Effect of selected balance exercises on the dynamic balance of children with visual impairments.

Structured abstract: Introduction: Maintaining balance while

walking is of utmost importance for individuals with visual impairments

because deficits in dynamic balance have been associated with a high

risk of falling. Thus, the primary aim of the study presented here was

to determine whether balance training effects the dynamic balance of

children with visual impairments. Methods: The study included 19

children with visual impairments (aged 8 to 14) from the school for

students with visual impairments in Isfahan, Iran, who were randomly

assigned to a balance-training (n = 9) or control (n = 10) group. The

balance-training group was required to participate in an eight-week

balance-training program, while the control group did not participate in

any organized balance-training program. The Modified Bass Test of

Dynamic Balance was used to measure the dynamic balance of the

participants. Both groups performed a pretest prior to the experimental

period and performed a posttest immediately after the experimental

period. Results: The scores on the pretest showed no significant

difference between the balance-training group and the control group.

However, after the balance-training group completed the balance-training

program, a between-group difference was found in the participants’

task scores, t (18) = 4.095, p < .05. Discussion: The findings

indicate that involvement in a balance-training program will

significantly improve the dynamic balance of individuals with visual

impairments relative to a control group. Implications for practitioners:

The study showed that if instructors require individuals with visual

impairments to perform balance-improving exercises, the result can be an

outstanding improvement in their dynamic balance. With improved balance,

individuals with visual impairments may encounter fewer falls and

experience a healthier lifestyle.


Balance has been defined as the ability to maintain one’s

equilibrium as the center of gravity shifts (dynamic balance), as in

walking and running, and while the center of gravity remains stationary

(static balance), as in standing or sitting (Gallahue & Ozmun,

2006). Several neural and biomechanical factors work together to achieve

balance. Among the components that play a vital role in the control of

one’s balance are the visual, vestibular, and somatosensory systems

(Woollacott & Shumway-Cook, 1990). Individuals with visual

impairments (that is, those who are blind or have low vision) are at an

increased risk of falls because vision, an important contributor to

balance, is disturbed (Cheung, Au, Lam, & Jones, 2008; Ray, Horvat,

Croce, Mason, & Wolf, 2008).

The lack of balance is one of the most profound problems observed

in children with visual impairments (Bouchard & Tetreault, 2000;

Buell, 1950; PortforsYeomans & Riach, 2008). Complications with

postural control and poor balance and a stiff and hesitant gait have

been found in children and adolescents with visual impairments (Bouchard

& Tetreault, 2000; Sleeuwenhoek, Boter, & Vermeer, 1995).

Moreover, investigators have reported that gait problems, balance

impairment, postural sway, and visual impairment are the most

significant risk factors for falls (Lord & Dayhew, 2001; Rubenstein,

Josephson, & Robbins, 1994). One area that has received attention

from researchers of visual impairments has been physical exercise-based

intervention programs (Blessing, McCrimmon, Stovall, & Williford,

1993; Campbell et al., 2005; Cheung et al., 2008).

The majority of studies on the prevention of falls have been

conducted among older adults (Maeda, Nakamura, Otomo, Higuchi, &

Motohashi, 1998; Province et al., 1995; Shumway-Cook, Gruber, Baldwin,

& Liao, 1997; Steinman, Nguyen, Pynoos, & Leland, 2011).

Furthermore, exercises have been designed to increase various

musculoskeletal systems and fitness factors in older individuals

(Fatouros et al., 2002; Shumway-Cook et al., 1997; Taaffe, Duret,

Wheeler, & Marcus, 1999). In these studies, balance has been

presented as a whole, not as specifically dynamic or static. However, it

seems that children with visual impairments also need training to

achieve better balance and postural stability to prevent falling.

To our knowledge, no study has used balance-improving exercises to

determine whether they result in an improvement in dynamic balance in

children with visual impairments. The purpose of the study presented

here was to examine whether balance-improving exercises would improve

the dynamic balance of children with visual impairments. The

experimental design chosen for the study was a two-grouped matched

pretest-posttest design. The primary hypothesis was that children with

visual impairments who were required to do balance-improving exercises,

compared to those who were not, would show improvements in dynamic

balance. We believe that improvement in dynamic balance can largely

affect stability in walking and therefore reduce falling among this




In the study, a student with a visual impairment was defined as one

who sustained a loss in vision (regardless of the cause) to such a

degree as to be beyond conventional corrective measures, such as

refractive correction, medication, or surgery (Arditi & Rosenthal,

1998). Each participant had been formerly diagnosed as having a visual

impairment (low vision or “legally blind”) by an

ophthalmologist. The students’ visual acuity was 20/70 or less in

the better eye after conventional correction. All the participants were

screened by an experienced physician and were found eligible to

participate in balance training.


Nineteen students with visual impairments (aged 8 to 14) from the

school of students with visual impairments in Isfahan, Iran, volunteered

to participate in the study. We did not include individuals who were

blind. None of the participants had previously experienced

balance-training programs. The participants were randomly assigned to a

balance training group (n = 9, 7 boys and 2 girls; 10.44 [+ or -] 1.59

years) or a control group (n = 10, 5 boys and 5 girls; 10.10 [+ or -]

2.13 years). They took part in the study after their scheduled classes.

All the participants were in reasonably good health and physical

condition except for their visual impairments. They and their families

all gave their informed consent. The Committee for Ethical

Considerations in Human Experimentation of the University of Isfahan

assessed and approved the experimental protocol.


Balance platform

An apparatus was designed to simulate the Modified Bass Test of

Dynamic Balance. Figure 1 presents the geometric dimensions of a mixed

wooden platform (3 inches high by 190 inches long by 25 inches wide). On

the surface, landing locations are marked as shown in Figure 1. For

better visibility, beneath each marking is a halogenic light that is

fixed inside the wooden surface.

Testing protocol

The Modified Bass Test of Dynamic Balance was used to examine

dynamic balance. Reliability for this test was found to be r = 0.75. A

validity of r = 0.46 was found when the test was correlated with the

Bass Dynamic Balance Test (Johnson & Nelson, 1979). The Modified

Bass Test of Dynamic Balance was originally designed to assess dynamic

balance in school-aged children. Moreover, we asked a multidisciplinary

team (including a physician, three certified trainers, a certified

physical fitness judge, and an ophthalmologist) to watch some children

with visual impairments while performing the balance test. They

confirmed that the test was appropriate for children to test their

dynamic balance and that it does not hurt them. All the measurements for

all the participants were made by an experimenter (with an M.Sc. in

physical education and sport sciences) and an assistant (an

undergraduate student of the College of Physical Education and Sport

Sciences, University of Isfahan). Both the experimenter and the

assistant were trained before the experimental protocol began.

Prior to the experimental period, we organized an initial

instructional balance-training session in which the participants of both

groups were instructed in how to complete the dynamic balance test. At

the beginning of the test, the participant was required to stand

stationary on the sole of the right foot on the starting point light. He

or she then hopped diagonally on Point 1 with his or her left foot on

the mark. He or she was required to hold a stationary position for five

seconds and then to hop with his or her right foot to Point 2. The

participant then held a static position for another five seconds and

hopped to the next point. This process continued to Point 10 with

alternate hops and holding a static position for five seconds. For each

successful landing, the participants were awarded five points. For every

one second the balance was held on the mark, an additional one point was

awarded. Thus, the maximum points that could be attained by the

participant were 10 points for every mark and a total of 100 points for

the complete test.

Two kinds of errors were made in this test, landing errors and

balance errors. There was a five-point deduction if the following

landing errors occurred: (1) the heel of the foot or other parts of the

body touched the floor, (2) the sole of the foot did not cover the light

so that it could not be seen, and (3) the participant was unable to stop

on every mark after landing from a leap. There was a one

point-per-second deduction if the following balance errors occurred

before the participant completed five seconds on the mark: (1) the

participant was unable to hold a static position while his or her foot

was on the mark and (2) any part of the participant’ s body other

than the sole of the supporting foot touched the floor (Sports

Information and Science Agency, 2000). If the participant lost balance,

he or she had to go back to the proper mark and leap to the next mark.

The time for completion of each balance attempt was counted aloud in

seconds for the participant. Each participant made two attempts, and the

better score was considered the final measurement.


We organized a program in which balance exercises were

progressively set. To do so, we followed the principles of training

proposed in exercise physiology texts. The training program was found to

be specific, progressive, realistic, challenging, attainable, and time

limited according to three certified trainers of physical fitness

batteries. The trainers made some corrections to our balance-training

program and confirmed that the program was appropriately set. The

balance-training program was carried out in one group.

The balance-training program consisted of such movements as

standing still without rocking, movements from standing (swinging the

arms back and forth together rhythmically, bending and straightening the

knees), standing games, crawling (through a hoop, under a rope, and over

a rolled-up mat), rolling, walking (in straight lines, forward and

backward, then along curves and then with abrupt changes of direction,

walking through the space made by two facing benches), hopping,

skipping, and galloping, jumping, and bunny jumping over a straight line

from side to side (Macintyre, 2005). The training sessions consisted of

60 minutes of exercise, two times per week for eight weeks (16

sessions). For each session, there were 10 minutes of stretching and

warm-up exercises, 45 minutes of balance exercises, and 5 minutes for a

cool down. We held practice sessions in an appropriate schoolyard. The

participants took the pretest after the initial instructional practice

and the posttest immediately after the 16th session of practice.


We performed statistical analyses with an independent t test by

using SPSS software (Version 11.5). We expressed all data as the mean [+

or -] SD. We set the statistical significance at p < .05.


To confirm that the random assignment of participants produced

equally talented groups for dynamic balance, we compared the mean test

scores of the two groups in the pretest. The mean test scores of the

balance-training group and the control group were 11.11 and 11.5,

respectively. We found no significant difference.

Figure 2 illustrates the balance test scores for the experimental

and control groups throughout the experimental period. Typically, when

the scores of balance tests are interpreted, they are judged against

normative data. Since we did not find any normative values for the

Modified Bass Test of Dynamic Balance for children with visual

impairments, each participant’s pretest score was compared to the

same person’s score in the posttest. As can be seen in Figure 2,

the experimental group improved their dynamic balance scores

considerably (from 11.11 to 34.11). In addition, to investigate the

effects of balance training on the dynamic balance of children with

visual impairments, we compared the mean task score of the two groups in

the posttest. The mean test scores of the balance-training group and the

control group were 34.11 and 10.5, respectively. We found a significant

difference, t (18) = 4.095, p < .05.


Owing to their visual disabilities, individuals with visual

impairments spend less time on daily activities than do sighted

individuals, which may affect their capabilities, such as balance

(Graham & Reid, 2000; Lahtinen, Rintala, & Malin, 2007;

Seok-Min, Silliman-French, & Hyun-Su, 2010; Steinman, Pynoos, &

Nguyen, 2009). In addition, sustaining balance and stability are

necessary to avoid falls (Rubenstein et al., 1994; Steinman et al.,

2011). The study examined the effect of balance-improving exercises on

the dynamic balance of children with visual impairments. Previous

studies have shown that well-organized balance and strength-training

programs improve the balance of sighted individuals (Granacher,

Gollhofer, & Kriemler, 2010; Kahle, 2009; Province et al., 1995;

Shumway-Cook et al., 1997; Skelton, 2001). These results are in

accordance with the results of our study. We found that after going

through eight weeks of selected balance exercises, the children’s

dynamic balance had significantly improved.

As we mentioned earlier, various sensory processes contribute to

the development of stability and balance. To accommodate the inadequacy

of their visual capacities, individuals with visual impairments must

rely on their somatosensory and vestibular systems to maintain balance

and postural stability in everyday life, including physical activity

(Pereira, 1990). Although we did not directly assess the likely

adjustments in the somatosensory and vestibular systems, it is possible

that taking part in regular balance-improving exercises could improve

the efficiency of these structures in children with visual impairments.

Research has shown that certain physical activities improve

proprioception (an element of the somatosensory system) in particular

joints. Xu, Hong, Li, and Chan (2004) reported that long-term training

could improve proprioception in the knee and ankle joints. Jacobson,

Chert, Cashel, and Guerrero (1997) observed the same results on shoulder

proprioception. Because the somatosensory system in general and

proprioception in particular influence balance status, it is possible

that the kinesthetic senses in the children’s joints improved after

eight weeks of balance training. As a result of their likely increase in

their reliance on proprioception, we observed improvements in dynamic

balance of the children.

The vestibular system is another contributor to balance in

individuals with visual impairments. Seemungal, Glasauer, Gresty, and

Bronstein (2007) suggested that long-term training for persons who are

blind can affect navigation and orientation (a function of the

vestibular system). As we stated before, maintaining balance depends

partly on how the vestibular system operates. The results of the studies

mentioned earlier can explain the probable reasons for the improved

balance of the children in our study. It seems that as a consequence of

balance training, some aspects of vestibular performance could have been

positively enhanced in the children.

In summary, the study showed an improvement in the dynamic balance

of the children with visual impairments that could probably have been a

result of the increased use of proprioception and vestibular structures.

However, it should be noted that there was no direct method of

determining the exact changes in the function of the somatosensory and

vestibular systems in our study. Thus, we cannot confidently state that

our results were related to the mentioned adjustments. Further research

is needed on the role of sensory structures underlying the enhancement

of balance in children with visual impairments. In addition, most of the

research in the field of visual impairments and balance disorders has

been conducted on adults, rather than children. It is obvious that

physical exercise should begin at a young age to produce the best

outcome. Therefore, early “body preparation” can have a major

impact on the social lives of children with visual impairments. Thus,

through exercise and training, fewer falling incidents are likely to

occur, and the children can achieve a better lifestyle.


The children with visual impairments showed a significant

improvement in their dynamic balance after taking part in

balance-improving exercises for eight weeks. Because of the absence of

enough scientific support for the role of sensory adaptation to balance

training in individuals with visual impairments and the lack of a

physiological evaluation of the results of training in the study, the

fundamental reasons for the children’s improvement in balance could

not be completely detected. It is important to point out that the next

step in future research is to understand the supporting factors, such as

kinesthetic and proprioceptive cues, underlying the improvement in the

dynamic balance of children with visual impairments.


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Figure 2. Mean scores of the experimental

and control groups on the pretest and posttest.

Mean scores Pretest Posttest

Experimental 11.11 34.11

Control 11.5 10.5

Note: Table made from bar graph.

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