Research Report
Effects of a Balance Training Program Using a
Foam Rubber Pad in Community-Based Older
Adults: A Randomized Controlled Trial
Tatsuya Hirase, PT, MS1; Shigeru Inokuchi, PT, PhD2;
Nobuou Matsusaka, PhD, MD2; Minoru Okita, PT, PhD1
ABSTRACT
Background and Purpose:  Exercise programs aimed at improv-
ing balance are effective in fall prevention for older adults.
Guidelines indicate that unstable elements should be integrat-
ed in balance training with this population. Balance training
on an unstable surface facilitates proprioception mediated by
skin receptors in the soles of the feet and by mechanorecep-
tors in the joints and muscles. This randomized controlled
trial examined whether balance training performed using a
foam rubber pad was more beneficial than balance training
performed on a stable flat surface in older adults.
Methods:  Older adults using Japanese community day cen-
ters once or twice per week were enrolled in this trial. In
total, 93 participants were randomized to 1 of 3 groups:
foam rubber exercise group (n = 32), stable surface exercise
group (n = 31), and control group (n = 30). Participants in
the foam rubber and stable surface exercise groups attended
a 60-minute exercise class once a week for 4 months and
followed a home-based exercise routine. Outcome measures
were the following performance tests: the one-leg standing
test (OLST), the chair standing test, the timed up-and-go test
(TUGT), and the tandem-stance test (TST). These assess-
ments were conducted before the intervention, and at 1, 2, 3,
and 4 months after starting the intervention.
Results:  There were group × time interactions (P < 0.001)
for all performance tests. The foam rubber exercise group
showed significant improvements in the OLST, TST, and
TUGT at 1 to 4 months compared with the control group
(P < 0.02). The foam rubber exercise group also showed
significant improvements in the OLST and TST at 2 and 3
months compared with the stable surface exercise group
(P < 0.02). Within the foam rubber exercise group, the OLST,
TUGT, and TST, at 1 to 4 months, were significantly improved
compared with before the intervention (P < 0.01). Within the
1Department
of Locomotive Rehabilitation Science, Unit
of Rehabilitation Sciences, Graduate School of Biomedical
Sciences, Nagasaki University, Japan.
2Department of Health Sciences, Graduate School of
Biomedical Sciences, Nagasaki University, Japan.
The authors declare no conflicts of interest.
Address correspondence to: Shigeru Inokuchi, PT, PhD,
Department of Health Sciences, Graduate School of
Biomedical Sciences, Nagasaki University, 1-7-1 Sakamoto,
Nagasaki 852-8520, Japan (shigeru@nagasaki-u.ac.jp).
Kevin Chui was the Decision Editor.
DOI: 10.1519/JPT.0000000000000023
62 Volume 38 • Number 2 • April-June 2015
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JGPT-D-13-00026.indd 62
stable surface exercise group, the TUGT and TST, at 3 and
4 months, were significantly improved compared with before
the intervention (P < 0.01).
Conclusions:  This study confirms that balance training in
older adults performed using a foam rubber pad is effective for
improving balance ability, and that this improvement occurs 2
months earlier compared with balance training performed on
a stable surface. These findings suggest that balance training
performed using a foam rubber pad is beneficial to clients
and service providers because the programs improve physi-
cal functioning with a reduced number of exercise sessions.
Key words:  balance, foam rubber, older adults, randomized
controlled trial
(J Geriatr Phys Ther 2015;38:62–70.)
INTRODUCTION
Worldwide, fall-related injuries and mortality in older
adults are major health care concerns, and their incidence
continues to rise.1 Approximately 30% of community-
dwelling adults aged 65 years and older fall at least once
a year, with 6% of these falls resulting in fractures.2,3 Falls
are a risk factor not only for fractures but also for the devel-
opment of traumatic cerebral or visceral hemorrhage, trau-
matic pain syndromes, functional limitations, dislocations,
soft tissue injuries, excess health care costs, and increased
mortality.3 Thus, because of the increased incidence of falls
in older adults and the associated risk for other problems,
fall prevention is a major health care priority.
Previous studies of fall prevention have shown that exer-
cise interventions effectively reduced both the risk of falls
and the actual number of falls in older adults by improving
physical function.4,5 Poor balance and muscle weakness
seem to be associated with an increased risk of falls in older
adults.6 Numerous exercise programs aimed at improv-
ing balance and muscle strength have been conducted in
the community.7-16 Recently, exercise programs aimed at
improving balance ability have been shown to be effective
in fall prevention for older adults.17
Researchers have reported that balance training improves
lower extremity muscle strength in addition to balance.12-14
Many balance training programs for older adults comprise
performance-based exercises aimed at improving static and
14/03/15 3:07 AM

dynamic balance, such as one-leg standing, tandem stance,
reaching, and walking sideways.15,16,18-20 Such programs
for older adults are traditionally conducted on flat, stable
surfaces to help reduce the risk of falls and associated inju-
ries. However, sports medicine research has reported that
balance training performed on unstable surfaces signifi-
cantly improves balance compared with balance training
on stable surfaces.21,22 This may be because of improved
proprioception mediated by skin receptors in the soles of
the feet and by mechanoreceptors in the joints and muscles.
Previous studies have reported that proprioception and
posture are enhanced by the increase in the afferent input
from mechanoreceptors in the muscles and joints caused by
postural sway on unstable surfaces.21,22
Guidelines for balance training indicate that unstable
elements should be integrated in balance training with
older adults.23,24 Several studies have reported that stand-
ing on a foam rubber pad affects the skin receptors in the
soles and mechanoreceptors in the joints and muscles,
and provide useful proprioceptive information for pos-
tural reactions.25,26 However, the effectiveness of balance
training in older adults performed using a foam rubber
pad compared with using a stable surface has not been
fully tested and remains unclear; we thus undertook an
investigation of such effectiveness in the present study. We
hypothesized that balance training performed using a foam
rubber pad would be effective in improving balance and
reducing the number of falls of study participants, and that
balance would improve at a faster rate compared with bal-
ance training on a stable surface.
METHODS
Participants
Older adults using community day centers in the Japanese
cities of Nagasaki and Unzen once or twice per week were
enrolled in the study. We selected 7 day centers where
physical therapists worked together with community care
staff. The physical therapists were asked to choose poten-
tial participants over the age of 65 years who were living
at home, able to walk with or without a cane, and had at
least 4 risk factors, as identified using the questionnaire for
fall assessment reported by Suzuki.27 The questionnaire
consisted of 15 items, which included questions about fall
history, walking ability, muscle power, medical disorders,
medication, vision and hearing, and fear of falling.27-29 A
cross-sectional study showed that the number of risk fac-
tors identified by the questionnaire correlated significantly
with the number of falls in the previous year, psychological
status, and physical function related to muscle strength
and balance.30 In addition, the questionnaire predicted
falls with sensitivity and specificity of 59.4% and 83.1%,
respectively, when a cutoff point of 4 risk factors was used.
Specifically, older adults with at least 4 risk factors were
regarded as high-risk fallers.29 This questionnaire has been
Journal of GERIATRIC Physical Therapy 63
Copyright © 2015 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-13-00026.indd 63
Research Report
widely adopted by community care staff for the assessment
of falls among older adults in Japan.28
Participants who had participated in exercise at least 4
times a month before the intervention, and who had mus-
culoskeletal, neurological, or cardiovascular disorders that
may be aggravated by exercise were excluded. Participants
who were unable to respond to interview questions because
of cognitive impairment were also excluded.
Written informed consent was obtained from each par-
ticipant in accordance with the guidelines approved by the
Nagasaki University Graduate School of Medicine and the
Declaration of Human Rights, Helsinki, 2008.
Design and Randomization
This study was a randomized controlled trial conducted
between October 2010 and September 2012. Participants
who met the inclusion and exclusion criteria were random-
ized into 3 groups using the sealed envelope method.31 The
randomized groups were as follows: (1) a group perform-
ing a balance training program on a foam rubber pad with
6 cm in thickness, 50 cm in width, and 40 cm in length
(Airex® mat, Sakai Medical, Japan; Figure 1) (foam rubber
exercise group); (2) a group performing the same balance
training program on a stable flat surface (stable surface
exercise group); and (3) a control group. Physical therapists
working in the day centers assessed the participants and
implemented the intervention program.
Intervention
Participants in the foam rubber and stable surface exercise
groups were asked to attend a 60-minute weekly exercise
class for 4 months that was supplemented with daily home-
based exercises. The exercise program consisted of 10 min-
utes of warm-up, 40 minutes of balance training, and 10
minutes of cool-down. All exercise sessions were conducted
with the participants in training groups of approximately
10 people.
Figure 1. Foam rubber pad used in the study.
14/03/15 3:07 AM
 Research Report
The balance training program has been described in
previous studies.15,18 The program included 10 exercises
performed in a standing position as follows: double-stance
standing, one-leg standing, neck hyperextension, free-leg
swinging, heel and toe raises, neck and trunk rotation,
touching the floor, walking in place, sideways walking, and
walking (Table 1). The intensity of balance training over
the 40 minutes was constant throughout the intervention
period and was interrupted with breaks totaling 10 min-
utes, depending on the participants’ physical capacity. The
study exercises were videotaped to ensure the consistency
of the balance training given to the participants.
Table 1. Balance Training Exercises in the Foam Rubber
Exercise Group and the Stable Surface Exercise Group
Exercise Description
Hold for 20 s
Double-stance
standing Repeat twice with eyes open, twice with eyes
closed
Stand on one leg with the other placed
midway up the calf
One-leg standing Hold for 10 s, if possible
Repeat 3 times on each leg, once with eyes
open and once more with eyes closed
Stand while slowly hyperextending the neck
Neck and then tipping it down forward
hyperextension Repeat 5 times with eyes open, 5 times with
eyes closed
Stand on one leg while moving the other
slowly forward, side and back
Switch legs and repeat 3 times, then again
Free-leg swinging
with eyes closed
Initially, participants may slide feet over the
floor, but later in the class they should try
to progress to lift the leg completely off the
floor
Rock slowly up onto toes and hold, then roll
back onto heels and hold
Heel and toe raises
Repeat 3 times with eyes open, 3 times with
eyes closed
Neck and trunk Stand while slowly rotating the neck and trunk
rotation Repeat 3 times with eyes open
Touch the floor while squatting down
Touching the floor
Repeat 5 times with eyes open
Walk in place for 20 s
Walking in place
Repeat twice with eyes open
Walk sideways, bringing the trailing foot just
up to the lead one
Sideways walking
Repeat 5 times with eyes open for
approximately 7-m distance
Walk forward without looking at the ground
Forward walking Repeat 5 times with eyes open for
approximately 7-m distance
64 Volume 38 • Number 2 • April-June 2015
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JGPT-D-13-00026.indd 64
Regarding the daily home-based program, we ensured
that the exercises were simple enough to be performed
easily and continuously by older adults. Therefore, only
3 exercises (ie, one-leg standing, heel and toe raises, and
walking in place) were selected from the balance training
program for home-based repetition. The participants in
the 2 exercise groups were given monthly training diaries
to record their performance of the home-based exercise
program. These training diaries were checked every week
by the physical therapist working in each day center. The
participants in the foam rubber and stable surface exercise
groups were asked to perform the home-based exercise
program on the foam rubber pad, and on the stable flat
surface, respectively.
Participants in the control group participated in weekly
social programs, including recreational activities, educa-
tional programs, and tea breaks. They continued their daily
activities at the day centers, but performed neither balance
training nor muscle strengthening exercises at the centers or
in a structured setting at home.
Assessment
Physical function, risk factors for falls, fear of falling, and
the number of falls during the intervention period were
assessed. Before commencing the study, the physical thera-
pists received training from one of the authors (TH) on the
assessment protocols.
Physical function was assessed using the following
performance tests: the one-leg standing test (OLST),32
the chair standing test (CST),33 the timed up-and-go test
(TUGT),34 and the tandem-stance test (TST).35 These tests
were conducted twice, and the best value from the 2 tests
was recorded. Physical function was measured before the
intervention, and at 1, 2, 3, and 4 months after starting the
intervention.
Risk factors for falls were identified using Suzuki’s fall
assessment questionnaire.27 Fear of falling was evaluated
using the modified Falls Efficacy Scale (FES) translated
into Japanese. The FES used the same 10 items reported
by Tinetti et al,36 and each item was assessed on the fol-
lowing scale: 1, “I have no confidence to do so”; 2, “I
have little confidence to do so”; 3, “I have some confidence
to do so”; 4, “I have full confidence to do so.” The total
score on the FES can range from 10 to 40, with high scores
indicating greater confidence. These assessments were self-
administered with guidance from the care staff at the day
centers as needed. Risk factors for falls and fear of falling
were evaluated before the intervention and at 4 months
after starting the intervention.
A fall was defined as “unintentionally coming to rest on
the ground, floor, or other lower level in a manner that did
not result from a major intrinsic event or an overwhelm-
ing hazard.”37 Each participant was given a diary with
a monthly sheet to record the number of additional falls
during the follow-up period. The number of additional falls
14/03/15 3:07 AM

was recorded every week by a physical therapist working
in each day center.
Required Sample Size
We searched previous literature examining the effect of bal-
ance exercise on elderly people living at home. The reports
indicated a large effect size (0.8-1.3).19,20 Therefore, with a
statistically significant level of 5% (P = 0.05), a statistical
power of 80%, and an effect size of 0.8, a minimum of 26
participants were required per group. Allowing for a 10%
dropout rate, a minimum of 29 participants were required
per group.
Statistical Analysis
Statistical analysis was performed using SPSS 11.0
Japanese version for Windows (SPSS Inc, Chicago, IL).
One-way analysis of variance was performed using an
unpaired t test with a Bonferroni adjustment to compare
the age, height, weight, and physical function between the
3 groups before the intervention. Chi-square tests were
used to compare sex distributions, the presence of falls
in the year before the intervention, and the proportion
of participants who dropped out during the intervention
between the 3 groups. The Kruskal-Wallis test, combined
with the Mann-Whitney U post hoc test with a Bonferroni
adjustment, was used to assess differences between the 3
groups in terms of the number of medications, the num-
ber of risk factors, and the FES scores at baseline and 4
months after starting the intervention. This test was also
used to investigate the differences in the numbers of falls
Figure 2. Flowchart outlining the number of participants in each arm of the study.
Journal of GERIATRIC Physical Therapy 65
Copyright © 2015 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-13-00026.indd 65
Research Report
during the intervention at 4 months after starting the
intervention.
The effect of exercise on each physical function item
was analyzed using a 3 (group: foam rubber exercise
group, stable surface exercise group, and control group) ×
5 (time: baseline, 1, 2, 3, and 4 months after starting the
intervention) analysis of variance. Post hoc Bonferroni tests
were used to assess which group or time periods showed
significant differences. A 2-sided P value of ≤0.05 was
considered significant.
RESULTS
A flowchart outlining study participation is shown in
Figure 2. A total of 171 individuals were screened for the
potential participants. Seventy-eight of 171 potential par-
ticipants were excluded because of refusal to participate
in the study (n = 19) and not meeting inclusion criteria
(n = 59). Out of the 59 participants who did not meet
inclusion criteria, 15 participants had severe musculoskel-
etal or cardiovascular disorders and 44 participants had
exercised regularly 4 or more times a month before the
initial interview. The remaining individuals (n = 93) were
enrolled in the study, and were randomly allocated to the
foam rubber exercise group (n = 32), stable surface exer-
cise group (n = 31), or control group (n = 30).
A total of 7 participants (7.5%) withdrew from the
trial. Three participants (9.4%) in the foam rubber exer-
cise group were admitted to hospital because of serious
illness (pneumonia [n = 2] and heart disease [n = 1]), 2
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 Research Report

participants (6.5%) in the stable surface exercise group
were admitted to hospital with pneumonia, and 2 (6.7%)
in the control group withdrew because of serious illness
(pneumonia [n = 1] and heart disease [n = 1]). There was
no significant difference between the 3 groups in terms of
withdrawal from the study (P = 0.89). No participants
dropped out as a result of the balance training program
itself. In short, eighty-six of 93 participants completed
the 4-month intervention: 29 in the foam rubber exercise
group, 29 in the stable surface exercise group, and 28 in
the control group.
During the intervention, participants who completed
the study attended 95.5%, 93.3%, and 91.2% of all pos-
sible classes in the foam rubber, stable surface, and control
groups, respectively. There was no significant difference
between the 3 groups in terms of program adherence
(P = 0.20). Participants in the foam rubber and stable
surface exercise groups performed the home-based exercise
program 3.5 (standard deviation [SD]: 2.0) and 3.4 (SD:
2.3) days per week, respectively. There was no significant
difference between the 2 exercise groups in terms of their
home-based program adherence (P = 0.75).
Baseline Characteristics
The baseline characteristics of the participants are sum-
marized in Table 2. There were no significant differences
between the 3 groups in terms of age, sex, incidence of
falls in the previous year, number of medications, physical
function, risk factors for falls, and FES scores (P ≥ 0.55).
Effects of Balance Training
Changes in physical function
Table 3 shows the changes in physical function over
4 months across the groups. For physical function
assessments, there were significant group × time interac-
tions (P < 0.001).
For the OLST, the mean values at 1 to 4 months after
the intervention in the foam rubber exercise group were sig-
nificantly better than those in the control group (P < 0.02),
and the mean values at 2 to 4 months in the foam rubber
exercise group were significantly better than those in the
stable surface exercise group (P < 0.02). Within the foam
rubber exercise group, the mean values at 1 to 4 months
showed significant improvement compared with before the
intervention (P < 0.01).
For the CST, the mean values at 2 to 4 months in the
foam rubber exercise group were significantly better than
those in the control group (P < 0.02). The mean values
at 2 to 4 months in the stable surface exercise group were
also significantly better than those in the control group
(P < 0.02). Within the foam rubber exercise group, the
mean values at 2 to 4 months showed significant improve-
ment compared with before the intervention (P < 0.01).
Within the stable surface exercise group, the mean value at
4 months showed significant improvement compared with
before the intervention (P < 0.01).
For the TUGT, the mean values at 1 to 4 months in the
foam rubber exercise group were significantly better than
those in the control group (P < 0.02). Within the foam rub-
ber exercise group, the mean values at 1 to 4 months after
the intervention showed significant improvement compared
with before the intervention (P < 0.01). Within the stable
surface exercise group, the mean values at 3 and 4 months
after the intervention showed significant improvement
compared with before the intervention (P < 0.01).
For the TST, the mean values at 1 to 4 months after the
intervention in the foam rubber exercise group were signifi-
cantly better than those in the control group (P < 0.02),
and the mean values at 2 and 3 months in the foam rubber

Table 2. Baseline Characteristics of Study Participants

Foam Rubber Exercise Stable Surface Exercise Control Group
Characteristic Group (n = 32) Group (n = 31) (n = 30) P
Age, yr—mean (SD) 82.1 (5.5) 82.0 (5.7) 82.2 (6.3) 0.99
Female—n (%) 23 (71.9) 23 (74.2) 19 (63.3) 0.62
Height, cm—mean (SD) 151.0 (6.1) 149.5 (7.2) 150.2 (6.0) 0.67
Weight, kg—mean (SD) 52.9 (9.1) 51.2 (7.7) 53.3 (9.1) 0.61
Medication, n—mean (SD) 5.4 (2.3) 5.9 (2.4) 5.8 (1.8) 0.75
Falls in previous year—n (%) 16 (50.0) 14 (45.2) 14 (46.7) 0.93
OLST, s—mean (SD) 4.9 (5.3) 4.7 (4.3) 5.6 (8.4) 0.86
CST, s—mean (SD) 13.6 (4.2) 12.8 (5.2) 13.5 (3.1) 0.71
TUGT, s—mean (SD) 13.6 (3.7) 13.9 (5.1) 14.1 (3.0) 0.92
TST, s—mean (SD) 18.3 (13.4) 16.3 (17.1) 17.2 (17.7) 0.89
Risk factors of falls, n—mean (SD) 6.9 (1.7) 7.3 (2.1) 7.1 (2.1) 0.90
FES score, points—mean (SD) 28.7 (4.5) 28.8 (5.7) 26.7 (6.7) 0.55
Abbreviations: CST, chair standing test; FES, Falls Efficacy Scale; OLST, one-leg standing test; SD, standard deviation; TST: tandem-stance test; TUGT, timed up-and-go test.

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Table 3. Comparison of Physical Function Performance Tests Between the 3 Groups During the Intervention Period
Before the
Intervention After 1 mo After 2 mos After 3 mos After 4 mos F Value
Group
Item Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD) Time Group × Time
One-Leg Standing Test, s
  Foam rubber exercise group 4.9 (5.3) 8.2 (7.5)ab 11.5 (11.1)abc 12.0 (11.8)abc 12.0 (11.7)abc 7.09** 6.69** 6.52**
  Stable surface exercise group 4.7 (4.3) 5.3 (5.2) 5.3 (3.6) 6.2 (5.4) 6.9 (5.5)
  Control group 5.6 (8.4) 3.8 (5.2) 3.3 (2.4) 4.6 (4.7) 4.2 (4.5)
Chair Standing Test, s
  Foam rubber exercise group 13.6 (4.2) 12.5 (4.7) 10.6 (2.7)ab 10.3 (2.6)ab 9.9 (2.8)ab 10.67** 5.24** 5.47**
  Stable surface exercise group 12.8 (5.2) 12.5 (5.3) 11.4 (3.0)d 11.2 (2.9)d 10.8 (3.1)bd
  Control group 13.5 (3.1) 13.7 (3.3) 14.2 (4.2) 14.0 (4.2) 13.9 (3.9)
Timed Up-and-Go Test, s
  Foam rubber exercise group 13.6 (3.7) 11.8 (2.9)ab 11.3 (3.2)ab 11.2 (2.6)ab 11.3 (2.5)ab 7.51** 3.83* 4.46**
  Stable surface exercise group 13.9 (5.1) 13.1 (4.7) 12.7 (4.2) 12.3 (3.8)b 12.1 (4.2)b
  Control group 14.0 (3.0) 14.2 (3.6) 14.8 (5.0) 14.4 (4.8) 14.6 (5.0)
Tandem-Stance Test, s
  Foam rubber exercise group 18.3 (13.4) 27.4 (19.1)ab 32.3 (19.6)abc 35.6 (16.6)abc 37.4 (17.6)ab 18.76** 6.04** 6.74**
  Stable surface exercise group 16.3 (17.1) 19.3 (18.2) 19.4 (17.2) 23.8 (18.5)b 27.6 (20.1)b
  Control group 17.2 (17.7) 15.8 (18.0) 14.2 (16.2) 16.9 (18.9) 16.8 (19.2)
Abbreviations: SD, standard deviation.
aSignificant differences between the foam rubber exercise group and the control group.
bSignificant differences from preintervention (baseline).
cSignificant differences between the foam rubber and stable surface exercise groups.
dSignificant differences between the stable surface exercise group and the control group,

*P < 0.05; **P < 0.01.

exercise group were significantly better than those in the
stable surface exercise group (P < 0.02). Within the foam
rubber exercise group, the mean values at 1 to 4 months
after the intervention showed significant improvement
compared with before the intervention (P < 0.01). Within
the stable surface exercise group, the mean values at 3 and
4 months after the intervention showed significant improve-
ment compared with before the intervention (P < 0.01).
Changes in risk factors for falls, fear of falling, and
additional falls
The mean (SD) number of risk factors for falls at 4 months
for the foam rubber, stable surface, and control groups was
5.7 (1.9), 6.5 (2.4), and 7.6 (2.1), respectively. The mean
(SD) FES scores for the foam rubber, stable surface, and
control groups were 28.8 (4.5), 27.7 (6.0), and 24.4 (6.5),
respectively. There were significant differences between the
3 groups in terms of the number of risk factors for falls and
the FES score (P = 0.002 and P = 0.01, respectively). Post
hoc analysis revealed that the fall risk factors and the FES
score for the foam rubber exercise group were significantly
improved compared with the control group (P < 0.02), but
were not different from the stable surface exercise group.
Journal of GERIATRIC Physical Therapy 67
Copyright © 2015 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
There were no significant differences between the stable
surface exercise group and the control group.
The mean (SD) number of additional falls during the
intervention for the foam rubber, stable surface, and con-
trol groups was 0.24 (0.51), 0.59 (1.94), and 0.90 (1.45),
respectively. The difference between the 3 groups was
approaching significance (P = 0.07).
DISCUSSION
The main finding of this randomized controlled trial was
that a balance training program was effective for improv-
ing physical function in community-dwelling older adults.
Specifically, there were improvements in the performance of
the OLST, TST, and TUGT identified as markers of static
and dynamic balance,32,34,35 at 1 to 4 months in the foam
rubber exercise group compared with the control group.
There were no significant differences between the stable
surface and control groups. However, the CST, identified
as a marker of lower extremity muscle strength,33 was
significantly improved at 2 to 4 months in both the foam
rubber and stable surface exercise groups compared with
the control group. For the OLST and TST, the mean values
at 2 and 3 months were significantly better in the foam

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 Research Report
rubber exercise group than in the stable surface exercise
group. Within the foam rubber exercise group, the OLST,
TUGT, and TST, at 1 to 4 months, were significantly
improved compared with before the intervention. Within
the stable surface exercise group, the TUGT and TST, at 3
and 4 months, were significantly improved compared with
before the intervention. These results suggest that balance
training in older adults performed using a foam rubber
pad is effective for improving balance ability, and that this
improvement occurs 2 months earlier compared with bal-
ance training performed on a stable surface.
Previous studies reported that exercise performed on
an unstable surface such as a balance board increased the
sensitivity of muscle mechanoreceptors and facilitated
the proprioceptive input to the spinal cord.38 McIlroy
et al39 showed that an increase in the afferent input from
the cutaneous receptors in the soles of the feet acted to
mediate the postural reflex when body sway increased on
an unstable surface. Several studies have examined the
relationship between Hoffmann reflex (H-reflex) modula-
tion and postural stability.39-44 Researchers have reported
that the amplitude of soleus H-reflex is depressed in rela-
tion to increased body sway during upright standing on
a soft surface compared with that on a solid surface.40,41
The amplitude of soleus H-reflex modulation under such
a condition was suggested to be predominately regulated
by presynaptic inhibitory mechanisms that acted to pre-
vent oversaturation of the spinal motoneurons.39 This
inhibitory effect was suggested to alter the saturation of
motoneuron excitability for receiving central descend-
ing commands.42 Taube et al43 showed that the soleus
H-reflex amplitude was down-modulated in parallel with
improvement in balance control after balance training
performed on a foam rubber pad, suggesting improve-
ment in functional status resulting from more effective
regulation of motor outputs.
From the above-mentioned studies, balance training
performed on a foam rubber pad seems to lead to adapta-
tions in the mechanisms regulating balance at supraspinal
levels.39,42,43 In a study that was similar to the present
study, Granacher et al44 found that balance training per-
formed on a foam rubber and stable surface influenced the
postural reflex in older adults. Thus, previous research sug-
gests that balance training performed using a foam rubber
pad improves proprioception in the lower limbs and the
sensitivity of the cutaneous receptors in the soles. These
adaptations may explain why balance training performed
using a foam rubber pad effectively improved balance in
the present study. However, we acknowledge that we did
not investigate the possible underlying mechanisms.
Regarding the CST, the mean values at 2 to 4 months
in both the foam rubber and stable surface exercise groups
were significantly better than those in the control group.
There were no significant differences between the foam
rubber and stable surface exercise groups. Previous studies
68 Volume 38 • Number 2 • April-June 2015
Copyright © 2015 The Section on Geriatrics of the American Physical Therapy Association. Unauthorized reproduction of this article is prohibited.
JGPT-D-13-00026.indd 68
reported that balance training improved lower extremity
muscle strength as well as balance.12-14 The CST finding in
the present study is consistent with these previous studies.
Therefore, the results from our study suggest that a balance
training program is effective for improving not only bal-
ance but also lower extremity muscle strength.
In the foam rubber exercise group, the mean value at 4
months for the FES scores was significantly improved com-
pared with the control group. Fall-related emotional status,
such as fear of falling or lack of confidence, is thought to
be associated with poor functional performance and may
be improved through increasing physical performance.45
This outcome was therefore secondary to improvements in
physical function in this study. We suspect that once their
physical function improved, participants in the foam rubber
exercise group developed more confidence regarding falls.
Three (9.4%) of participants withdrew from the foam
rubber exercise group, 2 (6.5%) of participants withdrew
from the stable surface exercise group, and 2 (6.7%) of
participants withdrew from the control group for the
reasons previously noted. Of those participants who did
not withdraw from the study, 95.5% and 93.8% of par-
ticipants from the foam rubber and stable surface groups,
respectively, completed all study exercises; 91.2% of par-
ticipants in the control group participated in all of the day
center's weekly social activities. In addition, regarding the
daily home-based exercise program, participants in the
2 exercise groups performed the exercises 3.5 (SD: 2.0)
and 3.4 (SD: 2.3) days per week, respectively. There were
no significant differences between the 3 groups in terms
of study withdrawal and program adherence. From the
above-mentioned results, we suggest that the balance train-
ing program was widely accepted by the participants and
is safe and feasible as an ambulatory service provided at a
day center.
In this current study, the balance training program on
the foam rubber pad was likely to reduce the number
of additional falls during the 4-month intervention (P =
0.07). A previous meta-analysis of fall prevention indicated
that it took 6 or more months to reduce the actual number
of falls significantly.17 Therefore, a longer-term intervention
study may be required to show the effects of balance train-
ing using a foam rubber pad on fall prevention.
One limitation of the present study is that the same
physical therapists assessed the participants and also con-
ducted the intervention programs. Therefore, there is a
possibility that our results were influenced by the physical
therapists’ expertise and/or reporting bias at each day cen-
ter. In addition, participants in the balance training groups
may not have wanted to report the number of fall risk
factors and FES to avoid disappointing their physical thera-
pists.46 However, given the significant improvements in
physical function observed in the balance training groups,
participant attitudes seemed to have played a minimal role.
In addition, the physical therapists who participated in
14/03/15 3:07 AM

the study received the same level of training from a senior
physical therapist before initiating the trial, and the exercise
program was videotaped to ensure consistency. We thus
propose that the physical therapists’ expertise had a mini-
mal effect on study results.
The balance training program used in this study had 10
different exercises. Gardner et al4 reported that exercise
programs should be simple, easily instituted, and provided
at low cost if they are part of a public health program to
be introduced widely in the community. We expect that a
simpler training program than the one studied here may
thus be accepted within the community. A previous study
reported that performing a simply designed balance train-
ing program comprising 7 different exercises improved bal-
ance and fall rates.47 We recommend that future research
investigates which exercises are most effective to provide a
feasible program in the community.
CONCLUSIONS
Balance training performed by older adults using a foam
rubber pad effectively improved balance ability and at a
faster rate (2 months) compared with balance training on
a stable surface. In addition, balance training improved
lower extremity muscle strength and reduced participants’
fear of falling. These improvements required a fairly low
time commitment of 1 day a week of structured exercise at
the day center and a daily short exercise session at home.
These findings suggest that balance training performed
using a foam rubber pad would be widely accepted by day
center clients, and would be beneficial to clients and service
providers because the programs not only improve physical
functioning but also reduce the number of exercise sessions.
We propose that the use of a foam rubber pad in balance
training is safe and feasible as an ambulatory service pro-
vided to older adults at a day center.
ACKNOWLEDGMENTS
The authors acknowledge Mr Satoshi Tanaka, Mr Tomohiko
Iino, Mr Kenichirou Tanaka, Mr Hiroshi Watanabe, and Mr
Yasuhiro Mine for their contributions to the data collection.
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