Journal of Bodywork & Movement Therapies (2015) 19, 429e433
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
Clinical analysis and baropodometric evaluation in diagnosis of abnormal foot posture: A clinical trial Hugo Pasini Neto, PT, PhD a,b,c, ´ Collange Grecco, PT a,c, Luanda Andre Luiz Alfredo Braun Ferreira, PT a,c, ˜o, PhD a,b,c, Thaluanna Calil Lourenc ¸o Christova ´lia de Almeida Carvalho Duarte, PhD a,b,c, Nata ´udia Santos Oliveira, PhD a,c,* Cla a
Universidade Nove de Julho, Sa˜o Paulo, SP, Brazil Universidade de Sorocaba, Sorocaba, SP, Brazil c Laboratory of Human Movement Biodynamics, Universidade Nove de Julho e UNINOVE, Sa˜o Paulo, SP, Brazil b
Received 27 November 2013; received in revised form 8 September 2014; accepted 15 September 2014
KEYWORDS Posture; Baropodometry; Insoles
Summary Foot posture involves the integration of sensory information from the periphery of the body. This information generates precise changes through fine adjustments that compensate for the continuous, spontaneous sway of the body in the standing position. Orthopedic insoles are one of the therapeutic resources indicated for assisting in this process. Evaluation of these podal influences, by clinical examination and/or the assistance of baropodometry becomes crucial. Thus, the aim of the present study was determine the combination of the components of orthopedic insoles using two different evaluation methods. Forty healthy female volunteers between 18 and 30 years participated in the study. The volunteers were submitted to two different evaluations: clinical analysis and baropodometry. During the exams, different insole components were tested. The statistical analysis of the two evaluations revealed differences regarding the normalization of posture following the application of the insole components and in the determination of the combination of these components. The findings suggest that the clinical analysis is a fast and accurate method for determining the immediate benefits of the postural insole components and is therefore the more indicated method for the
* Corresponding author. R. Itapicuru 380, apt 111, Perdizes, CEP: 05006-000, Sa ˜o Paulo, SP, Brazil. Fax: þ55 11 3868 1681. E-mail addresses: [email protected] (H.P. Neto), [email protected] (L.A.C. Grecco), [email protected] (L.A. Braun Ferreira), [email protected] (T.C.L. Christova ˜o), [email protected] (N.A.C. Duarte), [email protected] (C.S. Oliveira). http://dx.doi.org/10.1016/j.jbmt.2014.09.007 1360-8592/ª 2014 Elsevier Ltd. All rights reserved.
430
H.P. Neto et al. evaluation of foot posture, but does not present a concrete foundation to differentiate it with respect to baropodometric evaluation in the assessment and diagnosis of foot posture, however, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry. ª 2014 Elsevier Ltd. All rights reserved.
Introduction Human balance is determined by a multi-sensory process involving the visual, somatosensory, vestibular and cerebellar systems. To maintain postural control in a variety of environmental situations, these systems must be closely integrated (Ying-Shuo, 2009). Postural orientation is linked to the position and alignment of the different parts of the body in relation to each other and to the environment through coordinated movements (Barela and Freitas, 2006; Bankoff et al., 2006; Ferreira et al., 2007). Foot posture involves the integration of sensory information from the periphery of the body, especially mechanoreceptors in the sole of the foot, related to gravitational acceleration, the environment and the position of the segments of the body (Oliveira et al., 2009). According to Bricot (1999) and Gagey and Weber (2000), this sensory information generates precise changes through postural fine adjustments that compensate for the continuous, spontaneous sway of the body in the standing position. The study of foot posture assists in the evaluation of overall posture. Thus, there is a need to correct abnormalities and instabilities in foot posture for a better control of postural tone (Gagey and Weber, 2000). The early diagnosis of abnormal foot posture is of extreme importance to avoiding postural problems, excessive joint loads, cumulative micro-traumas and gait disorders (Pantanali et al., 2005; Bianchi et al., 2005; Azevedo and Nascimento, 2009; Tokars et al., 2003). For such, orthopedic insoles are indicated (Almeida et al., 2009). The aim of these devices is to correct the distribution of plantar loads in contact with a hard surface, favoring a better distribution of body mass on the plantar region and providing better alignment of the knees, hips, pelvis and spinal column (Almeida et al., 2009). According to Bricot (1999), these effects occur due to the fact that orthopedic insoles reorganize the tonus of muscle chains and exert an influence over posture correction reflexes. These insoles affect muscle proprioception, leading to changes in the ascending proprioceptive chains (Bricot, 1999). According to Gagey and Weber (2000), the stimulation of specific regions of the sole of the foot leads to a change in postural tonus and a repositioning of the pelvis and muscle asymmetries along the spinal column. Postural reprogramming occurs when mechanoreceptors in the plantar region are activated by deformation of the skin due to the topographic relief of the support surface, as occurs with posture-control insoles (Przysiezny and Salgado, 2002). The components of orthopedic insoles are made of ethylene vinyl acetate in different shapes. According to Moraes and Przysiezny (2004), clinical analysis based on the references points of arm length, level of the iliac crest and paravertebral muscle tension is indicated for the
determination of the combination of postural insole components. Described these clinical tests are able to analyze the rising influence of foot posture in postural control and therefore you can select the ideal postural reprogramming insole. Another important factor in the diagnosis of abnormal posture is knowledge regarding plantar pressure through baropodometry, which allows an understanding of the physiopathology of postural alterations (Martinez et al., 2007). The principle is to map the pressure of the plantar surface, which, indirectly, indicates important postural abnormalities (Bellizzi et al., 2011; Kaercher et al., 2011). Computerized baropodometry furnishes useful information on the positioning of the foot. It also provides the stabilometric parameters derived from the spatial and temporal behavior of the center of pressure, similar to a force plate (Menezes et al., 2012). However, data on plantar pressure patterns are difficult to analyze and interpret when compared to clinical evaluation, but provide important information regarding plantar pressure and balance. Mean plantar pressure is generally used to detect imbalances in the anteroposterior and mediolateral directions (Keijsers et al., 2009). Therefore, this method is very important to understand the adaption of a modified orthostatic position which could result in/from an erratic postural adaptation, secondary to certain diseases that affect, or can be affected by posture (Kaercher et al., 2011; Bricot, 2008). The aim of the present study was to compare two forms of evaluating foot posture (clinical analysis based on reference points and baropodometry) for the determination of the combination of the postural insole components.
Materials and methods Volunteers Forty volunteers fulfilled the eligibility criteria and participated in the present study. Because it is an analysis of ways of assessing foot posture, the inclusion criteria were the female gender, age between 18 and 30 years, adequate health status and body mass index (BMI) between 20 and 25 kg/m2 (Who, 2003), without any kind of illness or musculoskeletal injury. The exclusion criteria were a history of musculoskeletal injury in the previous 12 months, neurological condition or metabolic-endocrine disease.
Ethical considerations The present study was carried out in compliance with the ethical standards of the Declaration of Helsinki and received approval and registry from the Human Research Ethics Committee of the Plataforma Brasil under process number 14117113.3.0000.5511/2013. All participants were
Clinical analysis and baropodometric evaluation in diagnosis of abnormal foot posture informed regarding the objectives and procedures of the study and signed a statement of informed consent.
Procedures Anthropometric data were collected and evaluations were performed for the determination of the components of the orthopedic insoles for each volunteer. This evaluation was divided into two steps: clinical analysis and baropodometry. The order of the evaluations was determined randomly by lots with the use of opaque envelopes. Each evaluation was performed by two examiners, with each examiner blinded to the findings of the other. Only those volunteers for which the results were identical between both examiners were considered for the analysis (36 volunteers). The method proposed by Moraes and Przysiezny (2004) was used for the clinical analysis based on postural information for the determination of the components of the insoles used to normalize posture. Normalization is determined based on arm length, the level of the iliac crest and the level of the thumbs positioned in the cervical and lumbar regions (C5 and L5) using the Bassani test, in order to check the paraspinal musculature tension (Ceci et al., 2004). According to the authors cited, this protocol is indicated for the best determination of the components of orthopedic insoles. After these clinical trials were selected the ideal elements that would be used on the insole for correction of abnormalities found. After clinical analysis, with the same volunteers, baropodometric review was conducted. For the analysis of average pressure baropodometric, the volunteers were positioned barefoot on a pressure plate system (Tekscan MatScan, Boston, USA) at a distance of two meters from a fixed point located specifically at the time of the individual and instructed to stand comfortably, with eyes directed to the fixed point. Different insole components were tested to find the combination that offered the best plantar support with ideal percentages of weight distribution regarding anteroposterior and mediolateral plantar support. According to Tribastone (2001) and Magee (2005), the ideal load values are 60% of the weight on the heel and 40% on the anterior region of the foot as well as symmetrical mediolateral distribution (50%). After these baropodometric information were selected the ideal elements that would be used on the insole for correction of abnormalities found.
Equipment The pressure plate of the Tekscan MatScan System (Boston, USA) was used. This platform measures 5 mm in thickness, 432 in length and 368 mm in width and has lines and columns that form an XeY grid, with 2288 sensors, resolution of 1.4 sensor/cm2 and sampling frequency of 40 Hz. The insole components were formed with ethylene vinyl acetate in the shape of bars, wedges, half-moons and shims measuring 3 mm in thickness.
Data analysis Relative and absolute frequencies were determined to describe the categorical variables (insole components [yes/
431
no] and normalization of posture [yes/no]). Descriptive statistics (mean and standard deviation values) were used for the continuous variables (age, body mass, height and BMI). The chi-square (c2) test was used to compare the evaluation methods (clinical exam and baropodometry) regarding the alterations found, insole components used and the normalization of posture. The level of significance was set to 5% (p < 0.05). All data were organized and tabulated using the SPSS program v.15.0.
Results Forty volunteers were recruited, 36 of whom received identical evaluations from the two examiners and therefore participated in the present study. Table 1 displays the anthropometric characteristics of the participants. The clinical analysis revealed the following distribution of alterations: difference in arm length in 27.5%; difference in height between iliac crests in 22.5%; difference in height of thumbs in cervical region in 25% and difference in height of thumbs in lumbar region in 25% of the volunteers. Based on the alterations, different insole components were tested to find the combination that normalized these references points, which occurred in 100% of cases. The baropodometric analysis revealed imbalances in the prevalence of weight load: anterior in 42%, posterior in 8% and lateral in 50% (22% with right-side prevalence and 28% with left-side prevalence) of the volunteers. Based on the alterations, different insole components were tested to find the combination that normalized these references, which occurred in 77% of cases (28 volunteers). The statistical analysis of the results of posture normalization demonstrated a significant difference between the clinical analysis and baropodometry (c2 Z 10.8; p Z 0.001), showing a difference between the two techniques and greater accuracy of analysis compared the clinical baropodometric evaluation regarding the indication of the corrective insole elements for postural reprogramming. Regarding the combinations of insole components that led to posture normalization using the different evaluation methods, significant differences were found for the indication of the left-side dome piece (c2 Z 22.0; p Z 0.000) and right-side anti-rotator (c2 Z 10.5; p Z 0.001). The other pieces employed in the combinations for posture normalization did not exhibit statistically significant differences between evaluation methods regarding their indication for use (Table 2).
Table 1 Mean and standard deviation values of anthropometric characteristics of the participants. Anthropometric characteristics
Mean Standard deviation
Age (years)
Height (m)
Body mass (kg)
BMI (kg/m2)
21.3 2.95
1.65 0.09
60 12
21.96 2.57
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H.P. Neto et al.
Table 2 Comparison of components different evaluation methods. Components Half-dome e right Half-dome e left Anti-rotator e left Anti-rotator e right Retro-capital e right Retro-capital e left
Clinical evaluation
indicated
by
Baropodometry
p
8
6
10
0
14
8
10
2
0
4
0
2
c2 Z 0.4; p Z 0.484 c2 Z 22.0; p Z 0.000 c2 Z 3.3; p Z 0.068 c2 Z 10.5; p Z 0.001 c2 Z 4.3; p Z 0.038 c2 Z 2.0; p Z 0.150
Discussion The results demonstrated significant differences between the two evaluation methods for the determination of the combination of insole components for the normalization of posture. Moreover, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry. According to Bricot (1999), the aim of orthopedic insoles is to reorganize the tonus of muscle chains and influence body posture through correction reflexes, which act on muscle proprioception and lead to changes in the ascending proprioceptive chains. Przysiezny and Salgado (2002) report that postural reprogramming occurs when the mechanoreceptors in the plantar region are activated by the deformation of the skin caused by the topography of insoles. Thus, it is evident that orthotics may play a role proprioceptive instead of correction sensitive afferents enhancing the sole of the foot and drives the body to react in order to establish a new posture. Therefore, the postural normalization evidenced by the clinical evaluation based on reference points may be related to this biomechanical rearrangement. The non-normalization of plantar pressure in a significant number of the volunteers using the combinations of insole components indicated by baropodometric analysis may be related to the lack of a period of adaptation. In a study involving elderly individuals, Palluel et al. (2012) assessed the use of a textured insole and found no significant immediate effect, but the participants demonstrated a significant improvement in postural balance after five minutes of walking with the insoles. In a study involving adults with episodes of blisters, orthopedic insoles were used with the aim of improving postural balance through the reduction in sensitivity in the sole of the foot. The subjects were randomly distributed into two groups (insole group and control group). The results demonstrated improved stability during gait and a lower number of falls in the insole group, but 12 weeks were needed for these benefits to appear (Perry et al., 2008). Corbin et al. (2007) assessed balance in 33 individuals with proprioceptive insoles and traditional insoles with eyes open and eyes
closed. The results demonstrated that the proprioceptive insoles led to an improvement in balance, but only when the volunteers had their eyes closed, suggesting that this effect occurred precisely by the removal of visual information and, in the long term, the prolonged increase in afference may offer improved postural balance with eyes open as well. Thus, the immediate effect of the insole components evidenced by baropodometry in the present study may not reflect the benefits of the application of the insoles with regard to posture, as the participants were not allowed time to adapt to the use of the insoles. According to Saitoa et al. (2011), another aspect to consider is that this device has limitations from the therapeutic standpoint. These insoles are not designed for daily measurements in real time or with the use of feedback. According to the authors, such measures exhibit considerable inter-individual as well as intra-individual variability, which is a limiting factor with regard to the determination of abnormal postural performance. The inherent variability in this measure under normal conditions has been widely discussed. Considering the importance of evaluating the process of therapy and the difficulty of many centers may have regarding baropodometry, studies that can help in this process are important for physical therapists who treat foot and body posture. Regarding study limitations, it is believed that the need to use a control group would have brought greater clinical potential for the present study.
Conclusion Clinical analysis and baropodometry indicate different compositions of orthotics for postural proprioceptive stimulation of the foot. The results suggest that clinical examination is a fast and accurate method to determine the immediate benefits of postural components insole, but does not present a concrete foundation to differentiate it with respect to baropodometric evaluation in the assessment and diagnosis of foot posture, however, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry.
References Almeida, J.S., Carvalho Filho, G., Pastre, C.M., Padovani, C.R., Martins, R.A.D.M., 2009. Comparac ¸˜ ao da pressa ˜o plantar e dos sintomas osteomusculares por meio do uso de palmilhas customizadas e pre ´-fabricadas no ambiente de trabalho. Rev. Bras. Fisioter. 13, 542e548. Azevedo, L.A.P., Nascimento, L.F.C., 2009. A distribuic ¸˜ ao da forc ¸a plantar esta ´ associada aos diferentes tipos de pe ´s? Rev. Paul. Pediatr. 27, 309e314. Bankoff, A.D.P., Bekedorf, R.G., Schmidt, A., Ciol, P., Zamai, C.A., 2006. Ana ´lise do equilı´brio corporal esta ´tico atrave ´s de um baropodo ˆmetro eletro ˆnico. Rev. Conex. 4, 19e30. Barela, J.A., Freitas Jr., P., 2006. Alterac ¸˜ oes no funcionamento do sistema de controle postural de idosos. Uso da informac ¸˜ ao visual. Rev. Port. Cie ˆncia do Desporto 6, 94e105. Bellizzi, M., Rizzo, G., Bellizzi, G., Ranieri, M., Fanelli, M., Megna, G., Procoli, U., 2011. Electronic baropodometry in patients affected by ocular torticollis. Strabismus 19 (1), 21e25.
Clinical analysis and baropodometric evaluation in diagnosis of abnormal foot posture Bianchi, T.C.V., Cepeda, C.P.C., Izaki, M., Regatieri, T.L., 2005. Relac ¸˜ ao entre o pe ¸a ¸a ´ cavo e a posteriorizac ˜o do centro de forc em crianc ¸as de 7e14 anos, avaliadas por meio da baropodometria. Rubs 1, 21e22. Bricot, B., 1999. Posturologia. Sa ˜o Paulo, Icone. Bricot, B., 2008. Total Postural Reprogramming. Dux Lucis Books, Santa Monica. Ceci, L.A., Salgado, A.S.I., PRZYsieZNY, W.L., 2004. Modificac ¸o ˜es das afere ˆncias sensitivas podais e sua influencia na amplitude. Rev. Fisio Mag. 1, 116e119. Corbin, D.M., Hart, J.M., McKeon, P.O., Ingersoll, C.D., Hertel, J., 2007. The effect textured insoles on postural control in double and single limb stance. J. Sport Rehabilitation 14, 363e372. Ferreira, L.A.B., Pereira, W.M., Bulla, H., Castilho, A.J., Rossi, L.P., Kerppers II, , Vieira, F.F., Thome ´, M.R., Paula Junior, A.R., 2007. Estudo comparativo entre obesidade em crianc ¸as e o controle postural atrave ´s da baropodometria. In: XII Encontro Latino Americano de Iniciac ¸˜ ao Cientı´fica e VIII Encontro Latino Americano de Po ¸a ´s-Graduac ˜o. Universidade do Vale do Paraı´ba, Sa ˜o Jose ´ dos Campos. Gagey, P.M., Weber, B., 2000. Posturologia, regulac ¸˜ ao e distu ´rbios da posic ¸a ˜o ortosta ´tica. Manole, Sa ˜o Paulo. Kaercher, C.W., Genro, V.K., Souza, C.A., Alfonsin, M., Berton, G., Cunha Filho, J.S., 2011. Baropodometry on women suffering from chronic pelvic pain e a cross-sectional study. BMC Women’s Heal. 11, 51. Keijsers, N.L.W., Stolwijk, N.M., Nienhuis, B., Duysens, J., 2009. A new method to normalize plantar pressure measurements for foot size and foot progression angle. J. Biomech. 42, 87e90. Magee, D.J., 2005. Musculoskeletal Assessment, fourth ed. Manole, Sa ˜o Paulo. Martinez, N.A., et al., 2007. Estudio baropodome ´trico de los valores de presio ´n plantar en pies no patolo ´gicos. Rehabilitacio ´n 41, 155e160.
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Menezes, L.T., Barbosa, P.H.F.A., Costa, A.S., Mundim, A.C., Ramos, G.C., Paz, C.C.S.C., Martins, E.F., 2012. Baropodometric technology used to analyze types of weight-bearing during hemiparetic upright position. Fisioter. Mov. 25 (3), 583e594. Moraes, S.T., Przysiezny, W.L., 2004. Estudo da influe ˆncia da lateralidade e da barra infracapital na reprogramac ¸a ˜o postural em pacientes lomba ´lgicos cro ˆnicos. Rev. Ter. Man. 3, 278e283. Oliveira, L.F., Vieira, T.M.M., Macedo, A.R., Simpson, D.M., Nadal, J., 2009. Postural sway changes during pregnancy: a descriptive study using stabilometry. Eur. J. Obstetrics Gynecol. Reprod. Biol. 147, 25e28. Pantanali, S.B., Rosa Neto, F.R., Caon, G., 2005. Incide ˆncia de alterac ¸˜ oes podais em pre ´-escolares de 2 a 6 anos de idade. Rev. Fisioter. Bras. 6, 245e248. Palluel, E., Nougier, V., Olivier, I., 2012. Do spike insoles enhance postural stability and plantar-surface cutaneous sensitivity in the elderly? Age 30, 53e61. Perry, S.D., Radtke, A., McIlroy, N.O.S., Fernie, G.R., Maki, B.E., 2008. Efica ´cia e efetividade de uma palmilha equilı´brio de reforc ¸o. J. Gerontol. Ser. A Biol. Sci. Med. Sci. 63, 595e602. Przysiezny, W.L., Salgado, A.S.I., 2002. Manual de Podoposturologia. Reeducac ¸˜ ao Postural Atrave ´s de Palmilhas. Laborato ´rio de Do Cefit - Hospital Evange ´lico de Brusque, Brusque. Saitoa, K., et al., 2011. An in-shoe device to measure plantar pressure during daily human activity. Med. Eng. Phys. 33, 638e645. Tokars, E., Motter, A.A., Moro, A.R., Gomes, Z.C., 2003. A influe ¸ados ˆncia do arco plantar na postura e no conforto dos calc ocupacionais. Rev. Fisioter. Bras. 4, 157e162. Tribastone, F., 2001. Tratados de exercı´cios corretivos: aplicados a reeducac ¸a ˜o motora postural. Manole, Sa ˜o Paulo. Ying-Shuo, H., Chen-Chieh, k, Young, Yi-Ho, 2009. Assessing the development of balance function in children using stabilometry. Int. J. Pediatr. Otorhinolaryngol. 73, 737e740.
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/jbmt
ORIGINAL RESEARCH
Clinical analysis and baropodometric evaluation in diagnosis of abnormal foot posture: A clinical trial Hugo Pasini Neto, PT, PhD a,b,c, ´ Collange Grecco, PT a,c, Luanda Andre Luiz Alfredo Braun Ferreira, PT a,c, ˜o, PhD a,b,c, Thaluanna Calil Lourenc ¸o Christova ´lia de Almeida Carvalho Duarte, PhD a,b,c, Nata ´udia Santos Oliveira, PhD a,c,* Cla a
Universidade Nove de Julho, Sa˜o Paulo, SP, Brazil Universidade de Sorocaba, Sorocaba, SP, Brazil c Laboratory of Human Movement Biodynamics, Universidade Nove de Julho e UNINOVE, Sa˜o Paulo, SP, Brazil b
Received 27 November 2013; received in revised form 8 September 2014; accepted 15 September 2014
KEYWORDS Posture; Baropodometry; Insoles
Summary Foot posture involves the integration of sensory information from the periphery of the body. This information generates precise changes through fine adjustments that compensate for the continuous, spontaneous sway of the body in the standing position. Orthopedic insoles are one of the therapeutic resources indicated for assisting in this process. Evaluation of these podal influences, by clinical examination and/or the assistance of baropodometry becomes crucial. Thus, the aim of the present study was determine the combination of the components of orthopedic insoles using two different evaluation methods. Forty healthy female volunteers between 18 and 30 years participated in the study. The volunteers were submitted to two different evaluations: clinical analysis and baropodometry. During the exams, different insole components were tested. The statistical analysis of the two evaluations revealed differences regarding the normalization of posture following the application of the insole components and in the determination of the combination of these components. The findings suggest that the clinical analysis is a fast and accurate method for determining the immediate benefits of the postural insole components and is therefore the more indicated method for the
* Corresponding author. R. Itapicuru 380, apt 111, Perdizes, CEP: 05006-000, Sa ˜o Paulo, SP, Brazil. Fax: þ55 11 3868 1681. E-mail addresses: [email protected] (H.P. Neto), [email protected] (L.A.C. Grecco), [email protected] (L.A. Braun Ferreira), [email protected] (T.C.L. Christova ˜o), [email protected] (N.A.C. Duarte), [email protected] (C.S. Oliveira). http://dx.doi.org/10.1016/j.jbmt.2014.09.007 1360-8592/ª 2014 Elsevier Ltd. All rights reserved.
430
H.P. Neto et al. evaluation of foot posture, but does not present a concrete foundation to differentiate it with respect to baropodometric evaluation in the assessment and diagnosis of foot posture, however, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry. ª 2014 Elsevier Ltd. All rights reserved.
Introduction Human balance is determined by a multi-sensory process involving the visual, somatosensory, vestibular and cerebellar systems. To maintain postural control in a variety of environmental situations, these systems must be closely integrated (Ying-Shuo, 2009). Postural orientation is linked to the position and alignment of the different parts of the body in relation to each other and to the environment through coordinated movements (Barela and Freitas, 2006; Bankoff et al., 2006; Ferreira et al., 2007). Foot posture involves the integration of sensory information from the periphery of the body, especially mechanoreceptors in the sole of the foot, related to gravitational acceleration, the environment and the position of the segments of the body (Oliveira et al., 2009). According to Bricot (1999) and Gagey and Weber (2000), this sensory information generates precise changes through postural fine adjustments that compensate for the continuous, spontaneous sway of the body in the standing position. The study of foot posture assists in the evaluation of overall posture. Thus, there is a need to correct abnormalities and instabilities in foot posture for a better control of postural tone (Gagey and Weber, 2000). The early diagnosis of abnormal foot posture is of extreme importance to avoiding postural problems, excessive joint loads, cumulative micro-traumas and gait disorders (Pantanali et al., 2005; Bianchi et al., 2005; Azevedo and Nascimento, 2009; Tokars et al., 2003). For such, orthopedic insoles are indicated (Almeida et al., 2009). The aim of these devices is to correct the distribution of plantar loads in contact with a hard surface, favoring a better distribution of body mass on the plantar region and providing better alignment of the knees, hips, pelvis and spinal column (Almeida et al., 2009). According to Bricot (1999), these effects occur due to the fact that orthopedic insoles reorganize the tonus of muscle chains and exert an influence over posture correction reflexes. These insoles affect muscle proprioception, leading to changes in the ascending proprioceptive chains (Bricot, 1999). According to Gagey and Weber (2000), the stimulation of specific regions of the sole of the foot leads to a change in postural tonus and a repositioning of the pelvis and muscle asymmetries along the spinal column. Postural reprogramming occurs when mechanoreceptors in the plantar region are activated by deformation of the skin due to the topographic relief of the support surface, as occurs with posture-control insoles (Przysiezny and Salgado, 2002). The components of orthopedic insoles are made of ethylene vinyl acetate in different shapes. According to Moraes and Przysiezny (2004), clinical analysis based on the references points of arm length, level of the iliac crest and paravertebral muscle tension is indicated for the
determination of the combination of postural insole components. Described these clinical tests are able to analyze the rising influence of foot posture in postural control and therefore you can select the ideal postural reprogramming insole. Another important factor in the diagnosis of abnormal posture is knowledge regarding plantar pressure through baropodometry, which allows an understanding of the physiopathology of postural alterations (Martinez et al., 2007). The principle is to map the pressure of the plantar surface, which, indirectly, indicates important postural abnormalities (Bellizzi et al., 2011; Kaercher et al., 2011). Computerized baropodometry furnishes useful information on the positioning of the foot. It also provides the stabilometric parameters derived from the spatial and temporal behavior of the center of pressure, similar to a force plate (Menezes et al., 2012). However, data on plantar pressure patterns are difficult to analyze and interpret when compared to clinical evaluation, but provide important information regarding plantar pressure and balance. Mean plantar pressure is generally used to detect imbalances in the anteroposterior and mediolateral directions (Keijsers et al., 2009). Therefore, this method is very important to understand the adaption of a modified orthostatic position which could result in/from an erratic postural adaptation, secondary to certain diseases that affect, or can be affected by posture (Kaercher et al., 2011; Bricot, 2008). The aim of the present study was to compare two forms of evaluating foot posture (clinical analysis based on reference points and baropodometry) for the determination of the combination of the postural insole components.
Materials and methods Volunteers Forty volunteers fulfilled the eligibility criteria and participated in the present study. Because it is an analysis of ways of assessing foot posture, the inclusion criteria were the female gender, age between 18 and 30 years, adequate health status and body mass index (BMI) between 20 and 25 kg/m2 (Who, 2003), without any kind of illness or musculoskeletal injury. The exclusion criteria were a history of musculoskeletal injury in the previous 12 months, neurological condition or metabolic-endocrine disease.
Ethical considerations The present study was carried out in compliance with the ethical standards of the Declaration of Helsinki and received approval and registry from the Human Research Ethics Committee of the Plataforma Brasil under process number 14117113.3.0000.5511/2013. All participants were
Clinical analysis and baropodometric evaluation in diagnosis of abnormal foot posture informed regarding the objectives and procedures of the study and signed a statement of informed consent.
Procedures Anthropometric data were collected and evaluations were performed for the determination of the components of the orthopedic insoles for each volunteer. This evaluation was divided into two steps: clinical analysis and baropodometry. The order of the evaluations was determined randomly by lots with the use of opaque envelopes. Each evaluation was performed by two examiners, with each examiner blinded to the findings of the other. Only those volunteers for which the results were identical between both examiners were considered for the analysis (36 volunteers). The method proposed by Moraes and Przysiezny (2004) was used for the clinical analysis based on postural information for the determination of the components of the insoles used to normalize posture. Normalization is determined based on arm length, the level of the iliac crest and the level of the thumbs positioned in the cervical and lumbar regions (C5 and L5) using the Bassani test, in order to check the paraspinal musculature tension (Ceci et al., 2004). According to the authors cited, this protocol is indicated for the best determination of the components of orthopedic insoles. After these clinical trials were selected the ideal elements that would be used on the insole for correction of abnormalities found. After clinical analysis, with the same volunteers, baropodometric review was conducted. For the analysis of average pressure baropodometric, the volunteers were positioned barefoot on a pressure plate system (Tekscan MatScan, Boston, USA) at a distance of two meters from a fixed point located specifically at the time of the individual and instructed to stand comfortably, with eyes directed to the fixed point. Different insole components were tested to find the combination that offered the best plantar support with ideal percentages of weight distribution regarding anteroposterior and mediolateral plantar support. According to Tribastone (2001) and Magee (2005), the ideal load values are 60% of the weight on the heel and 40% on the anterior region of the foot as well as symmetrical mediolateral distribution (50%). After these baropodometric information were selected the ideal elements that would be used on the insole for correction of abnormalities found.
Equipment The pressure plate of the Tekscan MatScan System (Boston, USA) was used. This platform measures 5 mm in thickness, 432 in length and 368 mm in width and has lines and columns that form an XeY grid, with 2288 sensors, resolution of 1.4 sensor/cm2 and sampling frequency of 40 Hz. The insole components were formed with ethylene vinyl acetate in the shape of bars, wedges, half-moons and shims measuring 3 mm in thickness.
Data analysis Relative and absolute frequencies were determined to describe the categorical variables (insole components [yes/
431
no] and normalization of posture [yes/no]). Descriptive statistics (mean and standard deviation values) were used for the continuous variables (age, body mass, height and BMI). The chi-square (c2) test was used to compare the evaluation methods (clinical exam and baropodometry) regarding the alterations found, insole components used and the normalization of posture. The level of significance was set to 5% (p < 0.05). All data were organized and tabulated using the SPSS program v.15.0.
Results Forty volunteers were recruited, 36 of whom received identical evaluations from the two examiners and therefore participated in the present study. Table 1 displays the anthropometric characteristics of the participants. The clinical analysis revealed the following distribution of alterations: difference in arm length in 27.5%; difference in height between iliac crests in 22.5%; difference in height of thumbs in cervical region in 25% and difference in height of thumbs in lumbar region in 25% of the volunteers. Based on the alterations, different insole components were tested to find the combination that normalized these references points, which occurred in 100% of cases. The baropodometric analysis revealed imbalances in the prevalence of weight load: anterior in 42%, posterior in 8% and lateral in 50% (22% with right-side prevalence and 28% with left-side prevalence) of the volunteers. Based on the alterations, different insole components were tested to find the combination that normalized these references, which occurred in 77% of cases (28 volunteers). The statistical analysis of the results of posture normalization demonstrated a significant difference between the clinical analysis and baropodometry (c2 Z 10.8; p Z 0.001), showing a difference between the two techniques and greater accuracy of analysis compared the clinical baropodometric evaluation regarding the indication of the corrective insole elements for postural reprogramming. Regarding the combinations of insole components that led to posture normalization using the different evaluation methods, significant differences were found for the indication of the left-side dome piece (c2 Z 22.0; p Z 0.000) and right-side anti-rotator (c2 Z 10.5; p Z 0.001). The other pieces employed in the combinations for posture normalization did not exhibit statistically significant differences between evaluation methods regarding their indication for use (Table 2).
Table 1 Mean and standard deviation values of anthropometric characteristics of the participants. Anthropometric characteristics
Mean Standard deviation
Age (years)
Height (m)
Body mass (kg)
BMI (kg/m2)
21.3 2.95
1.65 0.09
60 12
21.96 2.57
432
H.P. Neto et al.
Table 2 Comparison of components different evaluation methods. Components Half-dome e right Half-dome e left Anti-rotator e left Anti-rotator e right Retro-capital e right Retro-capital e left
Clinical evaluation
indicated
by
Baropodometry
p
8
6
10
0
14
8
10
2
0
4
0
2
c2 Z 0.4; p Z 0.484 c2 Z 22.0; p Z 0.000 c2 Z 3.3; p Z 0.068 c2 Z 10.5; p Z 0.001 c2 Z 4.3; p Z 0.038 c2 Z 2.0; p Z 0.150
Discussion The results demonstrated significant differences between the two evaluation methods for the determination of the combination of insole components for the normalization of posture. Moreover, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry. According to Bricot (1999), the aim of orthopedic insoles is to reorganize the tonus of muscle chains and influence body posture through correction reflexes, which act on muscle proprioception and lead to changes in the ascending proprioceptive chains. Przysiezny and Salgado (2002) report that postural reprogramming occurs when the mechanoreceptors in the plantar region are activated by the deformation of the skin caused by the topography of insoles. Thus, it is evident that orthotics may play a role proprioceptive instead of correction sensitive afferents enhancing the sole of the foot and drives the body to react in order to establish a new posture. Therefore, the postural normalization evidenced by the clinical evaluation based on reference points may be related to this biomechanical rearrangement. The non-normalization of plantar pressure in a significant number of the volunteers using the combinations of insole components indicated by baropodometric analysis may be related to the lack of a period of adaptation. In a study involving elderly individuals, Palluel et al. (2012) assessed the use of a textured insole and found no significant immediate effect, but the participants demonstrated a significant improvement in postural balance after five minutes of walking with the insoles. In a study involving adults with episodes of blisters, orthopedic insoles were used with the aim of improving postural balance through the reduction in sensitivity in the sole of the foot. The subjects were randomly distributed into two groups (insole group and control group). The results demonstrated improved stability during gait and a lower number of falls in the insole group, but 12 weeks were needed for these benefits to appear (Perry et al., 2008). Corbin et al. (2007) assessed balance in 33 individuals with proprioceptive insoles and traditional insoles with eyes open and eyes
closed. The results demonstrated that the proprioceptive insoles led to an improvement in balance, but only when the volunteers had their eyes closed, suggesting that this effect occurred precisely by the removal of visual information and, in the long term, the prolonged increase in afference may offer improved postural balance with eyes open as well. Thus, the immediate effect of the insole components evidenced by baropodometry in the present study may not reflect the benefits of the application of the insoles with regard to posture, as the participants were not allowed time to adapt to the use of the insoles. According to Saitoa et al. (2011), another aspect to consider is that this device has limitations from the therapeutic standpoint. These insoles are not designed for daily measurements in real time or with the use of feedback. According to the authors, such measures exhibit considerable inter-individual as well as intra-individual variability, which is a limiting factor with regard to the determination of abnormal postural performance. The inherent variability in this measure under normal conditions has been widely discussed. Considering the importance of evaluating the process of therapy and the difficulty of many centers may have regarding baropodometry, studies that can help in this process are important for physical therapists who treat foot and body posture. Regarding study limitations, it is believed that the need to use a control group would have brought greater clinical potential for the present study.
Conclusion Clinical analysis and baropodometry indicate different compositions of orthotics for postural proprioceptive stimulation of the foot. The results suggest that clinical examination is a fast and accurate method to determine the immediate benefits of postural components insole, but does not present a concrete foundation to differentiate it with respect to baropodometric evaluation in the assessment and diagnosis of foot posture, however, a greater difficulty was encountered in achieving posture normalization when using information obtained through baropodometry.
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