European Journal of Applied Physiology

https://doi.org/10.1007/s00421-018-3997-6

ORIGINAL ARTICLE

Effects of barefoot and footwear conditions on learning of a dynamic

balance task: a randomized controlled study
Astrid Zech1 · Stephanie Meining2 · Kirsten Hötting3 · Dominik Liebl4 · Klaus Mattes2 · Karsten Hollander5,6

Received: 2 March 2018 / Accepted: 18 September 2018

© Springer-Verlag GmbH Germany, part of Springer Nature 2018

Abstract
Purpose Although barefoot balancing has shown to be more challenging compared to shod balancing, it is still unclear
whether this may also influence the balance learning effects. The purpose of this study was to explore the impact of barefoot
and shod exercising on learning of a dynamic balance task.
Methods Sixty healthy and physically active adults (mean age 25.3 ± 3.4 years) were randomly allocated into one of three
groups (barefoot, shod and controls). The barefoot and shod intervention groups exercised once weekly over 7 weeks on a
stability platform with an unstable surface. Each training session included 15 trials over 30 s. Before and after the interven-
tion period, all participants completed two balance tests (stability platform and Balance Error Scoring System = BESS) under
barefoot and shod conditions. Group effects in stability gains (pre to post-test differences) were analysed using ANOVA.
Development of balance learning curves during the intervention period was analysed using a mixed effects model.
Results Balance times improved in both intervention groups (p < 0.001, 95% CI barefoot 5.82–9.22 s, shod 7.51–10.92 s)
compared to controls. The barefoot intervention group showed a significantly less sloped balance learning curve compared to
the shod intervention group (p = 0.033). No changes over time or differences between groups were found for the BESS test.
Conclusions Improvements in the dynamic balance task did not differ between individuals exercising barefoot or with
footwear although the progression was slower in the barefoot group. The lack of changes in the BESS supports the task-
specificity of balance learning effects.

Keywords Balance · Postural control · Barefoot · Shod · Motor learning

Abbreviations
ANOVA Analysis of variance
BESS Balance error scoring system
CNS Central nervous system
Communicated by Håkan Westerblad. ßF,C Intercept for the shod group
ß∆B,C Differential intercept for the barefoot group
* Astrid Zech
astrid.zech@uni‑jena.de compared to the shod group
ßF,L Slope coefficient for the linear learning effect
1
Department of Human Movement Science and Exercise in the shod group
Physiology, Institute of Sport Science, University of Jena, ß∆B,L Differential slope coefficient for the linear
Seidelstraße 20, 07749 Jena, Germany
learning effect in the barefoot group compared
2
Institute of Human Movement Science, Universität Hamburg, to the shod group
Hamburg, Germany
ßF,Q Slope coefficient for the quadratic learning
3
Institute of Psychology, Biological Psychology effect in the shod group
and Neuropsychology, Universität Hamburg, Hamburg,
Germany ß∆B,Q Differential slope coefficient for the quadratic
4 learning effect in the barefoot group compared
Institute of Statistics, University of Bonn, Bonn, Germany
to the shod group
5
Department of Sports and Rehabilitation Medicine, BG
Trauma Hospital of Hamburg, Hamburg, Germany
6
Department of Sports and Exercise Medicine, Universität
Hamburg, Hamburg, Germany

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 European Journal of Applied Physiology

Introduction differently influenced by presence or absence of footwear

(Maurer et al. 2001; Corbin et al. 2007; Mildren and Bent
Individuals, especially in the Western population are used 2016). Indeed, evidence exists that stabilization after jump
to footwear during most activities of daily living. From an landing (Zech et al. 2015) or standing balance control are
anthropological perspective, barefoot walking is thought impaired during barefoot conditions (Broscheid and Zech
to be more natural and the use of footwear has long been 2016; Federolf et al. 2012). This emphasizes that bare-
discussed as an influencing factor on foot health and the foot conditions might be more challenging for maintain-
development of movement patterns (Kurup et al. 2012). ing standing balance than shoe conditions and therefore,
This is supported by studies showing that regular physi- provide a different stimulus for balance learning.
cal activities without footwear can be beneficial for the The objective of this study was, therefore, to investigate
foot morphology, motor control and running foot strike whether learning of a dynamic balance task can be influ-
patterns (Lieberman et al. 2010; Rao and Joseph 1992; enced by barefoot vs. shod conditions. Based on previous
Hollander et al. 2018; Zech et al. 2018). In detail, habitu- research, we hypothesized that due to the unfamiliar con-
ally barefoot living populations have a higher prevalence ditions, barefoot exercising will result in a slower learn-
of wider feet (Rao and Joseph 1992), higher foot arches ing progress than shod exercising. We used an established
and fewer flat feet or hallux valgus conditions (Hollander balance task able to elicit progressive improvements in
et al. 2017a) when compared to shod living individu- motor performance during the time course of learning on
als. Regardless of the habituation to footwear, wearing the basis of central and peripheral adaptations (Taubert
shoes has an immediate effect on human biomechanics et al. 2010). We further examined if improvements in the
during standing and any kind of movement. Most types dynamic balance task can be transferred to other dimen-
of footwear do not only change the standing and walking sions of standing balance control.
conditions due to cushioning but also provide an external
fixation like a corset restricting the freedom of foot move-
ment. This certainly changes the involvement of proximal
body segments such as the ankle, knee and hip (Hall et al. Methods
2013; Hollander et al. 2015). Furthermore, acute barefoot
running in habitual shod individuals promotes forefoot Participants
striking, changes ankle and knee angles and reduces ver-
tical forces during the touch down phase compared to shod Sixty healthy and physically active adults were included
running (Bishop et al. 2006; Lieberman et al. 2010; Hall [mean age (SD) 25.3 (3.4) years; height 176.3 (7.6) cm;
et al. 2013; Hollander et al. 2014). These changes have mass 70.6 (10.9) kg]. They were recruited among the
long been discussed in association with a decreased risk sports student population of the local university. Inclu-
for running related injuries, but no conclusive evidence sion criteria were an age between 18 and 35 years and
was found (Nigg et al. 2015; Altman and Davis 2016; Hol- regular physical activity using footwear. Exclusion criteria
lander et al. 2017b). were regular participation in barefoot sports (e.g., gymnas-
Recently, differences in motor performance were shown tics, judo, taekwondo), previous experience with the sta-
between habitual shod and barefoot children and adoles- bilometer platform and any lower extremity injury (acute
cents (Zech et al. 2018). The barefoot living individu- or overuse) that prevented from participating in sports
als scored higher in the balance and jumping tasks. This activities for at least 1 day in the previous 6 months. All
finding indicates that learning of basic motor skills such participants were given detailed information on the study
as balance control is influenced by the use of footwear. and written informed consent was obtained. The study was
However, this is still speculative since no prospective approved by the local ethics committee and was conducted
study has ever been performed on balance learning using in accordance with the Declaration of Helsinki.
barefoot vs. shod conditions. Balance skills are task-spe-
cific (Giboin et al. 2015) and highly adaptively, rapidly
improving with increasing number of trials and training Experimental design
sessions (Taubert et al. 2010; Zech et al. 2010, 2014; Les-
inki et al. 2015). Numerous sensory, biomechanical and A randomized controlled design was used for the prospec-
coordination components have been described to inter- tive intervention study. Immediately after pre test, partici-
act with the performance during balancing (Horak et al. pants were randomly allocated into one of three groups
1997). These include lower leg cutaneous, articular and (barefoot, shod and controls) using sealed envelopes.
muscular information (Horak et al. 1990) which can be

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Fig. 1  Stability platform (stabilometer) used for balance exercising and testing

Procedures number of the standardized errors (lifting hands off, opening

eyes, stepping, stumbling, falling, moving the hip, lifting the
The pre- and post-test procedure included a balance test on forefoot or heel, remaining out of the testing position for
a stability platform (Stability Platform, Model 16030 L, more than 5 s) was counted (Docherty et al. 2006).
Lafayette Instrument Company, Lafayette, IN, USA, Fig. 1)
under barefoot and shod (ASICS, Kobe, Japan, Asics Cumu- Intervention
lus 17) conditions.
The shoes had a 10 mm heel drop, no/neutral arch support The intervention period for the barefoot and shod group
and 336 g for US size 9. The order of barefoot and shod test started 1 week after pre tests and included seven training ses-
conditions was counterbalanced across participants and each sions on the stability platform. The intervention protocol was
participant was randomly allocated to one order. The plat- based on exercising conditions (stabilometer settings, num-
form has been previously used in other studies on balance ber of repetitions and exercise volume) that has been previ-
learning effects (Taubert et al. 2010; Rogge et al. 2017). All ously successfully used to analyse motor learning effects
participants were given three 30 s-trials in each condition (Taubert et al. 2010). Each training session comprised of
(barefoot and shod) after a 1-min trial for test familiariza- 15 trials over 30 s with 1 min rest between trials. The time
tion. Participants were asked to keep the unstable surface period between sessions was 6 days. All participants in the
(maximum deviation of 15°) of the platform as long as pos- shod group used the same shoe model (fitted shoe size) for
sible in a horizontal position (± 3° deviation) to each side exercising (ASICS, Kobe, Japan, Asics Cumulus 17). No
of its horizontal alignment. No other instructions or verbal verbal feedback was given by the investigator throughout
feedback was given to the participants before and during the training. The time the participants were able to keep
testing. One week after the final training session all partici- the platform in a horizontal position (± 3° deviation) was
pants completed post-tests using two balance trials on the measured in each trial. After each stabilometer exercise ses-
stabilometer in the shod and barefoot condition. sion, participants of both interventions groups performed a
In consideration of the task-specificity of balance exer- moderate and not exhausting treadmill running for 10 min
cises the transferability of potential improvements in the with their allocated footwear condition to become familiar
stabilometer test to other test situations of standing postural with the standardized shoe (shod group) and barefoot situ-
control was evaluated. Accordingly, the balance error scor- ation (barefoot group) during habitual bipedal locomotion.
ing system (BESS test) was performed at pre- and post-
tests (Bell et al. 2011; Docherty et al. 2006). The BESS test Outcomes
includes six 20 s standing conditions of increasing challenge
using the double-leg, tandem and single-leg stance on firm Primary outcome was the total time a participant was able to
and foam surfaces with closed eyed. In each condition the balance within the ± 3° range of the horizontal position of

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the stabilometer platform during the 30 s trial. A longer time complete the study (two in the shod group, one in the bare-
indicated a better balance performance. For pre- vs. post-test foot group and four in the control group) indicating a drop
analysis the mean score of the three trials was calculated for out rate of 11.7%. Mean adherence to balance exercising was
barefoot and shod conditions in the three groups. To analyse 97.9% ± 5.1% (barefoot group: 97.1% ± 5.9%, shod group:
the balance learning curve in both intervention groups, the 98.6% ± 4.3%).
mean time over the 15 trials was calculated for each of the
seven exercise sessions. Pre to post‑test effects
Secondary outcome was the cumulative number of errors
of the BESS test at pre and post-test. Table 1 shows the summarized statistics of stabilometer
measurements at pre- and post-tests, for each group and each
Statistics test condition. Regarding pre to post-test effects, one-way
ANOVA for differenced (post-minus pre-test) data showed
The group × time interaction effect in the paired (post- and significant between group effects (p < 0.001) for both testing
pre-test) sample was analysed by testing for a group effect conditions (Table 2). Post hoc t tests (Bonferroni adjusted)
in the differenced (post-minus pre- test) data using ANOVA. showed significant differences between the barefoot group
Balance learning curves were analysed using a mixed effects and control group (p < 0.001), and the shod group and con-
model with a random intercept component and orthogo- trol group (p < 0.001) for both balance test conditions. No
nal polynomial contrasts. For computing the denominator differences were found between both intervention groups
degrees of freedom the Kenward–Roger approximation was (shod balancing: p = 0.35; barefoot balancing: p = 1.000)
applied. P values were adjusted for multiple testing (Ben- although there was a tendency towards higher improvements
jamini and Hochberg 1995). Temporal improvements were in the shod test condition for the shod intervention group
modelled using orthogonal linear and quadratic polynomial (Fig. 2).
contrasts, where the linear components model the slope of
the regression curves (mean learning curves) and the quad- Balance learning curves
ratic components their curvatures. The degree of the poly-
nomials was determined using a forward model selection The estimation results for balance learning differences
process. To account for the individual effects in the repeated between both intervention groups are shown in Table 3.
measurements design, we used a mixed effects regression Mean curves significantly differ in their slope coefficients
model with Gaussian mean zero random intercept per par- of the linear learning effects (p = 0.033). As seen in Fig. 3,
ticipant and interaction effects between intervention groups the barefoot group initially showed better balance skills on
and each component of the regression curves. The following the stabilometer than the shod group while the shod group
model parameters were used: ßF,C = intercept for the shod catches up over the first three training sessions. There were
group; ß∆B,C = differential intercept for the barefoot group no significant differences between the intervention groups
compared to the shod group; ßF,L = slope coefficient for the in each exercise session.
linear learning effect in the shod group; ß∆B,L = differential
slope coefficient for the linear learning effect in the barefoot Transfer effects to other balance skills
group compared to the shod group; ßF,Q = slope coefficient
for the quadratic learning effect in the shod group; ß∆B,Q = No group effects were found for pre (barefoot group:
differential slope coefficient for the quadratic learning effect 16.6 ± 5.9; shod group: 13.9 ± 4.2; controls: 15.6 ± 5.1) vs.
in the barefoot group compared to the shod group. P-val- post-tests (barefoot group: 14.5 ± 5.4; shod group: 12.4 ± 3.3;
ues were adjusted to control the false discovery rate of this controls: 14.1 ± 5.1) differences in the BESS score (Fig. 4).
multiple testing problem (Benjamini and Hochberg 1995).
Statistical analysis was performed using R (version 3.2.3).

Table 1  Pre- and post-test mean ± SD of the stabilometer perfor-

mance (s) in the three groups for shod and barefoot test conditions
Results
Barefoot testing (s) Shod testing (s)
At baseline, there were no statistically significant differences Pre-test Post-test Pre-test Post-test
between groups in age (p = 0.868), mass (p = 0.638), height
(p = 0.605), BMI (p = 0.405), sex (p = 0.984), foot length Barefoot 11.44 ± 4.30 19.57 ± 5.44 10.51 ± 3.67 18.03 ± 5.59
group
(p = 0.367), shoe size (p = 0.381), and balance tests (shod on
Shod group 10.99 ± 3.36 19.54 ± 3.44 10.50 ± 3.26 19.72 ± 3.70
stabilometer: p = 0.994; barefoot on stabilometer: p = 0.734;
Controls 10.49 ± 2.67 13.26 ± 3.26 10.39 ± 3.18 12.51 ± 2.87
BESS: p = 0.268). Out of the 60 participants seven did not

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European Journal of Applied Physiology

Table 2  One-way ANOVA Pre- to post-test dif- 95% CI Effects

effects between groups ference (s)
Mean SD p value F Generalized
eta-squared

Shod testing
Barefoot group 7.52 3.53 5.815–9.217 < 0.001 22.163 0.470
Shod group 9.21 3.43 7.509–10.916
Controls 2.12 2.50 0.789–3.453
Barefoot testing
Barefoot group 8.14 3.46 6.472–9.803 < 0.001 14.638 0.369
Shod group 8.54 3.91 6.600–10.488
Controls 2.77 2.80 1.281–4.268

Fig. 2  Comparisons between groups for the pre- to post-test differences (time in s) and 95% family-wise confidence intervals regarding balance
time on the stabilometer under shod and barefoot testing

Table 3  Estimation results for the fixed effects model components of Discussion
motor learning curve comparison between both intervention groups
Parameter Estimate Std. Error Adj. p value The major finding is that footwear differently influences the
learning of a dynamic balance task over time, but has no
ßF,C 17.801 0.928 < 0.001
impact on the amount of improvements after completion of
ß∆B,C − 0.044 1.359 0.974
the intervention period. The improvements in standing pos-
ßF,L 4.784 0.408 < 0.001
tural control are in accordance with other studies evaluating
ß∆B,L − 1.381 0.597 0.033
the effects of balance exercising in healthy, physically active
ßF,Q − 1.214 0.408 0.007
and young adults (Taubert et al. 2010; Zech et al. 2010;
ß∆B,Q 0.635 0.597 0.347
Lesinki et al. 2015; Hrysomallis 2011). We observed signifi-
F = shod group; B = barefoot group; C = intercept; L = slope coeffi- cant improvements in both intervention groups compared to
cient for the linear learning effect; Q = slope coefficient for the quad- non-trained controls. This is in agreement with Taubert et al.
ratic learning effect; Δ = differential effects compared to the shod
(2010), who used the same dynamic balance task on the sta-
group
bilometer for six training sessions in healthy young adults.
However, the improvements in our study were exclusively
One-way ANOVA showed no significant effects between found in the same balance task that was used for exercis-
groups for the pre- to post-test differences (p = 0.902). ing. No changes were observed in the BESS test. The task-
specificity of balance tasks have previously been reported
(Kümmel et al. 2016; Giboin et al. 2015; Zech et al. 2014).

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 European Journal of Applied Physiology

Fig. 3  Mean learning curves (with 95% confidence intervals) for balance time on the stabilometer in both intervention groups over the seven
training sessions

Fig. 4  Boxplots for pre- vs.

post-test differences in the
BESS score in all groups

Considering that standing postural control seems particu- improvements in balance performance should consider the
larly influenced by joint somatosensory information from the use of electromyography, magnetic resonance imaging or
lower legs (Fitzpatrick and McCloskey 1994) we expected other neurophysiology approaches (e.g., peripheral nerve
that balance learning would be influenced by barefoot or stimulation, transcranial magnetic stimulation) to get a bet-
shod conditions. Indeed, we found significantly different ter insight into the adaptation processes.
learning curves between the barefoot vs. shod groups. The Although this indicates that footwear is more benefi-
shod group improved balance control faster, whereas the cial than barefoot situations for learning of a dynamic bal-
barefoot group showed flatter learning curves. A possible ance task several limitations should be taken into account
explanation may be that barefoot activities are more unfa- for interpretation. First, all participants in our study were
miliar or / and provide a greater sense of instability due habitual shod living individuals. The habituation to footwear
to lower stiffness around the ankle or foot or alterations in or barefoot activities influences foot anthropometrics and
muscle activation (Bishop et al. 2006; Shultz et al. 2012; running gait control (Hollander et al. 2017a, 2018). Habitu-
Federolf et al. 2012). However, due to the lack of additional ally barefoot living individuals may, therefore, respond dif-
assessments the attribution of the observed footwear vs. ferently to balance interventions with or without footwear.
barefoot impact to one or multiple underlying physiologi- Second, the effects were shown only for the stabilometer
cal mechanisms remains speculative. In this context, future balance task. Due to the task-specificity of balance abilities
studies investigating the influence of barefoot exercising on (Giboin et al. 2015; Kümmel et al. 2016), other balance task

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European Journal of Applied Physiology

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of footwear. It is also possible that different exercise pro- atic review of the balance error scoring system. Sports Health
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tocols with longer intervention periods and a higher num- Benjamini Y, Hochberg Y (1995) Controlling the false discovery
ber or frequency of sessions could change the amount of rate: A practical and powerful approach to multiple testing. J R
improvements in the balance task. Third, the participants Stat Soc Ser B Stat Methodol 57(1):289–300
were recruited in a healthy sports student population limit- Bishop M, Fiolkowski P, Conrad B, Brunt D, Horodyski M (2006)
Athletic footwear, leg stiffness, and running kinematics. J Athl
ing the generalizability of findings to other populations. The Train 41(4):387–392
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Acknowledgements We would like to thank Dr. Simon Steib for help- Hollander K, de Villiers JE, Venter R, Sehner S, Wegscheider K, Brau-
ing with the Stabilometer pictures. The study was funded by the Min- mann KM, Zech A (2018) Foot strike patterns differ between chil-
istry for Science and Research in Hamburg, Germany (Grant number dren and adolescents growing up barefoot vs. shod. Int J Sports
LFF-FV13). Med 39(2):97–103
Horak FB, Nashner LM, Diener HC (1990) Postural strategies asso-
Author contributions AZ, KaHo and KM conceived and designed ciated with somatosensory and vestibular loss. Exp Brain Res
research. SM and KaHo conducted experiments. DL performed the 82(1):167–177
statistical analysis. SM, KaHo and KiHo analyzed data. AZ wrote the Horak FB, Henry SM, Shumway-Cook A (1997) Postural perturba-
manuscript. All authors read and approved the manuscript. tions: new insights for treatment of balance disorders. Phys Ther
77(5):517–533
Hrysomallis C (2011) Balance ability and athletic performance. Sports
Compliance with ethical standards Med 41(3):221–232
Kümmel A, Kramer A, Giboin LS, Gruber M (2016) Specificity of
Conflict of interest The authors declare that they have no conflict of balance training in healthy individuals: a systematic review and
interest related to the publication of this article. meta-analysis. Sports Med 46:1261–1271
Kurup HV, Clark CI, Dega RK (2012) Footwear and orthopaedics. Foot
Ankle Surg 18(2):79–83
Lesinki M, Hortobágyi T, Muehlbauer T, Gollhofer A, Granacher U
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