli is shown
in Figure 3. To represent the same data in the frequency
domain, the amplitude spectrum was computed from the time
series by taking the absolute value of the Fourier transform
(Figure 4A-E).
For each sensory input (vision or touch) the mathemati-
cal transfer function at the stimulus frequency was calculated
by dividing the transformed COM postural sway by the trans-
formed sensory stimulus motion. From each transfer func-
tion, we obtained 2 COM motion variables, gain and phase,
that together represent how the participant responded to the
sensory stimuli motions. Changes in the sensitivity and tim-
ing of the postural sway response to the unique vision/touch
motion frequencies (0.2 Hz/0.28 Hz) were indicated by gain
and phase values, respectively. The postural sway response at
all frequencies other than the 2 stimulus frequencies is the
residual COM displacement and was used to calculate 2 ad-
ditional variables, position variability and velocity variabil-
ity. Hence, the 6 dependent variables in the MSR analysis
were vision and touch gain, vision and touch phase, posi-
tion variability, and velocity variability. Supplemental Digital
Content 1, Appendix 4, http://links.lww.com/JNPT/A202, de-
scribes these measures and the rationale for their inclusion in
this study. Supplemental Digital Content 1, Appendix 5,
http://links.lww.com/JNPT/A202, contains a list of definitions

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Copyright © 2018 Academy of Neurologic Physical Therapy, APTA. Unauthorized reproduction of this article is prohibited.
Sensory-Challenge Balance Exercises
Condition 3 Condition 4 Condition 5
2 2 2
2 4 8
Neutral Upweight touch; Upweight touch;
Downweight vision Downweight vision
for many terms used in this article that may or may not be
familiar to the reader.
Statistical Analysis
All statistical analyses were performed using SPSS Ver-
sion 12. Multisensory reweighting gain and phase data were
analyzed with a Test by Condition (3 × 5) repeated measures
(RM) multivariate analysis of variance (MANOVA). Position
variability and velocity variability were examined separately
with a Test by Condition (3 × 5) RM-MANOVA. Each RM
MANOVA was followed by planned multiple pairwise com-
parisons with Bonferroni correction to P ≤ 0.05.
Differences in scores from the ABC Scale and BBS were
analyzed using Freidman test, with planned multiple pairwise
comparisons performed using related samples paired t tests
with Bonferroni correction to P ≤ 0.016. Four composite
scores were compiled from the (1) bilateral lower extremity
range of motion, (2) bilateral lower extremity strength mea-
sures, (3) the SOT Equilibrium scores, and (4) the LOS Max-
imum Excursion scores. These composite scores were exam-
ined using a 3 × 3 (Test by Trainer) RM MANOVA. Unless
otherwise noted, significance was set at 0.05 or less for all
analyses. Nonsignificant results are not reported.
RESULTS
Of the 33 participants who were enrolled in the study, 20
completed all training and testing sessions. Participants had
a history of 1 or more unexplained falls within the past year
(range: 1-6, mean = 3). The first stage of screening was a
questionnaire; 95/104 were returned. Thirty-three volunteers
were excluded at this stage due to medical conditions (N = 23)
and major polypharmacy (N = 10). Telephone calls were made
to the remaining 62 volunteers; at this stage, 16 volunteers de-
clined to participate further. Forty-six volunteers underwent
clinical screening, and 13 of these were excluded due to sen-
sory loss (N = 11) and frailty (N = 2). Thirty-three fall-prone
older adults were accepted into the study. Twenty-eight partici-
pants (22 female; mean age of 83 ± 5 years) began the training
program and 20 finished all 16 sessions. The primary reasons
reported for discontinuing the study were problems related to
age: health status changes (N = 6) and caregiver burden (N =
4). The exercise program was well tolerated, with partici-
pants reporting temporary fatigue after exercise but no adverse
effects.
Multisensory Reweighting Outcome Measures
At all 3 test periods, we saw decreasing vision gains
with increasing visual motion amplitudes and increasing touch
gains with decreasing touch motion amplitudes (Figure 5A
and B). Significant differences between Conditions were found
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Figure 5. A-D. Group mean gain and phase results. The group mean (± SE) scores on the Y-axis for visual gain (A), touch gain
(B), visual phase (C), and touch phase (D), versus test condition on the X-axis, at each of the 3 test periods (3 lines). In 5A, note
that vision gain values decrease as visual motion stimulus amplitude increases (intramodality reweighting) and as touch motion
stimulus amplitude decreases (intermodality reweighting). Also note that vision gain values are lower after training, though not
statistically significantly so, reflecting less influence of environmental motion stimuli on postural sway. In 5B, note that touch
gain values increase as touch motion stimulus amplitude decreases (intramodality reweighting) and as visual motion stimulus
amplitude increases (intermodality reweighting). Also note that touch gain values are lower after training, reflecting less
influence of environmental motion stimuli on postural sway. In 5C, note the general lack of change in vision phase values
between conditions. After training, these phase values are generally higher, indicating a slightly greater lead of postural sway to
the visual motion stimulus. In 5D, note the slight decline in touch phase values between conditions. After training, these phase
values are generally higher, indicating slightly less lag of postural sway to the touch motion stimulus.

for touch phase, but not for vision phase (Figure 5C and
D). Following training, both vision and touch gain values de-
creased overall.
The RM-MANOVA multivariate analysis for vision and
touch gain and phase revealed significant main effects for Test
(Wilks’ Lambda: 0.735, F = 2.119, P = 0.041) and Condition
(Wilks’ Lambda: 0.073, F = 30.814, P ≤ 0.001) but no Test
by Condition interaction. For the main effect of condition,
univariate tests revealed statistically significant changes for
touch gain (F = 69.005, P ≤ 0.001), touch phase (F = 7.478,
P ≤ 0.001), and vision gain (F = 85.838, P ≤ 0.001) but not for
vision phase. Significant differences between Conditions were
found for vision and touch gains and touch phase (Figure 5A,
B and D respectively). Planned pairwise comparisons revealed
significant differences between numerous pairs of conditions
for vision gain, touch gain, and touch phase (see Table 2).
The second RM-MANOVA for position and velocity
variability revealed a significant main effect only for Condi-
tion (Wilks’ Lambda: 0.699, F = 10.527, P ≤ 0.001). Univari-
ate tests revealed statistically significant changes for position
variability (F = 4.728, P = 0.002) and velocity variability
(F = 22.878, P ≤ 0.001). Significant differences in posi-
tion and velocity variability between Conditions were found
(Figure 6 A and B). Planned pairwise comparisons revealed
significant differences between numerous pairs of conditions
for position and velocity variability (see Table 2).

88 
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JNPT r Volume 42, April 2018 Sensory-Challenge Balance Exercises

Table 2. Summary of Planned Post hoc Pairwise Analyses for the Main Effect of Condition for the MSR Variables (Vision
Gain, Vision Phase, Touch Gain, Touch Phase, below the diagonal, and Position Variability, and Velocity Variability above
the diagonala )
MSR Sensory
Condition Touch 8: Vision 2 Touch 4: Vision 2 Touch 2: Vision 2 Touch 2: Vision 4 Touch 2: Vision 8
Touch 8: VV P = 0.001 PV P = 0.007 VV P = 0.004
Vision 2 VV P ≤ 0.001
Touch 4: VGn P ≤ 0.001 VV P = 0.004 VV P ≤ 0.001
Vision 2 VPh P = 0.027
TGn P ≤ 0.001
TPh P = 0.017
Touch 2: VGn P ≤ 0.001 TGn P = 0.001 VV P = 0.004 PV P = 0.009
Vision 2 TGn P ≤ 0.001 VV P = 0.001
TPh P = 0.037
Touch 2: VGn P ≤ 0.001 VGn P < 0.001 VGn P ≤ 0.001 PV P = 0.020
Vision 4 TGn P ≤ 0.001 TGn P = 0.001 VV P < 0.001
TPh P ≤ 0.001
Touch 2: VGn P ≤ 0.001 VGn P ≤ 0.001 VGn P ≤ 0.001 VGn P ≤ 0.001
Vision 8 TGn P ≤ 0.001 TGn P ≤ 0.001
TPh P = 0.028
Abbreviations: MSR, multisensory reweighting; PV, position variability; TGn, touch gain; TPh, touch phase; VGn, vision gain; VPh, vision phase; VV, velocity variability.
a
Planned comparisons revealed significant differences (P ≤ 0.05) between 9 pairs of conditions for vision gain, 7 pairs of conditions for touch gain, 4 pairs of conditions for touch
phase, 3 pairs of conditions for position velocity, and 8 pairs of conditions for velocity variability. The variable(s) indicated in a block were significantly different between the 2 MSR
conditions comprising that pair. For example, the cell at the interception of column Touch 4:Vision 2 and row Touch 2:Vision 2 shows that touch gain was significantly different in
Condition Touch 4:Vision 2 than in Condition Touch 2:Vision 2.

Do Sensory-Challenge Exercises Influence MSR?
From the RM-MANOVA for gain and phase, for the main
effect of test, univariate tests revealed statistically significant
decreases between test periods for touch gain (F = 5.946,
P = 0.005) and touch phase (F = 3.312, P = 0.044) but not for
vision gain or phase. However, in absolute terms, vision gain
decreased more than touch gain (mean change posttraining:
0.282 vs 0.189) (see Figure 5 A and B and Table 3). The power
to detect significant differences in vision gain and phase was
lower than in touch gain and phase (0.389 and 0.197 vs 0.861
and 0.604, respectively). The standard error for vision gain
was over twice that for touch gain (vision SE = 0.16; touch
SE = 0.07). Planned pairwise comparisons found significant
decreases in touch gain between pretest 1 versus posttest (mean
change: 0.239, SE = 0.070, P = 0.001) and pretest 2 versus
posttest (mean change: 0.138, SE = 0.070, P = 0.05), and in

Figure 6. A-B. Group mean position and velocity variability results. The group mean (± SE) scores on the Y-axis for position
variability (A) and velocity variability (B), versus test condition on the X-axis, at each of the 3 test periods (3 lines). In both 6A
and 6B, note that there are only slight changes between conditions, reflecting little change in postural sway at frequencies other
than the driving motion stimulus frequencies. Also note the “U shape” in the pattern of change across conditions, reflecting that
postural sway at frequencies other than the driving motion stimulus frequencies is least when both driving motion stimulus
amplitudes are small and equal.


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Allison et al JNPT r Volume 42, April 2018

Table 3. Results of RM-MANOVA Analyses of Laboratory MSR Data for Between-Test Differencesa
Touch Gain Vision Gain
Between-Test Difference Between-Test Difference
Mean Ratio (SE), Significance Mean Ratio (SE), Significance
Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post
0.101 (0.070) 0.239 (0.070) 0.138 (0.070) 0.023 (0.164) 0.293 (0.164) 0.270 (0.164)
P = 0.15 P = 0.001 P = 0.05 P = 0.892 P = 0.081 P = 0.106
Ratio Values: Mean (SD) Ratio Values: Mean (SD)
Pretest 1 Pretest 2 Posttest Condition Pretest 1 Pretest 2 Posttest
0.495 (0.243) 0.410 (0.197) 0.330 (0.171) Tch-8:Vis-2 2.08 (0.731) 2.05 (0.670) 1.73 (0.668)
0.837 (0.229) 0.853 (0.334) 0.678 (0.243) Tch-4:Vis-2 1.76 (0.662) 1.68 (0.782) 1.36 (0.627)
1.07 (0.321) 1.02 (0.334) 0.839 (249) Tch-2:Vis-2 1.61 (0.712) 1.59 (0.603) 1.34 (0.575)
1.07 (292) 0.985 (0.266) 0.853 (0.320) Tch-2:Vis-4 1.30 (0.689) 1.22 (0.529) 0.961 (0.440)
1.31 (0.434) 1.02 (0.358) 0.891 (0.412) Tch-2:Vis-8 0.713 (0.502) 0.790 (0.497) 0.585 (0.300)
Touch Phase Vision Phase
Between-Test Difference Between-Test Difference
Mean Degree (SE), Significance Mean Degree (SE), Significance
Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post
−0.019 (0.099) − 0.229 (0.099) − 0.210 (0.099) − 0.022 (0.099) − 0.104 (0.099) − 0.126 (0.099)
P = 0.851 P = 0.024 P = 0.038 P = 0.827 P = 0.305 P = 0.214
Degrees: Mean (SD) Degrees: Mean (SD)
Pretest 1 Pretest 2 Posttest Condition Pretest 1 Pretest 2 Posttest
−0.096 (0.352) − 0.012 (0.642) 0.083 (0.540) Tch-8:Vis-2 0.281 (0.312) 0.291 (0.314) 0.498 (0.402)
−0.267 (0.219) − 0.207 (0.354) − 0.145 (0.395) Tch-4:Vis-2 0.392 (0.318) 0.343 (0.293) 0.387 (0.423)
−0.301 (0.281) − 0.250 (0.318) 0.024 (0.458) Tch-2:Vis-2 0.375 (0.380) 0.434 (0.310) 0.545 (0.550)
−0.317 (0.291) − 0.478 (0.461) − 0.132 (0.468) Tch-2:Vis-4 0.346 (0.346) 0.374 (0.235) 0.584 (0.405)
−0.393 (0.280) − 0.334 (0.462) − 0.061 (0.492) Tch-2:Vis-8 0.562 (0.753) 0.404 (0.478) 0.459 (0.631)
Position Variability Velocity Variability
Between-Test Difference Between-Test Difference
Mean cm/s (SE), Significance Mean cm/sec (SE), Significance
Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post Pre 1 vs Pre 2 Pre 1 vs Post Pre 2 vs Post
−0.033 (0.074) 0.080 (0.074) 0.112 (0.074) − 0.020 (0.088) 0.034 (0.088) 0.054 (0.088)
P = 0.658 P = 0.283 P = 0.132 P = 0.818 P = 0.703 P = 0.541
Values in cm/s: Mean (SD) Values in cm/s: Mean (SD)
Pretest 1 Pretest 2 Posttest Condition Pretest 1 Pretest 2 Posttest
0.917 (0.238) 0.944 (0.296) 0.859 (0.261) Tch-8:Vis-2 1.18 (0.317) 1.18 (0.316) 1.06 (0.259)
0.811 (0.238) 0.938 (0.449) 0.823 (0.306) Tch-4:Vis-2 1.01 (0.269) 1.02 (0.216) 1.05 (0.304)
0.797 (0.232) 0.860 (0.354) 0.723 (0.200) Tch-2:Vis-2 0.937 (0.245) 0.975 (0.256) 0.950 (0.249)
0.907 (0.321) 0.823 (0.258) 0.778 (0.219) Tch-2:Vis-4 1.02 (0.287) 1.08 (0.307) 1.02 (0.296)
1.01 (0.453) 1.04 (0.432) 0.859 (0.222) Tch-2:Vis-8 1.24 (0.464) 1.25 (0.432) 1.14 (0.274)
Abbreviations: Pre 1, Pretest 1; Pre 2, Pretest 2; Post, Posttest; Tch, Touch; Vis, Vision.
a
For Each of the 6 Dependent Variables in the RM-MANOVA Analyses of the Laboratory MSR Data (Touch and Vision Gain, Touch and Vision Phase, Position, and Velocity
Variability) Included Here Are (1) the Actual Values (Mean ± SD) in Each of the 5 Test Conditions at Each of the 3 Test Times and (2) for the Main Effect of Test, the Planned Post
hoc Pairwise Analyses for Between-Test Differences. Gain values are calculated as a ratio of the amplitude spectrum value of postural sway at the driving sensory stimulus frequency
divided by the amplitude spectrum value of the driving sensory stimulus (as shown in Figure 4).

touch phase between pretest 1 versus posttest (mean change:
−0.229, SE = 0.099, P = 0.024) and pretest 2 versus posttest
(mean change: −0.210, SE = 0.099, P = 0.038).
Are Posttraining Changes in MSR Accompanied
by Improvements in Clinical Measures
of Balance and Fall Risk?
Clinical outcome results are reported in Table 4. Fried-
man test indicated significant between-test differences for the
BBS (P ≤ 0.001). Planned related samples paired t tests
(Bonferroni-corrected significance level, P < 0.016) demon-
strated significant differences between pretest 1 versus pretest
2 (P = 0.006), pretest 1 versus posttest (P ≤ 0.001), and pretest
2 versus posttest (P = 0.002).
A Test by Trainer (3 × 3) MANOVA for the SOT,
LOS, and lower extremity strength scores found a significant
main effect for Test only (Wilks’ Lambda: 0.154, F = 8.000,
P ≤ 0.001). Univariate tests revealed significant differences

90 
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JNPT r Volume 42, April 2018 Sensory-Challenge Balance Exercises

Table 4. Clinical Test Results

Overall Sig Pretest 1 vs Pretest 1 vs Pretest 2 vs
Pretest 1, Pretest 2, Posttest, Diff (for any Pretest 2 (Sig Posttest (Sig Posttest (Sig
Test M (SD) M (SD) M (SD) Test Pair) Diff at Baseline) Diff After Rx) Diff After Rx)
ABC (0-160 pts) 124.38 (28.80) 127.29 (21.50) 133.43 (24.42) Friedman No Sig Diff, NA NA NA
P = 0.115
BBS (0-56 pts) 48.67 (5.41) 50.43 (4.84) 51.76 (3.75) Friedman, P < 0.001 P = 0.006 P ≤ 0.001 P = 0.002
Composite bilateral LE 162.8 (41.2) 165.7 (41.3) 180.9 (41.4) MANOVA, P < 0.001; No Sig Diff, P = 0.051 P = 0.005
Strength (lbs of force) Univariate, P = 0.013 P = 0.674
Composite bilateral LE 752.24 (29.08) 751.76 (20.92) 757.52 (18.02) MANOVA, P < 0.001; NA NA NA
ROM (0◦ -870◦ ) Univariate No Sig Diff,
P = 0.227
SOT composite score 62.7 (12.7) 69.2 (10.5) 78.0 (8.5) MANOVA, P < 0.001; P = 0.004 P ≤ 0.001 P = 0.002
(0%-100%) Univariate, P ≤ 0.001
LOS mean Maximum 59.67 (12.52) 61.62 (13.01) 69.57 (12.64) MANOVA, P < 0.001; No Sig Diff, P ≤ 0.001 P = 0.001
Excursion (0%-100%) Univariate, P ≤ 0.001 P = 0.216
Abbreviations: ABC, Activities-specific Balance Confidence Scale; BBS, Berg Balance Scale; LE, Lower Extremity; LOS, Limits of Stability Test; MANOVA, multivariate analysis
of variance; NA, not applicable; pts, points; ROM, range of motion; Rx, Intervention; Sig Diff, Significant Difference; SOT, Sensory Organization Test.

between tests for the composite SOT Equilibrium scores (F
= 25.979, P ≤ 0.001), LOS Maximum Excursion scores (F
= 21.882, P ≤ 0.001), and lower extremity strength scores (F
= 5.846, P = 0.006) but not for the ABC or lower extremity
composite range of motion scores.
Significant differences were found for the compos-
ite SOT Equilibrium score between pretest 1 versus pretest
2 (P = 0.011), pretest 1 versus posttest (P ≤ 0.001), and pretest
2 versus posttest (P ≤ 0.001). For the composite LOS Max-
imum Excursion scores, significant differences were found
between pretest 1 versus posttest (P ≤ 0.001) and pretest 2
versus posttest (P ≤ 0.001). For the composite lower extrem-
ity Strength scores, significant differences were found between
pretest 1 versus posttest (P ≤ 0.028) and pretest 2 versus
posttest (P = 0.003).
To determine whether the increase in strength scores ex-
plained the improved SOT, LOS, and BBS scores, 2 unplanned
repeated measures multivariate analysis of covariance analy-
ses were run with strength as the covariate. In the first, these
3 outcome measures were the dependent variables. In the sec-
ond, the differences in scores between tests were the dependent
variables. For both analyses, all previously reported significant
effects were maintained. Significant differences in scores fol-
lowing training (pretest 2 vs posttest) were observed for the
SOT (P = 0.001), LOS (P = 0.003), and BBS (P = 0.007),
indicating that strength was not a factor.
DISCUSSION
Sensory-Challenge Exercises Influence MSR
Prior to training, vision and touch gain values for fall-
prone older adults were markedly higher than for healthy young
and older adults.11,32 After training, the range of gain values
in the fall-prone older adults was decreased such that it was
similar to that of healthy young adults. This finding may re-
flect improved discrimination and dissociation of self-motion
from environmental motion. Posttraining declines in vision
and touch gain values cannot be attributed to an overall reduc-
tion in residual postural sway, since there was no posttraining
difference in position or velocity variability. These results may
represent a generalized ability to suppress or decouple from
environmental motion cues, since no training under laboratory
testing conditions occurred.49 The sensory-challenge exercise
program did improve MSR in these fall-prone older adults.
Posttraining Changes in MSR Are Accompanied
by Improvements in Clinical Measures of
Balance Associated With Fall Risk
Our pretraining findings of low scores on the clinical
outcome measures were expected and consistent with results
from previous studies.29,30,50-52 After training, we observed
increased scores on the BBS, SOT, LOS, and lower extremity
(LE) strength tests. We cannot say that these changes were
caused by improvements in MSR, only that they occurred
concurrently.
How Do the Current Findings Fit Within the
Context of Prior Research?
Our current finding that sensory challenge balance exer-
cises are associated with subsequently lower vision and touch
gain values is consistent with prior intervention studies that
used the SOT or “Clinical Test of Sensory Interaction on
Balance” to reflect MSR capabilities.19,29,30,53 Thus, sensory-
challenge practice may improve perception of environmental
conditions, estimation of body position and motion, or both.
Prior studies of balance exercise programs that in-
cluded sensory challenge exercises have reported positive
SOT outcomes.27,29,30 Our posttraining improvements in SOT
composite scores were consistent with these earlier findings.
Similarly, our posttraining findings of increased LOS Maxi-
mum Excursion scores are consistent with other balance exer-
cise intervention studies that used the LOS test as a measure of
center of gravity excursion and control.30,52 In contrast, these
studies included dynamic balance exercises, while ours did
not. The significant improvements seen in dynamic balance
following our static balance training program may thus seem
unexpected from a specificity of training viewpoint. However,
improved estimation of body position and motion in space
(perception) could support and facilitate improved dynamic
balance (action).


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Allison et al
After training, we found significant increases in BBS
scores. Other balance exercise intervention studies that have
used the BBS to measure balance and fall risk have also
reported improvements in BBS scores.30,54,55 We recognize
that, as our intervention was intentionally limited to sen-
sory challenge balance exercises, other studies with more
comprehensive exercise interventions were likely to achieve
larger increases in BBS scores.
Increases in BBS scores may seem even more surpris-
ing than increases in LOS scores from a specificity of training
viewpoint. The BBS includes 14 activities, a majority of which
are dynamic (eg, turning 360◦ ) or mimic functional activities
(eg sit-to-stand, retrieving an object from the floor). Our partic-
ipants practiced only static standing balance exercises and no
functional activities whatsoever. However, the BBS has 4 static
balance test items that were practiced by our participants; this
may have contributed to improved posttraining BBS scores.
The posttraining increase in lower extremity strength
scores was unexpected as we intentionally did not include re-
sistance training in our exercise program. Furthermore, prior
research has demonstrated that balance exercises alone do
not increase strength.51 It is possible that the observed lower
extremity strength increase may have been associated with ac-
tual muscle hypertrophy due to increased physical activity in
our sample of older individuals. A second explanation may be
related to pretraining failure of central activation of muscle
in older adults.56,57 A third possibility is that the recorded in-
crease in lower extremity strength was due to measurement er-
ror. The 2 MANCOVA analyses revealed that improved lower
extremity strength was not the primary reason for improve-
ments in the BBS, LOS, or SOT clinical balance measures.
Posttraining ABC scores did not change despite im-
proved SOT, LOS, and BBS scores. It is possible that because
no functional training occurred, participants did not consider
improved ability to perform the sensory-challenge exercises as
related to the functional tasks in the ABC Scale. It is also pos-
sible that because the exercises were progressed aggressively,
participants always felt the exercises to be effortful and never
achieved a sense of ease and mastery that might heighten their
confidence levels.58,59
Limitations
We observed control-phase increases in the SOT and
BBS scores that hamper a straightforward interpretation of
the positive effects of the training program on SOT and BBS
scores. Variability of performance in frailer older adults is
well recognized and, in fall-prone older adults, more than 2
baseline measures may be advisable to establish a control-
phase performance range.
Additional limitations include the small sample size and
high dropout rate common to longitudinal studies with older
adults. These may have contributed to the lack of statistical
power for the analysis of the vision gain and phase variables.
However, these data can be used for future power analyses.
CONCLUSIONS
Abnormally elevated sensitivity to dynamic environ-
mental stimuli in the fall-prone elderly was reduced following
participation in a sensory-challenge balance exercise program.
This change may reflect an improved ability to discriminate
92
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JNPT r Volume 42, April 2018
and dissociate self-motion from environmental motion.
These results support the hypotheses that MSR is one of the
mechanisms through which sensory challenge balance
exercises may effect improvements in postural control.
ACKNOWLEDGMENTS
The authors recognize The Erickson Foundation for their
generous support of this research and thank Linda House,
PT, Julie Howe, PTA, and Gloria Wilmer, PTA, for their in-
valuable assistance with the clinical evaluations and exercise
intervention.
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