Comprehensive insights into balance control of individuals with hearing impairment are compared with individuals with hearing. Primary sources were obtained from 7 databases including PubMed, LILACS, SCOPUS, CINAHL, PEDro, CENTRAL, and Web of Science. The search period extended from inception until January 5, 2022. The systematic review included 24 studies and 27 trials, with a total of 2,148 participants. The meta-analysis showed a significant difference in the average balance control between individuals with hearing impairment and individuals with hearing, with individuals with hearing having a favorable advantage (p = 0.001). Additionally, average balance control was found to be in favor of individuals with hearing (p = 0.001) when comparing individuals with hearing impairment who participated in sports. Finally, individuals with hearing impairment who participated in sports demonstrated a significantly higher average difference in balance control (p = 0.001) when compared to sedentary people with hearing impairment. Our meta-analysis results indicate a balance defect in individuals with hearing impairment compared to individuals with hearing. In addition, with increasing age, the balance in individuals with hearing impairment improved. Additionally, the dependence of individuals with hearing impairment on the visual and proprioception systems to maintain balance increased. Finally, there was more dependence on the proprioception than the visual system, while individuals with hearing had stronger average balance control than individuals with hearing impairment who participated in sports, when compared to sedentary people with hearing impairment.

Postural control is a function of the complex interaction of musculoskeletal and nervous systems [Samuel et al., 2015; Ivanenko and Gurfinkel, 2018]. Neural components involved in postural control are motor processes such as neuromuscular synergies, sensory processes, and higher order neural processes [Jeka et al., 2000; Ting and McKay, 2007; Kerkman et al., 2018]. Sensory data from visual, vestibular, and proprioception systems are major sensory inputs for postural control [Peterka, 2002]. The proprioception system provides internal body information [Tuthill and Azim, 2018]. The visual system provides external body information and how a human is positioned in the immediate environment [Palm et al., 2009]. Furthermore, the vestibular receptors play a significant role in basic motor responses through the reception of data related to the position of the head in space [Khan and Chang, 2013].

Defects in the vestibular system are common in the otoneurological assessment of individuals with hearing impairment [Mai and Paxinos, 2011]. Hearing and vestibular organs are closely related, both anatomically and physiologically. These organs have similar mechanoreceptors which detect sound, head orientation, and movement in space [Tribukait et al., 2004; Pajor and Jozefowicz-Korczynska, 2008]. Hearing loss has been associated with the decline of labyrinthine function and as a result may contribute to postural instability [Santos et al., 2015]. Based on this association, previous research has examined the balance control of individuals with hearing impairment (HI) and has shown that individuals with HI have deficits in balance control while demonstrating higher levels of instability in balance control when compared to individuals with hearing [Long, 1932; Boyd, 1967; De Kegel et al., 2011; Derlich et al., 2011; de Souza Melo et al., 2011; Hartman et al., 2011; Jafari et al., 2011; de Sousa et al., 2012].

Balance deficiencies in individuals with HI can negatively affect the development of motor skills in this group. Performance, exercise, or recreational activities can be negatively affected for individuals with HI due to the greater level of motor deficiency when compared to individuals with hearing [Rajendran et al., 2012]. Furthermore, when it comes to motor function, balance defects in individuals with HI are vastly different from individuals with hearing. These differences can affect individuals with HI social relations with sedentary people with hearing impairments (SHI), causing emotional turmoil and isolation [Hartman et al., 2011]. Therefore, the importance of balance in increasing the quality of life (QoL) of individuals with HI should not be underestimated as balance is an essential prerequisite in most activities of daily life [Ivanenko and Gurfinkel, 2018].

Balance defects in individuals with HI have been examined from the perspective of sensory systems. Information obtained from proprioception and dermal receptors is adequate in individuals with HI which can compensate for any information defects from other balance control sensory systems [Szymczyk et al., 2012]. When maintaining static balance, individuals with HI compensate for the deficits of vestibular system information through visual and proprioception systems [Potter and Silverman, 1984]. In addition, when both visual and proprioception information are transmitted without difficulty, individuals with HIs may have normal balance control in a standing position. In contrast, when visual and proprioception information is insufficient, individuals with HI have demonstrated difficulty when attempting to maintain their balance control [An et al., 2009]. However, no systematic review and meta-analysis have been performed to determine which system is dominant in individuals with HI.

Contradictory results are also observed for the dominance of each of the sensory systems involved in balance control with increasing age in individuals with HI. Previous research reported a predominance of the visual system with increasing age for individuals with HI. These studies revealed that with increasing age, the visual, not the proprioception, system dominates balance control. These results partially compensate for the imbalance caused by the vestibular system to the extent that the balance control in individuals with HI is similar to the balance control in individuals with hearing [An et al., 2009]. Nevertheless, other research disclosed results to the contrary, indicating that the proprioception system is the dominant system [Walicka-Cupryś et al., 2014; Seyedi et al., 2015]. Given these contradictions from previous results, a systematic review and meta-analysis are vital to determine which sensory systems are more dominant in individuals with HI for maintaining balance control.

Previous studies have examined the effect of exercise interventions on the balance control in individuals with HI. A previous review study reported that participating in sports or recreational activities can somewhat improve balance in individuals with HI [Melo et al., 2020]. Another review study showed that vestibular rehabilitation exercise programs can improve the balance control of individuals with HI [Melo et al., 2019]. Previous results indicate that individuals with HI who participated in sports had better balance control than the individuals with HI who participated in sports [Eliöz et al., 2013; Seyedi et al., 2015; Cobanoglu et al., 2021]. However, no systematic review and meta-analysis have so far been performed to compare the balance control in individuals with HI who participated in sports and SHI as well as individuals with hearing.

This systematic review and meta-analysis has several purposes: (1) Comparison of balance control in individuals with HI and individuals with hearing in a systematic review and meta-analysis to determine if the individuals with HI have a balance defect. (2) Evaluation of the predominance of each of the sensory systems involved in balance control with increasing age in individuals with HI. (3) Comparison of sensory systems in individuals with HI and individuals with hearing to determine how the visual and proprioception systems function in individuals with HI as compared to individuals with hearing. (4) Comparison of balance control in individuals with HI who participated in sports with SHI to determine whether sports activities influence the balance control of these individuals, and (5) comparison of the balance control of individuals with HI who participated in sports and individuals with hearing to determine which balance control group has a better performance.

This was a systematic review based on guidelines of preferred reporting items for systematic reviews and meta-analyses (PRISMA). The proposed protocol was registered in PROSPERO with the number of CRD42022302573.

Search Strategy

Primary sources were obtained from 7 databases including PubMed, LILACS, SCOPUS, CINAHL, PEDro, CENTRAL (Cochrane Central Register of Controlled Trials), and Web of Science. The search period covered years from inception to January 5, 2022. The keywords were originally selected from MeSH terms and then modified to ensure that all eligible studies were found. Google Scholar was used to further expand the scope of our search list of target papers from various databases. After the selection process, the references of included studies were hand-searched to identify potentially overlooked citations.

These electronic databases were searched using combinations of the following keyword groups: (1) hearing loss; vestibular dysfunction; deafness; hearing impaired; congenital deafness; sensorineural hearing loss; deaf; AND (2) balance control; center of pressure; balance; postural stability; postural balance; postural sway; stability; static balance; static stance; dynamic balance; AND (3) deaf players; deaf athlete; hearing-impairment athlete; hearing-impairment players. The “AND” operator was used between the 3 keyword groups, while the “OR” operator was used within each keyword group.

Eligibility Criteria

Inclusion criteria were as follows: (1) Individuals with a HI aged 5–22 years old were assigned to two groups (HI and typically developing or healthy controls) and presented no physical problems; (2) Peer reviewed and published in the English and Persian language; (3) Original studies with a cross-sectional design were considered relevant; (3) All participants were free from any orthopedic or neurological conditions that might affect balance control; (4) Athletes with HI who participated in any sports activities (inclusion criteria for athletes with Hearing-impairment); (5) No use of neurological drugs that influence balance control; (6) People with hearing-impairment who did not participate in any sports activities (inclusion criteria for sedentary hearing impaired); (7) Participants with any cause of deafness (congenital, acquired, neurological).

Two independent researchers (H.Z. and A.A.N.) performed the search and independently applied further screening of title and abstract using the above criteria. Any disagreement was negotiated. The level of agreement between the researchers was measured using Cohen’s kappa (j). A κ value of ≤0.4 indicated poor agreement, 0.41–0.6 moderate agreement, 0.61–0.8 good agreement, and 0.81–1 excellent agreement [Landis and Koch, 1977]. Studies that only explored gait, falling risk, or QoL (in other words: studies that did not include balance control) were excluded. Also, studies that examined balance control in the elderly with HI were excluded.

Data Extraction

Data from studies were extracted independently by researchers (H.Z. and A.A.N.) using some measures including first author’s name, participants’ characteristics (e.g., sample size, age range or mean values and standard deviation [SD] for age, and sex distribution), main outcome measures, assessment instruments, and quality assessment of the study (Tables 1, 2).

Table 1.

General description of the samples (individuals with HI vs. individuals with hearing) included in the individual studies

Source, yearIndividuals with HIIndividuals with hearingOutcome measuresInstruments used for the assessment
total sample sizemen/womenage±SDtotal sample sizemen/womenage±SD
Melo et al. [2012] 44 22/22 12±3.2 44 22/22 12±3.2 • Battery balance test • Tinetti’s balance and mobility scale 
Melo et al. [2015] 48 24/24 12±3.5 48 24/24 12±3.5 • Static balance –frim-EO• Static balance –foam-EO • Balance Error Scoring Systems scale 
Simon and Koku [2017] 50 30/20 13±2.1 50 30/20 13±2.6 • Static balance –frim-EO• Dynamic balance • Stork Balance Stand• Bass Test 
Karakoc and Mujdeci [2021] 40 24/16 6–15 40 25/15 6–15 • Dynamic balance• Static balance –frim-EC• Static balance –frim-EO• Battery balance test • SLS• FRT• TUG• PBS 
Walicka-Cupryś et al. [2014] 65 46/19 13.4±2.4 163 79/84 11.9±2.2 • Static balance –frim-EO• Static balance –frim-EC • Force platform 
Ebrahimi et al. [2016] 85 55/30 8.9±1.5 60 31/29 8.7±1.5 • Battery balance test • BOTMP 
An et al. [2009] 57 33/24 4–14 57 32/25 4–14 • Static balance –frim-EO• Static balance –frim-EC• Static balance –foam-EO• Static balance –foam-EC • SLS 
Jafari et al. [2011] 30 16/14 6.93±1.11 40 20/20 7.17±0.72 • Battery balance test • BOT-2 
Brunt and Broadhead [1982] 154 85/69 7–14 154 85/69 7–14 • Battery balance test • BOTMP 
Soylemez et al. [2019] 25 22/3 14.92±2.59 25 21/4 13.76±2.75 • Battery balance test• Static balance –frim-EO• Static balance –frim-EC• Static balance –foam-EO • FBT• Tandem stance test• One-leg standing test• PBS 
Derlich et al. [2011] 29 19/10 12.2±1.7 29 11/18 12.5±0.8 • Static balance –frim-EO• Static balance –foam-EO • Force plate 
Horak et al. [1988] 30 12/18 9.2±1.8 54 28/26 9.2±2.3 • Battery balance test • BOTMP 
de Sousa et al. [2012] 43 20/23 8.42±1.14 57 27/30 8.42±1.10 • Static balance –frim-EO• Static balance –frim-EC • Force platform 
de Souza Melo et al. [2018] 48 24/24 12.5±3.5 48 24/24 12.5±3.5 • Battery balance test • PBS 
Farahani et al. [2013] 30 30/0 20.13±1.60 30 30/0 18.98±2.92 • Dynamic balance• Static balance –frim-EO • YBT• Balance Error Scoring Systems scale 
Wolter et al. [2016] 14 11/3 15.8±6.1 14 9/5 16.1±5.75 • Static balance –frim-EO• Static balance –frim-EC • BOT-2• Force plate 
Engel-Yeger and Weissman [2009] 22 8/14 6.53±1.26 26 10/16 6.56±1.41 • Battery balance test • MABC 
Rine et al. [1996] 3/4 4.27±0.3 3/3 4.35±0.3 • Static balance –frim-EO• Static balance –frim-EC • SLS 
Gheysen et al. [2008] 36 15/21 9.25±4.16 43 15/28 9.64±5.1 • Static balance –frim-EO• Static balance –frim-EC• Battery balance test • SLS• MABC 
Source, yearIndividuals with HIIndividuals with hearingOutcome measuresInstruments used for the assessment
total sample sizemen/womenage±SDtotal sample sizemen/womenage±SD
Melo et al. [2012] 44 22/22 12±3.2 44 22/22 12±3.2 • Battery balance test • Tinetti’s balance and mobility scale 
Melo et al. [2015] 48 24/24 12±3.5 48 24/24 12±3.5 • Static balance –frim-EO• Static balance –foam-EO • Balance Error Scoring Systems scale 
Simon and Koku [2017] 50 30/20 13±2.1 50 30/20 13±2.6 • Static balance –frim-EO• Dynamic balance • Stork Balance Stand• Bass Test 
Karakoc and Mujdeci [2021] 40 24/16 6–15 40 25/15 6–15 • Dynamic balance• Static balance –frim-EC• Static balance –frim-EO• Battery balance test • SLS• FRT• TUG• PBS 
Walicka-Cupryś et al. [2014] 65 46/19 13.4±2.4 163 79/84 11.9±2.2 • Static balance –frim-EO• Static balance –frim-EC • Force platform 
Ebrahimi et al. [2016] 85 55/30 8.9±1.5 60 31/29 8.7±1.5 • Battery balance test • BOTMP 
An et al. [2009] 57 33/24 4–14 57 32/25 4–14 • Static balance –frim-EO• Static balance –frim-EC• Static balance –foam-EO• Static balance –foam-EC • SLS 
Jafari et al. [2011] 30 16/14 6.93±1.11 40 20/20 7.17±0.72 • Battery balance test • BOT-2 
Brunt and Broadhead [1982] 154 85/69 7–14 154 85/69 7–14 • Battery balance test • BOTMP 
Soylemez et al. [2019] 25 22/3 14.92±2.59 25 21/4 13.76±2.75 • Battery balance test• Static balance –frim-EO• Static balance –frim-EC• Static balance –foam-EO • FBT• Tandem stance test• One-leg standing test• PBS 
Derlich et al. [2011] 29 19/10 12.2±1.7 29 11/18 12.5±0.8 • Static balance –frim-EO• Static balance –foam-EO • Force plate 
Horak et al. [1988] 30 12/18 9.2±1.8 54 28/26 9.2±2.3 • Battery balance test • BOTMP 
de Sousa et al. [2012] 43 20/23 8.42±1.14 57 27/30 8.42±1.10 • Static balance –frim-EO• Static balance –frim-EC • Force platform 
de Souza Melo et al. [2018] 48 24/24 12.5±3.5 48 24/24 12.5±3.5 • Battery balance test • PBS 
Farahani et al. [2013] 30 30/0 20.13±1.60 30 30/0 18.98±2.92 • Dynamic balance• Static balance –frim-EO • YBT• Balance Error Scoring Systems scale 
Wolter et al. [2016] 14 11/3 15.8±6.1 14 9/5 16.1±5.75 • Static balance –frim-EO• Static balance –frim-EC • BOT-2• Force plate 
Engel-Yeger and Weissman [2009] 22 8/14 6.53±1.26 26 10/16 6.56±1.41 • Battery balance test • MABC 
Rine et al. [1996] 3/4 4.27±0.3 3/3 4.35±0.3 • Static balance –frim-EO• Static balance –frim-EC • SLS 
Gheysen et al. [2008] 36 15/21 9.25±4.16 43 15/28 9.64±5.1 • Static balance –frim-EO• Static balance –frim-EC• Battery balance test • SLS• MABC 

HI, hearing impairment; SD, standard deviation; Frim, frim surface; Foam, foam surface; EO, eye open; EC, eye close; SLS, Single Leg Stance Test; FRT, Functional Reach Test; TUG, Timed Up and Go Test; PBS, Pediatric Balance Scale; BOTMP, Bruininks-Oseretsky test of motor proficiency; BOT-2, Bruininks-Oseretsky Test-2; FBT, Flamingo Balance Test; YBT, Y Balance Test; MABC, Movement Assessment Battery for Children.

Table 2.

General description of the samples (individuals with HI who participated in sports vs. individuals with hearing or SHI) included in the individual studies

Source, yearIndividuals with HI who participated in sportsControl groupsOutcome measuresInstruments used for the assessment
total sample sizemen/womenage±SDgrouptotal sample sizemen/womenage±SD
Cobanoglu et al., 2021 12 NR 22.5±1.37 NH 13 NR 24±1.5 • Static balance – frim-EO• Static balance – frim-EC • Biodex-BioSway Balance System 
Eliöz et al., 2013 15 NR 18.13±2.26 SHI 17 NR 18.29±1.53 • Static balance – frim-EO• Static balance – frim-EC • FBT 
Güzel et al., 2016 A 18 NR 27.17±4.46 SHI 10 NR 17.90±0.88 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Güzel et al., 2016 B 18 NR 27.17±4.46 NH 10 NR 21.20±2.86 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Seyedi et al., 2015 15 15/0 18.08±1.34 SHI 15 15/0 18.08±1.03 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Kanber and Boyali, 2018 20 10/10 16.53±1.68 SHI 20 10/10 17.10±1.12 • Static balance – frim-EO• Static balance – frim-EC• Static balance – foam-EO • Balance Error Scoring Systems scale 
Farahani et al., 2013 A 30 30/0 26.27±4.94 SHI 30 30/0 20.13±1.60 • Dynamic balance• Static balance – frim-EO • YBT• Balance Error Scoring Systems scale 
Farahani et al., 2013 B 30 30/0 26.27±4.94 NH 30 30/0 18.98±2.92 • Dynamic balance• Static balance – frim-EO • YBT• Balance Error Scoring Systems scale 
Source, yearIndividuals with HI who participated in sportsControl groupsOutcome measuresInstruments used for the assessment
total sample sizemen/womenage±SDgrouptotal sample sizemen/womenage±SD
Cobanoglu et al., 2021 12 NR 22.5±1.37 NH 13 NR 24±1.5 • Static balance – frim-EO• Static balance – frim-EC • Biodex-BioSway Balance System 
Eliöz et al., 2013 15 NR 18.13±2.26 SHI 17 NR 18.29±1.53 • Static balance – frim-EO• Static balance – frim-EC • FBT 
Güzel et al., 2016 A 18 NR 27.17±4.46 SHI 10 NR 17.90±0.88 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Güzel et al., 2016 B 18 NR 27.17±4.46 NH 10 NR 21.20±2.86 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Seyedi et al., 2015 15 15/0 18.08±1.34 SHI 15 15/0 18.08±1.03 • Static balance – frim-EO• Static balance – frim-EC • Biodex-Balance System 
Kanber and Boyali, 2018 20 10/10 16.53±1.68 SHI 20 10/10 17.10±1.12 • Static balance – frim-EO• Static balance – frim-EC• Static balance – foam-EO • Balance Error Scoring Systems scale 
Farahani et al., 2013 A 30 30/0 26.27±4.94 SHI 30 30/0 20.13±1.60 • Dynamic balance• Static balance – frim-EO • YBT• Balance Error Scoring Systems scale 
Farahani et al., 2013 B 30 30/0 26.27±4.94 NH 30 30/0 18.98±2.92 • Dynamic balance• Static balance – frim-EO • YBT• Balance Error Scoring Systems scale 

SHI, sedentary people with hearing impairment; IwH, individual with hearing; SD, standard deviation; NR, not reported; Frim, frim surface; Foam, foam surface; EO, eye open; EC, eye close; FBT, Flamingo Balance Test; YBT, Y Balance Test.

Quality of Evidence

The risk of bias was evaluated by both reviewers using Newcastle-Ottawa Quality Assessment Scale (NOS). The checklist from Herzog et al. [2013] for cross-sectional studies was employed. NOS is an instrument that assesses the risk of bias by awarding a star for each answer that meets the criteria. A maximum of ten stars can be obtained: five stars for selection, three stars for comparability, and two stars for outcome. Each given star projects a low risk of bias for the given criterion [Newcastle, 2018]. Quality was assessed based on Herzog et al. [2013] as follows: very good studies: 9–10 stars, good studies: 7–8 stars, satisfactory studies: 5–6 stars, unsatisfactory studies: 0–4 stars. Unsatisfactory studies were not included in the systematic review as prescribed by the NOS checklist guidelines. NOS designers have established face and criterion validity, and inter-rater reliability [Hartling et al., 2012; Instruments, 2012; Hartling et al., 2013].

Statistical Analyses

The heterogeneity was assessed using I2 index according to the following thresholds: 0–30% = no heterogeneity; 30–50% = low heterogeneity, 50–75% = moderate heterogeneity, 75–100% = high heterogeneity. Therefore, both a random and a fixed-effects model for between-study heterogeneity were used in this study. A random-effects model was used for a value of I2 >50% [Labanca et al., 2020]. Hedges’ g effect size was also used to calculate the effects of training (effect size) [Becker, 2000]. Threshold values for assessing magnitudes of ES were <0.2, trivial; 0.2–0.6, small; 0.6–1.2, moderate; 1.2–2.0, large; 2.0–4.0, very large; and >4.0, nearly perfect [Montgomery et al., 2010]. The effect size was reported with a 95% confidence interval (CI) for all analyzed measures. The significance level was set at p ≤ 0.05. The Egger’s regression test of the intercept was used to examine the publication bias [Rine et al., 2004; Neyeloff et al., 2012]. Finally, the Comprehensive Meta-Analysis version 2.0 (Biostat Inc, Englewood, NJ, USA) was used for statistical analysis.

A total of 2,144 potentially eligible papers were retrieved from seven databases. Moreover, 25 additional records were identified through the screening of reference lists. A total of 1,325 duplicate studies were excluded. The remaining 844 potentially relevant abstracts were screened from which 798 were excluded after the screening. The remaining 46 full-text papers were considered for complete review. Additionally, another 22 papers were excluded because they did not meet the eligibility criteria (Fig. 1). Finally, 24 studies with 27 trials involving a total of 2,148 participants were included in the present systematic review. The main characteristics of the selected studies are shown in Tables 1 and 2.

Fig. 1.

Flowchart for screening of articles.

Fig. 1.

Flowchart for screening of articles.

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Population Characteristics

Of the 24 studies that were included in the systematic review, 19 studies with 1,845 participants compared the balance control between individuals with HI and individuals with hearing. Three studies with fourteen conditions (113 participations) compared the balance control between individuals with HI who participated in sports and individuals with hearing. Five studies with nine conditions (190 participations) compared the balance control between individuals with HI who participated in sports and SHI.

The age range of participants in 19 studies comparing balance control between individuals with HI and individuals with hearing was from 5 to 22 years old. For this purpose, age was considered as a moderator in the present meta-analysis. Therefore, the participants were categorized into three different groups: with the age range of 4–10 years old, 11–14 years old, and 15–22 years old. These studies also used various tests to examine the balance of participants. To investigate the role of each sensory system in balance control while standardizing the tests used in balance assessment, the outcome measures were also considered as a modulator. Outcomes were meta-analyzed in five groups including dynamic balance, battery balance tests, static balance without sensory perturbation, static balance with visual perturbation, and static balance with proprioception perturbation.

Quality of Evidence

Based on the results of NOS, 24 studies that were systematically reviewed and meta-analyzed had desirable qualities: 6 studies (25%), very good (9–10 stars); 18 studies (75%), good (7–8 stars). Therefore, six were not included in this systematic review as prescribed by the NOS checklist guidelines due to unsatisfactory evidence. Therefore, the studies that were systematically reviewed and meta-analyzed were of very good and good quality. The results are provided in Table 3.

Table 3.

Quality of evidence assessment of individual studies: consensus score

AuthorsSelectionComparabilityOutcomeQualityh
representa-tiveness of the sampleasample sizebnonrespondentscascertainment of the exposuredthe subjects in different outcome groups are comparableeassessment of the outcomefstatistical testg
Melo et al., 2012 ** ** ─ Good 
Melo et al., 2015 ** ** Very good 
Simon and Koku, 2017 ** ** ─ Good 
Karakoc and Mujdeci, 2021 ** ** ─ Good 
Walicka-Cupryś et al., 2014 ** ** ** ─ Very good 
Ebrahimi et al., 2016 ** ** ─ Good 
An et al., 2009 ** ** ─ Good 
Jafari et al., 2011 ─ ** ** ─ Good 
Suarez et al., 2007 ─ ─ ** ─ ─ Unsatisfactory 
Brunt and Broadhead, 1982 ** ** ─ Good 
Soylemez et al., 2019 ─ ** ** ─ Good 
Jernice et al., 2011 ─ ─ ** ─ ─ Unsatisfactory 
Derlich et al., 2011 ─ ** ** ** ─ Good 
Dummer et al., 1996 ─ ─ ** ─ ─ Unsatisfactory 
Horak et al., 1988 ** ** ** ─ Very good 
Potter et al., 1984 ─ ** ─ ─ Unsatisfactory 
de Sousa et al., 2012 ** ** ** ─ Very good 
de Souza Melo et al., 2018 ** ** ** Very good 
Carlson, 1972 ─ ─ ** ─ ─ Unsatisfactory 
Farahani et al. 2013 A ** ** ─ Good 
Wolter et al., 2016 ─ ** ** ─ Good 
Engel-Yeger and Weissman, 2009 ─ ** ** ─ Good 
Rine et al., 1996 ─ ** ** ** ─ Good 
Gheysen et al., 2008 ─ ** ** ─ Good 
Siegel et al., 1991 ─ ─ ** ─ ─ Unsatisfactory 
Cobanoglu et al., 2021 ─ ** ** ** ─ Good 
Eliöz et al., 2013 ─ ** ** ─ Good 
Güzel et al., 2016 ─ ** ** ─ Good 
Güzel et al., 2016 ─ ** ** ─ Good 
Seyedi et al., 2015 ─ ** ** ** ─ Good 
Kanber and Boyali, 2018 ** ** ** ─ Very good 
Farahani et al., 2013 B ** ** ─ Good 
Farahani et al. 2013 C ** ** ─ Good 
AuthorsSelectionComparabilityOutcomeQualityh
representa-tiveness of the sampleasample sizebnonrespondentscascertainment of the exposuredthe subjects in different outcome groups are comparableeassessment of the outcomefstatistical testg
Melo et al., 2012 ** ** ─ Good 
Melo et al., 2015 ** ** Very good 
Simon and Koku, 2017 ** ** ─ Good 
Karakoc and Mujdeci, 2021 ** ** ─ Good 
Walicka-Cupryś et al., 2014 ** ** ** ─ Very good 
Ebrahimi et al., 2016 ** ** ─ Good 
An et al., 2009 ** ** ─ Good 
Jafari et al., 2011 ─ ** ** ─ Good 
Suarez et al., 2007 ─ ─ ** ─ ─ Unsatisfactory 
Brunt and Broadhead, 1982 ** ** ─ Good 
Soylemez et al., 2019 ─ ** ** ─ Good 
Jernice et al., 2011 ─ ─ ** ─ ─ Unsatisfactory 
Derlich et al., 2011 ─ ** ** ** ─ Good 
Dummer et al., 1996 ─ ─ ** ─ ─ Unsatisfactory 
Horak et al., 1988 ** ** ** ─ Very good 
Potter et al., 1984 ─ ** ─ ─ Unsatisfactory 
de Sousa et al., 2012 ** ** ** ─ Very good 
de Souza Melo et al., 2018 ** ** ** Very good 
Carlson, 1972 ─ ─ ** ─ ─ Unsatisfactory 
Farahani et al. 2013 A ** ** ─ Good 
Wolter et al., 2016 ─ ** ** ─ Good 
Engel-Yeger and Weissman, 2009 ─ ** ** ─ Good 
Rine et al., 1996 ─ ** ** ** ─ Good 
Gheysen et al., 2008 ─ ** ** ─ Good 
Siegel et al., 1991 ─ ─ ** ─ ─ Unsatisfactory 
Cobanoglu et al., 2021 ─ ** ** ** ─ Good 
Eliöz et al., 2013 ─ ** ** ─ Good 
Güzel et al., 2016 ─ ** ** ─ Good 
Güzel et al., 2016 ─ ** ** ─ Good 
Seyedi et al., 2015 ─ ** ** ** ─ Good 
Kanber and Boyali, 2018 ** ** ** ─ Very good 
Farahani et al., 2013 B ** ** ─ Good 
Farahani et al. 2013 C ** ** ─ Good 

aRepresentativeness of the sample: The studies choose the samples which were truly or somewhat representative of the average in the target population or not.

bSample size: The sample size the study selected was justified and satisfactory or not.

cNonrespondents: If comparability between respondents and nonrespondents’ characteristics was established, and the response rate was satisfactory, we assigned one star. If the response rate is unsatisfactory, or no description of the response rate, we did not assign a star.

dAscertainment of the exposure: If the study applied validated measurement tool to ascertain the risk factors, we assigned two stars. Additionally, we still assigned one star to the study that applied non-validated measurement tool which was available or described.

eThe subjects in different outcome groups are comparable: The study controlled for the confounding factors or not.

fAssessment of the outcome: The study applied independent blind assessment, record linkage, self-report, or no description. If it used independent blind assessment or record linkage, we assigned two stars. If it used self-report, we assigned one star.

gStatistical test: If the statistical test used to analyze the data was clearly described and appropriate, and the measurement of the association was presented, including confidence intervals and the probability level (i.e., p value), we assigned one star.

hQuality: The quality of the study; We assigned stars to evaluate study quality, with nine to ten stars indicating “very good” quality, seven to eight stars indicating “good” quality, five to six stars indicating “satisfactory” quality, and zero to four stars indicating “unsatisfactory” quality.

Data Synthesis

Dynamic Balance

Dynamic balance was assessed in six trials [Farahani et al., 2013; Simon and Koku, 2017; Karakoc and Mujdeci, 2021]. Of these six trials, the I2 overall index was equal to 61.23%, indicating that there was moderate heterogeneity between the six trials. Therefore, the random effect was used for the overall group. For the age range of 4–10 years old, the I2 index was equal to 35.63%, indicating that there was low heterogeneity between the trials; therefore, the fixed effect model was used. For the age range of 11–14 years old, the I2 index was equal to 76.00%, indicating that there was high heterogeneity between the trials. Therefore, the random-effect model was used for these individuals. For the age range of 15–22 years old, because only one study was performed, no meta-analysis was conducted.

The average difference of overall dynamic balance between the individuals with HI and individuals with hearing was in favor of individuals with hearing (Hedges’ g effect size = 0.93; 95% CI = 0.60–1.27; Z = 5.46; p = 0.001). For the age range of 4–10 years old, it favored individuals with hearing (Hedges’ g effect size = 1.13; 95% CI = 0.55–1.72; Z = 3.82; p = 0.001). For the age range of 11–14 years, it was in favor in favor of individuals with hearing (Hedges’ g effect size = 0.70; 95% CI = 0.04–1.35; Z = 2.09; p = 0.001) and was significant. The result of Egger’s test was p = 0.35, implying no significant publication bias (Fig. 2).

Fig. 2.

Forest plot of average dynamic balance difference in individuals with HI and individuals with hearing groups at different ages.

Fig. 2.

Forest plot of average dynamic balance difference in individuals with HI and individuals with hearing groups at different ages.

Close modal

Balance Assessment with Battery Balance Tests

Battery balance tests were assessed in seventeen trials [Brunt and Broadhead, 1982; Horak et al., 1988; Gheysen et al., 2008; Engel-Yeger and Weissman, 2009; Jafari et al., 2011; Melo et al., 2012; Ebrahimi et al., 2016; Wolter et al., 2016; de Souza Melo et al., 2018; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. Of these seventeen trials, the I2 overall index was equal to 93.68%. For the age range of 4–10 years old, the I2 index was equal to 95.92%. For the age range of 11–14 years old, the I2 index was equal to 88.45%, indicating that there was high heterogeneity between the trials. Therefore, the random-effect model was used for these groups. Additionally, for the age range of 15–22 years old, the I2 index was equal to 55.38%, indicating that there was moderate heterogeneity between the trials. Therefore, the random-effect model was used for these individuals.

The average difference of overall battery balance tests between the individuals with HI and individuals with hearing was in favor of individuals with hearing (Hedges’ g effect size = 1.48; 95% CI = 1.07–1.88; Z = 7.19; p = 0.001). For the age range of 4–10 years old, the results were in favor of individuals with hearing (Hedges’ g effect size = 2.24; 95% of CI = 1.31–3.18; Z = 4.70; p = 0.001). For the age range of 11–14 years old, the results were in favor of individuals with hearing (Hedges’ g effect size = 1.86; 95% CI = 1.08–2.63; Z = 3.68; p = 0.001). For the age range of 15–22 years old, the results were in favor of individuals with hearing (Hedges’ g effect size = 1.03; 95% CI = 0.48–1.57; Z = 3.70; p = 0.001) and were significant. The result of Egger’s test was p = 0.48, implying no significant publication bias (Fig. 3).

Fig. 3.

Forest plot of average battery balance difference in individuals with HI and individuals with hearing groups at different ages.

Fig. 3.

Forest plot of average battery balance difference in individuals with HI and individuals with hearing groups at different ages.

Close modal

Static Balance without Sensory Perturbation

Static balance without sensory perturbation was assessed in sixteen trials [Rine et al., 1996; Gheysen et al., 2008; An et al., 2009; Derlich et al., 2011; Frahani et al., 2013; Walicka-Cupryś et al., 2014; Melo et al., 2015; Wolter et al., 2016; Simon and Koku, 2017; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. Of these sixteen trials, the I2 overall index was equal to 92.63%. For the age range of 4–10 years old, the I2 index was equal to 94.27%. For the age range of 11–14 years old, the I2 index was equal to 92.17%. Finally, for the age range of 15–22 years old, the I2 index was equal to 92.75%, indicating high heterogeneity between all age groups under study. Therefore, the random-effect model was used for all age groups between 4 and 22 years old.

The average difference of overall static balance without sensory perturbation between the individuals with HI and individuals with hearing favored individuals with hearing (Hedges’ g effect size = 1.09; 95% CI = 0.76–1.43; Z = 6.40; p = 0.001). For the age range of 4–10 years old, static balance favored individuals with hearing (Hedges’ g effect size = 1.83; 95% CI = 1.01–2.64; Z = 4.39; p = 0.001). Furthermore, for the age range of 11–14 years old, static balance also favored individuals with hearing (Hedges’ g effect size = 1.30; 95% CI = 0.63–1.98; Z = 3.79; p = 0.001). Finally, for the age range of 15–22 years old, static balance favored individuals with hearing (Hedges’ g effect size = 0.79; 95% of CI = 0.36–2.38; Z = 1.23; p = 0.001) and was significant. The result of Egger’s test (p = 0.26) implied no significant publication bias (Fig. 4).

Fig. 4.

Forest plot of average static balance difference without sensory perturbation in individuals with HI and individuals with hearing groups at different ages.

Fig. 4.

Forest plot of average static balance difference without sensory perturbation in individuals with HI and individuals with hearing groups at different ages.

Close modal

Static Balance with Visual Perturbation

Static balance with visual perturbation was assessed in ten trials [Rine et al., 1996; Gheysen et al., 2008; An et al., 2009; de Sousa et al., 2012; Walicka-Cupryś et al., 2014; Wolter et al., 2016; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. Of these ten trials, the I2 overall index was equal to 87.73%. For the age range of 4–10 years old, the I2 index was equal to 90.14%. Additionally, for the age range of 11–14 years old, the I2 index was equal to 90.61%, indicating that there was high heterogeneity between all age groups. Therefore, the random-effect model was used for all age groups between 4 and 22 years old. A meta-analysis was not performed for static balance in individuals between the ages of 15 and 22 years old due to a lack of studies.

The average difference of overall static balance with visual perturbation between the individuals with HI and individuals with hearing was in favor of individuals with hearing (Hedges’ g effect size = 1.43; 95% CI = 0.93–1.92; Z = 5.65; p = 0.001). For the age range of 4–10 years old, static balance with visual perturbation was in favor of individuals with hearing (Hedges’ g effect size = 1.79; 95% CI = 0.91–2.68; Z = 3.97; p = 0.001). For the age range of 11–14 years old, it favored individuals with hearing (Hedges’ g effect size = 1.69; 95% CI = 0.73–2.65; Z = 3.46; p = 0.001) and was significant. The result of Egger’s test (p = 0.26) indicated no significant publication bias (Fig. 5).

Fig. 5.

Forest plot of average static balance difference with visual perturbation in individuals with HI and individuals with hearing groups at different ages.

Fig. 5.

Forest plot of average static balance difference with visual perturbation in individuals with HI and individuals with hearing groups at different ages.

Close modal

Static Balance with Proprioception Perturbation

Static balance with proprioception perturbation was assessed in seven trials [An et al., 2009; Derlich et al., 2011; Melo et al., 2015; Soylemez et al., 2019]. Of these seven trials, the I2 overall index was equal to 96.71%. For the age range of 4–10 years old, the I2 index was equal to 97.65%. For the age range of 11–14 years old, the I2 index was equal to 97.49%, indicating that there was high heterogeneity between all age groups. Therefore, the random-effect model was used for all age groups between 4 and 22 years old. For the age range of 15–22 years old, no meta-analysis was performed because only one study was included in this category.

The average difference of overall static balance with proprioception perturbation between the individuals with HI and individuals with hearing was in favor of individuals with hearing (Hedges’ g effect size = 1.93; 95% CI = 1.47–2.39; Z = 8.20; p = 0.001). For the age range of 4–10 years old, static balance with proprioception perturbation was in favor of individuals with hearing (Hedges’ g effect size = 3.71; 95% CI = 0.35–7.07; Z = 2.16; p = 0.001). For the age range of 11–14 years old, it was in favor of individuals with hearing (Hedges’ g effect size = 2.51; 95% CI = 0.31–4.71; Z = 2.24; p = 0.001) and was significant. The result of Egger’s test (p = 0.34) implied no significant publication bias (Fig. 6).

Fig. 6.

Forest plot of average static balance difference with proprioception perturbation in individuals with HI and individuals with hearing groups at different ages.

Fig. 6.

Forest plot of average static balance difference with proprioception perturbation in individuals with HI and individuals with hearing groups at different ages.

Close modal

Balance Control of Individuals with HI Who Participated in Sports versus Individuals with Hearing

The balance control of individuals with HI who participated in sports versus individuals with hearing was assessed in three studies with fourteen conditions [Farahani et al., 2013; Güzel et al., 2016; Cobanoglu et al., 2021]. Of these fourteen conditions, the I2 overall index was equal to 89.29%, indicating that there was high heterogeneity between the fourteen conditions. Therefore, the random-effect model was used for these conditions. The average difference of overall balance control between the individuals with HI who participated in sports and individuals with hearing groups was in favor of individuals with hearing (Hedges’ g effect size = 0.94; 95% CI = 0.28–1.59; Z = 2.81; p = 0.001). The result of Egger’s test (p = 0.31) implied no significant publication bias (Fig. 7).

Fig. 7.

Forest plot of average balance control difference in individuals with HI who participated in sports versus individuals with hearing.

Fig. 7.

Forest plot of average balance control difference in individuals with HI who participated in sports versus individuals with hearing.

Close modal

Balance Control of Individuals with HI Who Participated in Sports versus SHI

The balance control of individuals with HI who participated in sports versus SHI was assessed in five studies with nine conditions [Eliöz et al., 2013; Frahani et al., 2013; Seyedi et al., 2015; Güzel et al., 2016; Kanber and Boyali, 2018]. Of these nine conditions, the I2 overall index was equal to 63.86%, indicating that there was moderate heterogeneity between the nine conditions. Therefore, the random-effect model was used for this category. The average difference of overall balance control between the individuals with HI who participated in sports and SHI groups was in favor of individuals with HI who participated in sports (Hedges’ g effect size = 0.61; 95% CI = 0.23–0.98; Z = 3.18; p = 0.001). The result of Egger’s test (p = 0.92) implied no significant publication bias (Fig. 8).

Fig. 8.

Forest plot of average balance control difference individuals with HI who participated in sports versus SHI.

Fig. 8.

Forest plot of average balance control difference individuals with HI who participated in sports versus SHI.

Close modal

The present systematic review and meta-analysis aimed to compare the balance control between individuals with HI and individuals with hearing. To the knowledge of the authors, there was no meta-analysis study in the literature to address the issue. Considering that previous studies in different age groups compared the balance between individuals with HI and individuals with hearing, this systematic review sought to use different balance tests to compare the involvement of each of the sensory systems participating in the balance control between individuals with HI and individuals with hearing. A meta-analysis was conducted based on age and type of outcome that was used to assess balance control. The results showed that in all age groups between 4 and 22 years old, individuals with HI has a balance deficit when compared to individuals with hearing. Additionally, the results also demonstrated that in all balance control outcomes, with increasing ages between 4 and 22 years old, the balance improved in individuals with HI, while the balance difference between individuals with HI and individuals with hearing decreased. The present meta-analysis also showed that with increasing age between 4 and 22 years old, the individuals with HI dependence on the visual systems and proprioception increased in maintaining balance. However, the dependence on the proprioception system was greater than the visual system. In addition, the meta-analysis uncovered that individuals with hearing had a better balance than individuals with HI who participated in sports. It was also shown that individuals with HI who participated in sports had better balance than SHI. These results suggest that as the level of engagement in sports activities increased, the balance of individuals with HI improved.

Dynamic balance was assessed in six trials [Farahani et al., 2013; Simon and Koku, 2017; Karakoc and Mujdeci, 2021]. The results of meta-analysis on these trials showed that the dynamic balance of individuals with HI improved with increasing age between 4 and 14 years old. In this age range, the effect size was equal to 1.13. However, more precisely, within the age range of 11–14 years old, the effect size was equal to 0.7. The larger effect size indicates that the difference in dynamic balance between individuals with HI and individuals with hearing was greater in the age range of 4–10 years old than in 11–14 years old. These results indicate that the dynamic balance of individuals with HI improved with increasing age between 4 and 14 years old. Dynamic balance improvement with increasing age between 4 and 14 in individuals with HI could be due to a variety of factors, including improved muscle strength, greater coordination of the neuromuscular system, greater dependence on other sensory systems involved in balance, or increased daily physical activity and social participation.

The battery balance tests were performed in seventeen trials [Brunt and Broadhead, 1982; Horak et al., 1988; Gheysen et al., 2008; Engel-Yeger and Weissman, 2009; Jafari et al., 2011; Melo et al., 2012; Ebrahimi et al., 2016; Wolter et al., 2016; de Souza Melo et al., 2018; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. The present meta-analysis on these trials showed that the balance control in individuals with HI, evaluated with battery balance tests, improved with increasing age between 4 and 22 years old. Balance control improvements were due to the effect size being equal to 2.24 in the age range of 4–10 years old, 1.86 in the age range of 11–14 years old, and 1.03 in the age range of 15–22 years old. The effect size decreased with increasing age in individuals with HI compared to individuals with hearing. These results revealed that with increasing age, the balance difference between individuals with HI and individuals with hearing decreased. As a result, the balance control of individuals with HI as assessed by battery balance tests, improved with increasing age between 4 and 22 years old.

The test used as the battery balance test was Movement Assessment Battery for Children (MABC), Bruininks-Oseretsky Test-2 (BOT-2), Bruininks-Oseretsky test of motor proficiency (BOTMP), Tinetti’s balance and mobility scale. This set of tests had various balance and mobility assessment items that in addition to assessing static and dynamic balance, also assessed gross motor skills. These batteries indicated that with increasing age, the amount of motor skills improved in individuals with HI.

The static balance without sensory perturbation was assessed in sixteen trials [Rine et al., 1996; Gheysen et al., 2008; An et al., 2009; Derlich et al., 2011; Frahani et al., 2013; Walicka-Cupryś et al., 2014; Melo et al., 2015; Wolter et al., 2016; Simon and Koku, 2017; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. The results of meta-analysis on these trials showed that the static balance of individuals with HI was lower than that of individuals with hearing in all age groups between 4 and 22 years old. In addition, the present meta-analysis showed that with increasing age between 4 and 22 years old, the static balance of individuals with HI improved because the effect size was equal to 1.83 in the age range of 4–10 years old, 1.30 in the age range of 11–14 years old and 0.79 in the age range of 15–22 years old. The results showed that with increasing age, the effect size of the static balance difference between individuals with HI and individuals with hearing decreased. This indicated that with increasing age, the static balance difference decreased between individuals with HI and individuals with hearing. In static balance without sensory perturbation tests, all the sensory systems of the participants were involved in static balance. In fact, both the proprioception and the visual systems were active to maintain static balance and were not disturbed during the test. Therefore, it could be concluded that static balance in individuals with HI improved with increasing age between 4 and 22 years old.

The static balance with visual perturbation was assessed in ten trials [Rine et al., 1996; Gheysen et al., 2008; An et al., 2009; de Sousa et al., 2012; Walicka-Cupryś et al., 2014; Wolter et al., 2016; Soylemez et al., 2019; Karakoc and Mujdeci, 2021]. The purpose of this set of tests was to evaluate the effect of visual system perturbation on balance control in individuals with HI when compared to individuals with hearing. The present meta-analysis on these trials showed that in all age groups between 4 and 22 years old, with the perturbation of the visual system, the balance was lower in individuals with HI than individuals with hearing and induced a balance defect for these individuals. With the perturbation of the visual system, the effect size of the balance difference was equal to 1.79 in the age range of 4–10 years old, and 1.69 in the age range of 11–14 years old. With increasing age between 4 and 14 years old, the effect size of the balance difference decreased with the perturbation of the visual system. These results show that with increasing age, with the perturbation of the visual system, the balance difference between individuals with HI and individuals with hearing decreased. More consequently, the visual system was disturbed, and with increasing age, the level of proprioception system involvement increased in individuals with HI for maintaining balance control. Finally, the proprioception system in individuals with HI improved with increasing ages between 4 and 14 years old. This may be due to the fact that the visual system information was eliminated and the proprioception system information was involved in maintaining balance.

The static balance with proprioception perturbation was assessed in seven trials [An et al., 2009; Derlich et al., 2011; Melo et al., 2015; Soylemez et al., 2019]. In these tests, the information of the proprioception system was disturbed by placing the person on the foam. In fact, the purpose was perturbation in the proprioception system to evaluate the involvement of the visual system to maintain balance control. The results of the present meta-analysis on these trials showed that in all age groups between 4 and 22 years old, with the perturbation of the proprioception system, individuals with HI had a higher balance deficit compared to individuals with hearing. Moreover, individuals with HI had a weaker performance in balance control than individuals with hearing. With the perturbation of the proprioception system, the effect size of the balance difference was equal to 3.71 in the age range of 4–10 years old and 2.51 in the age range of 11–14 years old. With increasing age, the effect size of the balance difference between individuals with HI and individuals with hearing decreased with the perturbation of the proprioception system. These results indicate that with increasing age, the balance difference between individuals with HI and individuals with hearing decreased with the perturbation of the proprioception system. The static balance with proprioception perturbation also showed that with the involvement of the visual system in maintaining balance increased with increasing age in the individuals with HI. The individuals with HI’s visual system improved with increasing age between 4 and 14 years old because, in these tests, the information of the proprioception system was removed, and visual system information was involved in maintaining balance.

The present meta-analysis results showed that if the balance was examined by perturbation of the visual system, the effect size was equal to 1.79 in the age range of 4–10 years old and 1.69 in the age range of 11–14 years old. However, by perturbation of the proprioception system, the effect size was 3.71 in the age range of 4–10 years old and 2.51 in the age range of 11–14 years old. These effect sizes indicate that the proprioception system was disturbed. In addition, the effect size of the balance difference between individuals with HI and individuals with hearing was greater than when the visual system was disturbed. This signifies that with the perturbation of the proprioception system, the balance difference between individuals with HI and individuals with hearing increased. As a result, individuals with HIs were more dependent on the proprioception system than the visual system to maintain balance control.

In three studies with fourteen conditions, balance control of individuals with HI who participated in sports versus individuals with hearing was assessed (Farahani et al., 2013; Güzel et al., 2016; Cobanoglu et al., 2021]. The present meta-analysis on these studies showed that individuals with HI who participated in sports had a weaker balance than individuals with hearing. From the analysis, participation in sports activities could not compensate for the loss of balance caused by defects of the vestibular system in a similar way that individuals with hearing had a better balance than individuals with HI who participated in sports. Also, in five studies with nine conditions, balance control of individuals with HI who participated in sports versus SHI was assessed [Eliöz et al., 2013; Farahani et al., 2013; Seyedi et al., 2015; Güzel et al., 2016; Kanber and Boyali, 2018]. Meta-analysis results on these studies showed that individuals with HI who participated in sports had a better balance than SHI. Additionally, the results of these studies showed that participation in sports activities improved balance in individuals with HI. The results of these studies showed that individuals with HIs who participated in sports activities, competitions, and sports teams had a better balance than individuals with HI who did not participate in any sports activities. Therefore, to improve the balance control of these individuals, they should be encouraged to participate regularly in sports and recreational activities. Consistent with the results of the present meta-analysis, a review study reported that participating in sports or recreational activities could, to some extent, improve balance in individuals with HI [Melo et al., 2020]. Therefore, consistent with these results, participation in sports and recreational activities is recommended for these individuals.

Strengths and Limitations

The current systematic review had several strengths. According to our knowledge, it was the first systematic review and meta-analysis that comprehensively evaluated the balance control of individuals with HI in different age ranges, compared with individuals with hearing. Additionally, using the NOS checklist for assessing methodological quality was a strength of this study. The checklist allowed the identification of poorly designed studies to be removed from the review, leaving only studies of at least satisfactory quality. Also, subgroup analysis was conducted based on the age of participants and outcome measures. In addition, it evaluated the effect of participating in sports activities on the balance of the individuals with HI who participated in sports.

This study had a few methodological limitations that warrant further discussion. None of the authors showed allocation concealment in their studies. Therefore, the high risk of selection bias could not be eliminated. Also, the present study only assessed balance control and did not examine other variables such as motor skills, QoL, and gait. Therefore, it is suggested that other review studies be conducted on these variables.

The present systematic review and meta-analysis showed that there was a balance defect in individuals with HI compared to individuals with hearing. Also, the balance improved with increasing age between 4 and 22 years old in the individuals with HI. Furthermore, the balance difference between individuals with HI and individuals with hearing decreased with increasing age between 4 and 22 years. The results also showed that with increasing age between 4 and 22 years, the dependence of individuals with HI on the visual and proprioception systems in maintaining balance increased. However, their dependence on the proprioception system was greater than the visual system. This meta-analysis also revealed that individuals with hearing had better balance control than individuals with HI who participated in sports and that individuals with HI who participated in sports had a better balance than SHI. This indicates that the higher the level of participation in sports activities, the better the balance in individuals with HI. Therefore, regular participation in sports and recreational activities is recommended for these individuals to improve their overall balance control.

The researcher thanks the head of the Faculty of Physical Education, University of Guilan.

No ethical approval was needed because data from previously published studies in which informed consent was obtained by primary investigators was retrieved and analyzed.

The authors have no conflicts of interest to declare.

No funding was received to conduct the research shown in the manuscript.

Conceptualization, investigation, formal analysis, and funding acquisition: Hamed Zarei and Ali Asghar Norasteh; methodology, software, data curation, and writing original draft: Hamed Zarei; validation: Hamed Zarei, Ali Asghar Norasteh, Lauren J. Lieberman, and Ali Brian; resources, writing review and editing, visualization, and project administration: Hamed Zarei, Ali Asghar Norasteh, Lauren J. Lieberman, Michael W. Ertel, and Ali Brian; supervision: Ali Asghar Norasteh, Lauren J. Lieberman, and Ali Brian.

Additional Information

Registry Number: CRD42022302573.

Authors share their research data in the manuscript. Further inquiries can be directed to the corresponding author.

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