Balance Training to Maintain Mobility and Prevent Disability

James Oat Judge, MD Abstract: Balance is important for the safe performance of many activities that allow older people to remain independent in their community. Housework, cooking, shopping, and travel generally require the ability to stand, reach, turn, and bend down and pick up objects from the oor. Multiple interacting factors are implicated in the deterioration of balance. Several strategies have been tested to improve balance and reduce falls. Home-based individualized training that attempted to improve identied decits reduced falls and improved physical performance and stabilized or reduced disability. Home-based exercise programs that included low-intensity strength and balance training have improved balance and reduced fall rates by about 40% compared to controls. Class-based exercise programs in senior centers or exercise centers have improved balance and physical performance, and some have reduced falls. Programs such as tai chi and social dance look promising and should be further investigated.
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Introduction
he Public Broadcasting System series on jazz,1 directed by Ken Burns, featured amazing moves of swing dancers in the 1930s and 1940s and interviews with some of the dancers who are now in their 70s and 80s. Dance was part of the fabric of life in the early and mid-20th century but is no longer. Is there anything we can learn from the life experiences of these elders to provide guidance to exercise strategies that can help older people maintain or improve their balance and mobility in late life? Good balance is associated with independence in housework, cooking, shopping, and travel2; poor balance is a major risk factor for falls3 and admission to a nursing home.4 Falls and fall-related injuries are responsible for about one quarter of admissions to nursing homes.5 Hip fractures are common and costly, with more than 250,000 fractures annually at an estimated lifetime attributable cost of $81,300,6 predominantly due to nursing home costs following the fracture. The following discussion focuses on physical factors related to balance, but a strategy to reduce falls and injuries and maintain mobility must address the multiple contributors to falls and poor mobility. Three quarters of hip fractures occur indoors, and less than half occur during walking forward; most occur during standing, changing position, turning, backing

up, sitting, and on stairs.7 Thus, reducing injurious falls must target balance and stability in turning and leaning, as well as preventing slips or missteps.

Balance Changes with Advancing Age

Balance is dependent on sensory input, central processing (or motor control), and muscle strength and power. Nearly every clinical or laboratory measure of balance is impaired in advanced age.8 Sophisticated laboratory measures of balance have helped describe specic components of balance changes with aging.8 10 Healthy older persons have measurable declines in each sensory system related to balance. Touch/pressure sensation on plantar surface, joint position sense, visual acuity, visual edge detection, and vestibular input are reduced in advanced age and are associated with decrements in laboratory measures of balance.8,11 Both cohort and cross-sectional studies have reported that individuals who fall are more likely to have decreased cutaneous sensation, proprioception, lowcontrast visual acuity, and contrast sensitivity.12,13 Impaired balance in older people may also be produced by altered coordination of postural strategies due to delayed vestibular and propriospinal responses as a result of increased sensory thresholds.14 Muscle functionmuscle strength or rate of joint torque developmentpredicts performance-challenging balance measures15,16 and falls,17 but not sway when standing.18 Deterioration in motor control appears to be an important factor responsible for changes in balance in advanced age.8,9 A population-based study found that the prevalence of parkinsonian signs (dis-

From the University of Connecticut School of Medicine, Farmington, Connecticut Address correspondence and reprint requests to: James Oat Judge, MD, Associate Professor of Medicine, University of Connecticut School of Medicine, Farmington CT 06030-5215. E-mail: jamesjudge@attbi.org.

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Table 1. Guideline for prevention of falls in older people Exercise recommendations 1. Exercise has many proven benets; however, the optimal type, duration, and intensity of exercise for falls prevention remain unclear (evidence level B). 2. Older people who have had recurrent falls should be offered long-term exercise and balance training (evidence level B). 3. Tai chi cuan is a promising type of balance exercise, although it requires further evaluation before it can be recommended as the preferred balance exercise.
From American Geriatrics Society/British Geriatrics Society (released 2001).31

tinct from Parkinson disease) increased from 15% in persons aged 65 to 74 years to 52% in those aged 85 years.19 A large cross-sectional study20 found moderate associations between MRI ndings (increased ventricular size and white matter hyperintensity) and clinical and laboratory balance measures, after adjusting for age. A 4-year prospective MRI study found that increases in periventricular white matter hyperintensity predicted deterioration in balance.21 These studies suggest that a proportion of balance and mobility impairments are due to structural changes in the brain.

Clinical Measures of Balance

Simple clinical measures of balance predict falls, lossof-independence functional status and are sensitive to change with training.4,2226 The static balance battery, Frailty and Injuries: Cooperative Studies of Intervention Techniques (FICSIT), is a summary measure of performance on four stancesincluding feet together, semi-tandem stance, tandem stance, and single stance26and is sensitive to training.27 The Balance Scale of the Performance Oriented Mobility Assessment (POMA) and the Berg Balance Scale grade performance of specic activities that require balance.25,28 The Berg Balance Scale includes 14 items, two of which test rotation of the body in a standing position and the ability to turn around. The Berg Balance Scale is sensitive to change in the frail elderly, but healthy elderly score at the ceiling.25 Functional reachthe distance a person can lean forward with his/her arm exed to 90 degreesis predictive of falls and functional status,23,24 is related to the range of motion of axial spinal rotation,29,30 and is sensitive to change with exercise.30

exercise, including a recommendation for long-term exercise and balance training for recurrent fallers. After analyzing all exercise interventions, the panel was unable to recommend a preferred type, duration, or intensity of exercise. The FICSIT meta-analysis of seven interventions that enrolled nearly 2000 volunteers found that the overall effect of any kind of exercise training was a 10% reduction in fall rates in the subsequent year. Balance training of any type reduced falls by 17%,32 and the multimodal intervention that trained balance and strength and corrected environment and medications was the most effective FICSIT intervention.33 Balance training studies have tested a wide range of techniques to improve balance measures. Studies have tested training: simple movements similar to everyday activities,3335 standing postures, tai chi, and high-tech visual feedback of the center of pressure at the feet.36 In a thorough review of balance-training interventions, Whipple37 found that intensity of training characterized studies that improved balance measures. Only a qualitative scoring of the interventions was possible. Whipple concluded that the intensity of training estimated by how challenging the balance exercises werewas associated with improvements in balance. The number of modes of training (e.g., static training, such as leaning, eyes closed postures, standing on one leg, or dynamic training, such as balance balls, walking on foam, perturbations of balance, tandem gait, walking backwards, sudden turns when walking) did not appear to predict balance improvement. Single stance was the most common outcome measure, and single stance was trained in half of the intervention trials. Many interventions trained balance using static postures (standing on one foot or narrowed base of support, forward leans) and active balance activities (fast walking with rapid turns, walking backward, tandem gait, walk to the side).38 Since this review was completed, a number of large community-based trials have tested the effectiveness of balance training using other modes of training to improve mobility and reduce falls.

Home-Based Interventions to Reduce Falls

Campbell et al.35,39 in New Zealand and other studies40,41 have demonstrated the effectiveness of a homebased strength and balance program in several trials. Initially, older women were trained in a home-based intervention using a physiotherapist making four home visits and follow-up phone calls. Strengthening exercises used ankle-cuff weights (0.51.0 kg at start) of hip extensors and abductors, knee exors and extensors, and ankle plantar and dorsiexors. Balance exercises were single stance and tandem gait (walking placing one foot directly in front of the other); walking on toes and on heels; walking backwards, sideways, and turning
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Interventions That Work to Improve Balance or Prevent Falls

Guidelines to prevent falls were developed by a panel from the American and British Geriatrics Societies (AGS/BGS) and the American Academy of Orthopedic Surgeons31 (Table 1). The guidelines recommended

around; stepping over an object; bending and picking up an object. Some activities provided both resistance and mobility training for frail volunteers, such as stair climbing, chair rises, and knee squats. Finally, volunteers performed exibility exercises to increase active range of movement of neck rotation and hip and knee extension. The exercises took about 30 minutes to complete. After 6 months, balance had improved in the exercise group compared to the control group.35 The four-test static balance score improved in the exercise group at 0.42 (0.86), and was unchanged in the controls (0.01 0.80) (95% condence interval [CI]0.21 0.65, for between-group difference). A higher proportion of those in the exercise group had improved their performance in the chair-stand test (relative risk [RR]1.41; 95% CI, 1.071.87). There were no differences between the two groups for the remaining physical assessment measures.35 Fall rates were much lower at 1 and 2 years. At 1 year, the fall rate per person per year was 0.87 1.29 in the exercise group and 1.34 1.93 in the control group falls per year, a rate reduction of 0.47 falls per person per year. This was due to a reduction in multiple falls per person, not the number of people who fell. The relative hazard for a rst fall with injury was lower at 0.61 (95% CI, 0.39 0.97) in the exercise group compared with the control group. After 2 years, the relative hazard for all falls in the exercise group continued to be much lower: RR0.69 (95% CI, 0.4 0.97). The relative hazard for an injurious fall was also lower: 0.63 (95% CI, 0.42 0.95).39 Robertson et al.40 tested the same exercise program when provided by a district nurse instead of a physiotherapist. The results were similar: the RR for falls at 1 year was 0.54 (95% CI, 0.32 0.90). The group then tested the acceptability of prescribing this home-based exercise program in primary care practices for older community residents of New Zealand.41 They had remarkable results. Overall, 85% of primary care doctors agreed to participate in the project, and they identied 71% of their patients aged 80 as appropriate to join the exercise program. Overall, 47% (330 of 700) of people invited agreed to participate in the exercise program, and 70% of those who began the exercises were still exercising at 1 year. Thus, 37% of all older persons whose physicians felt the home-based program would be benecial to them were successful participants (261 of 700). The FICSIT balance score26 increased by 0.4 (0.1 0.6) and the ve chair-stand time improved by 2.4 seconds (95% CI, 4.0 0.8 seconds) compared to controls. To summarize the efforts of this group from New Zealand, it is possible to develop and implement a home-based exercise program that (1) has good accep152

tance by physicians and older people; (2) has good adherence at 1 and 2 years; and (3) reduces falls and injurious falls, and improves measures of mobility.

Center-Based Exercise Training

A recent large Australian study42 completed a complex intervention trail testing the independent effects of exercise, vision, and environmental interventions on fall rates in relatively healthy community residents of Melbourne, Australia. Group exercise was held at senior centers. The exercise training reduced the rate of falls about 18% (RR0.82; 95% CI, 0.70 0.97; p0.02). Balance measures improved signicantly in the exercise group. Neither home hazard management nor treatment of poor vision showed an independent effect on falls, but the three interventions combined reduced the fall rate ratio to 0.67 (95% CI, 0.51 0.88; p0.004), producing an additional 14.0% reduction in the annual fall rate. The number of people needed to be treated to prevent one fall per year was seven for the three combined interventions.42 Balance measures that improved after the 15-week group class session were maximal sway (at waist) from 13.3 to 15.1 cm (p0.001 group time) and a coordinated sway measure of errors made during moving the torso in specied directions (12.2 to 9.7 cm; p0.001). In the United States, King et al.43 tested a centerbased intervention that transitioned to a home-based program. The multicomponent training improved physical performance, in a study of somewhat frail elderly living in the community. The rst 3 months included moderate resistance using weights in hip abduction, exion, and extension; elbow exion; ankle dorsiexion; dips; and weighted stair climbing and walking using weighted waist vests. Participants improved standing balance (combined semi-tandem and tandem stance time) 2.1 seconds (21%) compared to controls. In months 4 to 6, participants trained in functional balance that included backward, tandem, heel and toe walks, leans in all directions, single stance postures, lunge/kneel exercise, and functional exercise training with low resistance. Balance measures improved an additional 3.5 seconds (35%) from baseline and were signicantly better than the controls who received an exercise prescription for walking. Condence in performing balance-challenging activities also improved in the class-based exercise group. The improvements were sustained during a 6-month period when classes were once a week and home exercise was prescribed twice a week. However, balance measures returned to baseline levels after an additional 6 months of home exercises with a monthly support class at the center. Adherence to the home-based program was poor in the nal 6 months.43

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Tai Chi
In tai chi training, practitioners focus on just moving, and focus on control of the center of mass during smooth, owing movements. Tai chi appears to be an ideal exercise to maintain mobility and balance. Tai chi exercise increases heart rate consistent with a moderate intensity aerobic exercise, and provides a low-impact exercise. One year of tai chi training in older adults (Chan style with all 108 forms) improved VO2max by 18%; knee extensor and exor strength 18% and 15%, respectively; and lumbar/thoracic exion ROM (range of movement) 11 degrees.44,45 In another trial, shortterm tai chi training improved reported physical function substantially in walking, lifting, bending, and ADLs.46 Tai chi training was used by two of the FICSIT interventions and reduced the frequency of recurrent falls by over 40% in one of the trials.47 Tai chi training reduced falls but did not improve sophisticated platform balance outcome measures, while balance training using biofeedback improved balance measures but did not reduce falls.48 A larger prospective trial by Wolf et al.49 is in progress. The AGS/BGS guidelines noted that tai chi was a promising intervention, but more research was recommended before considering it a preferred exercise mode.31

movements and continuous lower-extremity movement, including sagittal stepping forward, backward, and sideward stepping, and lunges forward and sideward. Mean heart rate during the class was 99 beats/ minute.34 At 12 weeks, the intervention group improved two balance measuressingle stance with eyes closed and functional reachand reduced the time to complete a modied up-and-go test,51 which includes a 180-degree turn. How might dance help balance and motor control? Cross-sectional data comparing professional dancers to nondancers supports the concept that dancers rely more on proprioception and less on visual input than nondancers.52 Ballet dancers are trained to have a stable visual reference.53 Dance training changes muscle activation when performing specic movements. Modern dancers have different patterns of quadriceps activity than ballet dancers performing a grand-plie movement.54 Recent studies have explored whether testing Hoffman reexes (H-reexes)which measure the magnitude of muscle responses to muscle stretch may help clarify the changes in motor control with advanced age. Older persons have larger H-reex responses to soleus stretch compared to young adults55 and early Parkinson disease patients have increased H-reexes.56 These ndings suggest that older persons may overrespond or over-react to real-world stimuli that challenge balance. Motor tone may be affected by training or adaptation. For example, ballet dancers have a reduced muscle response to soleus stretch in the standing position, measured with H-reexes.54 H-reexes can be suppressed over a 2-hour experiment in a functionally appropriate manner in young adults.57 These results and those of other experiments58 support the concept that older adults may have higher motor tone during standing. Further exploration of H-reexes may be one strategy to understand motor control mechanisms that may underlie the deterioration of balance in advanced age. H-reexes and other balance measures developed by Collins et al.10 that provide insight into motor control may help researchers understand how balance performance improves following tai chi and balance training. The popularity of dance activity in senior centers that offer programs suggests that dance is a pleasurable activity for older people and that dance may be a way to encourage sedentary older persons to take the rst step to increase their physical activity. Understanding the cardiovascular responses during social dancing of different types is important. Also, determining the longterm effects of regular dance on balance, mobility, and condence in performing challenging tasks using subjective measures of condence59 is needed.
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Dance
Social dance appears to be a very appropriate physical activity for older persons. The history of social dancing in the United States is complex. The disappearance of dance halls and big bands in the late 1940s was a blow to participatory dance for large groups of Americans. For Americans of many cultures and regions in the United States, opportunities for dance in social settings are limited to weddings and special occasions. However, there are communities where dance is a regular part of life and participation rates are high. Dance classes, whether line or pairs dancing, are popular activities at many senior centers, but no national data are available. However, there is so little information on the effects of dance in older persons that the only recommendation that can be made is that research is needed. Appropriate avenues of research would include measuring the impact of social dance on balance, mood, social isolation, physical function, and falls. A cross-sectional study from Finland50 found that older recreational gymnasts, who perform graceful rhythmic movements, and folk dancers had greater leg strength (13%; 95% CI, 7%19%) and better dynamic balance in performing a gure-eight course (8%; 95% CI, 5%10%) than healthy inactive peers. One recent study from Japan tested a dance aerobics program in older women. The exercise was done on tatami mats and included frequent upper-extremity

Understanding How People Turn

Another challenging area of balance research is how people turn and why turning deteriorates. Turning is a key element in many ADLs, but it is difcult to model and measure biomechanically. Many hip fractures occur during turns.7 Thigpen et al.60 has characterized turning. She found that young and most high-functioning older adults usually perform a 180-degree turn using a pivot strategy. However, all older persons with subjective difculty turning did not use a pivot strategy, as did some without subjective difculty. These subjects staggered and took more than 3 seconds and 4.7 steps to turn 180 degrees. Older people without subjective difculty on average took 2.7 steps to turn 180 degrees. The Berg Balance Scale includes items testing rotation of the body in a standing position and the ability to turn around.25 Scoring is based on time and stability during a 360-degree turn. Schenkman29,30 has also focused on the contribution of spinal exibility in advanced age and in Parkinson disease. Turning is a key element of tai chi exercise, where slow and moderate speed turns are performed, focusing on control of the torso and arms during rotations on the hip/leg stance.

Table 2. Future research focus Laboratory-based research Understanding how older persons turn Torso mobility Indices of motor control and motor tone Muscle stiffness: Hoffman reex and other techniques Clinical trials Community-based trials: adherence and effectiveness Home-based Center-based Self-selected site of exercise Test effects of dance/movement and tai chi training on: Mobility Balance Turning Mood and self-efcacy Acceptability of movement and dance classes

Summary and Future Opportunities for Balance Research to Prevent Disability

There is sufcient evidence from community-based trials in New Zealand that simple programs can work. These home exercise programs improve balance, reduce falls, and improve performance,39 which may result in delays in future disability. A home-based intervention by Gill et al.61 in the United States trained frail elderly in balance and strengthening exercises and demonstrated short-term improvement in a summary disability measure compared to a control group over a 1-year follow-up. The training protocol was similar to the multifactorial intervention by Tinetti33 that reduced falls substantially. Exercise programs that can prevent falls can improve performance and appears to delay disability.61 Center-based interventions by Day et al.,42 King et al.,43 and Binder et al.62 improved performance in people willing and able to travel to a center for exercise. However, two of these center-based studies44,62 found that frailer participants were more likely to drop out. In another study, frailer participants were less likely to benet from a home-based program.61 Community trials designed to overcome barriers and provide support for inactive elderly people to begin exercise programs are needed. These trials should rst determine if it is possible to duplicate the excellent results from New Zealand in the United States and other countries. It is crucial to identify the elderly at risk before they are so frail that they are unlikely to
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respond to training. As measures of muscle strength and balance are independently associated with IADL function2 and disability,4 intervention trials designed to prevent disability should provide both strength and balance training. There are opportunities to test whether different types of training will be more effective than currently reported interventions to prevent disability. Until recently, there has been less investigation of rotational movements that are critical to safe performance of ADLs. Interventions that include both abdominal muscle and torso muscle strengthening combined with spinal extension and rotation should be tested. The positive effect of exercise in patients with Parkinson disease63 supports the usefulness of testing interventions in older persons with parkinsonian signs and evidence of motor disease.9 Tai chi has great promise as a primary preventive exercise to maintain function and as a secondary preventive strategy for elderly people with poor balance. Research is needed to understand the acceptance of and adherence to tai chi. Can tai chi be an effective home-based program following initial training in a group? Will acceptance vary with older persons from different cultural and ethnic backgrounds? What is the minimal dose of tai chi that can improve balance and mobility? In a recent review, Wu64 recommended further eld testing of tai chi in people with poor balance. A key ingredient of tai chi is full attention and focus on movement. Woollacott and Shumway-Cook65 recently reviewed the literature on the importance of attention to how older persons perform balance tasks. Future interventions may test strategies other than tai chi that train focus and attention to task. These trials may determine if there is a carry-over from paying attention during exercise to paying attention in real-life situations lled with distractions and stress. We still do not know whether a lifetime of social dance has enhanced mobility or delayed disability in those jazz and swing dancers who are now in their 80s.

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We have only anecdotes asserting that dance brings joy and lifts the spirit of those who participate. Research is also needed here, especially for older people who self-report having two left feet.

References
1. Burns K. Jazz. Documentary, Public Broadcasting System, VHS, 2001. 2. Judge JO, Schechtman K, Cress E. The relationship between physical performance measures and independence in instrumental activities of daily living. J Am Geriatr Soc 1996;44:133241. 3. Tinetti ME, Speechley M, Ginter SF. Risk factors for falls among elderly persons living in the community. N Engl J Med 1988;319:17017. 4. Guralnik JM, Simonsick EM, Ferrucci L, et al. A short physical performance battery assessing lower extremity function: association with self-reported disability and prediction of mortality and nursing home admission. J Gerontol Med Sci 1994;49:8594. 5. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997;337:1279 84. 6. Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality and costs. J Am Geriatr Soc 2003;51:364 70. 7. Norton R, Campbell AJ, Lee-Joe T, Robinson E, Butler M. Circumstances of falls resulting in hip fractures among older people. J Am Geriatr Soc 1997;45:1108 12. 8. Alexander NB. Postural control in older adults. J Am Geriatr Soc 1994;42: 93108. 9. Wolfson LI. Gait and balance dysfunction: a model of the interaction of age and disease. Neuroscientist 2001;7:178 83. 10. Collins JJ, De Luca CJ, Burrows A, Lipsitz LA. Age-related changes in open-loop and closed-loop postural control mechanisms. Exp Brain Res 1995;104:480 92. 11. Thelen DG, Brockmiller C, Ashton-Miller JA, Schultz AB, Alexander NB. Thresholds for sensing foot dorsi- and plantar-exion during upright stance: effects of age and velocity. J Gerontol A Biol Sci Med Sci 1998;53: 338. 12. Lord SR, Ward JA, Williams P, Anstey KJ. Physiological factors associated with falls in the older community dwelling women. J Am Geriatr Soc 1994;42:1110 7. 13. Ivers RQ, Cumming RG, Mitchell P, Attebo K. Visual impairment and falls in older adults: the Blue Mountains Eye Study. J Am Geriatr Soc 1998;46: 58 64. 14. Keshner EA. Postural abnormalities in vestibular disorders. In: Herdman S, ed. Vestibular rehabilitation. Philadelphia: FA Davis, 1994;4767. 15. Thelen DG, Schultz AB, Alexander NB, Ashton-Miller JA. Effects of age on rapid ankle torque development. J Gerontol A Biol Sci Med Sci 1996;51: 226 32. 16. Judge JO, King MB, Whipple R, Clive J, Wolfson LI. Dynamic balance in older persons: effects of reduced visual and proprioceptive input. J Gerontol A Biol Sci Med Sci 1995;50:26370. 17. Wolfson L, Judge J, Whipple R, King M. Strength is a major factor in balance, gait, and the occurrence of falls. J Gerontol A Biol Sci Med Sci 1995;5:64 7. 18. Hughes MA, Duncan PW, Rose DK, Chandler JM, Studenski SA. The relationship of postural sway to sensorimotor function, functional performance, and disability in the elderly. Arch Phys Med Rehab 1996;77:56772. 19. Bennett DA, Beckett LA, Murray AM, et al. Prevalence of parkinsonian signs and associated mortality in a community population of older people. N Engl J Med 1996;334:716. 20. Tell GS, Lefkowitz DS, Diehr P, Elster AD. Relationship between balance and abnormalities in cerebral magnetic resonance imaging in older adults. Arch Neurol 1998;55:739. 21. Whitman GT, Tang Y, Lin A, Baloh RW, Tang T. A prospective study of cerebral white matter abnormalities in older people with gait dysfunction. Neurology 2001;57:990 4. 22. Thapa PB, Gideon P, Brockman KG, Fought RL, Ray WA. Clinical and biomechanical measures of balance as fall predictors in ambulatory nursing home residents. J Gerontol A Biol Sci Med Sci 1996;51:239 46. 23. Duncan PW, Studenski SA, Chandler JM, Prescott BA. Functional reach: predictive validity. J Gerontol A Biol Sci Med Sci 1992;47:938. 24. Duncan PW, Weiner D, Chandler JM. Functional reach: a new clinical measure of balance. J Gerontol A Biol Sci Med Sci 1990;45:1927. 25. Berg K, Wood-Dauphinee S, Williams JI. The balance scale: reliability assessment with elderly residents and patients with an acute stroke. Scand J Rehabil Med 1995;27:2736.

26. Rossiter-Fornoff JE, Wolf SL, Wolfson LI, Buchner DM. A cross-sectional validation study of the FICSIT common data base static balance measures. Frailty and injuries: cooperative studies of intervention techniques. J Gerontol A Biol Sci Med Sci 1995;50:2917. 27. Gardner MM, Phty M, Robertson MC, McGee R, Campbell AJ. Application of a falls-prevention program for older people to primary health care practice. Prev Med 2002;34:546 53. 28. Tinetti ME. Performance-oriented assessment of mobility problems in elderly patients. J Am Geriatr Soc 1986;34:119 26. 29. Schenkman ML, Clark K, Xie T, Kuchibhatla M, Shinberg M, Ray L. Spinal movement and performance of a standing reach task in participants with and without Parkinson disease. Phys Ther 2001;81:1400 11. 30. Schenkman M, Morey M, Kuchibhatla M. Spinal exibility and balance control among community-dwelling adults with and without Parkinson disease. J Gerontol A Biol Sci Med Sci 2000;55:4415. 31. American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. Guideline for the prevention of falls in older persons. J Am Geriatr Soc 2001;49:664 72. 32. Province MA, Hadley EC, Hornbrook MC, et al. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and injuries: cooperative studies of intervention techniques. JAMA 1995;273:13417. 33. Tinetti ME, Baker DI, McAvay G, et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:8217. 34. Shigematsu R, Chang M, Yabushita N, et al. Dance-based aerobic exercise may improve indices of falling risk in older women. Age Ageing 2002;31: 2616. 35. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Tilyard MW, Buchner DM. Randomized controlled trial of a general practice programme of home based exercise to prevent falls in elderly women. BMJ 1997;315:10659. 36. Wolfson L, Whipple R, Derby C, et al. Balance and strength training in older adults: intervention gains and tai chi maintenance. J Am Geriatr Soc 1996;44:498 506. 37. Whipple RH. Improving balance in older adults: identifying the signicant training stimuli. Masedeu JC, Sudarsky L, Wolfson L, eds. Gait disorders of aging: falls and therapeutic strategies. Philadelphia: Lippincott-Raven, 1997;35579. 38. Ledin T. Effects of balance training in elderly evaluated by clinical tests and dynamic posturography. J Vestib Res 1991;1:129 38. 39. Campbell AJ, Robertson MC, Gardner MM, Norton RN, Buchner DM. Falls prevention over 2 years: a randomized controlled trial in women 80 years and older. Age Ageing 1999;28:5138. 40. Robertson MC, Gardner MM, Devlin N, McGee R, Campbell AJ. Effectiveness and economic evaluation of a nurse delivered home exercise programme to prevent falls. 2: Controlled trial in multiple centres. BMJ 2001;322:7014. 41. Gardner MM, Phty M, Robertson MC, McGee R, Campbell AJ. Application of a falls prevention program for older people to primary health care practice. Prev Med 2002;34:546 53. 42. Day L, Fildes B, Gordon I, Fitzharris M, Flamer H, Lord S. Randomised factorial trial of falls prevention among older people living in their own homes. BMJ 2002;325:128 31. 43. King MB, Whipple RH, Gruman CA, Judge JO, Schmidt JA, Wolfson LI. The Performance Enhancement Project: improving physical performance in older persons. Arch Phys Med Rehabil 2002;83:1060 9. 44. Lan C, Lai JS, Chen SY, Wong MK. 12-month tai chi training in the elderly: its effect on health tness. Med Sci Sports Exerc 1998;30:34551. 45. Lan C, Lai JS, Wong MK, Yu ML. Cardiorespiratory function, exibility, and body composition among geriatric tai chi chuan practitioners. Arch Phys Med Rehabil 1996;77:6126. 46. Li F, Harmer P, McAuley E, et al. An evaluation of the effects of tai chi exercise on physical function among older persons: a randomized controlled trial. Ann Behav Med 2001;23:139 46. 47. Wolf SL, Barnhart HX, Kutner NG, et al. Reducing frailty and falls in older persons: an investigation of tai chi and computerized balance training. Atlanta FICSIT Group. Frailty and injuries: cooperative studies of intervention techniques. J Am Geriatr Soc 1996;44:489 97. 48. Wolf SL, Barnhart HX, Ellison GL, Coogler CE. The effect of tai chai quan and computerized balance training on postural stability in older subjects. Atlanta FICSIT Group. Frailty and injuries: cooperative studies on intervention techniques. Phys Ther 1997;77:37181.

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49. Wolf SL, Sattin RW, OGrady M, et al. Study design to investigate the effect of intense tai chi in reducing falls among older adults transitioning to frailty. Controlled Clin Trials 2001;22:689 704. 50. Uusi-Rasi K, Sievanen H, Vuori I, et al. Long-term recreational gymnastics, estrogen use, and selected risk factors for osteoporotic fractures. J Bone Miner Res 1999;14:12318. 51. Podsiadlo D, Richardson S. The timed up & go: a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc 1991;39:1428. 52. Golomer E, Cremieux J, Dupui P, Isableu B, Ohlmann T. Visual contribution to self-induced body sway frequencies and visual perception of male professional dancers. Neurosci Lett 1999;267:189 92. 53. Stretanski MF, Weber GJ. Medical and rehabilitation issues in classical ballet: Literature review. Am J Phys Med Rehabil 2002;81:38391. 54. Trepman E, Gellman RE, Micheli LJ, De Luca CJ. Electromyographic analysis of grand-plie in ballet and modern dancers. Med Sci Sports Exerc 1998;30:1708 20. 55. Mynark RG, Koceja DM. Comparison of soleus H-reex gain from prone to standing in dancers and controls. Electroencephalogr Clin Neurophysiol 1997;105:13540. 56. Chalmers GR, Knutzen KM. Soleus H-reex gain in healthy elderly and young adults when lying, standing, and balancing. J Gerontol A Biol Sci Med Sci 2002;57:3219. 57. Sabbahi M, Etnyre B, Al-Jawayed IA, Hasson S, Jankovic J. Methods of

58. 59. 60. 61.

62.

63.

64.

65.

H-reex evaluation in the early stages of Parkinson disease. J Clin Neurophysiol 2002;19:6772. Trimble MH, Koceja DM. Effect of a reduced base of support in standing and balance training on the soleus H-reex. Int J Neurosci 2001;106:120. Powell LE, Myers AM. The Activities-specic Balance Condence (ABC) Scale. J Gerontol Med Sci 1995;50:28 34. Thigpen MT, Light KE, Creel GL, Flynn SM. Turning difculty characteristics of adults aged 65 years or older. Phys Ther 2000;80:1174 87. Gill TM, Baker DI, Gottschalk M, Peduzzi PN, Allore H, Byers A. A program to prevent functional decline in physically frail, elderly persons who live at home. N Engl J Med 2002;347:1068 74. Binder EF, Schechtman KB, Ehsani AA, et al. Effects of exercise training on frailty in community-dwelling older adults: results of a randomized, controlled trial. J Am Geriatr Soc 2002;50:19218. Schenkman M, Cutson TM, Kuchibhatla M, et al. Exercise to improve spinal exibility and function for people with Parkinson disease: a randomized, controlled trial. J Am Geriatr Soc 1998;46:120716. Wu G. Evaluation of the effectiveness of tai chi for improving balance and preventing falls in the older populationa review. J Am Geriatr Soc 2002;50:746 54. Woollacott M, Shumway-Cook A. Attention and the control of posture and gait. a review of an emerging area of research. Gait Posture 2002;16:1 14.

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