ARTICLE INFO

Article Type

Original Research

Authors

Mohamadtaghi   B. (*)
Hejazi Dinan   P. (1)
Shamsipour Dehkordi   P. (1)






(*) Physical Education Department, Physical Education & Sport Sciences Faculty, Alzahra University, Tehran, Iran
(1) Physical Education Department, Physical Education & Sport Sciences Faculty, Alzahra University, Tehran, Iran

Correspondence

Address: No. 2, Abshar Street, Mojen. Shahroud. Postal Code: 3651713543
Phone: +982332573821
Fax: +982188041468
batol.mohamadtaghi@yahoo.com

Article History

Received:  November  17, 2015
Accepted:  February 9, 2016
ePublished:  April 3, 2016

BRIEF TEXT


The amputation of lower limb that is usually caused by trauma, vascular diseases, diabetes, cancer, congenital disorders and surgery [1, 2] impairs the ability to balance [3].

... [4-10]. Li and Hung stated in their research that the effectiveness of balanced exercises on postural control depends on the length of the training period [11] ... [12].

The aim of this study was to investigate the effect of selected balanced program under manipulation of visual, vestibular and proprioceptive systems on controlling the balance of people with lower limb amputation.

This is a semi-experimental research.

This study was accomplished in 2015 among all the patients who were referring to Tehran`s Red Crescent rehabilitation center.

14 people were selected with amputations below the knee through the calling of Tehran`s Red Crescent`s Research Center as convenience samples and were randomly put in two groups of control and selected balanced exercises each with seven members. The criteria for entering the study included one side amputation below the knee, age range of 35 to 55, the absence of musculoskeletal disorders or functional limitations for standing and walking, and the ability to walk a flat path up to 45 meters without assistance, as well as Modular Prosthesis System, PTB Suspension System (patella tendon prop), and terete and uniaxial claw type. Participants were excluded from the study in case of the absence of one of the above criteria plus vestibular visual disorders, remaining the pain of the organ, neurological or musculoskeletal disorders, factors affecting the balance and mobility such as neural and orthopedic factors, rheumatic disorders, taking antipsychotic drugs and antidepressants.

To assess the postural control and the subjects` balance, the computerized dynamic posturographic device was used which is one of the most advanced systems for examining and manipulating sensory systems affecting the postural control [13, 14]. The device has two discs of mobile force and 8 sensors for examining the kinetic variables of postural control. The device determines the balance control using sensory organization test (SOT) and based on this test, to specify the amount of the balance, it introduces the scores to the tester on two scales of stability and pressure center. The device has also a smart system to prevent people from slipping and falling. Accordingly, during the assessment of postural control, the individual`s age and height are given to the system and according to them if he/she bents or excessive movement is felt in the legs on the force plates, the system will automatically stop. Each of the subjects was placed barefoot with hands beside the body on the surface of posturographic system forces [15]. To make sure that the subjects would not fall, special vests were used which were fixed to posturographic device. Subjects wore these vests before being placed on the device, and then the vests attached to device from the top by canvas belts so in case of subjects` imbalance, the belts attached to the vest and the device would prevent the subjects from falling. Saverz and Ting [16], Mohyeldin et al [17], and Barnett et al [10] introduced the computerized dynamic posturographic device with high validity and reliability to determine the postural control in patients with lower limb amputation. Moreover, in this study, the validity of the device was achieved by Biodex machine as was the reliability through test-retest method in lower limb amputees. Sensory organization test was used in this study. This test consists of six conditions. In the first three positions the force plates are static and in other conditions they move in anterior and posterior directions. In the first case, the person is placed on the system, so that all sensory information involved in postural control is available. In the second case, the subject is tested with a blindfold (omitting the information of visual system). In the third case, the subject`s eyes are open, but the visual environment is moving, such that it results in presenting incorrect visual arrays. In the fourth case, the force plates are movable and proprioceptive information is manipulated. In the fifth case, eyes are closed with blindfold and the moving force plate causes the manipulation of proprioceptive information. In this situation, the information of vestibular system in postural control is tested. In the sixth case, information available for visual sense is omitted and the information of vestibular and proprioceptive senses is manipulated. Duration of each case of the test was 20 seconds and each situation was repeated 3 times. In each of the six cases of this test, a score of zero to 100 is presented as an indicator of the individual`s balance control [14]. Adjusting sensory afferent information was examined (visual, vestibular and proprioceptive) and the scores of sustainability and displacement of the center of gravity were analyzed as the dependent variables. Training group participated in balanced exercise selected program. These exercises held five times a week for four weeks. The protocol exercises included 10 different balanced exercises which were performed in accordance with the schedule of the protocol and the duration of each training session was about 30 minutes. The period of performing each exercise in the first week was 3 minutes and every week one minute was added to this time. Such training protocol was fairly complete in terms of varied exercises, the number of weeks, the number of training sessions per week, and the level of exercises and was confirmed by experts and occupational therapists. The training was conducted from 9 to 12 in the Red Crescent, rehearsal hall. To draw the graphs, the mean and standard deviation of descriptive statistics were used. In order to determine the significance of effect of the balanced exercises on the amount of displacement of the center of gravity, stability and strategy, the combination of variance analysis test 2 x 2 x 6 with repeated measures as well as Bonferroni post hoc test were used to analyze the data. The data was analyzed using SPSS19 software.

The reliability of Biodex device was calculated 0.82 using Pearson's correlation coefficient. Intraclass correlation coefficient reliability of the device was 0.94 in two balance measurements in lower limb amputees. Thus, the device had the acceptable reliability and validity to be used for people with lower limb amputation. The effect of situation (F (5 and 60)=11.538; p=0.001), the groups (F(5 and 60)=21.351; p=0.001), time (F (5 and 60)=5.297; p=0.04), " group status " (F (5 and 60)=3.023; p=0.017), "the time of groups" (F (5 and 60)=15.461; p=0.002) and " time status" (F (5 and 60)=1.977; p=0.001) on displacement of the center of gravity were significant. The score of displacement of the center of gravity in the balanced group (with a mean of 1.800 ± 0.18) was less than the control group (with the mean of 3.029 ±0.18) and lower limb amputees in the balanced group had less fluctuation and more balance compared to the control group. The results of interactive effect showed that the score of displacement of the center of gravity in amputees of balanced training group in post-test`s first case (existence of visual, proprioceptive and vestibular senses) and second case (elimination of visual sense and existence of vestibular and proprioceptive senses) was less than other situations, and in the sixth case (manipulation of vestibular and proprioceptive senses) it was more than other situations (Figure 1). The effect of situation (F (5 and 60) =97.350; p=0.0001), time (F (5 and 60)= 76.280; p=0.0001) and " the time of groups" (F (5 and 60)=84.774; p=0.0001) on the stability were significant. The score of stability in the balanced group (with the mean of 81.409 ± 1.8) did not differ significantly compared to the control group (with the mean of 77.337 ± 1.8) and lower limb amputees in both groups had similar performance of balanced situations. The subjects of balanced training group showed a better performance in post-test`s first case (existence of visual, vestibular and proprioceptive senses) and second case (elimination of visual sense and the existence of vestibular and proprioceptive senses) compared to other stages and stability score in the sixth case (the manipulation of vestibular and proprioceptive senses) was less than other cases (Figure 2). The effect of situation (F (5 and 60) =106.722; p=0.0001), time (F (5 and 60) =79.446; p=0.0001), "the time of groups" (F (5 and 60) =20.830; p=0.001), and "time status" (F (5 and 60) =11.080; p=0.0001) on the strategy were significant. The strategy score while manipulating sensory information in the balanced group (with the mean of 79.361 ±2.32) did not differ significantly compared to the control group (with the mean of 74.266 ±2.32). The interactive effect was also significant. The subjects of balanced training group had a better performance in post-test`s first case (of visual, vestibular and proprioceptive senses) and second case (vestibular and proprioceptive senses) than the other steps and strategy score in the sixth situation (manipulation of vestibular and proprioceptive senses) was less than other cases (Figure 3).

According to the findings of this study, difference between the control and balanced group was significant. The comparison of means showed that the amount of movement of the center of gravity, sustainability, and strategy of the subjects in balanced training group were better than the control group. These results were in line with the researches by Moradi et al. [7], Matja and Burger [8], Setti et al. [18], Barnett et al. [10], and Kamali et al. [4]. According to the researchers` statements, the balance of the body is controlled based on the information received from the three systems of visual, vestibular and proprioceptive… [19-30].

The occupational therapists and physiotherapist, rehabilitation and sports experts are recommended to design and use balanced training programs in order to improve postural control variables of lower limb amputees, especially in hard conditions in which there are a lack of two or three senses among the afferent information`s senses. Furthermore, it is suggested to investigate the effect of other selected training programs such as strengthening, endurance, and flexibility exercises or combination of programs on the kinetic parameters of postural control while manipulating sensory information in the study. Examining the provided exercises in children, adolescents and the elderly should also be performed separately.

Only people who had the criteria for entering the study were selected to participate in the test and those with features like vestibular visual impairment, remaining the pain of the organ, neurological or musculoskeletal disorders, factors which affect the balance and mobility such as neural and orthopedic factors, rheumatic disorders, taking antipsychotic drugs and antidepressants were not confirmed for the study.

Performing a course of exercise therapy of selected program reduces the range of fluctuation, increases stability and strategy in people with amputations below the knee which illustrates the increasing of the balance and postural control in these patients.

Many thanks are regarded to the officials of the rehabilitation lab of Tehran`s Red Crescent and authorities of the amputation ward of this center, all the participants in this study and those who have helped us enormously in collecting the data of this research.

Non-declared

This study is approved by the ethics committee of Tehran's Red Crescent organization.

This study is taken from a MA thesis. There have been no financial support from any institution or organization.

TABLES and CHARTS

Show attach file


CITIATION LINKS

[1]Unwin N. Epidemiology of lower extremity amputation in centres in Europe, North America and East Asia. Br J Surg. 2000;87(3):328-37.
[2]Kavounoudias A, Tremblay C, Gravel D, Iancu A, Forget R. Bilateral changes in somatosensory sensibility after unilateral below-knee amputation. Arch Phys Med Rehabil. 2005;86(4):633-40.
[3]Bamman MM, Hill VJ, Adams GR, Haddad F, Wetzstein CJ, Gower BA, et al. Gender differences in resistance- training- induced myofiber hypertrophy among older adults. J Gerontol A Biol Sci Med Sci. 2003;58(2):108-16.
[4]Kamali M, Qaderi M, Karimi M. Visual effects on people with amputations below the knee Station balance. Urmia Med J. 2014;25(9):845-52.
[5]Geurts AC, Mulder TW, Nienhuis B, Rijken RA. Postural reorganization following lower limb amputation Possible motor and sensory determinants of recovery. Scand J Rehabil Med. 1992;24(2):83-90.
[6]Viton JM1, Mouchnino L, Mille ML, Cincera M, Delarque A, Pedotti A, et al. Equilibrium and movement control strategies in trans-tibial amputees. Prosthet Orthot Int. 2000;24(2):108-16.
[7]Moradi Y, Behpoor N, Ghaeeni S, Shamsakohan P. Effects of 8 weeks aquatic exercise on static balance in veterans with unilateral lower limb amputation. Iran J War Public Health. 2014;6(2):27-34. [Persian]
[8]Matjaĉić Z, Burger H. Dynamic balance training during standing in people with trans-tibial amputation: A pilot study. Prosthet Orthot Int. 2003;27(3):214-20.
[9]Shumway-Cook A, Patla AE, Stewart A, Ferrucci L, Ciol MA, Guralnik JM. Environmental demands associated with community mobility in older adults with and without mobility disabilities. Phys Ther. 2002;82(7):670-81.
[10]Barnett CT, Vanicek N, Polman RC. Postural responses during volitional and perturbed dynamic balance tasks in new lower limb amputees: A longitudinal study. Gait Posture. 2013;37(3):319-25.
[11]Lee S, Hong J. The effect of prosthetic ankle mobility in the sagittal plane on the gait of transfemoral amputees wearing a stance phase controlled knee prosthesis. Proc Inst Mech Eng H. 2009;223(2):263-71.
[12]Brown AP. Reducing falls in elderly people: A review of exercise interventions. J Phys Ther. 1999;15(2):59-68.
[13]Cumberworth VL, Patel NN, Rogers W, Kenyon GS. The maturation of balance in children. J Laryngol Otol. 2007;121(5):449-54.
[14]Ferber-Viart C, Ionescu E, Morlet T, Froehlich P, Dubreuil C. Balance in healthy individuals assessed with Equitest: Maturation and normative data for children and young adults. Int J Pediatr Otorhinolaryngol. 2007;71(7):1041-6.
[15]Rinaldi NM, Polastri PF, Barela JA. Age-related changes in postural control sensory reweighting. Neurosci Lett. 2009;467(3):225-9.
[16]Sawers A, Ting LH. Beam walking can detect differences in walking balance proficiency across a range of sensorimotor abilities. Gait Posture. 2015;41(2):619-23.
[17]Mohieldin AM, Ambalavanan C, Ramar S, Waleed AB. Quantitative assessment of postural stability and balance between persons with lower limb amputation and normal subjects by using dynamic posturography. Mac J Med Sci. 2010;3(2):138-43.
[18]Sethy D, Kujur ES, Sau K. Effect of balance exercise on balance control in unilateral lower limb amputees. Indian J Occup Ther. 2009;7(3):63-8.
[19]Siriett V, Salerno MS, Berry C, Nicholas G, Bower R, Kambadur R, et al. Antagonism of myostatin enhances muscle regeneration during sarcopenia. Mol Ther. 2007;15(8):1463-70.
[20]Carlson CJ, Booth FW, Gordon SE. Skeletal muscle myostatin mRNA expression is fiber- type specific and increases during hindlimb unloading. Am J Physiol. 1999;277(2 Pt 2):R601-6.
[21]Bolger D, Ting LH, Sawers A. Individuals with transtibial limb loss use interlimb force asymmetries to maintain multi-directional reactive balance control. Clinical Biomechanics. 2014;29(9):1039-47.
[22]Ku PX, Abu Osman NA, Wan Abas WA. Balance control in lower extremity amputees during quiet standing: A systematic review. Gait Posture. 2014;39(2):672-82.
[23]Vrieling AH, van Keeken HG, Schoppen T, Otten E, Hof AL, Halbertsma JP, et al. Balance control on a moving platform in unilateral lower limb amputees. Gait Posture. 2008;28(2):222-8.
[24]Dornan J, Fernie GR, Holliday PJ. Visual input: Its importance in the control of postural sway. Arch Phys Med Rehabil. 1978;59(12):586-91.
[25]Nadollek H, Brauer S. Isles R. Outcomes after trans-tibial amputation: the relationship between quiet stance ability, strength of hip abductor muscles and gait. Physiother Res Int. 2002;7(4):203-14.
[26]Duclos C, Roll R, Kavounoudias A, Mongeau JP, Roll JP, Forget R. Postural changes after sustained neck muscle contraction in persons with a lower leg amputation. J Electromyogr Kinesiol. 2009;19(4):e214-22.
[27]Shumway-Cook A, Woollacott M. Attentional demands and postural control: The effect of sensory context. J Gerontol A Biol Sci Med Sci. 2000;55(1):M10-6.
[28]Shumway-Cook A, Matsuda PN, Taylor C. Investigating the validity of the environmental framework underlying the original and modified Dynamic Gait Index. Phys Ther. 2015;95(6):864-70.
[29]Benjuya A, Melzer I, Kaplanski J. Aging-induced shifts from the reliance on sensory input to muscle co-contraction during balanced standing. J Gerontol A Biol Sci Med Sci. 2004;59(2):166-71.
[30]Peterka RJ. Sensorimotor integration in human postural control. J Neurophysiol. 2002;88(3):1097-118.