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The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis

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Several studies have examined the effects of balance training in elderly individuals following total knee arthroplasty (TKA), although findings appear to be equivocal.


This systematic review and meta-analysis examined the effects of balance training on walking capacity, balance-specific performance and other functional outcome measures in elderly individuals following TKA.


Data sources: Pubmed, PEDro, Cinahl, SportDiscus, Scopus. Eligibility criteria: Data were aggregated following the population-intervention-comparison-outcome (PICO) principles. Eligibility criteria included: (1) randomised controlled trials; (2) studies with comparative groups; (3) training interventions were incorporated post-TKA; and (4) outcome measures included walking capacity, balance-specific performance measures, subjective measures of physical function and pain and knee range-of-motion. Participants: Elderly individuals (65 + years) who underwent total knee arthroplasty. Interventions: Balance interventions that consisted of balance exercises, which were compared to control interventions that did not involve balance exercises, or to a lesser extent. Participants also undertook usual physiotherapy care in conjunction with either the balance and/or control intervention. The intervention duration ranged from 4 to 32 weeks with outcome measures reported immediately following the intervention. Of these, four studies also reported follow-up measures ranging from 6 to 12 months post-interventions. Study appraisal: PEDro scale.

Synthesis methods

Quantitative analysis was conducted by generating forest plots to report on standardised mean differences (SMD; i.e. effect size), test statistics for statistical significance (i.e. Z values) and inter-trial heterogeneity by inspecting I2. A meta-regression was also conducted to determine whether training duration predicted the magnitude of SMD.


Balance training exhibited significantly greater improvement in walking capacity (SMD = 0.57; Z = 6.30; P < 0.001; I2 = 35%), balance-specific performance measures (SMD = 1.19; Z = 7.33; P < 0.001; I2 = 0%) and subjective measures of physical function (SMD = 0.46; Z = 4.19; P < 0.001; I2 = 0%) compared to conventional training immediately post-intervention. However, there were no differences in subjective measures of pain (SMD = 0.77; Z = 1.63; P > 0.05; I2 = 95%) and knee range-of-motion (SMD = 0.05; Z = 0.39; P > 0.05; I2 = 1%) between interventions. At the 6- to 12-month follow-up period, improvement in combined measures of walking capacity and balance performance (SMD = 041; Z = 3.55; P < 0.001; I2 = 0%) were significantly greater for balance training compared to conventional training, although no differences were observed for subjective measures of physical function and pain (SMD = 0.26; Z = 2.09; P > 0.05; I2 = 0%). Finally, the training duration significantly predicted subjective measures of pain and physical function (r2 = 0.85; standardised β = 0.92; P < 0.001), although this was not observed for walking capacity and balance-specific performance measures (r2 = 0.02; standardised β = 0.13; P = 0.48).


A number of outcome measures indicated high inter-trial heterogeneity and only articles published in English were included.


Balance training improved walking capacity, balance-specific performance and functional outcome measures for elderly individuals following TKA. These findings may improve clinical decision-making for appropriate post-TKA exercise prescription to minimise falls risks and optimise physical function.

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Correspondence to Kenji Doma.

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Data Availability Statement

The mean and standard deviation measures for each effect point is presented in the forest plot. Thus, to avoid repetition, the data set for this review has not been included as a separate file.

Conflict of Interest

Kenji Doma, Jodie Morris and Andrea Grant declare that they have no conflicts of interest.

Study Funding

No financial support was received for the conduct of this study or preparation of this manuscript.

Electronic supplementary material

Below is the link to the electronic supplementary material.


Online resource 1. Funnel plot of the walk capacity measures. 2MWT – two minute walk test; 6MWT – six minute walk test (PDF 142 kb)


Online resource 2. Funnel plot of the walking capacity and balance measures during the 6-12 month follow-up period. 6MWT – six minute walk test (PDF 140 kb)


Online resource 3. Funnel plot of the subjective measures of function and pain during the 6-12 month follow-up period (PDF 186 kb)


Online resource 4. Funnel plot of the balance measures. BBS – Berg balance scale; SLS TKR EC – single leg stance time for the total knee replacement limb with eyes closed; SLS Non-TKR EC – single leg stance time for the limb without total knee replacement with eyes closed; CSTS – chair sit-to-stand; SLS TKR EO – single leg stance time for the total knee replacement limb with eyes open; SLS Non-TKR EO – single leg stance time for the limb without total knee replacement with eyes opened (PDF 192 kb)


Online resource 5. Funnel plot of the subjective measures of function and pain and range-of-motion measures (PDF 194 kb)

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Doma, K., Grant, A. & Morris, J. The Effects of Balance Training on Balance Performance and Functional Outcome Measures Following Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. Sports Med 48, 2367–2385 (2018).

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