title: Effects of Strength Training Using Unstable Surfaces on Strength, Power and Balance Performance Across the Lifespan: A Systematic Review and Meta-analysis.
abstract: BACKGROUND
  The effectiveness of strength training on unstable surfaces (STU) versus stable surfaces (STS) or a control condition (CON; i.e., no training or regular training only) for strength, power and balance performance across the lifespan has not yet been investigated in a systematic review and meta-analysis.
  
  
  OBJECTIVE
  The aims of this systematic review and meta-analysis were to determine the general effects of STU versus STS or CON on muscle strength, power and balance in healthy individuals across the lifespan and to investigate whether performance changes following STU are age specific.
  
  
  METHODS
  A computerized systematic literature search was performed in the electronic databases PubMed and Web of Science from January 1984 up to February 2015.
  
  
  METHODS
  Initially, 209 articles were identified for review. Only controlled trials were included if they investigated STU in healthy individuals and tested at least one measure of maximal strength, strength endurance, muscle power, or static/dynamic balance. In total, 22 studies met the inclusion criteria.
  
  
  METHODS
  The included studies were coded for the following criteria: age, sex, training status, training modality, exercise and test modality. Effect size measures included within-subject standardized mean differences (SMDw) and weighted between-subject standardized mean differences (SMDb). Heterogeneity between studies was assessed using I2 and χ2 statistics. The methodological quality of each study was assessed using the Physiotherapy Evidence Database (PEDro) Scale.
  
  
  RESULTS
  Our search failed to identify studies that examined the effects of STU versus STS or CON in children and middle-aged adults. However, four studies were identified that investigated the effects of STU versus CON or STS in adolescents, 15 studies were identified in young adults and three studies were identified in old adults. Compared with CON, STU produced medium effects on maximal strength in young adults and no effects to medium effects in old adults. In addition, large effects were detected on strength endurance in adolescents and in young adults; in old adults, a small effect was found. With regard to muscle power, medium effects were observed in young adults and small effects were observed in old adults. Further, large effects were found for static and dynamic balance in old adults, but only a small effect was found for dynamic balance in young adults. The comparison of STU and STS revealed inconsistent results as indicated by training-induced changes in favour of STU, as well as STS. Small to medium effects were found for maximal strength in adolescents in favour of STS, and small effects were found in young adults in favour of STU. With regard to strength endurance, large effects were found in adolescents in favour of STS and small effects were found in favour of STU. Additionally, we detected small effects in young adults in favour of STU. In terms of muscle power, no effects were observed in adolescents but medium effects were found in favour of STS in young adults. With regard to balance, small effects were detected in adolescents for static and dynamic balance in favour of STU. In young adults, small effects were found for static balance in favour of STS. With regard to dynamic balance, the analysis revealed small effects in young adults in favour of STU.
  
  
  CONCLUSIONS
  The quality of the included studies was rather low, with mean PEDro scores of 5.8, 4.0 and 5.0 for studies including adolescents, young adults and old adults, respectively. Further, trivial to considerable heterogeneity between studies (i.e., 0% ≤ I2 ≤ 96%) was detected.
  
  
  CONCLUSIONS
  Compared with CON, STU is effective in improving muscle strength, power and balance in adolescents, young adults and old adults. However, inconsistent results were particularly found in adolescents and young adults when the specific effects of STU were compared with those of STS. We conclude that the performance of STU compared with STS has limited extra effects on muscle strength, power and balance performance in healthy adolescents and young adults. Given that our systematic search did not identify studies that examined the effects of STU versus STS in children, middle-aged adults and old adults, further research of high methodological quality is needed to determine whether there are additive effects of STU as compared with STS in those age groups.
authors.affiliation: School of Human Kinetics and Recreation, Memorial University of Newfoundland, St. John's, NL, Canada.
authors.forename: David G
authors.initials: DG
authors.lastname: Behm
authors.affiliation: Division of Training and Movement Sciences, Research Focus Cognition Sciences, University of Potsdam, Am Neuen Palais 10, Building 12, 14469, Potsdam, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Muehlbauer
authors.affiliation: Institute for Sports and Sport Science, University of Kassel, Kassel, Germany.
authors.forename: Armin
authors.initials: A
authors.lastname: Kibele
authors.affiliation: Division of Training and Movement Sciences, Research Focus Cognition Sciences, University of Potsdam, Am Neuen Palais 10, Building 12, 14469, Potsdam, Germany. urs.granacher@uni-potsdam.de.
authors.forename: Urs
authors.initials: U
authors.lastname: Granacher
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000375:Aging / Q000502:physiology*; D004779:Environment Design; D006801:Humans; D008875:Middle Aged; D053580:Muscle Strength / Q000502:physiology*; D004856:Postural Balance / Q000502:physiology*; D055070:Resistance Training / Q000379:methods*; D055815:Young Adult