Journals of Gerontology: Medical Sciences

cite as: J Gerontol A Biol Sci Med Sci, 2019, Vol. 74, No. 10, 1679–1685
doi:10.1093/gerona/gly271
Advance Access publication December 4, 2018

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Research Article

Effect of Balance Training After Hip Fracture Surgery:

A Systematic Review and Meta-analysis of Randomized
Controlled Studies
Sang Yoon  Lee, MD, PhD,1, Se Hee  Jung, MD, PhD,1 Shi-Uk  Lee, MD, PhD,1
Yong-Chan Ha, MD, PhD,2 and Jae-Young Lim, MD, PhD3,*
Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Dongjak-gu.
1

Department of Orthopaedic Surgery, Chung-Ang University College of Medicine, Seoul. 3Department of Rehabilitation Medicine, Seoul
2

National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.

*Address correspondence to: Jae-Young Lim, MD, PhD, Department of Rehabilitation Medicine, Seoul National University Bundang Hospital, 82,
Gumi-ro 173 Beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea. E-mail: drlim1@snu.ac.kr

Received: March 5, 2018; Editorial Decision Date: November 19, 2018

Decision Editor: Anne Newman, MD, MPH

Abstract
Background:  Although balance impairment after hip fracture surgery (HFS) can constitute a long-term problem of limiting mobility and
increasing the risk of falls in older adults, little is known about the effect of balance training (BT) on physical functioning after HFS. Thus, we
performed a meta-analysis to evaluate whether BT improved the overall physical functioning of patients after HFS.
Methods:  We searched the PubMed-Medline, Embase, and Cochrane Library databases in January 2018 and included all randomized
controlled trials comparing BT with usual care after HFS. We performed a pairwise meta-analysis using fixed- and random-effects models.
Results:  Eight randomized controlled trials including a total of 752 participants were retrieved. The BT group showed significantly improved
overall physical functioning after HFS compared with the usual care group (overall standardized mean difference [SMD]  =  0.390; 95%
confidence interval [CI] = 0.114–0.667; p = .006). Both, balance and gait improved (SMD = 0.570; 95% CI = 0.149–0.992; p = .008 and
SMD = 0.195; 95% CI = 0.043–0.347; p = .012, respectively) in the BT group. Lower limb strength, performance task, activity of daily living,
and health-related quality of life also improved significantly in the BT group.
Conclusion:  Our meta-analysis revealed that BT after HFS improved overall physical functioning. Positive effects on balance, gait, lower limb
strength, performance task, activity of daily living, and health-related quality of life were evident. Therefore, BT should be specifically included
in postoperative rehabilitation programs and balance must be thoroughly checked in elderly patients with hip fractures.
Keywords: Balance, Exercise, Hip fracture, Rehabilitation, Meta-analysis

The risk factors for falls are intrinsic (eg, lower limb weakness,
cognitive impairment, and balance deficit), extrinsic (eg, polyphar-
macy), or environmental (eg, poor lighting, loose carpets, and lack
of bathroom safety equipment) (1). Of these, balance deficits (rela-
tive risk = 2.9; 95% CI = 1.6–5.4) is the major risk factor for falls
(2). Therefore, balance should be included when evaluating fall risk,
and balance training (BT) is essential to prevent falls in elderly indi-
viduals. The American College of Sports Medicine and the American
Heart Association have suggested that community-dwelling older
adults at substantial risk of falls should perform exercises that main-
tain or improve balance to reduce the risk of injury (3).
In those with hip fractures, a balance problem may actually have
caused the fracture in addition to being a major sequela after acute
fracture care. Balance impairment may be a long-term issue among
older adults with hip fracture histories and may limit mobility and
increase the risk of falls (4). One cross-sectional study reported that
balance confidence was independently correlated with mobility in
patients with fall-related hip fractures (5). After such fractures, older
subjects lose confidence in their balance, increasing their risk of falls
(6) and initiating a vicious cycle that may culminate in subsequent
fracture. Therefore, BT should be a component of all comprehensive
rehabilitation programs after hip fracture surgery (HFS).

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1680
Currently, many such programs include BT to strengthen phys-
ical functioning and performance with the intention of improving
gait and balance (7,8). However, in long-term follow-up studies, con-
ventional rehabilitation programs had no significant effect on fall
rate (9) and mortality (10). Furthermore, the overall functional gain
afforded by BT has not yet been fully evaluated. Additionally, BT
immediately after HFS is not practical for patients whose balance
confidence is low and who still have severe pain at the surgical site.
Therefore, there was a question whether rehabilitation programs
focused on BT can improve their postoperative function. Thus, we
conducted a meta-analysis to explore whether BT improved the
overall physical functioning of patients after HFS. We compared bal-
ance improvements (primary outcomes) and other functional param-
eters (secondary outcomes) after HFS between a BT and a control
(usual care) group. We hypothesized that rehabilitation programs
featuring BT would yield better functional improvements than those
lacking BT.
Methods
Search Methods for Identifying Studies
We conducted our meta-analysis according to the updated Preferred
Reporting Items for Systematic Review and Meta-Analysis Protocols
guidelines (11). We searched the PubMed-Medline, Embase, and
Cochrane Library databases in January 2018 using the key terms:
(hip fracture OR femur neck fracture OR femur intertrochanteric
fracture) AND (balance exercise OR balance training OR balance
OR standing on one leg OR balance equipment OR tai chi OR step-
ping OR fall prevention exercise OR foot taps OR step up). An over-
view of the search strategy is presented in Supplementary Appendix
A. We included all randomized controlled trials (RCTs) comparing
BT with usual care after HFS. We imposed no limitation on the sur-
gical procedure and no language restriction.
Study Selection Criteria
All identified records were saved to EndNote software (ver. X7.2;
Thomson Reuters). Two independent reviewers (S.Y.L., J.Y.L.) first
screened the titles and abstracts to ensure that the articles were rele-
vant. Inclusion criteria were as follows: (i) an RCT and (ii) evalu-
ation of the utility of BT after HFS. BT was defined as any training
seeking to maintain the bodily position over the base of support
both statically and dynamically, within certain stability limits (12).
All types of BT, such as standing on one leg, exercise using balance
equipment, tai chi, yoga, stepping, fall-prevention exercise, foot tap-
ping, and step-ups, were included, as suggested by the American
Diabetes Association (13). In this meta-analysis, we finally selected
only studies that showed detailed descriptions of the protocols for
BT and focused on functional gain by BT in the Methods section.
Reviews, basic science articles, comments, letters, and protocols were
excluded. When studies involving the same cohort of patients were
identified, only the latest update was included in analysis.
Outcome Measures and Data Extraction
The primary outcome of interest was balance function, assessed
in any manner. The various assessments included the use of Berg’s
balance scale, Tinetti scoring, functional reach evaluation, assess-
ment of lateral stability, maximal balance range testing, single-limb
stance evaluation, assessment of swaying on a floor or foam, use of
a modified falls efficacy scale, completion of the balance domain of
the Short Physical Performance Battery, and assessment of overall
Journals of Gerontology: MEDICAL SCIENCES, 2018, Vol. 74, No. 10
coordination. The secondary outcomes were other functional param-
eters: (i) gait (walking speed assessed using the 6-minute walk test,
steadiness, the ability to walk unaided, and cadence); (ii) lower limb
strength (the strength or torque of the hip flexors, hamstrings, and
knee extensors); (iii) the activities of daily living (ADLs; the Barthel
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index, the Functional Independence Measure, basic and instrumental
ADL tests, and Lawton’s instrumental ADL test); (iv) performance
tasks (the timed up-and-go test, the modified Physical Performance
Test, the Physical Performance and Mobility Examination, and the
Short Physical Performance Battery); and (v) health-related quality
of life (HRQoL; the Short Form-36 questionnaire of the Perceived
Health and Self-Reported Outdoor Mobility and EuroQol-5D). If
raw data of an article could not be extracted because the results were
shown using figures instead of texts or tables, we sent e-mails ask-
ing the correspondents of the article for raw data. The studies were
excluded in case of no response of the authors and we have regarded
it as “failed raw data extraction.” For each eligible study, the fol-
lowing data were extracted and entered into a spreadsheet by the
two reviewers: first author’s family name, year of publication, num-
ber of patients, mean patient age at time of operation, enrollment
time, rehabilitation type and treatment duration, control condition,
follow-up duration, and outcome variables.
Quality Assessment and Publication Bias
Two authors (S.Y.L., J.Y.L.) independently evaluated study quality
using the criteria of the Cochrane Handbook for Systematic Reviews
of Interventions (14). These include the following seven items: (i)
random sequence generation, (ii) allocation concealment, (iii) blind-
ing of participants and personnel, (iv) blinding to outcome data, (v)
incomplete outcome data addressed, (vi) selective reporting, and (vii)
other bias. We assessed the publication bias using Begg’s funnel plot
(15) and Egger’s test (16).
Statistical Analysis
Effect sizes were computed as standardized mean differences (SMDs)
(17); thus, the pre- to post-test differences in all outcomes were
analyzed. SMDs were computed separately for all the control and
treatment groups in each study. Heterogeneity among comparable
studies was tested using the chi-square (χ2) and I2 tests. Values of p
more than .1 and I2 less than 50% were considered statistically sig-
nificant (18). As significant heterogeneity was apparent among the
eight studies (p = .005 and I2 = 65.4%), we used a random-effects
meta-analysis model to measure the pooled effect size of the included
studies. For each analysis by outcome parameters, balance (p < .001
and I2  =  85.1%), ADLs (p < .001 and I2  =  81.1%), performance
task (p < .001 and I2 = 90.0%), and HRQoL scores (p = .005 and
I2  =  80.9%) were also analyzed using the random-effects model.
However, we used a fixed-effects model to analyze the effect of BT
on gait (p = .510 and I2 = 0.0%) and lower limb strength (p = .758
and I2 = 0.0%). All analyses were performed using Comprehensive
Meta-Analysis Software (version 3.3; Biostat, Englewood, NJ). Our
study was exempted from institutional review board review because
we did not deal directly with any human subjects.
Results
Description of Included Studies
The primary database searches yielded 232 records. After dupli-
cates were removed, the titles and abstracts of 102 articles were ini-
tially screened, and 20 were selected for full-text review; 8 met all
Journals of Gerontology: MEDICAL SCIENCES, 2018, Vol. 74, No. 10
quality-inclusion criteria.(7, 8, 19–24) The excluded and included
studies are shown in Figure  1, and the characteristics of included
studies are summarized in Table 1. The same eight RCTs (published
from 1997 to 2017)  fulfilled the inclusion criteria for quantitative
analysis. The studies included a total of 752 subjects. The sample
sizes varied from 28 to 232 (15–120 cases and 13–112 controls).
The studies contained a total of 385 patients who underwent BT
after HFS and 367 who were treated conservatively. Participants
were enrolled within 14  days after HFS, at which time inpatient
exercise commenced in three studies (21,23,24); however, patients
in the other studies were enrolled in the chronic stage and home-
or outpatient-based exercise programs were delivered. The control
groups usually received conventional or minimal physical therapy,
although the group of one study received no treatment (19) and one
study supplied only nutritional education (7). The follow-up dur-
ation ranged from 1 to 12 months.
Results After Analysis
The BT group showed significantly improved overall physical func-
tioning after HFS compared the usual care group (overall Hedges’
g-pooled SMD  =  0.390; 95% confidence interval [CI]  =  0.114–
0.667; p = .006; Figure  2). BT also improved balance (pooled
SMD  =  0.570; 95% CI  =  0.149–0.992; p = .008). In terms of
Figure  1.  A preferred reporting items for systematic review and meta-
analysis flow diagram detailing our clinical study selection process.
Figure  2.  Forest plot of the effect of balance training on overall physical
functioning after hip fracture surgery as determined by random-effects meta-
analysis. Effect sizes are shown as Hedges’ g-standardized mean differences
with 95% confidence intervals.
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secondary outcomes, gait (SMD = 0.195; 95% CI = 0.043–0.347; p
= .012), lower limb strength (SMD = 0.276; 95% CI = 0.122–0.429;
p < .001), ADLs (SMD = 0.484; 95% CI = 0.043–0.926; p = .032),
performance task scores (SMD = 0.660; 95% CI = 0.127–1.193; p =
.015), and HRQoL scores (SMD = 0.602; 95% CI = 0.023–1.181; p
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= .042) all improved significantly (Figure 3).
Quality Assessment and Publication Bias
In terms of methodological quality, all subjects were randomized
using established allocation sequences, and the investigators and
research assistants were blind to the allocation. However, it is unclear
whether all trials met  all quality-assessment criteria (Figure  4).
Publication bias was evident; the Begg’s funnel plot was asymmet-
rical (Supplementary Appendix B), but the bias was not significant
according to the Egger testing of the eight trials (p = .249). After
trimming by imputing missing studies, adding these to the analysis,
and recomputing the effect size (the trim-and-fill method of Duval
and Tweedie), the overall Hedges’ g-pooled SMD actually increased
from 0.390 to 0.593 and thus remained statistically significant (95%
CI = 0.303–0.885).
Discussion
BT improved overall physical functioning after HFS. BT improved
not only balance but also walking, lower limb strength, ADLs, per-
formance task scores, and HRQoL scores. Such functional improve-
ments may reduce the refracture rate. To the best of our knowledge,
this is the first meta-analysis of the overall effect of BT after HFS.
Several conditions can compromise balance in elderly individuals,
including central nervous system diseases (cerebrovascular accidents
(25), cerebellar ataxia (26), and multiple sclerosis (27)). Cervical
spondylotic myelopathy affecting the dorsal column can destroy
proprioception and compromise balance (28). Additionally, osteo-
porosis and kyphosis, which develop during normal aging, reduce
balance in elderly individuals and thus increase the risk of falls (29).
The vestibular balance–maintenance function also decreases with
aging (30), triggering a need for vestibular rehabilitation (31).
The balance problems of elderly individuals are directly associ-
ated with fragility fractures such as hip fractures that may cause
serious morbidity and mortality. Thus, it is necessary to anticipate
and seek to solve such problems. Specifically, elderly subjects who
have undergone HFS fear falling and thus lack balance confidence
(6). In this review, we included three studies (21,23,24) featuring
acute inpatient BT programs; subjects in the other five studies were
enrolled in the chronic period after HFS, and BT was delivered either
at home or via outpatient-based programs. Although the difference
was not significant, the overall effect size of the three acute-BT
studies (pooled SMD  =  0.359; 95% CI  =  0.109–0.609; p = .005)
was somewhat higher than that of the chronic-BT studies (pooled
SMD  =  0.288; 95% CI  =  0.103–0.473; p = .002). Therefore, ini-
tiation of BT immediately after HFS is both feasible and clinically
useful for preventing secondary fracture.
Various types of BT have been applied in clinical settings. The
core feature of such training is to allow maintenance of bodily pos-
ition, both statically and dynamically, over the base of support,
within defined stability limits (12). BT usually features walking up
and down stairs (19,22,23) and/or walking on uneven surfaces (a
rugged floor or a fluffy sponge) (32). Recently, a computerized bal-
ance-training machine with a force plate that detects weight loads
and a monitor giving visual feedback has been used to train elderly
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Table 1.  Characteristics of Included Individual Studies

No. of participants
Study Subjects Intervention exercise (types of Control F/U
Study period Region characteristic balance training) condition Duration Frequency period Intervention Control Outcomes

Sherrington and — Australia >60 y old/fracture Stepping exercise with weight- No treatment 1 mo At least once a day 1 mo 20 20 LE strength, postural sway,
Lord (19) within the last bearing exercise functional reach, weight-bearing
9 mo ability, walking velocity, and
self-rated fall risk
Hauer and — Germany >75 y old, female Progressive functional training Motor placebo 3 mo 3 Days a week 3 mo 15 13 LE strength, maximal gait speed,
colleagues (20) 6–8 weeks after with walking, stepping or activities TUG, Tinnetti test, modified
hip surgery balancing (calisthenics, balance test
games)
Binder and 1998–2003 United States >65 y old/fracture Phase 1: flexibility, balance, Core exercise 6 mo 3 Days a week 6 mo 46 44 PPT, FSQ, skeletal muscle
colleagues (8) within the last coordination, movement speed focused on strength, gait, BBS, QoL, and
16 wks Phase 2: add progressive flexibility body composition
resistance training
Peterson and — United States >65 y old/ [Inpatient] High-intensity circuit Conventional 2 mo 2 Days a week 12 mo 38 32 LE strength, 6MWT, TUG, FRT
colleagues (21) immediate postop. training physical therapy
with balance and gait training
Sherrington and — Australia Mean 79 ± 9 y old Sit-to-stand, lateral step-up, Non-weight 4 mo Not mentioned 4 mo 40 40 LE strength, step test, function
colleagues (22) 82% community forward step-up-and-over, bearing exercise reach, sway distance, 6MWT, sit
dwellers forward foot taps, and a stepping (supine) and LE to stand, supine to sit, PPME
grid ROM exercise
Moseley and 2002–2005 Australia Mean 84 y old, [Inpatient] Standing up, sitting Lower dose 4 mo Twice daily 4 mo 80 80 Functional abilities, balance
colleagues (23) median time from down, tapping the foot, and exercise abilities, pain, fear of falling,
fracture to rehab stepping onto and off a block (30 min/d) QoL
14 d
Latham and 2008–2012 United States >60 y old/ Functionally oriented exercises Nutritional 6 mo 3 Days a week 9 mo 120 112 LE strength, BBS, self-efficacy,
colleagues (7) discharged within (standing from a chair, climbing education adverse events, and exercise
20 mo a step) adherence.
Monticone and 2012–2014 Italy >70 y old (7–10 d [Inpatient] Balance task-specific Walking training 3 wks 3 Days a week 12mo 26 26 WOMAC, pain, BBS, FIM,
colleagues (24) after hip surgery) training while standing and open kinetic SF-36
chain exercise

Note: BBS = Berg balance scale; FIM = Functional Independence Measure; FSQ = Functional Status Questionnaire; LE = lower limb; PPME = physical performance and mobility examination; PPT = physical performance
test; QoL = quality of life, SF-36 = Short Form-36 questionnaire of perceived health; TUG = timed up-and-go; WOMAC = Western Ontario and McMaster Universities Osteoarthritis Index; 6MWT = 6-min walking test.
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Journals of Gerontology: MEDICAL SCIENCES, 2018, Vol. 74, No. 10
Figure 3.  Forest plots of the effects of balance training on various characteristics (outcomes): (A) balance, (B) gait, (C) lower limb strength, (D) activities of daily
living, (E) performance tasks, and (F) health-related quality of life.
Figure 4.  Summary of bias risk of the randomized controlled trials.
subjects (33). Dodd and colleagues (34) found that such training was
feasible and useful after HFS in elderly subjects. An effort has been
made to use only balance task-specific exercises, rather than general
actions or exercises, in the BT for HFS patients. Patients were asked
to walk straight with or without crutches while changing speed and
direction or while performing motor–cognitive tasks, such as turning
the head to the right or left side (24). Although this RCT included
only 52 subjects, the intervention significantly improved physical
functioning, pain, ADLs, and even HRQoL.
We found that subjects experiencing interventions that
included BT exhibited significant improvements in ADL and
HRQoL as well as balance, gait, lower limb strength, and per-
formance. The forest plot for each outcome showed that, of the
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eight RCTs studied, only the study performed by Monticone and
colleagues (24) reported higher effect sizes for all outcome vari-
ables. The cited work featured balance task-specific performance
training and was more focused on balance than were the other
studies; thus, these results are not surprising. However, even after
removal of this study, the effect size of the remaining seven studies
remained statistically significant (corrected pooled effect size of
the seven RCTs = 0.237; 95% CI = 0.084–0.390). As mentioned
earlier, balance task-specific exercise may be superior to conven-
tional BT, but further larger-scale clinical studies should be added
to strengthen such findings.
Our study had certain limitations. First, we included only a small
number of reports because only a few studies have evaluated BT in
detail and used balance as an outcome variable. To overcome this
limitation, we included various types of BT and several outcomes of
exercise. However, this increased heterogeneity. Moreover, we have
not limited the comparative (control) intervention. Because the com-
parators of Monticone’s and Peterson’s studies were conventional
rehabilitation unlike other studies, these two studies investigated
the additional effects of adding BT to conventional treatments after
HFS. This is a clear disadvantage of this study as it can vary the
magnitude of the effect size according to the comparative interven-
tions that differ from one study to the next. Second, we analyzed
the effect sizes of several outcomes of individual studies in either
a pooled or overall manner. These data are of limited clinical util-
ity and should be interpreted with caution. As the significance of
each outcome variable differed, the absence of weighting is another
limitation of the study. Finally, a clear publication bias was evident.
There was no unpublished report (such as a dissertation) among the
final eight articles, and all were written in English. Furthermore, the
study of Monticone and colleagues (24) had larger effect sizes than
the other studies, as mentioned earlier. However, after adjustment
using the trim-and-fill method of Duval and Tweedie, the effect size
remained meaningful and, indeed, even increased (overall pooled
SMD  =  0.390; 95% CI  =  0.114–0.667 to SMD  =  0.593; 95%
CI = 0.303–0.885).
1684
Conclusions
Our meta-analysis suggests that BT after HFS improved overall
physical functioning. Positive effects on balance, gait, lower limb
strength, ADLs, performance task scores, and HRQoL were evident.
Therefore, BT should be specifically included in all postoperative
rehabilitation programs, and the balance function must be thor-
oughly checked in elderly patients with hip fractures.
Supplementary Material
Supplementary data are available at The Journals of Gerontology,
Series A: Biological Sciences and Medical Sciences online.
Funding
This research was supported by a grant of the Korea Health Technology R&D
Project through the Korea Health Industry Development Institute, funded
by the Ministry of Health & Welfare, Republic of Korea (grant number:
HC15C1189).
Conflict of Interest
None declared.
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