RESEARCH ARTICLE
Immediate Effects of Talocrural and Subtalar Joint Mobilization on Balance in the Elderly Alain Chevutschi1*, Juliette D’Houwt1, Vinciane Pardessus2 & André Thevenon2 1
IFMKNF, Loos, France
2
CHRU, Lille, France
Abstract Background and Purpose. The aim of the present study was to evaluate the immediate effects of therapeutic mobilization of the talocrural and subtalar joints on ankle mobility and postural control in elderly subjects. Methods. Nineteen subjects (83.1 ± 6 years, 159 ± 1 cm; 56.1 ± 9.7 kg mean ± standard deviation) participated in this study. The centre of pressure (COP) displacements along the anterior–posterior and medial–lateral axes was recorded in static and dynamic conditions on a force platform before and after therapeutic mobilization of the feet and ankles without blinding the subjects. Results. In static conditions, the sway area is reduced contrarily to dynamic conditions where the sway area is increased. In the two experimental sessions, subjects showed comparable COP displacements and the total length of the oscillations. Results demonstrated a significant improvement immediately after mobilization for ankle range of motion in dorsal flexion (right +4.7°; left +3.2°) and plantar flexion (right 5.2°; left +4.2°). Conclusion. These results suggested that postural control is improved in static conditions and decreased in dynamic conditions. Therapeutic mobilization of feet and ankles in the elderly provides an immediate improvement in joint range of movement in dorsal and plantar flexion. Copyright © 2014 John Wiley & Sons, Ltd. Received 24 September 2012; Revised 19 July 2013; Accepted 13 February 2014 Keywords ankle; balance; elderly; foot; mobilization *Correspondence Alain Chevutschi, IFMKNF, Loos, France. E-mail: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1582
Introduction Human postural control is a very complex system integrating various sensory and motor elements. Balance is the result of this multimodal function involving vision, the vestibular system, brain and proprioception. Nowadays, it has been clearly established that feet and ankle joints and plantar sole play a determining role in balance and gait (Dietz, 1992; Meyer et al., 2004a, 2004b). Gagey (1998) validated the importance of the foot in gaining balance; he compared the human body with its centre of mass at pelvic level to a reverse pendulum revolving around the ankles. Information Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
received from skin, tendon, muscle and joint receptors have an impact on postural control (Kavounoudias et al., 2001; Perry et al., 2008). Most of the studies concern the receptors of the feet. These data were collected from various experiments with foot cooling (Magnusson et al., 1990), foot anaesthesia (Thoumie and Do, 1996; Meyer et al., 2004a; Meyer et al., 2004b), stimulation of the plantar sole (Kavounoudias et al., 1998; Kavounoudias et al., 2001; Maurer et al., 2001) or by changing the types of flooring surfaces (Redfern et al., 1997; Robbins et al., 1998). The musculotendinous system was studied by vibrations
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of the ankle muscles (Hay et al., 1996; Kavounoudias et al., 1998). One of the characteristics of normal aging process is the change in the various sensory receptors. With age, vision becomes less sensitive to contrast with a reduced visual field, and the vestibular system tends to be underused. Proprioception becomes altered because of a slowed-down nerve conduction (Thoumie, 1999). The affection to the skeletal muscles can be observed with muscle weakness and joint stiffness, especially in ankle dorsiflexion. Besides the natural aging process, certain age-related pathologies further affect postural balance, responsible for instability and falls in the elderly population. Peripheral neuropathies such as diabetes are to blame for an altered sensitivity of the plantar sole disrupting balance. Elderly subjects who are ‘fallers’ have very altered postural adjustment performances compared with ‘non-fallers’ (Ghulyan and Paolino, 2005). Most falls resulting from this altered balance system are so-called mechanical falls. Proper functioning of the various systems regulating balance is essential for the autonomy and gait of the elderly population. Therapeutic strategies are implemented to fight and delay the effects of aging and their subsequent negative impact in the elderly. In physical medicine and rehabilitation physiotherapists, with the approval of the medical team, the use of several techniques prevents falls and/or reduces their consequences when they happen. Muscle strengthening is indicated in preventing falls in the elderly (Faber et al., 2006). Exercises to maintain the musculoskeletal system are also part of these protocols, especially passive mobilization (Vaillant et al., 2008). Mecagni et al. (2000) reported the correlation between joint flexibility and balance performances in elderly subjects. Talar glide mobilization techniques have been previously investigated and appear to successfully address the deficit of dorsiflexion (Landrum et al., 2008). Even though physical medicine and rehabilitation teams use these techniques daily for patients with ankle splits or ankle sprains and for elderly patients with balance difficulty. It is quite surprising to note that there are very few studies available in the literature on this topic. Vaillant et al. (2009) studied the influence of ankle and foot mobilization and massage on double stance balance. The results showed a significant improvement after massage and mobilization compared with placebo for the One Leg Balance test and the Timed Up and Go test.
The aim of the present study was to evaluate in the elderly the immediate effects of passive ankle and foot mobilization on postural control when standing up. The second objective was to assess if passive mobilization of the talocrural and subtalar joints could help these patients regain some or all of their ankle mobility.
Methods Population Nineteen elderly adults (mean age = 83.1 ± 6 years; mean body weight = 56.1 ± 9.7 kg; mean height = 159 ± 0.1 cm) participated in this study. Subjects were volunteers and gave their written informed consent to be included in the research. As the study involved neither intrusive techniques nor randomization, the opinion of the regional ethical committee was not requested. Exclusion criteria were vestibular, neurological, metabolic, vascular and psychiatric pathologies. Subjects with uncorrected vision disorders and history of trauma in the past 6 months were also excluded. Material The platform (Satel) described by Mbongo et al. (2005) consisted of a static computerized force platform, on which a seesaw platform could be placed in order to induce dynamic conditions. The static force platform (Figure 1) was a square (side length, l = 48 cm; height, h = 6.5 cm) and contained three strain gauge force transducers positioned according to an equilateral triangle with a side length of 40 cm. The strain gauges recorded the displacements of the centre of foot pressure (COP) in an anterior–posterior and a medial– lateral direction, at a 40-Hz sampling frequency. For dynamic posturography, a seesaw platform consisting of a rigid Plexiglas plate (48 × 48 cm) supported by two lateral sections of a cylinder (radius, r = 55 cm; segment height, f = 6 cm) was placed on the static platform. The moveable platform had only one degree of freedom. Interventional procedure Mobilization of the talocrural and subtalar joints The aim of the mobilization was to enhance the mobility of the ankles and subtalar joints. Passive mobilization included gliding exercises as well as simple analytical passive mobilization exercises. Joints techniques Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Figure 1. Platform and statokinesigram
were applied to both the ankles for 20 minutes. It started with the right lower limb and consisted of 10 repetitions for each movement. A time of rest of 30 seconds is left between every series. Mobilizations elicited first anterior–posterior glide of the talocrural joints. Then mobilizations involved dorsiflexion and plantar flexion with posterior and anterior tibial glides of the talus on the ankle mortise. Mobilizations of the subtalar joints included flexion, extension, adduction, abduction, pronation and supination of the calcaneus (Pierron et al., 1988). The 3 steps of the mobilization (e.g going towards flexion, holding it, and getting back to resting position) last 1 second each. Pre-mobilization and post-mobilization evaluation All pre-intervention and post-intervention measurements were performed by the same examiner who was not involved in the mobilization procedure. The order of these different experimental conditions was standardized in all of our patients (static eyes open, dynamic eyes open). Static posturography The subject stood up with eyes open on the force platform, located 1 meter apart from the wall. Feet were apart, pointing outwards and positioned on marks to ensure the reproducibility of the position (30° angle with the heels at a distance of 2 cm from each other). The subject was asked to stare at a physical point mark straight ahead to maintain a Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
horizontal focus. The guidelines given to each subject were to maintain a static standing up posture with arms along the sides of the body during the whole recording period. Two trials with 10-second rest were recorded. Each recording session lasted 51.2 second. A try-out test was performed before the recording in order to allow each subject to get familiar with the platform. Dynamic posturography After a 2-minute rest period, the subject stood up, eyes open, on the seesaw platform which was positioned in the anterior–posterior plane on the force platform. Adapted supports were first placed under the seesaw to stop its movements. Supports were then removed and subject was asked to maintain the seesaw platform as horizontal as possible while keeping his/her arms along the body and his/her knees straight. Recordings started only when the subject was able to stand up on the seesaw platform. This dynamic situation was a self-regulated balance task. Postural reactions were mainly in the anterior–posterior direction. The guidelines that were given to the subject were the same as previously mentioned; the recording took 25.6 seconds sampled at 40 Hz. Two trials with 10 second rest were recorded. Each measurement lasted only 25.6 second because the test was difficult to perform. Each recording was preceded by a try-out test to familiarize the subject with the protocol. Sway parameters and statistical analysis The static and dynamic posturography analyses were conducted before and immediately after the experimentation. On the basis of the measures of the displacements of the
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COP, four variables were considered in both static and dynamic conditions. 1. COP displacements (mm) along the medial–lateral axe (X). The mean X corresponded to the mean position of the COP evolving on the right cleft axis in narrow limits. 2. COP displacements (mm) along the anterior– posterior (Y) axe. The mean Y corresponded to the mean value of movements and balancing postures forward and backward. 3. The total length of the oscillations (mm) represented the sum of the distances covered between each position of the COP. This parameter represents the length of the trajectory of the displacements of the COP. 4. Sway area surface (mm2) was used to estimate a global postural performance. Sway area corresponds to the ‘area’ of the confidence ellipse formed by the positions of the COP during the recording. About 10% of the most extreme points, resulting for poorly controlled oscillations were discarded. The surface, computed from 90% of the left over COP positions, was expressed in square millimetres, showing the amplitude of the oscillations of the centre of gravity. The surface of the reliable ellipse, which contains 90% of the positions sampled by the COP is the most rigorous statistical measure of the dispersal of these positions (Takagi et al., 1985). For all these variables, higher values correspond to lower stability. Joint range of movement The ranges of motion (ROM) of the right and left talocrural joints were measured in passive dorsiflexion (Figure 2) and plantar flexion (Figure 3) with a universal goniometer (Figures 2 and 3). The subject was asked to lie down, knee flexed at 90°. The flexion was maintained with a large pillow to eliminate any passive tension in the gastrocnemius muscles in order to record only the joint motion. The external markers were defined as the tip of the lateral malleolus for the joint centre, the styloid process of the fifth metatarsal and the head of the fibula. The measures were applied with repeatable force three times before and after the mobilization exercises; the mean of the three trials, rounded up at 5° was kept for the measures.
Figure 2. Measure of the dorsiflexion movement
Figure 3. Measure of the plantar flexion movement
Statistical analysis Means and standard deviations are presented for all variables. The Shapiro–Wilks test was used for normal distributions. To compare the differences before and after mobilization, we used the Student t-test for paired series. The statistical analysis was computed with the STATISTICA 6.0 (Statsoft software, StatSoft, Inc. (Headquarters)Tulsa, Oklahoma, OK, USA). The significance threshold was set at p < 0.05.
Results Static posturography The results from the static posturography are presented in Table 1. There was no difference in the COP displacement according to the anterior–posterior (X) and medial– lateral (Y) axes. Besides, the length (the total length of the statokinesigram) had not been modified. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Table 1. Results of the static posturography before and after talocrural and subtalar joint manipulations for the 19 subjects: X mean, Y mean, length in millimetre and surface in square millimetres X mean (mm)
Y mean (mm)
n = 19
Before
After
Before
Mean SD
0.18 10.67
2.84 10.63
38.70 14.64
After 37.38 14.90
2
Length (mm)
Surface (mm )
Before
After
Before
After
1,738.05 1,114.67
1,613.37 884.43
779.21 592.72
666.11* 425.29
SD, standard deviation. *Significant difference (p < 0.05).
The ellipse’s surface formed by the COP position had significantly decreased by 113.1 mm2 (p < 0.05): 779.2 ± 592.7 mm2 before and 666.1 ± 425.3 mm2 after.
Dynamic posturography The results from the dynamic posturography are presented in Table 2. There was no difference in COP displacement according to the anterior–posterior (X) and medial– lateral (Y) axes. Besides, the total length of the statokinesigram had not been modified. The ellipse’s surface formed by the COP position had significantly increased by 566.1 mm2 (p < 0.05): 2,310 ± 1,085.5 mm2 before and 2,876.2 ± 1,914.2 mm2 after.
Dorsiflexion and plantar flexion ROM values for dorsiflexion and plantar flexion of the right and left talocrural joints, before and after passive mobilization, are presented in Figure 4 for the 19 subjects. ROM values for dorsiflexion of the right talocrural joint have greatly improved by 4.7° after joint mobilization (p < 0.01): 12.4 ± 6.5°before and 17.1 ± 4.8°after. We also noted a significant 3.2° difference (p < 0.01)
for the left talocrural joint: 12.1 ± 4.6°before and 15.3 ± 5.9° after. ROM values for plantar flexion of the right talocrural joint have significantly improved (p < 0.01) by 5.2° after mobilization: 24.0 ± 7.7° before and 29.2 ± 6.7° after. We also noted a significant 4.2° difference (p < 0.01) for the left talocrural joint: 25.8 ± 6.1° before and 30.0 ± 5.5° after.
Discussion While the dorsiflexion ROM benefits associated with joint mobilization are well-documented in treating ankle sprains (Landrum et al., 2008), this study is one of the only ones to examine the effects of talocrural and subtalar joints mobilization on posture on elderly subjects. The results of the static posturography did not show any significant differences for COP displacements along the anterior–posterior and medial–lateral axes and for the total length of the oscillations. However, the sway area was significantly reduced after passive mobilization. According to Gagey (1998) and Weber and Villeneuve (2010), the reduction of the sway area corresponds to a better stability. Our results are in agreement with the results of Vaillant et al. (2009), which showed that 20 minutes of massage associated with mobilization of the feet improve the postural control at the elderly person.
Table 2. Results of the dynamic posturography before and after talocrural and subtalar joint manipulation for the 19 subjects: X mean, Y mean, length in millimetre and surface in square millimetres X mean (mm)
Y mean (mm)
Length (mm)
2
Surface (mm )
n = 19
Before
After
Before
After
Before
After
Before
After
Mean SD
6.88 15.99
7.45 14.17
9.97 12.50
8.52 11.14
1,857.37 840.99
1,982.53 941.91
2,310.05 1,085.50
2,876.16* 1,914.23
SD, standard deviation. *Significant difference (p < 0.05).
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Figure 4. Means and standard deviations of the ankle range of motion, for dorsiflexion and plantar flexion, in the 19 subjects before and after manipulation. ** Significant difference (p < 0.01)
Recovered mobility and flexibility cannot explain the reduction in surface. We could imagine that the mobilization of the osteoarticular structures and, to a lesser degree, muscle mobilization (soleus) reactivated the proprioceptive system, especially the mechanoreceptors of the ankle. The stimulation of these mechanoreceptors may increase the afferent input from the talocrural and subtalar joints and surrounding tissues, explaining the diminution of the sway area (Hoch and McKeon, 2010). These mechanoreceptors play a role in postural control and allow managing small displacements of the COP better (Vaillant et al., 2008). According to Rabischong (1996), skin plays a role in static postural control thanks to the Ruffini endings, which act as pressure captors. The skin around the joints and the various receptors responsible for the goniometric information needed for motor coordination seems to be connected. Even though it was not first intended in the study, the skin was stimulated during the exercises when grabbing the foot and ankle and could participated to the improvement of perception. The balance in dynamic standing was only evaluated in the anterior–posterior plane because the postural reactions are mainly in the anterior–posterior direction. This direction corresponds to the dorsal and plantar flexion of the ankle. The subtalar joint was mobilized in the three spatial planes corresponding to its mobility. We did not evaluate the dynamic standing balance in the frontal plane even though this joint moves in this direction during the stance phase. No significant changes were noted for COP displacements according to the anterior–posterior and medial–lateral axes and for the total length of the oscillations. Only
the sway area had significantly increased showing that it was harder to control COP displacements on the unstable platform. The instruction was to stand still as long as possible. Vision and the vestibular system were not disrupted because no changes were made to the environment between the two experiments, and a trial experiment was conducted before the first recordings to enable patients to get familiar with the protocol. We are surprised by the increase of surface on the unstable platform, which corresponds to instability. We did not find in the literature studies on the effects of the mobilization of the ankle on the dynamic balance. This is why we emit the hypothesis that the improvement of the amplitudes modifies the neuromuscular attention and could explain the delay in the answer. The modifications in postural control are probably because of alterations in neuromuscular activity (Yerys et al., 2002). The changes in strength and facilitation of spinal reflexes were exposed in previous studies (Liebler et al., 2001, Yerys et al., 2002). However, manipulating mechanoreceptor-associated inhibition of joint stabilizing muscles could also bring changes in postural control (Palmieri et al., 2003, Grindstaff et al., 2011). Mobilization exercises were conducted with the knee flexed, eliminating the input from gastrocnemius muscles (Delarque et al., 1998). These muscles, rich in Golgi organs, have a major impact on postural control when standing up. Joint ROM improvement was obtained without involving any muscle; this is why we bring forth the hypothesis that the muscle proprioceptive system might be the cause of this delayed muscle response. The muscle system might not be ‘informed’ of the new improved joint range of movements. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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The aim of the present study was to evaluate the effects of passive talocrural and subtalar joints mobilization exercises on postural standing control in an elderly population. At joint level, we reported a significant improvement in dorsiflexion and plantar flexion on both sides. Our results are in agreement with Landrum et al. (2008), which find an improvement of dorsiflexion ROM and posterior ankle joint of talocrural after a single application of grade III anterior-to-posterior talocrural joint mobilization. The results validated the immediate efficiency of therapeutic mobilization on the foot and ankle. Therefore it is impossible to predict the potential long lasting effect of the reported improvement. Joint ROM improvements observed after mobilization showed that ROM deficits in this elderly population were not irreversible; indeed, the ROM deficits seemed to be more underused joint system rather than caused by joint stiffness. These results were even more relevant because ankle stiffness is one of the main factors of instability and falls in elderly subjects. Ankle stiffness, especially ankle equinus seems to be responsible for foot brushing against the floor (ChaneTeng, 2009). El Laassel (2008) recommends a 15° dorsiflexion and 20° plantar flexion to obtain a normal gait. These amplitudes in dorsiflexion and plantar flexion were effectively obtained in our population after mobilization. In elderly patients, joint stiffness in the lower limbs is compensated by implementing a hip strategy for regulating balance, thus triggering changes in the gait pattern. The subjects increase their hip flexion to the expense of the ankle (Silder et al., 2008). In our study, passive ankle and foot mobilizations were conducted with the knee flexed discarding the action of the gastrocnemius muscles and increasing the stimulation on the osteoarticular structures. The improvement obtained was essentially located in the joints, even if the monoarticular soleus muscle controlling posture is stretched in this mobilization. These results demonstrated the major impact of mobilization in recovering joint functions.
Conclusion Regarding balance, the sway area is reduced during the static experiment showing a better stability in elderly subjects. However, the surface is increased in dynamic setting corresponding to an increased instability. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Passive mobilization immediately improves ankle mobility in dorsiflexion and plantar flexion in elderly subjects. The results support the efficacy of these rehabilitation techniques in demonstrating short-term improvement in ankle joint mobility in elderly subjects. The choice of passive exercises seems indicated to improve static balance rapidly and ankle joint mobility but not adequate to recover dynamic settings.
Conflict of interest The authors declare no conflict of interest.
Ethical approval No ethical approval required for this study.
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Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
Immediate Effects of Talocrural and Subtalar Joint Mobilization on Balance in the Elderly Alain Chevutschi1*, Juliette D’Houwt1, Vinciane Pardessus2 & André Thevenon2 1
IFMKNF, Loos, France
2
CHRU, Lille, France
Abstract Background and Purpose. The aim of the present study was to evaluate the immediate effects of therapeutic mobilization of the talocrural and subtalar joints on ankle mobility and postural control in elderly subjects. Methods. Nineteen subjects (83.1 ± 6 years, 159 ± 1 cm; 56.1 ± 9.7 kg mean ± standard deviation) participated in this study. The centre of pressure (COP) displacements along the anterior–posterior and medial–lateral axes was recorded in static and dynamic conditions on a force platform before and after therapeutic mobilization of the feet and ankles without blinding the subjects. Results. In static conditions, the sway area is reduced contrarily to dynamic conditions where the sway area is increased. In the two experimental sessions, subjects showed comparable COP displacements and the total length of the oscillations. Results demonstrated a significant improvement immediately after mobilization for ankle range of motion in dorsal flexion (right +4.7°; left +3.2°) and plantar flexion (right 5.2°; left +4.2°). Conclusion. These results suggested that postural control is improved in static conditions and decreased in dynamic conditions. Therapeutic mobilization of feet and ankles in the elderly provides an immediate improvement in joint range of movement in dorsal and plantar flexion. Copyright © 2014 John Wiley & Sons, Ltd. Received 24 September 2012; Revised 19 July 2013; Accepted 13 February 2014 Keywords ankle; balance; elderly; foot; mobilization *Correspondence Alain Chevutschi, IFMKNF, Loos, France. E-mail: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/pri.1582
Introduction Human postural control is a very complex system integrating various sensory and motor elements. Balance is the result of this multimodal function involving vision, the vestibular system, brain and proprioception. Nowadays, it has been clearly established that feet and ankle joints and plantar sole play a determining role in balance and gait (Dietz, 1992; Meyer et al., 2004a, 2004b). Gagey (1998) validated the importance of the foot in gaining balance; he compared the human body with its centre of mass at pelvic level to a reverse pendulum revolving around the ankles. Information Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
received from skin, tendon, muscle and joint receptors have an impact on postural control (Kavounoudias et al., 2001; Perry et al., 2008). Most of the studies concern the receptors of the feet. These data were collected from various experiments with foot cooling (Magnusson et al., 1990), foot anaesthesia (Thoumie and Do, 1996; Meyer et al., 2004a; Meyer et al., 2004b), stimulation of the plantar sole (Kavounoudias et al., 1998; Kavounoudias et al., 2001; Maurer et al., 2001) or by changing the types of flooring surfaces (Redfern et al., 1997; Robbins et al., 1998). The musculotendinous system was studied by vibrations
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of the ankle muscles (Hay et al., 1996; Kavounoudias et al., 1998). One of the characteristics of normal aging process is the change in the various sensory receptors. With age, vision becomes less sensitive to contrast with a reduced visual field, and the vestibular system tends to be underused. Proprioception becomes altered because of a slowed-down nerve conduction (Thoumie, 1999). The affection to the skeletal muscles can be observed with muscle weakness and joint stiffness, especially in ankle dorsiflexion. Besides the natural aging process, certain age-related pathologies further affect postural balance, responsible for instability and falls in the elderly population. Peripheral neuropathies such as diabetes are to blame for an altered sensitivity of the plantar sole disrupting balance. Elderly subjects who are ‘fallers’ have very altered postural adjustment performances compared with ‘non-fallers’ (Ghulyan and Paolino, 2005). Most falls resulting from this altered balance system are so-called mechanical falls. Proper functioning of the various systems regulating balance is essential for the autonomy and gait of the elderly population. Therapeutic strategies are implemented to fight and delay the effects of aging and their subsequent negative impact in the elderly. In physical medicine and rehabilitation physiotherapists, with the approval of the medical team, the use of several techniques prevents falls and/or reduces their consequences when they happen. Muscle strengthening is indicated in preventing falls in the elderly (Faber et al., 2006). Exercises to maintain the musculoskeletal system are also part of these protocols, especially passive mobilization (Vaillant et al., 2008). Mecagni et al. (2000) reported the correlation between joint flexibility and balance performances in elderly subjects. Talar glide mobilization techniques have been previously investigated and appear to successfully address the deficit of dorsiflexion (Landrum et al., 2008). Even though physical medicine and rehabilitation teams use these techniques daily for patients with ankle splits or ankle sprains and for elderly patients with balance difficulty. It is quite surprising to note that there are very few studies available in the literature on this topic. Vaillant et al. (2009) studied the influence of ankle and foot mobilization and massage on double stance balance. The results showed a significant improvement after massage and mobilization compared with placebo for the One Leg Balance test and the Timed Up and Go test.
The aim of the present study was to evaluate in the elderly the immediate effects of passive ankle and foot mobilization on postural control when standing up. The second objective was to assess if passive mobilization of the talocrural and subtalar joints could help these patients regain some or all of their ankle mobility.
Methods Population Nineteen elderly adults (mean age = 83.1 ± 6 years; mean body weight = 56.1 ± 9.7 kg; mean height = 159 ± 0.1 cm) participated in this study. Subjects were volunteers and gave their written informed consent to be included in the research. As the study involved neither intrusive techniques nor randomization, the opinion of the regional ethical committee was not requested. Exclusion criteria were vestibular, neurological, metabolic, vascular and psychiatric pathologies. Subjects with uncorrected vision disorders and history of trauma in the past 6 months were also excluded. Material The platform (Satel) described by Mbongo et al. (2005) consisted of a static computerized force platform, on which a seesaw platform could be placed in order to induce dynamic conditions. The static force platform (Figure 1) was a square (side length, l = 48 cm; height, h = 6.5 cm) and contained three strain gauge force transducers positioned according to an equilateral triangle with a side length of 40 cm. The strain gauges recorded the displacements of the centre of foot pressure (COP) in an anterior–posterior and a medial– lateral direction, at a 40-Hz sampling frequency. For dynamic posturography, a seesaw platform consisting of a rigid Plexiglas plate (48 × 48 cm) supported by two lateral sections of a cylinder (radius, r = 55 cm; segment height, f = 6 cm) was placed on the static platform. The moveable platform had only one degree of freedom. Interventional procedure Mobilization of the talocrural and subtalar joints The aim of the mobilization was to enhance the mobility of the ankles and subtalar joints. Passive mobilization included gliding exercises as well as simple analytical passive mobilization exercises. Joints techniques Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Figure 1. Platform and statokinesigram
were applied to both the ankles for 20 minutes. It started with the right lower limb and consisted of 10 repetitions for each movement. A time of rest of 30 seconds is left between every series. Mobilizations elicited first anterior–posterior glide of the talocrural joints. Then mobilizations involved dorsiflexion and plantar flexion with posterior and anterior tibial glides of the talus on the ankle mortise. Mobilizations of the subtalar joints included flexion, extension, adduction, abduction, pronation and supination of the calcaneus (Pierron et al., 1988). The 3 steps of the mobilization (e.g going towards flexion, holding it, and getting back to resting position) last 1 second each. Pre-mobilization and post-mobilization evaluation All pre-intervention and post-intervention measurements were performed by the same examiner who was not involved in the mobilization procedure. The order of these different experimental conditions was standardized in all of our patients (static eyes open, dynamic eyes open). Static posturography The subject stood up with eyes open on the force platform, located 1 meter apart from the wall. Feet were apart, pointing outwards and positioned on marks to ensure the reproducibility of the position (30° angle with the heels at a distance of 2 cm from each other). The subject was asked to stare at a physical point mark straight ahead to maintain a Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
horizontal focus. The guidelines given to each subject were to maintain a static standing up posture with arms along the sides of the body during the whole recording period. Two trials with 10-second rest were recorded. Each recording session lasted 51.2 second. A try-out test was performed before the recording in order to allow each subject to get familiar with the platform. Dynamic posturography After a 2-minute rest period, the subject stood up, eyes open, on the seesaw platform which was positioned in the anterior–posterior plane on the force platform. Adapted supports were first placed under the seesaw to stop its movements. Supports were then removed and subject was asked to maintain the seesaw platform as horizontal as possible while keeping his/her arms along the body and his/her knees straight. Recordings started only when the subject was able to stand up on the seesaw platform. This dynamic situation was a self-regulated balance task. Postural reactions were mainly in the anterior–posterior direction. The guidelines that were given to the subject were the same as previously mentioned; the recording took 25.6 seconds sampled at 40 Hz. Two trials with 10 second rest were recorded. Each measurement lasted only 25.6 second because the test was difficult to perform. Each recording was preceded by a try-out test to familiarize the subject with the protocol. Sway parameters and statistical analysis The static and dynamic posturography analyses were conducted before and immediately after the experimentation. On the basis of the measures of the displacements of the
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COP, four variables were considered in both static and dynamic conditions. 1. COP displacements (mm) along the medial–lateral axe (X). The mean X corresponded to the mean position of the COP evolving on the right cleft axis in narrow limits. 2. COP displacements (mm) along the anterior– posterior (Y) axe. The mean Y corresponded to the mean value of movements and balancing postures forward and backward. 3. The total length of the oscillations (mm) represented the sum of the distances covered between each position of the COP. This parameter represents the length of the trajectory of the displacements of the COP. 4. Sway area surface (mm2) was used to estimate a global postural performance. Sway area corresponds to the ‘area’ of the confidence ellipse formed by the positions of the COP during the recording. About 10% of the most extreme points, resulting for poorly controlled oscillations were discarded. The surface, computed from 90% of the left over COP positions, was expressed in square millimetres, showing the amplitude of the oscillations of the centre of gravity. The surface of the reliable ellipse, which contains 90% of the positions sampled by the COP is the most rigorous statistical measure of the dispersal of these positions (Takagi et al., 1985). For all these variables, higher values correspond to lower stability. Joint range of movement The ranges of motion (ROM) of the right and left talocrural joints were measured in passive dorsiflexion (Figure 2) and plantar flexion (Figure 3) with a universal goniometer (Figures 2 and 3). The subject was asked to lie down, knee flexed at 90°. The flexion was maintained with a large pillow to eliminate any passive tension in the gastrocnemius muscles in order to record only the joint motion. The external markers were defined as the tip of the lateral malleolus for the joint centre, the styloid process of the fifth metatarsal and the head of the fibula. The measures were applied with repeatable force three times before and after the mobilization exercises; the mean of the three trials, rounded up at 5° was kept for the measures.
Figure 2. Measure of the dorsiflexion movement
Figure 3. Measure of the plantar flexion movement
Statistical analysis Means and standard deviations are presented for all variables. The Shapiro–Wilks test was used for normal distributions. To compare the differences before and after mobilization, we used the Student t-test for paired series. The statistical analysis was computed with the STATISTICA 6.0 (Statsoft software, StatSoft, Inc. (Headquarters)Tulsa, Oklahoma, OK, USA). The significance threshold was set at p < 0.05.
Results Static posturography The results from the static posturography are presented in Table 1. There was no difference in the COP displacement according to the anterior–posterior (X) and medial– lateral (Y) axes. Besides, the length (the total length of the statokinesigram) had not been modified. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Table 1. Results of the static posturography before and after talocrural and subtalar joint manipulations for the 19 subjects: X mean, Y mean, length in millimetre and surface in square millimetres X mean (mm)
Y mean (mm)
n = 19
Before
After
Before
Mean SD
0.18 10.67
2.84 10.63
38.70 14.64
After 37.38 14.90
2
Length (mm)
Surface (mm )
Before
After
Before
After
1,738.05 1,114.67
1,613.37 884.43
779.21 592.72
666.11* 425.29
SD, standard deviation. *Significant difference (p < 0.05).
The ellipse’s surface formed by the COP position had significantly decreased by 113.1 mm2 (p < 0.05): 779.2 ± 592.7 mm2 before and 666.1 ± 425.3 mm2 after.
Dynamic posturography The results from the dynamic posturography are presented in Table 2. There was no difference in COP displacement according to the anterior–posterior (X) and medial– lateral (Y) axes. Besides, the total length of the statokinesigram had not been modified. The ellipse’s surface formed by the COP position had significantly increased by 566.1 mm2 (p < 0.05): 2,310 ± 1,085.5 mm2 before and 2,876.2 ± 1,914.2 mm2 after.
Dorsiflexion and plantar flexion ROM values for dorsiflexion and plantar flexion of the right and left talocrural joints, before and after passive mobilization, are presented in Figure 4 for the 19 subjects. ROM values for dorsiflexion of the right talocrural joint have greatly improved by 4.7° after joint mobilization (p < 0.01): 12.4 ± 6.5°before and 17.1 ± 4.8°after. We also noted a significant 3.2° difference (p < 0.01)
for the left talocrural joint: 12.1 ± 4.6°before and 15.3 ± 5.9° after. ROM values for plantar flexion of the right talocrural joint have significantly improved (p < 0.01) by 5.2° after mobilization: 24.0 ± 7.7° before and 29.2 ± 6.7° after. We also noted a significant 4.2° difference (p < 0.01) for the left talocrural joint: 25.8 ± 6.1° before and 30.0 ± 5.5° after.
Discussion While the dorsiflexion ROM benefits associated with joint mobilization are well-documented in treating ankle sprains (Landrum et al., 2008), this study is one of the only ones to examine the effects of talocrural and subtalar joints mobilization on posture on elderly subjects. The results of the static posturography did not show any significant differences for COP displacements along the anterior–posterior and medial–lateral axes and for the total length of the oscillations. However, the sway area was significantly reduced after passive mobilization. According to Gagey (1998) and Weber and Villeneuve (2010), the reduction of the sway area corresponds to a better stability. Our results are in agreement with the results of Vaillant et al. (2009), which showed that 20 minutes of massage associated with mobilization of the feet improve the postural control at the elderly person.
Table 2. Results of the dynamic posturography before and after talocrural and subtalar joint manipulation for the 19 subjects: X mean, Y mean, length in millimetre and surface in square millimetres X mean (mm)
Y mean (mm)
Length (mm)
2
Surface (mm )
n = 19
Before
After
Before
After
Before
After
Before
After
Mean SD
6.88 15.99
7.45 14.17
9.97 12.50
8.52 11.14
1,857.37 840.99
1,982.53 941.91
2,310.05 1,085.50
2,876.16* 1,914.23
SD, standard deviation. *Significant difference (p < 0.05).
Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Figure 4. Means and standard deviations of the ankle range of motion, for dorsiflexion and plantar flexion, in the 19 subjects before and after manipulation. ** Significant difference (p < 0.01)
Recovered mobility and flexibility cannot explain the reduction in surface. We could imagine that the mobilization of the osteoarticular structures and, to a lesser degree, muscle mobilization (soleus) reactivated the proprioceptive system, especially the mechanoreceptors of the ankle. The stimulation of these mechanoreceptors may increase the afferent input from the talocrural and subtalar joints and surrounding tissues, explaining the diminution of the sway area (Hoch and McKeon, 2010). These mechanoreceptors play a role in postural control and allow managing small displacements of the COP better (Vaillant et al., 2008). According to Rabischong (1996), skin plays a role in static postural control thanks to the Ruffini endings, which act as pressure captors. The skin around the joints and the various receptors responsible for the goniometric information needed for motor coordination seems to be connected. Even though it was not first intended in the study, the skin was stimulated during the exercises when grabbing the foot and ankle and could participated to the improvement of perception. The balance in dynamic standing was only evaluated in the anterior–posterior plane because the postural reactions are mainly in the anterior–posterior direction. This direction corresponds to the dorsal and plantar flexion of the ankle. The subtalar joint was mobilized in the three spatial planes corresponding to its mobility. We did not evaluate the dynamic standing balance in the frontal plane even though this joint moves in this direction during the stance phase. No significant changes were noted for COP displacements according to the anterior–posterior and medial–lateral axes and for the total length of the oscillations. Only
the sway area had significantly increased showing that it was harder to control COP displacements on the unstable platform. The instruction was to stand still as long as possible. Vision and the vestibular system were not disrupted because no changes were made to the environment between the two experiments, and a trial experiment was conducted before the first recordings to enable patients to get familiar with the protocol. We are surprised by the increase of surface on the unstable platform, which corresponds to instability. We did not find in the literature studies on the effects of the mobilization of the ankle on the dynamic balance. This is why we emit the hypothesis that the improvement of the amplitudes modifies the neuromuscular attention and could explain the delay in the answer. The modifications in postural control are probably because of alterations in neuromuscular activity (Yerys et al., 2002). The changes in strength and facilitation of spinal reflexes were exposed in previous studies (Liebler et al., 2001, Yerys et al., 2002). However, manipulating mechanoreceptor-associated inhibition of joint stabilizing muscles could also bring changes in postural control (Palmieri et al., 2003, Grindstaff et al., 2011). Mobilization exercises were conducted with the knee flexed, eliminating the input from gastrocnemius muscles (Delarque et al., 1998). These muscles, rich in Golgi organs, have a major impact on postural control when standing up. Joint ROM improvement was obtained without involving any muscle; this is why we bring forth the hypothesis that the muscle proprioceptive system might be the cause of this delayed muscle response. The muscle system might not be ‘informed’ of the new improved joint range of movements. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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The aim of the present study was to evaluate the effects of passive talocrural and subtalar joints mobilization exercises on postural standing control in an elderly population. At joint level, we reported a significant improvement in dorsiflexion and plantar flexion on both sides. Our results are in agreement with Landrum et al. (2008), which find an improvement of dorsiflexion ROM and posterior ankle joint of talocrural after a single application of grade III anterior-to-posterior talocrural joint mobilization. The results validated the immediate efficiency of therapeutic mobilization on the foot and ankle. Therefore it is impossible to predict the potential long lasting effect of the reported improvement. Joint ROM improvements observed after mobilization showed that ROM deficits in this elderly population were not irreversible; indeed, the ROM deficits seemed to be more underused joint system rather than caused by joint stiffness. These results were even more relevant because ankle stiffness is one of the main factors of instability and falls in elderly subjects. Ankle stiffness, especially ankle equinus seems to be responsible for foot brushing against the floor (ChaneTeng, 2009). El Laassel (2008) recommends a 15° dorsiflexion and 20° plantar flexion to obtain a normal gait. These amplitudes in dorsiflexion and plantar flexion were effectively obtained in our population after mobilization. In elderly patients, joint stiffness in the lower limbs is compensated by implementing a hip strategy for regulating balance, thus triggering changes in the gait pattern. The subjects increase their hip flexion to the expense of the ankle (Silder et al., 2008). In our study, passive ankle and foot mobilizations were conducted with the knee flexed discarding the action of the gastrocnemius muscles and increasing the stimulation on the osteoarticular structures. The improvement obtained was essentially located in the joints, even if the monoarticular soleus muscle controlling posture is stretched in this mobilization. These results demonstrated the major impact of mobilization in recovering joint functions.
Conclusion Regarding balance, the sway area is reduced during the static experiment showing a better stability in elderly subjects. However, the surface is increased in dynamic setting corresponding to an increased instability. Physiother. Res. Int. (2014) © 2014 John Wiley & Sons, Ltd.
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Passive mobilization immediately improves ankle mobility in dorsiflexion and plantar flexion in elderly subjects. The results support the efficacy of these rehabilitation techniques in demonstrating short-term improvement in ankle joint mobility in elderly subjects. The choice of passive exercises seems indicated to improve static balance rapidly and ankle joint mobility but not adequate to recover dynamic settings.
Conflict of interest The authors declare no conflict of interest.
Ethical approval No ethical approval required for this study.
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