BACKGROUND AND AIM: Physical therapy exercises can play a vital role in improving static and dynamic balance. Our current research aims to determine balance training exercises’ effects on improving static and dynamic balance in the deaf population.

METHODOLOGY: A randomized controlled trial (IRCT20200625047922N1) with a sample size of 28 deaf children was conducted. Congenitally deaf children aged 6 to 11 years without cochlear implantation and could walk independently were chosen from Special Education School, Faisalabad, Pakistan. Exclusion criteria were those with mental illness, unilateral hearing, Visual, Cognitive, and Physical impairment. After taking the informed consent from parents and students, the participants were divided into a control and a balance training exercises group. Data was collected through the Berg Balance scale (BBS), including static and dynamic balance tests. Statistical analysis was directed by utilizing SPSS version 20.

RESULTS: The mean value for Pre-treatment BBS in the experimental group is 32.71±4.58, and in the control group is 34.50±3.93. The P-value of Pre-treatment BBS is 0.28 and in post-treatment is 0.00, which shows statistically significant variance among the treatment and control groups.

CONCLUSION: Our study has shown that static and dynamic balance training exercises effectively improve the balance of the deaf population.

KEYWORDS: Deafness, Postural Balance, Hearing Loss, Vestibular Diseases, Persons with Hearing Impairments, Exercise Therapy, Bilateral Vestibulopathy.

Nimra Arshad


Department of Rehabilitation Sciences

The University of Faisalabad, Pakistan

 ORCID ID:0000-0003-4020-1221

Aimen Gulam Rasool


Department of Physiotherapy

Madina Teaching Hospital Faisalabad, Pakistan

 ORCID ID:0000-0003-4771-8303

Maryam Ashfaq


Department of Physiotherapy

Allied Hospital, Faisalabad, Pakistan

ORCID ID:0000-0001-8926-558X

[Arshad N, Rasool AG, Ashfaq M. Effects of Balance Training Exercises for Improving Static and Dynamic Balance in Deaf Population: A Randomized Controlled Trial

Pak.j.rehabil. 2022; 11(1):164-173]

DOI: 10.36283/pjr.zu.11.1/020

Hearing loss is generally identified initially in life leading to difficulties in communication1. In children, vestibular dysfunctions can cause a deficit in gross motor development and balance stability. At an early age, delayed gross motor development can cause impairment in the bilateral vestibular system and sensorineural hearing2. The children with balance impairment cannot usually participate in physical activities (Running, cycling, hoping), leading to social isolation3.
In Pakistan, 2.49% of the population suffers from some disability; the hearing loss population is 7.4%. In Pakistan, hearing loss is more reported in males as compared to females[4]. According to the non-official data, nearly 1.2 in every 1000 Pakistani children suffer from moderate to severe bilateral hearing loss5. In this, 15% population is suffering from profound and nearly 85% from moderate to severe hearing loss6.
Children who have vestibular dysfunctions may experience many disorders of the vestibular system. Acute unilateral vestibular loss (AUVL) is the most frequent vestibular dysfunction. The etiology of acute unilateral vestibular loss is unknown, but the studies say it may be due to genetic and acquired causes (inflammatory and viral infections). The symptoms include static and dynamic balance disturbance, including rotatory vertigo7.
Hearing impairment is termed a problem in communication. Children with problems in the communication level can also affect the child’s participation in physical activities, resulting in isolation. A recent systemic review of research shows that problems in the vestibular and sensorineural systems can cause a balance control deficit. The school teachers complain of balance instability, incoordination, and inelegance in these children that restricts their peak physical activities8. Deaf children show delayed language developments as well thus face communication problems leading to mental inactivity. These deafness-associated problems prevail life span of a deaf child. This experience can be emotionally traumatic for deaf child and their family9.
A major key component is gross motor skills that are necessary for children to perform at a sufficient level for the activities of daily livings. Due to vestibular impairment, deaf children show a problem in motor development that affects their cognitive, language, motor, social, and emotional development. Impaired motor skills reflect a deficiency in physical activity and a lack of dynamic behavior in deaf children. Body balance is of two types: Static Balance and Dynamic balance. Static balance is the fixed base of the body and supports the body equilibrium while an individual is not moving. In this, the balance center of mass and base of the body is maintained by feet. In dynamic balance, the body’s base is not fixed; both together, the base of gravity and center of mass is in motion10.
The adjustment of the stable body position depends upon vestibular, proprioceptive, and visual stimulations. Static balance can be measured in children to maintain an unchanged position while standing unilaterally or bilaterally. However, the dynamic balance might be calculated by limiting the focal point of gravity unilaterally while another limb reaches the most significant limit. The test used for dynamic balance has the highest demand on both the neuromuscular control system and balance. A tremendous difference in balance ability exists when children with cochlear implants are compared with age match11.
Hearing impairment in childhood also has a significant role in public health. Researches reveal that individuals with hearing dysfunction have a balance or postural control issues, specifically related to vestibular system deficiency. In clinical practice, it is a significant challenge for the therapist to improve the balance in the deaf population as motor and balance assessment in children with hearing dysfunction is not a practical choice. Neuromuscular training related to the vestibular system significantly enhances motor skills, which helps balance and postural control12.
Physical educators can help these children improve their balance in special education schools by utilizing games specifically designed to enhance balance and postural control. Different balance assessment tests are used to appraise the balance in children or adults. Pre and post-balance assessments are necessary to see the outcomes of intervention13.
Hearing loss is generally identified or diagnosed in the early years of life. Delayed and abnormal motor development in the deaf population is common. If balance training is initiated early in life, it is beneficial for deaf children to enhance their motor development. Static balance exercises and dynamic balance exercises or activity-based programs are arranged to improve balance and postural control. Physical therapy interventions are beneficial for children with hearing deficits. Most of the children with vestibular deficits have postural and balance deficits too. Different games like table tennis training also help in improving postural or balance control14.
Core stabilization training for the deaf population is also favorable[12]. For static and dynamic balance training, core stabilization training exercises can be used. These exercises are beneficial in the lower extremity or low back pain balance training [12].
The balance mechanism of the vestibular system of the inner ear functions with the help of muscles of the visual system as well. The brain sends the signals to guide the muscles to work and create the modifications to the body positions that will preserve the body alignment, balance, and coordination[15]. Vestibular system functions in controlling head movement and balance that is important for coordination, balance, developing motion tolerance, and protective reflex of the body[16]. Balance training exercises are carried out as a rehabilitation program to decrease the risk of falls in the deaf population to improve static and dynamic balance [17]. In all sports events, balance plays an important role. Vigorous sports require movement and quickness in conjunction with the greatest stability for performing wrestling and gymnastic. Success and failure in these games are a role of stability18.
Postural control is the main key point to assess the child’s motor development in the accurate evaluation to predict the postural instability. When comparing the deaf children with their normally developing peers, the deaf population is at higher risk of loss of gross motor skills and balance deficits19. The prime aim of postural stability is to make sure the position of the focal point of the body is ideal relative to the plane on which the child is standing upright to maintain adequate stability control under various conditions20.
Deaf children with bilateral vestibular dysfunction and early SNHL (sensorineural hearing loss) mostly present with balance deficits and delayed gross motor skills21. Evidence shows 20-70% occurrence of vestibular impairment revealed in those children with SNHL (sensorineural hearing loss). Ebrahimi et al. aimed to differentiate the static and dynamic balance in hearing-impaired children aged 7-12 years with and without cochlear implants. His research suggested that deaf children with cochlear implants show a greater risk for balance and motor problems22.
Hearing deficit is a serious problem in children that are linked with communication and physical impairment. Evidence reveals that vestibular system deficits cause balance problems in every age of life, and balance training in vestibular deficits gives positive results23.
The brain detects the movement and direction of the head through the balancing output between the two vestibular systems. And due to the failure of coordination and interpretation, this can cause balance impairment-related static and dynamic stability and motion perception24.
The rationale of this study was, as, in the deaf population, balance issues are predominantly present. There is evidence on individual effects of static and dynamic balance exercises, but little evidence is present on their combined effects. So, the objective of this research was to investigate the combined impact of results by training with static and dynamic balance exercises.

A randomized controlled trial (IRCT registration no: IRCT20200625047922N1) with a sample size of 28 deaf children was conducted. All participants were selected from Children Special Education School Millat Town, Faisalabad. Subjects were divided into two groups by lottery method of randomization, and each group had 14 participants. Group A was the experimental group that performed balance training exercises, and group B was the control group (Figure 1).
After taking the data collection permission from the university’s ethical committee, a consent form was filled by the participant’s parents and an assent form from participants. It was ensured to them that their data would be kept confidential & utilized just for research purposes. Provision of all information and description of the study had been given to the participants related to this research effectively, like the benefits and no harm during the treatment.
Inclusion criteria were congenitally deaf children ages 6 to 11 years, of both genders, who could understand simple instructions, those without cochlear implantation, and those who could walk independently. Exclusion criteria were those with Mental illness, unilateral hearing impairment, Visual impairment, Cognitive Impairment, and any physical impairment. Participants with any neurological and cardiovascular conditions were also excluded.


Group A was an experimental group that followed balance training exercises (5sets/20 reps, all exercises to be held for 30 sec before returning to starting position), and group B was the control group that received no treatment, only the routine activities. Following exercises were performed for 3 days per week for 4 weeks. Data was collected through the Berg Balance Scale, which includes static and dynamic balance tests.

Statistical Analysis was done using SPSS and dispensed through the descriptive and inferential statistics with the help of tables, graphs, and tests, respectively. An independent sample T-test was used to evaluate differentiation between pre and post-treatment values within the same group. Paired sample T-test was used for evaluation and comparison between pre and post-treatment values between two different groups.


The mean age of participants in the experimental group was 8.57±1.60 years and 9.43±1.95 years in the control group. The mean weight of participants in the experimental group was 28.35±3.92 kg compared to 29.89±4.80 kg in the control group. The participant’s mean height in the experimental group was 4.17±0.35 feet compared to 4.24±0.35 feet in the control group. The mean BMI of participants in the experimental group was 18.15±1.01 kg/m2 compared to the 18.57±1.33 kg/m2 in the control group (Table 1).

An Independent T-test was used to evaluate the Berg Balance Scale scoring between the two groups, and the results were statistically significant. It showed that the mean value for pre-treatment BBS in the experimental group was 32.71±4.58 and the control group was 34.50±3.93. Between-group analyses showed that the P-value of the pre-treatment Berg balance scale was 0.28 and post-treatment was 0.00, which indicated that there was a statistically significant difference between the treatment group and the control group (Table 2).In the experimental group, the balance was improved from 32.71±4.58 pre-treatment to 46.21±3.21 Post-treatment. In the control group, the pre-treatment balance was 34.50±3.93, which changed post-treatment to 34.86±4.29. A clustered bar chart showed significant improvement in the balance of the experimental group compared to the control group (Figure 2).

Table 2: Between Group Comparisons of pre and post-treatment Berg Balance Scale assessment

Figure 2: Cluster Bar Chart showing Berg Balance Scale Score of pre and post-treatment values of both groups


Table 1: Socio-Demographic characteristics of both groups

Deaf children face many problems in their day-to-day lives. Hearing impairment is typically considered a significant communication deficit. Along with the hearing impairment, deaf children also face difficulties in static and dynamic balance. Congenitally deaf children have a vestibular impairment that leads to balance impairment. Static and dynamic balance deficits can act negatively on the motor skills of deaf children. So, this research was done to improve balance impairments among children having a hearing impairment. Different balance training programs were designed to enhance balance, coordination, and gross motor skills in literature. Capoeira exercise training helps develop coordination in the muscles by increasing the flexibility and strength of the deaf population. Pre and post-values were compared to find out the results by using the berg balance scale. According to research, Capoeira exercises significantly improve the balance of deaf children[25].

Similarly, another research was conducted on static and dynamic balance training by applying Romberg and one-leg stance test for static balance and star excursion, time up and go test for dynamic balance training. The findings of the research suggested that the vestibular-related neuromuscular exercise program was helpful in the enhancement of motor skills, coordination, balance, and improved well-being in deaf children[26].

In a scoping review by Sibley, all subjects performed balance exercises for 45 minutes 3 times per week, consisting of 14 exercises with variations. The purpose of the study was to reduce postural sway by performing balance exercises in the deaf population, and results showed a significant decrease in postural sway. The limitation of this research was that the sample size was too small, and girls were not included in this research[27]. The static and dynamic balance exercises that we used in our study were referenced from research conducted by Bozkurt et.al. The followed research showed effective results of static and dynamic balance exercises in the deaf children age group of 10 to 12 years, but in our study, we took the younger age participants of age between 6 to 11 years. Hence it proved that these static and dynamic balance exercises are significant in both age groups [13].

According to research conducted by Vernadakis, the data analysis supported the effectiveness of the gaming-based exercise program. This regime was proved to be a better choice of intervention for the balance ability of children with a vestibular problem with deafness[28].

Hearing impairment influences the person’s mental, physical, and psychological health. Evidence shows many types of research regarding balance training on the hearing impaired or deaf children and adults population. In deaf people, balance control and muscle coordination are frequently disturbed. Evidence shows that using balance training exercises has good outcomes. In the research study by Walowska et al., the primary purpose was to determine the effects of Pilate exercises (in 13-24 aged students) compared with physical education on body postural control in the hearing-impaired population. The result showed that Pilate exercises improve body balance control in the static position[29].

The strength of our study is that it will provide an evidence-based protocol for children with vestibulocochlear dysfunction that causes balance impairment. We took the younger children population in our study as limited literature was available for the younger age deaf children in Pakistan.

Multiple factors can add limitations in the data significance. First of all, the sample size of 28 deaf children cannot represent the whole deaf children population with balance impairment. Secondly COVID-19 pandemic had a significant impact on the study conduct due to deaf schools shutting down during data collection. Lastly, the duration allowed for a treatment session in school timings was short, so the deaf children could not gainfully control each activity before proceeding to the next one.

For the future conductance of further research, we recommend dividing the Berg Balance Scale scoring according to the balance deficit severity to see how much improvement can be seen in each category of severity. Secondly, it is better if deaf participants from more than one setting are added to research for diversity. Lastly, more studies need to be conducted on deaf children using cochlear implants and unilateral vestibular impairment.


The current study has shown that static and dynamic balance training exercises effectively increase balance among the deaf population.


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