REVIEW ISSN 0103-5150

Fisioter. Mov., Curitiba, v. 31, e003135, 2018

DOI: http://dx.doi.org/10.1590/1980-5918.031.AO35
Licensed under a Creative Commons attribution

[T]

Proprioceptive activities to postural balance

of the elderly — systematic review

Atividades proprioceptivas para o equilíbrio

postural de idosos — revisão sistemática

Actividades propioceptivas para el equilibrio postural

de las personas mayores — revisión sistemática

Adriano Drummond, Clarissa Cardoso dos Santos Couto Paz, Ruth Losada de Menezes*

Universidade de Brasília (UnB), Brasília, DF, Brazil

[R]

Abstract

Introduction: Proprioceptive activities are commonly described for control of the postural balance of the
elderly in order to avoid falls. But, there is no consensus on which ones can significantly improve balance
or on intervention and assessment protocols. Objective: To investigate which proprioceptive activities are
specific to static and dynamic postural balance of the elderly through a systematic review. Method: This
is a systematic review based on PRISMA recommendation, by surveying PubMed, Medline, LILACS, Scielo
and EBSCO databases. The period considered for the search was from 2006 to 2016, using the following
descriptors – aged, proprioception, exercise therapy, and postural balance for articles in English, Portuguese
or Spanish. Randomized and non-randomized clinical trials were included using the PEDro scale to analyze
the methodological quality of the studies. Results: Eight articles were included with different protocols,
without standardization of evaluation and intervention, but, which demonstrated improvement of functional

*AD: Doctoral Student, e-mail: [email protected]

CCSCP: PhD, e-mail: [email protected]
RLM: PhD, e-mail: [email protected]

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 Drummond A, Paz CCSC, Menezes RL.
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abilities. Different kinds of walk, muscular strengthening exercises, stretching, postural oscillations and
Yoga patterns for the improvement of functional abilities. Conclusion: The association of static and dynamic
activities can contribute to the improvement of functional abilities, but it cannot be affirmed that they are
specific for postural control, given the lack of standardization of exercise protocols and evaluation tools.

Keywords: Aged. Exercise Therapy. Proprioception. Postural Balance.

Resumo

Introdução: Atividades proprioceptivas são comumente descritas para o controle do equilíbrio postural
de idosos, no intuito de se evitar quedas. Mas não há um consenso acerca de quais podem melhorar
significativamente o equilíbrio, bem como os protocolos de intervenção e avaliação. Objetivo: Investigar quais
atividades proprioceptivas são específicas para o equilíbrio postural estático e dinâmico de idosos, por meio
de uma revisão sistemática. Método: Trata-se de uma revisão sistemática baseada na recomendação PRISMA,
por meio das bases de dados PubMed, Medline, LILACS, Scielo e EBSCO. O período considerado para a busca
foi de 2006 a 2016, utilizando-se os descritores idosos, propriocepção, treinamento físico, e equilíbrio postural
para artigos nos idiomas em inglês, português ou espanhol. Foram incluídos os ensaios clínicos randomizados
e não-randomizados, com a utilização da escala PEDro para a análise da qualidade metodológica dos estudos.
Resultados: Foram elencados 8 artigos que abordaram diferentes protocolos, sem padronização de avaliação
e intervenção, mas demonstraram a melhora de algumas habilidades funcionais. Destacam-se as diferentes
caminhadas, exercícios de fortalecimento muscular, alongamento, oscilações posturais e padrões de Yoga para
a melhora de habilidades funcionais. Conclusão: A associação de atividades estáticas e dinâmicas podem
contribuir para a melhora de habilidades funcionais, mas não se pode afirmar que sejam específicos para o
controle postural, diante da falta de padronização dos protocolos de exercícios e de instrumentos de avaliação.

Palavras-chave: Idosos. Treinamento Físico. Propriocepção. Equilíbrio Postural.

Resumen

Introducción: Las actividades propioceptivas se conocen comúnmente para el control del equilibrio
postural de los ancianos, con el fin de evitar caídas. Pero no hay consenso sobre cuáles pueden mejorar
significativamente el equilibrio, así como los protocolos de intervención y evaluación. Objetivo: Investigar qué
actividades propioceptivas son específicas para el equilibrio postural estático y dinámico de los ancianos, a
través de una revisión sistemática. Método: Se trata de una revisión sistemática basada en la recomendación
PRISMA, a través de las bases de datos PubMed, Medline, LILACS, Scielo y EBSCO. El período considerado para
la búsqueda fue de 2006 a 2016, utilizando los descriptores ancianos, propiocepción, entrenamiento físico,
y equilibrio postural para artículos en los idiomas en inglés, portugués o español. Se incluyeron los ensayos
clínicos aleatorizados y no aleatorizados, con la utilización de la escala PEDro para el análisis de la calidad
metodológica de los estudios. Resultados: Se destacan las diferentes caminatas, ejercicios de fortalecimiento
muscular, estiramiento, oscilaciones posturales y patrones de Yoga para la mejora de habilidades funcionales.
Conclusión: La asociación de actividades estáticas y dinámicas puede contribuir a la mejora de habilidades
funcionales, pero no se puede afirmar que sean específicas para el control postural, ante la falta de
estandarización de los protocolos de ejercicios y de instrumentos de evaluación.

Palabras clave: Anciano. Ejercicio. Propiocepción. Balance Postural.

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Introduction However, the need for a detailed analysis of the

results presented in the literature regarding activities
Proprioception involves information generated carried out as a response to the proprioceptive stimuli,
by the mechanoreceptors, which are located in the objective of maintaining postural balance and,
articulations, tendons, muscles, and skin, allowing some consequently, preventing the risk of falls becomes
notion of the positioning of the human body regarding its evident, since treatments follow differentiated protocols
orientation in the space or in relation to movement [1]. due to the patients’ different necessities, and the
Postural balance is kept by the interaction of sensorial evaluation of this functional condition is developed
and neuromotor systems, enabling adaptation to a static with different instruments [2].
or dynamic situation, regarding one’s ability to keep the The objective of this research was, therefore,
body positioning according to the stability limits [2]. to investigate, through a systematic review, which
However, the aging process might generate a deficit proprioceptive activities are specific for the static and
in the maintenance of this control when responding to which for the dynamic postural balance of aged people.
unbalance external and internal stimuli. The review of
sensorial systems in the elderly body balance by Ricci et al.
[3] evidenced a reduction in the sharpness of the vestibular, Methods
visual and proprioceptive systems when compared to
young adult people. Thus, unbalance reactions might This is a systematic review based on the PRISMA
become slower, generating a risk of falling [4-6]. The recommendation [17], addressing the theme of
older the person is, the greater the instability of the frontal proprioceptive exercises and the postural balance of
plane becomes [7], for example. And, as a response to this the elderly.
instability, the displacement of the weight discharge to the The search was carried out between August and
front part of the foot sole might occur when the elderly September 2016, using the uniterms: idosos/aged,
remains in the orthostatic position [8]. propriocepção/proprioception, treinamento físico/
Postural control might also suffer influence from the exercise therapy, and equilíbrio postural/postural
hippocampus and thus changes in this region might promote balance. The uniterms were listed in the descriptors
lack of this functional ability [9]. Even cardiovascular (Descs) of the Health Virtual Library, using the words
conditions influence the maintenance of balance and require in Portuguese, and in the Mesh of the webpage PubMed,
close attention to the elderly’s blood pressure, which might using the words in English. The data bases accessed
present a sharp decrease risking their stability [10]. were Scielo, Medline, PubMed, LILACS and EBSCO.
Neuromuscular training and the regular practice In the data bases Medline and PubMed, the
of physical activities are factors that contribute to uniterms were associated with the Boolean operator
the maintenance of the functionality, balance, and “AND” as follows: “aged” AND “proprioception” AND
prevention of falls [11]. Promoting some stimuli “exercise therapy” AND “postural balance”. In Scielo, the
through exercise programs for over three hours a association carried out was between the words: “idosos”
week tends to present better results for the elderly (aged) AND “propriocepção” (proprioception); “idosos”
[12]. More specifically, muscular strengthening and (aged) AND “propriocepção” (proprioception) AND
aerobic exercises are recommended as a strategy to “treinamento físico” (exercise therapy); “idosos” (aged)
prevent those events [13]. However, there is evidence AND “propriocepção” (proprioception) AND “equilíbrio
that muscular strengthening benefits the dynamic postural” (postural balance). In LILACS, the association
stability, while proprioceptive stimuli favor the static was between “aged” AND “proprioception” AND
balance [14]. Water exercises are also recommended, “exercise therapy”; and “aged” AND “proprioception”
regarding activities of low and moderate intensity and AND “postural balance”. Finally, in the data base
taking into consideration their advantages in relation EBSCO, the uniterms associated were “aged” AND
to the practice of these exercises [15]. Even activities “proprioception”, “aged” AND “postural balance”, and
taught to be done at home might present positive results “aged” AND “exercise therapy”.
in relation to this objective, regarding stretching, walks, A differentiated association of descriptors in the
sitting and standing up exercises along with postural different data bases was necessary due to the results
control in the sitting position [16]. obtained with the search. Equal attempts of association

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 Drummond A, Paz CCSC, Menezes RL.
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of uniterms in the data bases sometimes generated ‘no unusual in the aging process or those that presented
result found’. Therefore, only those that presented at interventions in water therapy.
least one scientific paper were considered. The PEDro scale was used as a tool to quantify the
Eligibility criteria included: papers published up to methodological quality of the studies. Despite being a more
10 years ago, written in Portuguese, English or Spanish detailed tool for randomized clinical assays, meeting the
and characterized as randomized and non-randomized criteria 1, 10 and 11 can already legitimize the generalization
clinical assays, aiming at plausibility of interventions and interpretation of non-randomized clinical assays [18].
and results. Also, the use of exercises for the lower As a final search strategy, the analysis of references
limbs regarding static and/or dynamic activities [4] of the eligible papers was considered to verify the
was considered, using equipment or not and carried possibility of including some study that had not been
out on the floor. As a data comparison criterion, those identified in the pre-determined data bases.
that presented pre and post-therapy evaluations were Two evaluators carried out the search individually
considered, regardless of follow-up report, since the and followed the same strategy to deal with the pre-
objective was to identify acute alterations. Finally, the selected data bases in all processes to extract and obtain
authors evaluated postural balance, regardless of the data, without communicating to each other the results
evaluation of other functional aspects. obtained, until the search was ended. Only papers
Potentially relevant studies were included after title selected by both evaluators were initially included.
and abstracts were verified. Next, the same reviewers When a paper was selected by one of the evaluators only,
carried out, individually, the reading of the whole texts a third reviewer analysed that same article to decide
and selected them according to the eligibility criteria. whether it would be included or not.
After that, relevant data were extracted: objectives of
the study, sampling, exercise program data, frequency
of activities and main results. Results
The papers excluded were: those with
institutionalized elderly, or evaluating aged people The flowchart below shows that the number of
with osteoarthritis, osteoporosis, neurological diseases, documents included in the discussion after the eligibility
vestibular malfunction or ophthalmopathies that are criteria was 10 papers.

Figure 1 - Flowchart of the systematic review different phases.

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 Proprioceptive activities to postural balance of the elderly
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The intervention methods described favored the improvement of the postural balance through the combination
of static and dynamic activities, and one of the reports presented the proposal of verifying the results of Yoga
exercises [5, 19 - 27].
One paper presented the strategy of 24 weeks of therapy [25], three recommended 12 weeks of therapy [19,
20, 26], two suggested 8 weeks [5, 23], one paper recommended 6 weeks [21], two other papers recommended 5
weeks [22, 25] and another one suggested 4 weeks [24]. The frequency of participation in activities was established
between twice and three times a week, varying between 20-65 minutes per session.

Figure 2 - Characteristics of the papers included in the review (Brasília, 2016).

(to be continued)
Authors/ Objectives Sample Program of exercises Frequency of Results
year activities

CG: activities of daily life. EG: exercises After 8 weeks, the

To evaluate the to strengthen the quadriceps, hamstring, two therapy groups
effect of the gastrocnemius, maximus, medium and presented an
exercises on minimum gluteus. Initially with 3 series of increase in strength
Sohn et al.; 18
proprioception, 10 repetitions with a 50% da maximum load 3 times a week. and reduction in
2015 [5] elderly.
postural balance (ML), after 5 weeks, 3 series of 10 repetitions the probability of
and probability with a 70% ML; at the end, 3 series of 7 falls, with increase
of fall. repetitions with an 85% ML. PG: exercises of in muscular power
postural stability at different levels of difficulty. capacity.

Warming phase (10 minutes) considering

60% of the resting heart rate – slow
movements, including stretching the main
muscle groups of the lower and upper
limbs and trunk. Active phase (45 minutes) After 12
To evaluate
considering between 60 and 84% of the weeks, there
the effect of 3 times a week,
resting heart rate – forward and backward was increase
Todde et al.; supervised 20 for 65 minutes.
short walks, going up and down steps, upper in muscular
2016 [19] vigorous elderly.
and lower limb exercises with resistance to strength, balance,
exercises on the
elastic bands, which were changed, regarding flexibility and
functional ability.
their resistance each 4 weeks. Recovery agility.
phase (10 minutes) considering less than
60% of the resting heart rate – postural
control and exercises of spine mobility in
quadruped position, and stretching.
To evaluate
Twice a week, After 12 weeks,
the effects of
Breathing exercises (5 minutes), body for 60 minutes. there was
12 weeks of
Kelley et al.; 13 awareness (5 minutes), postural exercises It was necessary improvement of
therapeutic Yoga
2014 [20] elderly. standing, sitting and lying (40 minutes), to take part in at the walk speed,
on walking speed,
and meditation (10 minutes). least 19 sessions postural balance
postural balance
altogether. and mobility.
and mobility.

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(o be continued)

Authors/ Objectives Sample Program of exercises Frequency of Results

year activities
To evaluate
the effects of
combined stimuli
of mechanical,
proprioceptive Warming up for 15 minutes, with a
and vestibular comfortable speed walk and stretching After 6 weeks,
exercises, and of the muscle groups of the lower limbs. Three times there was
Kristinsdottir
prevention of 37 Proprioceptive therapy, mainly for the lower a week, for performance
et al.; 2014
fall in postural elderly. limbs, vestibular and visual control training, 45 minutes, improvement
[21]
control, functional facilitation and integration of vestibular and approximately. in all aspects
ability, self- proprioceptive stimuli, and movements evaluated.
confidence in preventing falls.
activities of daily
life, and frequency
of fall in unstable
elderly.

To evaluate the GC: Use of rocker board, round freeman After 5 weeks,
effects of a board, square freeman board, individual the proprioceptive
Twice a week;
proprioceptive trampoline (unipedal and bipodal therapy with
Treml et al.; 32 30 minutes of
therapy program support), use of skate to move the hips virtual reality was
2013 [22] elderly. stimulus.
on balance, (orthostatism), and twist disc. GE: circuit shown to be more
mobility, flexibility with obstacles (blindfolded), and use of a efficient than the
and falls. videogame platform. traditional one.

After 8 weeks,
there was
improvement
regarding the
Warming up (5 min) with forward, lateral support base,
and backward walks. Stretching (20 min) displacement in
To investigate
of the hip, knee, ankle and trunk muscles. Twice a week; 1 anteroposterior
the effects of
Alfieri et al.; 23 Coordination (25 min) throwing the ball hour of activities. direction with
exercises focused
2012 [23] elderly. one to another, or hitting balls with a open eyes and
on postural
bat, sometimes with one foot in front of blindfolded; and
control.
the other. Relaxation (5 min): breathing reduction in the
exercises, sitting. displacement in
the anteroposterior
direction in
individuals with
open eyes.
To analyze After 4 weeks,
the effect of there was
Walking training on a track with 4 different
do four weeks of increase in
types of soil, progressively, with 2m Twice a week, for
Nascimento proprioceptive balance and
9 elderly. distance between them, on which the 20 minutes.
et al.; 2012 therapy on reduction in the
patients would go and come back, and the
[24] the elderly’s time of execution
return was timed.
postural balance of the walking
measures training.

To verify the After 24 weeks,

effects of a there was
Warming-up (5-minute walk), global
physical exercise increase in the
Fernandes stretching (15 minutes), multi-sensorial
program on length of steps
et al.; 2012 8 elderly. exercises (30 minutes) – walking, strength, Twice a week.
walking and and walking
[25) balance and proprioception, in pre-
functional speed, improving
determined circuits.
mobility of the the functional
elderly. development.

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 Proprioceptive activities to postural balance of the elderly
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(conclusion)

Authors/ Objectives Sample Program of exercises Frequency of Results

year activities
To evaluate the
After 5 weeks,
effects of the use
Dougherty Three times a there was
of Nintendo Wii Training on a balance platform using an
et al.; 2011 9 elderly. week, for 10 improvement in
balance platform interactive game.
[26] minutes muscular strength
on balance and
and balance.
proprioception.

Warm up and flexibility (10 min), with

walking, playing ball with the feet and
To verify the hands, stretching of the hip, knee, ankle
Three times a
effects of a and paravertebral muscles. Strengthening After 12 weeks,
week, for 1 hour.
proprioceptive of lower muscle groups (15 min) with there was no
Walking, using
Alfieri; 2008 intervention 29 resistance elastic bands – 2 series of significant
postural instability
[27] regular program elderly. 20 or 15 repetitions; proprioception alteration of the
equipment,
on the distribution therapy (30 min), walking in different distribution of the
muscular
of the sole directions, on different types of soil, sole pressure.
strengthening.
pressure. going over obstacles, use of rocker board
and trampoline, with bipodal or unipedal
support, with open eyes or blindfolded.

Regarding methodological quality, Table 1 indicates the information obtained using the PEDro scale, as expected
the non-randomized studies presented lower score, considering the criteria evaluated by the scale.

Table 1- Bias control using the PEDro scale (Brasília, 2016)

Score 
Study 1 2 3 4 5 6 7 8 9 10 11 (0-11)
Sohn et al. [5] 1 1 1 1 1 0 0 1 1 1 1 9
Todde et al. [19] 1 1 0 1 0 0 0 1 1 1 1 7
Kelley et al. [20] 1 0 0 0 0 1 1 0 0 1 1 5
Kristinsdottir et al. [21] 1 0 0 0 0 0 1 0 1 1 1 5
Treml et al. [22] 1 1 0 1 1 0 0 1 1 1 1 8
Alfieri et al. [23] 1 0 0 0 0 0 0 1 1 0 1 4
Nascimento et al. [24] 1 0 0 0 0 0 0 1 1 0 1 4
Fernandes et al. [25] 1 0 0 0 0 0 0 1 1 0 1 4

Dougherty et al. [26] 1 0 0 0 0 0 0 1 1 0 1 4

Alfieri [27] 1 0 0 0 0 0 0 1 1 0 1 4
Note: * Score – 1 (presents the criterion); 0 (does not present the criterion). ** Items of evaluation – 1: eligibility criteria; 2: randomized
allocation; 3: secret allocation; 4: similarity between groups; 5: blindfolded participation; 6: blindfolded therapists; 7: blindfolded evaluators; 8:
dimension of results; 9: analysis trough treatment intention; 10: intergroup statistical comparison; 11: accuracy and variability measurements.

Discussion

The exercises proposed by the authors resulted, in general, in improvement in the participants’ postural control.
Since the proprioceptive response must be diversified in relation to the several kinds of internal and external
stimuli, it is necessary to consider the particularities of the participants so that the best option can be selected.

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The data were categorized as evaluation tools, types of portion of the back; the opposite hand, with the palm
activities and periods of intervention, for the discussion. turned backwards and positioned on the lumbar region
tries to reach the other hand. The distance between the
Evaluation tools two hands is also evaluated, evidencing whether there
The authors used several types of evaluation, was increase in flexibility or not.
depending on the objective of the study, among these The walking speed test was used by Sohn et al.
were: muscular strength test [5, 19, 27], flexibility [19], [5], Kelley et al. [20], Kristinsdottir et al. [21], Alfieri
time of walking speed [5, 20, 21, 23, 24], mobility [20, et al. [23], and Nascimento et al. [24]. Due to the
21], and postural balance [5, 19 - 27]. neurophysiological complexity of the walking function,
Todde et al. [19] inferred the degree of strength the measurement of the speed of execution of this
of lower limb muscles indirectly using the 30-second function might be a valuable analysis for the risk of
test to stand up from the sitting position in a chair, falls [28] and, therefore, for the evaluation of dynamic
in which during the determined time, the researcher body balance. Those authors used this tool coherently
measured how many times the elderly could perform to report the results obtained in their studies.
the movement of sitting in a chair and standing up. Postural balance was analyzed using the Berg
This function, according to the authors, requires Balance Scale (BBS) (EEB) [22, 24, 26], for Performance
strength from the muscles of the lower limbs to execute Oriented Mobility Assessment (POMA) [22], of BESTest
functional activities such as getting out of a car, standing [20], which is an evaluation that includes components
up from the sitting position, walking and going upstairs. of other scales and tests, such as EEB, Timed Up and Go
However, to be sure of the increase in muscular strength, (TUG) and the Ataxia Test Battery, which also analyzes
it is necessary to carry out a quantitative analysis of the biomechanical restrictions and stability during walking.
data, through a load cell, for example, since at the end Functional balance and mobility were tested using
of the therapy, the participants might have acquired Foot Up and Go (FUG) [21], like TUG, only differing in
ability and motor coordination for this test, improving distance, since FUG considers 2.4 meters to walk, turn
their performance in the test, which might mask the and go back to the starting point, watching the time of
real dimension of the inference. Sohn et al. employed execution of the distance covered. TUG was used by
the Biodex System 3 to quantify muscle effort through Fernandes et al. [25] and Alfieri et al. [23] with the same
the isokinetic peak prior and after training protocols, purpose. For the static postural balance, the Guralnik
contributing to a greater accuracy of results. test was also a resource used by Alfieri and collaborators
Also, regarding muscular strength, Dougherty et [23]. It consists of a battery of tests that include static
al. [26] concluded that there was an increase in the balance evaluation, ability to stand up from the sitting
strength of trunk and lower limb groups. However, the position in a chair and walking speed. The modified
evaluations applied were the Berg Balance Scale and a Romberg test was chosen by Nascimento et al. [24] and
videogame platform for the postural balance analysis. refers to the analysis of static balance with open and
There is some incoherence in concluding that there was closed eyes. The resource employed by Alfieri [27] in
increase in muscular strength, since no specific tool was 2008 was a computerized baropodometry system with
used to verify that, even if there was improvement in the a pressure platform coupled to a software, asking the
test results. Again, this might only mean that the elderly participants’ bipedal support on the platform, with open
acquired ability and motor coordination for the test. eyes and later on with closed eyes. The functional reach
Flexibility could be evaluated in the report by Todde and unipodal support test were used by Treml [22].
et al. [19], for both lower limbs, through the Chair Sit- There is no standardization of the postural balance
and-Reach Test, and the upper limbs using the Back evaluation in the studies analyzed. More suitable
Scratch Test. In the former, the volunteer sitting in a conclusions might have been described by the authors
chair stretches both lower limbs and tries to reach after using tools sensitive to this objective. It is also
the feet with both hands. The distance between their necessary to limit the intervention methods that can
fingers and the foot while keeping the spine erect is differentiate results regarding static and dynamic
measured and if there is reduction in distance (in cm), stimuli. The combination of static and dynamic exercises
some improvement in flexibility can be concluded. In was observed in the same protocol, using a single type
the latter, the volunteer has to put their hand on the of evaluation in some cases, which only informed the
shoulder of the same side and slip it towards the lower static or the dynamic ability. Also, the presence of clinical

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reasoning is necessary for the planning of interventions limbs, during most of the sessions. Also, varying this
with the participants. protocol, Alfieri [27] designed a training in which,
walking in different directions was stimulated as well
Types of activities as loss of balance on a trampoline, rocker board and
Stimulating lower limbs with exercises was a point muscle strengthening exercises for the lower limbs
in common between most of the authors. In a static or along with throwing a ball with both feet and hands.
dynamic way, using muscular strengthening exercises, The walking training has been associated to other
walking in different directions, training static stability stimuli to increase body balance, due to the complexity
control, going up and down the stairs and stretching of the interaction between systems with the purpose of
were all described in the protocols adopted. Kelley et promoting a more satisfactory result for the elderly [33,
al [20], when developing a sequence of Yoga specific 34]. However, results reported by Todde et al. presented
exercises with participants, which included stimuli in increase in muscular strength, agility, flexibility and
orthostatism, either sitting or lying, reported that not balance, differing from the results put forward by Alfieri,
only did the postural control improved, but also the since there was no significant alteration regarding pre
walking speed and mobility were favored. Therefore, and post-training data.
slower activities contributed to the authors’ goals, About the protocol for the muscular strengthening
conversely to what had been defended by Garcia et exercises, again referring to the study developed by
al. [29] regarding the need to prioritize muscular Alfieri [27], the approach was selective to the sole flexor
strengthening and power of the lower limbs [29] to muscles, knee extensor and flexor muscles, flexors,
alter the walking speed. Other alternative techniques adductors, hip abductors and extensor muscles, using
were already used aiming at observing their influence elastics and following the prescription of 2 series of 20
on the postural balance of older people, such as Tai repetitions and, if the load was increased, 2 series of 15
Chi Chuan, which also promotes slow and controlled repetitions. But, it is necessary to determine individually
movements. Despite not evaluating their participants the maximum volunteer load force and the training
in relation to their walking speed, Konig et al. noticed individual calculation, according to Sohn et al. [5],
some improvement in balance, using the TUG, EEB and who calculated the percentage of maximum voluntary
Romberg tests [30]. contraction of each participant for a proper training
Walking training is a therapeutic option adopted program. However, both studies used the strengthening
to improve the dynamic balance. With this proposal, protocol three times a week, and the results might be
Nascimento et al. [24] designed an exclusive route of more expressive regarding functional abilities [35].
walking training with four different types of soil, in Since the training of muscular strength of lower limb
sequence, with a total length of 8 metres, so that the groups enables improvement of postural balance [36].
elderly could walk, going ahead and coming back on the The resting time between the series was not informed.
adapted track. This protocol allowed them to observe This might be a relevant factor for a sedentary public,
some improvement in balance through the Berg Balance as the participants investigated.
Scale and the walking speed. Practicing walking and Later, Alfieri et al. [23] obtained different results
the speed test culminated in a scientific aspect that from those published in 2008, after adopting different
characterized the specific training. This has already evaluation measures and training protocol. Using static
been explained by Miyasike-da-Silva [31] and justifies and dynamic post urography, those authors described
the performance improvement. However, the Berg improvement in the support base and anteroposterior
Balance Scale also evaluates the static balance, even if movement with open or closed eyes. During the sessions,
it was not trained in this study, and demonstrated the the training procedures adopted were strictly dynamic,
participants’ evolution. It seems relevant to highlight in which the elderly had to walk in different directions,
that both types of balance require complex interaction throw the ball one to another with their hands and hit
between the sensorial systems and this is favored in the the ball with a bat, alternating the support base. Not only
dynamic training [32]. was the proposed activity altered but also the author’s
Todde et al. [19] asked their participants to walk method of evaluation, possibly due to the limitation of
backwards and forwards in a short distance, to go up the study published in 2008.
and down the stairs, to do muscular strengthening A different protocol was used by Kristinsdottir and
exercises with the lower limbs associated to the upper Baldursdottir [21], in which the participants started the

Fisioter Mov. 2018;31:e003135 Page 09 of 13

 Drummond A, Paz CCSC, Menezes RL.
10

training with a 15-minute walk, at a comfortable speed, Periods of intervention

and they could use the protection bars as a support The authors of the papers surveyed planned from
to their hands. Later, they stretched the muscles of four to twenty-four weeks of intervention and, in all
the lower groups to start a program of multisensory of them, it was possible to notice improvement in the
stimuli including: proprioceptive training, in which postural balance of the old people selected in their
the participants were stimulated to control their studies. It seems relevant to emphasize that, despite
body weight distribution during the body movements the great variation between the protocols, the analysis
and were discouraged to use their hands as eventual of the results obtained was only of the acute effect,
support, if they felt necessary. Vestibular training, therefore, four weeks with a specific walking training
in which the ocular movement was guided without [24], or twelve weeks with a varied protocol [19, 20,
moving the head and moving the head with closed eyes. 27], or even 24 weeks of multisensory stimuli [25],
Finally, the movements to prevent falls, about which might generate beneficial effects for those specific
the participants were instructed to react to sudden purposes, but the time the results lasted was not
disturbance, going a step forward to prevent the fall measured. Another finding was that the protocols
and when their stability was challenged by a manual used did not vary the stimulus during the weeks the
push to different directions. This protocol also reflected activities were developed. Therefore, four weeks of the
the beginning of a specific training, since it sought to same stimulus might generate positive results regarding
stimulate the different sensory systems related to the functional abilities.
ability to keep the postural balance, but it differed from However, this should not exempt further studies from
the others due to the vestibular component. adopting a follow up system to confirm the maintenance
Dougherty et al. [26] used a videogame platform of the results obtained and their magnitude. In a study
aiming at promoting dynamic postural control with nine with old women, Rebelatto et al. [40] could observe
participants, who were old people from the community, that the bilateral manual grasping strength was kept
for 10 minutes per session, three times a week for after 18 weeks of rest. The group of participants was
five weeks and concluded that there was increase in submitted to 58 weeks of strengthening and flexibility
muscular strength of the trunk and lower limb groups, exercises. However, the 18 weeks of rest was planned
in addition to the improvement in postural balance. in the middle of the program, after 29 weeks of stimuli.
The study by Craig et al. [37] can explain partially this Even if analyzing the proprioceptive response was not
benefit, those authors demonstrated that the elderly the objective, it seems relevant to observe that both
tend to present increase in co-contraction of the anterior strength and flexibility influence on the postural control
tibialis and the medial gastrocnemius muscles to keep and, therefore, the maintenance of their properties is
their balance. Therefore, taking into consideration vital to prevent falls, for example [2].
the stimulus of these muscles during the videogame Similar results described in this study were
platform activity, the muscular co-contraction might confirmed in other review studies, which reported
help the articular stabilization for the relevant activity moderate efficiency of the several stimuli proposed by
and, complementarily, the type of challenge proposed other authors, immediately after intervention, regarding
might make the proprioceptive sharpness in relation balance training, motor coordination, muscular strength
to the ankle articulation either easier or more difficult. and other types, to obtain improvement of the postural
Similar results from the research by Treml et al. [22], in balance. However, this does not lead to a concrete
which the participants in the experimental group, who conclusion to define the specific activity that would
used a videogame platform, obtained better postural guide the construction of a specific protocol, even for old
balance result from the stimulus with four different people with specific diseases such as diabetes [41, 42].
games and a walking training while blindfolded, when This study presents limitations that can be controlled
compared to the control group that carried out balance in further reviews of the theme. One of them is in
exercises on boards. These results might be related to relation to the number of data bases and, consequently,
the effort carried out by the elderly to succeed in their the unfeasibility of analyzing all papers published
interaction with the games. Also, the proprioceptive in the period defined and, therefore, more detailed
mechanism might overcome the visual and the data related to the object of study. Also, strategically,
vestibular ones, as a compensation, when referring to the papers chosen were those characterized as non-
the adaptation to the stimuli [39]. randomized clinical assays. However, the selective

Page 10 of 13 Fisioter Mov. 2018;31:e003135

 Proprioceptive activities to postural balance of the elderly
11

process of these publications revealed that evidence 8. Machado AS,  Bombach GD,  Duysens J,  Carpes FP.
can be found in studies with this design. This fact might Differences in foot sensitivity and plantar pressure
be a motivation for the development of other systematic between young adults and elderly. Arch Gerontol
reviews. The choice of other idioms for the selection Geriatr. 2016;63(1):67-71.
of papers is an important factor to complement the
9. Beauchet O, Barden J, Liu-Ambrose T, Chester VL, Szturm
findings of this research.
T, Allali G. The relationship between hippocampal
volume and static postural sway: results from the GAIT
study. Age (Dordr). 2016;38(19):1-8.
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11. Silva TO, Freitas RS, Monteiro MR, Borges SM. Avaliação
limbs, postural balance when facing alterations of the
da capacidade física e quedas em idosos ativos e
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functional abilities, but such activities cannot be
established as specific for postural balance, since there 12. Sherrington C, Michaleff ZA, Fairhall N, Paul SS,
is no standardization of the protocol or evaluation tools. Tiedemann A, Whitney J, et al. Exercise to prevent
It is necessary to control the number of weeks of falls in older adults: an updated systematic review
training and to produce more evidence regarding a and meta-analysis. Br J Sports Med 2017;51:1749–57.
suitable follow-up of the results obtained. doi:10.1136/bjsports-2016-096547.

13. Mat S, Tan MP, Kamaruzzaman SB, Ng CT. Physical

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proprioception rather than visual and vestibular cues
Received in 22/07/2017
for postural motor control. Front Aging Neurosci.
Recebido em 07/22/2017
2015;7:1-14.
Recibido en 22/07/2017

Approved in 28/08/2018
Aprovado em 08/28/2018
Aprobado en 28/08/2018

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