1 – Lecturer Banarsidas Chandiwala Institute of Physiotherapy, New Delhi
2 – Lecturer, ISIC Institute of Rehab Sciences, New Delhi
PURPOSE: This study investigated the relationship
between ankle and subtalar joint range of
motion with balance scores in females with no
health problems. Identification of modifiable factors
associated with balance may enable clinicians
to design treatments to help reduce the risk of
falls in elderly people.
SUBJECTS: A sample of convenience of 70 healthy adult females took part in this study. Subjects were assigned into two groups according to their age. Group A – elderly (60-80 years) Group B – young (20-30 years).
METHODS: Goniometry was used to determine ankle and subtalar joint active and passive range of motion (in sitting and lying). Balance capabilities were measured with the Functional Reach Test (FRT) and the Timed Up and Go Test (TUG). Balance data for the FRT and TUG score were correlated with ankle and subtalar joint ROM using the Pearson product moment correlation coefficient (PCC).
RESULTS: There were significant differences in ankle and subtalar ROM and balance scores between the two groups. A Significant positive correlation of functional reach with active and passive dorsiflexion (in sitting and lying) was found in both Group A & B. Timed Up and Go scores and active and passive dorsiflexion (in sitting and lying) showed a significant negative correlation in both Group A & B. No Significant correlation was found between ankle plantarflexion (active and passive) in sitting and lying and subtalar ranges of motion (inversion and eversion) and either of the balance test scores (functional reach value and timed up and go test scores) in any of the Groups.
CONCLUSION AND DISCUSSION: Correlations exist between ankle Dorsiflexion ROM and balance in females. Additional research is needed to determine whether treatment directed at increasing ankle ROM can improve balance
Key Words: Balance, Range of Motion, Goniometry.
Flexibility at the ankle joints provides an important contribution to safe execution of many functional tasks (e.g. walking, negotiating stairs, rising from a chair) and added efficiency in maintenance of postural stability.1 Ankle movements are also necessary for muscular responses used to maintain perturbations to balance, such as rapid compensatory stepping movements.2 Loss of joint range is considered to be a part of normal aging process. Therefore, decreased ankle range of motion with age may require altered movement patterns which may compromise balance, thus limiting functional activities such as ambulation.
Gender is a major factor in ankle joint ROM. Females experience a greater decrement in ankle range in old age. This may be a reflection of high heeled shoes worn by females or due to differences in levels of anabolic and growth hormones between males and females; which are responsible for differences in tensile strength and viscoelastic properties of connective tissues.
Balance maintenance is a highly integrated multifactorial process.3 According to the Systems approach, the ability to control our body position in space emerges from a complex interaction of musculoskeletal and neural system.4 It requires a coordinated effort of the neuromuscular system to obtain accurate sensory input (vision, vestibular and proprioception), organize motor programs and generate effective motor output responses.5,6 The aging process affects all components of postural control. In the sensory system, visual acuity, depth perception, proprioceptive sense loss has been demonstrated with age. In the central processing component, slowing of sensory information processing and nerve conduction velocity may contribute to latency of automatic postural responses. In the effector system, factors such as range of motion, muscle torque and power, and postural alignment7,8 can all affect the capacity of the person to effectively respond to a disturbance of balance.
Many studies have shown that power of the lower extremity muscles is a key element in effective balance control.9-12 But less is known about the influence of joint limitations on balance. According to Vandervoort, an individual with limited mobility at ankle joint may be at risk for tripping and a fall, an event which sometimes leads to serious injury and dependence. 5 Gehlsen and Whaley (1990) compared balance, muscular strength and flexibility of two groups of elderly adults; one with a history of falls and one with no history of falls.13 Their results indicated that flexibility of hip and ankle joints may be related to falls in the elderly. Nitz and Choy (2004) showed a significant relationship between ankle dorsiflexion range of movement, age and number of falls.1
Therefore, the purpose of this study was to examine the relationship between ankle and subtalar joint range of motion and balance in females.
70 healthy adult asymptomatic females took part in this study. Subjects were randomly assigned into two groups according to their age. Group A included elderly adults, between the age of 60-80 years, and Group B included young adults, between the age of 20-30 years. The subjects for Group A were selected from the elderly camp organized in the rehabilitation center of Indian Spinal Injuries Center. For Group B, subjects were selected from the students and staff of Indian Spinal Injuries Center. Subjects were excluded if there was history of recent injuries around the ankle joint, ankle edema, lower extremity pathology, presence of any disorder that could account for problems in balance such as lower limb joint replacements, stroke, etc., an active illness that may interfere with participation in the study, shoulder flexion less than 90°, persons undergoing mobilization exercises for the lower limb and balance training
The Functional Reach Test (FRT) and Timed Up and Go Test (TUG) were used as measures of balance. FRT measures the maximal distance one can reach forward beyond arms length in the horizontal plane while maintaining a fixed base of support in the standing position.14,15 TUG measures the time it takes for a subject to stand up from an arm chair, walk a distance of 3 meters, turn, walk back to the chair and sit down.16,17a transparent universal goniometer was used to measure range of motion at ankle and subtalar joints.
The purpose of the study was explained to the subject. Verbal description of all the procedure was given. Testing was performed only after informed consent was taken from the subject. The subjects who met the inclusion criteria were grouped into Group A and B according to their age. The subjects were assessed and demographic data such as height and weight were measured and noted. Then the subjects were measured for ankle dorsiflexion in sitting (active and passive) and lying (active and passive), plantarflexion in sitting (active and passive) and lying (active and passive), subtalar inversion and eversion ranges of motion. The method used to measure ROM was taken from Norkin and White18 and has been described by previous researchers.19,20 After this, subjects underwent balance measurement using forward reach test and timed up and go test according to the procedure described by the test developers. Data was collected on a data collection form.
The data was analyzed using SPSS software. Statistical test used was two sample t-test for finding the difference between the demographic data (height, weight), ankle and subtalar range of motion and balance scores (functional reach values and timed up and go test) between the two groups. Karl Pearsons Correlation Coefficient was used to find out the relationship between ankle and subtalar joint range of motion and balance scores (functional reach values and timed up and go test) in two groups. A significant level of p< 0.05 was fixed.
The results showed no significant difference in height between Group A (X = 156.02, S.D = ± 4.46) and Group B (X = 157.40, S.D = ± 4.32). But, difference was found in weight between Group A (X = 60.08, S.D = ±7.48) and Group B (X = 56.80, S.D = ±4.31). Except for passive plantarflexion in lying, there was a significant difference (p< 0.01) between Groups A and B for all motions at ankle and subtalar joints. (Table 1).
Table 1: Comparison of Ankle and Subtalar Range of Motion between Group A and Group B.
|GROUP 1 (N = 35)||GROUP 2 (N = 35)||t-value|
|Active dorsiflexion (sitting)||11.42||2.99||18.00||1.0||12.33
|Passive dorsiflexion (sitting)||12.54||2.84||19.15||92||13.07
|Active plantarflexion (sitting)||37.33||4.10||39.39||1.07||2.88
|Passive plantarflexion (sitting)||38.36||4.15||41.00||1.44||3.55
|Active dorsiflexion (lying)||8.59||2.93||16.21||1.03||14.47
|Passive dorsiflexion (lying)||10.37||2.94||19.65||88||17.84
|Active plantarflexion (lying)||35.35||4.64||37.23||1.15||2.32
|Passive plantarflexion (lying)||37.21||4.63||38.64||1.19||1.77NS|
**Significant at 0.01 level,
*Significant at 0.05 level, NS Not Significant
Balance scores of functional reach and timed up and go test also showed significant difference between the two Groups. (Table 2).
A Significant positive correlation of functional reach with active dorsiflexion (r = 0.7133) (Fig,1) and passive dorsiflexion (r = 0.7784) in sitting and active dorsiflexion (r = 0.6233) and passive dorsiflexion (r = 0.6719) in lying was found.
Timed Up and Go scores showed negative correlation with active dorsiflexion (r = 0.5064) (Fig.2) and passive dorsiflexion (r = 0.4808) in sitting. And active dorsiflexion (r = 0.4810) and passive dorsiflexion (r = 0.4552) in lying.
A Significant positive correlation of functional reach with active dorsiflexion (r = 0.7535) and passive dorsiflexion (r = 0.8040) in sitting and active dorsiflexion (r = 0.6105) and passive dorsiflexion (r = 0.7266) in lying was found. Timed Up and Go scores showed negative correlation with active dorsiflexion (r = 0.7030) and passive dorsiflexion (r = 0.6477) in sitting and active dorsiflexion (r = 0.4818) and passive dorsiflexion (r = 0.4270) in lying was found. Significant correlation was not found between ankle plantarflexion (active and passive) in sitting and lying and subtalar ranges of motion (inversion and eversion) and either of the balance test scores (functional reach value and timed up and go test scores).
Table 2: Comparison of Balance Scores between Group A and Group B.
(N = 35)
(N = 35)
**Significant at 0.01 level
Fig. 1: Correlation (r = 0.7133) of Active Dorsiflexion in Sitting with Functional Reach for Group A
Fig. 2: Correlation (r = – 0.5064) of Active Dorsiflexion in Sitting with Timed Up and Go Test Scores for Group A.
The results of the study showed a statistically significant reduction of range of motion of all movements of ankle and subtalar joint in women with increasing age. Speculations for decreased range of motion with aging include:
The results also showed significant reduction in balance scores (timed up and go and functional reach values) with age. These findings are in accordance with the previous studies.21 This is because aging affects all components of postural control (sensory, central processing and effector component).These results are due to the normal age related variability because only asymptomatic healthy female subjects were included in the study.
A positive correlation of ankle dorsiflexion (active and passive) in sitting and lying with functional reach was found. This implies that women with more ankle dorsiflexion range had more functional reach value. These findings are similar to those of Nitz and Choy as they also indicated a significant relationship between ankle dorsiflexion range and falls in elderly.1
It was also found that ankle dorsiflexion (active and passive) in sitting and lying had a negative correlation with scores on timed up and go test.This implies that women with more ankle dorsiflexion range takes lesser time on the timed get up and go test.
The possible reason may be that anterior translation of the body during forward reaching, getting up from seated position and walking requires adequate dorsiflexion range of motion which allows superincumbent body weight to rotate over the foot. Ankle dorsiflexion also acts to stop the backward movement produced by the destabilizing force and helps to create an anteriorly directed counter-moment that helps re-equilibrate the body. Values of correlation were found to be higher for Group B as compared to Group A. But, range of motion of ankle plantarflexion (active and passive) in sitting and lying and subtalar joint movements (inversion and eversion) did not show a significant correlation with scores on balance measures of functional reach and timed up and go test.
We can explain this in the background that reduced range of subtalar eversion may lead to loss of unlocking of transverse tarsal joints which may cause reduced ability to adapt to non-level surfaces.3 This provides us with a scope to further investigate this relationship on uneven surfaces which was not done in this study.
Stronger correlations were found between balance measures and ankle dorsiflexion range of motion in sitting position (knee flexed position). This finding may indicate that decreased performance on balance measures associated with restricted motion of ankle dorsiflexion may be due to non-contractile tissues such as capsule, ligaments, etc. rather than a short gastrocnemius muscle length.
Thus on the basis of this study, when assessing the balance of elderly we should not confine to the assessment of the nervous system alone. We should also take into consideration the changes in the musculoskeletal system as well. It is recommended that attention be paid to the incorporation of the specific range gaining exercises in addition to balance strategy training into intervention programs that aim to reduce falls and increase postural stability, balance and function.
The results of this study suggest the need to explore how loss of range might contribute to falls. The impact of articulatory techniques such as joint mobilizations and specific stretching on improvements in ankle range of motion and balance may be investigated. More detailed kinematic study may be carried out because limited ankle range of motion is usually compensated by excessive movement of hip and upper trunk.
M.P.T. (Musculoskeletal), M.I.A.P. Lecturer (Banarsidas Chandiwala Institute of Physiotherapy) H-201, Vikas Puri, New Delhi-110018