Gait & Posture 26 (2007) 214–218 www.elsevier.
Changes in postural stability with fatigue of lower extremity frontal and sagittal plane movers§
Mahyar Salavati a, Mojgan Moghadam b,*, Ismaeil Ebrahimi c, Amir Massoud Arab a
b a University of Social Welfare and Rehabilitation Sciences, Tehran, Iran Physical Therapy Department, Faculty of Rehabilitation Sciences, Iran University of Medical Sciences, Mirdamad Blvd, Tehran, Iran c Iran University of Medical Sciences, Faculty of Rehabilitation Sciences, Tehran, Iran
Received 22 March 2006; received in revised form 4 June 2006; accepted 10 September 2006
Abstract The purpose of this study was to quantify changes in postural stability with fatigue of the frontal and sagittal movers of the lower extremities. There were four test sessions, with a randomized order assigned according to the muscles tested and the plane of motion. Subjects were 20 healthy men (age: 22.6 Æ 2.4 years, height: 173.7 Æ 3.6 cm, weight: 63.3 Æ 7.9 kg). During each session, one set of muscle groups was fatigued using isokinetic contractions: ankle plantar/dorsi ﬂexors, ankle evertor/invertors, hip ﬂexor/extensors or hip abductor/adductors. The Biodex Stability System was used to assess anterior/posterior and medial/lateral stability before and after muscle fatigue. Repeated measures ANOVAs revealed that fatigue was associated with a signiﬁcant increase in all stability indices. Fatigue of the hip movers, whether in the frontal or sagittal planes, led to greater increments in stability indices than fatigue of the ankle musculature. Fatigue of the frontal movers resulted in greater increases in the medial/lateral stability index compared to fatigue of the sagittal movers. In conclusion, fatigue of proximal lower extremity muscles affects postural stability and fatigue of the frontal movers is associated with postural instability in the frontal plane. # 2006 Elsevier B.V. All rights reserved.
Keywords: Fatigue; Postural stability; Lower extremity
1. Introduction The maintenance of balance is an essential requirement for the performance of daily tasks and sporting activities [1,2]. Several studies have examined how pathologic conditions, aging and fatigue affect postural control [3–16]. Muscular fatigue is a key factor argued to impair proprioception and postural control [5–15,17,18]. Recent studies by Ochsendorf et al., Ramsdell et al., and Joyce et al. indicated that isokinetic fatigue of the ankle plantar ﬂexors and dorsiﬂexors was associated with signiﬁcant increases in
§ Institutional review board: The Institutional Review Board of University of Social Welfare and Rehabilitation Sciences, Tehran, Iran * Corresponding author. Tel.: +98 21 222 27124; fax: +98 21 224 18746. E-mail address: email@example.com (M. Moghadam).
postural sway [10–12]. Yaggie and McGregor found similar results following fatigue of the ankle plantar ﬂexors, dorsiﬂexors, invertors and evertors . Gribble and Hertel examined the effects of isokinetic fatigue of hip and ankle musculature on postural control during single leg stance. There was an adverse effect of localized fatigue on postural control maintenance and the effect was greater for fatigue of the sagittal or frontal plane movers of the hip compared to the ankles [14,15]. Most studies have examined the effects of fatigue of the ankle muscles and little attention has been paid to the ability to maintain postural stability with fatigue of the more proximal muscles. Recent ﬁndings have shown that proprioceptive inputs from the hip region are important for postural control . Nevertheless, there has been no previous attempt to evaluate the effects of fatigue of muscles that move joints in
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the fatigue protocol was initiated.9 kg) volunteered to participate. We conﬁrmed
. APSI and MLSI. NY. as measured by overall. assessments and interventions were performed with the dominant lower extremity. Fatigue was judged to have occurred when the torque output in both directions dropped below 50% IPT for three consecutive movements [6. previous history of surgery. / Gait & Posture 26 (2007) 214–218
different planes on the ability to maintain stability in those planes.M. respectively). The Biodex Stability System was shown to be reliable in several previous studies.2. After a 2–3 min rest. using a decreasing stability level from 8 to 2 over 30 s . we used test speeds that we had found during our pilot studies to cause fatigue in both muscle groups almost simultaneously. respectively. anterior–posterior. reported intraclass correlation coefﬁcient (ICC) values of . Proximal segment and sagittal plane: Flexors and extensors of the hip joint were fatigued by performing a similar fatigue protocol. Verbal encouragement was given throughout all tests and fatigue protocols using standard procedures [12. The independent variable was local muscle fatigue with four levels: (1) distal–sagittal (ankle plantar–dorsi ﬂexors). They were also excluded if they had taken any sedative drug or alcohol within the past 48 h or if they had professional sports participation in the past 6 months [9–11]. Pincivero et al. weight: 63. Muscle fatigue Distal segment and sagittal plane: Peak torque measurements and fatigue protocols were performed using the Biodex System III isokinetic dynamometer (Biodex Inc. Methods 2. The ﬁrst set was a familiarization task and consisted of three submaximal and three maximal contractions.8 to . Previous studies showed that physical activity level and speciﬁcity may inﬂuence balance ability and thus must be considered in examining balance .6 Æ 2. Schmitz and Arnold reported ICC values for dominant single limb stance ranging from . used a similar criterion to determine fatigue recovery . Subjects Twenty healthy male college students (age: 22. and (4) proximal–frontal (hip abductor–adductors). a similar procedure was performed for ankle eversion and inversion with contraction speeds of 608/s and 1208/s. during which subjects performed continuous concentric/concentric plantar/dorsiﬂexion movements at 608/s and 1208/s.10–12. Postural stability assessment In order to measure postural stability we used the Biodex Stability System (Biodex Inc. USA). with 1 representing the greatest instability. For all subjects. neurological or systemic disorders.43. Distal segment and frontal plane: In order to induce fatigue in the ankle invertors and evertors. Proximal segment and frontal plane: To induce fatigue in the hip abductors and adductors.). (3) proximal–sagittal (hip ﬂexor–extensors). This time interval was based on the results of our pilot testing which showed no recovery of fatigue within 2–4 min after the isokinetic fatigue protocol. three trials of maximal effort were performed with no rest. The Institutional Review Board of ‘‘University of Social Welfare and Rehabilitation Sciences’’ approved the study.3. During each session. 2. The purpose of this investigation is to compare changes in postural stability following isokinetic fatigue of frontal and sagittal movers. visual problems. any deformity in lower extremities or spine. acting on either proximal or distal segments of the lower extremities. which was the effect of fatigue of frontal and sagittal movers acting on either hip or ankle on postural stability. In order to determine the initial peak
torque (IPT) values two sets of concentric/concentric ankle plantar/dorsiﬂexion movements were performed at 608/s and 1208/s.
2. Shirley. postural stability was assessed before and after completing an isokinetic fatigue protocol. Schwendner et al. 2.1.7 Æ 3. There were four separate experimental sessions with a break period of at least 48 h and a randomized order assigned according to the muscles tested and the plane of motion.21]. and medial–lateral stability indices (OSI. The highest peak torque of three repetitions was recorded as IPT.. respectively. 2. (2) distal–frontal (ankle evertor–invertors). at 608/s and 908/s. Participants were excluded if they had any history of lower extremity injury within the past year.3 Æ 7.4 years.6 cm.15].95 (for stability level 2) in healthy subjects .14. Testing procedure A repeated measures design was used to test the primary research question.4. Because there were different fatigabilities of the antagonistic muscle groups around the ankle and hip joints. Recovery was deﬁned as the return of peak torque for two consecutive contractions above 80% IPT. This system consists of a circular movable platform interfaced with computer software that enables the device to perform objective measurements of stability indices. The platform stability ranges from 1–8. In the second set. height: 173. A sample of convenience of eligible subjects gave informed consent to participate. After completing the fatigue protocols. a similar fatigue protocol was performed at 608/s and 908/s. subjects were removed from the dynamometer and tested for postural stability with a delay of no more than 60 s. The dependent variable was postural stability.6 (for stability level 8) to . Salavati et al. dizziness and vertigo.
9].63.91. The condition Â segment interaction for: (A) mean APSI (F (1. while they were barefoot and their eyes were closed [8.47) 5. compared to fatigue of the sagittal movers (Fig. 01).126.96.36.199(. so as not to contact the test limb.35) 4.31) 4. p = . separate 2 Â 2 Â 2 analyses of variance (ANOVAs) with repeated measures for condition (pre-fatigue and post-fatigue).56(1.52. subjects were instructed to keep the moving platform as level as possible for 20 s.19) 5. 19) = 4. 19) = 71.16) 4. 19) = 24. 19) = 87. p = .11) Post-fatigue 6.58(1.73(2. 2.53)
4. The condition Â plane interaction for: (A) mean APSI (F (1. p = .00) 2. 00) and MLSI (F91.60) 7.5. For all trials. 19) = 6. Fatigue of the hip mover muscles led to greater increments in stability indices (deterioration in postural stability) compared to fatigue of the ankle musculature (Fig. APSI (F (1. Statistics To determine the effects of fatigue. / Gait & Posture 26 (2007) 214–218
Fig.04). and MLSI. the sagittal plane and frontal plane.98(1. Salavati et al. 00).11) Post-fatigue 5.23.30) 2.50) 7.00).
Fig.74(.00(2.71.17(1. 19) = 6.61(1.97) MLSI Pre-fatigue 3.01. To perform the dynamic balance test. These indicated the variance of platform displacements from level in all planes. p = . MLSI: F (1.48(1.58(1.32(1. p = .00.66) 8. The unsupported limb was held in a position of hip neutral extension with partial abduction and 908 of knee ﬂexion. p = . 19) = 39. fatigue segment and fatigue plane on postural instability. 19) = 13.84) Post-fatigue 3. APSI.30(1.46) and (B) mean MLSI (F (1.04). Discussion The results of this study suggest that localized muscle fatigue of the lower extremities reduces postural stability in
Table 1 Means (standard deviations) of stability indices for four conditions of fatigue segments and planes OSI Pre-fatigue Distal/sagittal Distal/frontal Proximal/sagittal Proximal/frontal 5.42(1.29(1.00.61) 3.84(2. p = .40) 4.52(1.216
M.90) 6. A signiﬁcant condition by segment interaction was also found for OSI (F (1. APSI. 1).
3.54. 2. 19) = 4.47(1.
reliability during our pilot study. p = .11. Results The means and standard deviations for pre-fatigue and post-fatigue measurements of all stability indices are presented in Table 1. p = . For each test a report was generated providing values of OSI. 19) = .23(2.25(1.13(1. The alpha level was set at .61) 8. fatigue segment (distal and proximal) and fatigue plane (sagittal and frontal) were conducted for OSI. p = . the platform was set and remained at stability level 7.83) 5.41(1. 2). p = .53) APSI Pre-fatigue 4.01). There was also a signiﬁcant condition by plane interaction for MLSI (F (1. Subjects were asked to maintain single leg stance on the platform with both arms folded across their chest.63.20) 4.89(1. 1. The results of the repeated measures ANOVAs showed that fatigue had a signiﬁcant effect on all stability indices (OSI: F (1. Fatigue of the frontal movers resulted in a signiﬁcantly greater increment in MLSI. APSI: F (1.77 to . and MLSI.05 for all analyses. with ICC values ranging from . 19) = 13.00) and (B) mean MLSI (F91.61(1.04) 3.39) 5.
/ Gait & Posture 26 (2007) 214–218
healthy young men. with proximal joints having an increased role under more challenging conditions . On the other hand. Anoushirvan Kazemnejad for statistical counseling. and trunk during single-leg stance on ﬁrm. Although these ﬁndings are consistent with those reported by Gribble and Hertel.  Riemann BL. Katdare K. Br J Sports Med 2003. Danion F. The ﬁrst was foot tilt due to the movements of the subtalar joint. Dr. Arch Phys Med Rehabil 2002. Kerrigan DC. Joyce et al. It is possible that participants in the present study employed a hip strategy to maintain stability. and Gribble and Hertel [6. J Athl Train 2002. compared the corrective actions of the ankle. Fatigue effects on body balance. hip.25].105: 309–20. Gansneder BM.24.83:224–8.  Vuillerme N. Giorano A.  Murphy DF. Nolan L.14. et al. Effects of isokinetic ankle fatigue on the maintenance of balance and postural limits. The second was similar to the known hip strategy. fatigue of the frontal movers of the lower extremity was associated with greater postural instability in the frontal plane. and multiaxial surfaces and concluded that the ankle is of primary importance during single-leg stance on ﬁrm. and multiaxial surfaces. Further kinematic analyses are necessary to determine the effects of segmental muscle fatigue on movement strategies used to maintain postural stability.333:131–5. The dynamic balance tests used in the present study may be more challenging and sensitive test to detect small changes in postural stability.
. These studies examined postural stability using static forceplates. 37:13–29. For single-leg stance on a ﬁxed surface. Salavati et al. Myerse JB. In conclusion. increased muscle reaction time or inappropriate efferent muscle responses [18.
Acknowledgments The authors would like to acknowledge Dr. The additional knowledge that our data has contributed is that localized muscle fatigue can also affect dynamic postural stability as measured using a movable platform. suggested that eccentric activation of ankle joint musculature might affect subtalar joint control and proprioception. Gait Posture 2003. Shumway-Cook suggested that stance on pliant surfaces caused an increased reliance on a hip strategy . Postural sway under muscle vibration and muscle fatigue in humans. we attempted to increase reliance on proprioceptive feedback by instructing participants to perform the dynamic balance tests without foot wear and with closed eyes . Fatigue in proximal musculature of the lower extremity was associated with the greater deterioration in postural stability in either the sagittal or frontal planes. The different ﬁndings may have occurred due to the use of different measurement protocols. Nougier V. Risk factors for lower extremity injury: a review of the literature. Brunet ME. This may be related to the single-leg stance as the position of dynamic balance test in our study. Muscle spindles of peroneal muscles might also affect joint position sense at both the ankle and subtalar joints . Ramsdell et al. In addition... Schiepatti M. Connolly DAJ. foam. Forestier N. Iran.15]. Slavin M. Fatigue of the frontal movers of the lower extremities reduced postural stability in frontal plane to a greater extent than for the sagittal plane.18].37:85–98. explained two frontal plane strategies. especially after fatigue induction. Beynnon B. knee. Partially supported by the University of Social Welfare and Rehabilitation Sciences.
 Cote KP.18:101–8. Bean JF. foam. such an effect was not seen in the case of fatigue in sagittal plane movers.M.  Yaggie JA. Yaggie and Mcgregor. Further investigations are needed to clarify the effects of local muscle fatigue on postural stability in health and disease. Shultz SJ.28].15]. Tehran. Neurosci Lett 2002. In contrast to the domination of sagittal plane control in double-leg stance. compared to measuring center of pressure excursion velocity as performed by Gribble and Hertel [14. muscle activity. Sensorimotor system measurement techniques. Although our results do not pinpoint which aspects of the neuromuscular loop were affected by muscle fatigue. This was not observed in the study of Gribble and Hertel  who reported that fatigue of the ankle plantar ﬂexors and dorsiﬂexors impaired postural stability in the sagittal plane only. it is hypothesized that the frontal plane is more important during single-leg stance control. and balance control: physiologic changes associated with balance impairment. Riemann et al. The helpful comments and suggestions of the anonymous reviewers were greatly appreciated. situations whereby local muscle fatigue occurs after sports or daily activities might be associated with disturbances in balance.10–12.40:41–6. Electoencephalogr Clin Neurophysiol 1997. Effects of pronated and supinated foot postures on static and dynamic postural stability. for ongoing support of their work. Tarantola J. Aging.  Laughton CA. except that it occured in the frontal plane [27.  Nardone A. due to the difﬁcult and challenging conditions of dynamic balance test. These ﬁndings are consistent with Ochsendorf et al. McGregor SJ. The speciﬁc effects of fatigue plane on the direction of postural stability impairment may be due to the known directionally
sensitive activity of postural muscles . Nyland et al. J Athl Train 2005. Kayvan Davatgaran for his contribution to language editing and the Research Committee of University of Social Welfare and Rehabilitation Sciences. Lephart SM. we found deterioration of postural stability in both sagittal and frontal planes. following fatigue of the ankle evertors and invertors. we have demonstrated that fatigue of proximal musculature of the lower extremity has a greater effect on postural stability than the more distal muscles. However. In the real world. It is possible that the results reﬂect proprioceptive deﬁciencies associated with muscle fatigue [17. Hoogvliet et al.
 Ramsdell KM.  Hoogvliet P. Nougier V.. Can vision compensate for a lower limbs muscular fatigue for controlling posture in humans? Neurosci Lett 2001.14:641–6. 2001 [p. Lephart SM.  Wojtys EM. Mulder PG.  Ochsendorf DT. Myers JB.34:106–14.  Pincivero D. Salavati et al. Neurol Clin 1990. Effect of lower extremity muscular fatigue on motor control performance. lower extremity kinematics.  Shumway-Cook A. J Sport Rehabil 1998.  Gribble PA. Burr DB. J Athl Train 2001. Wylie BB. Arnold BL. Butler JE. Mikesky AE.  Shumway-Cook A. Gandevia SC. Lephart SM. J Athl Train 1999.9:15–8.31:598–605. 163–91].30:S35. Stine RL. The effects of muscle fatigue on neuromuscular function and anterior tibial translation in healthy knees. Wigglesworth JK. Granata KP. Bloem BR. Comparison of the ankle.
 Rozzie SL. Arnold BL. Vestergaard E. Arch Phys Med Rehabil 2004. Prieur JM.
. Gieck JH. Perrin DH.  Vuillerme N.  Joyce CJ. Intertester and intratester reliability of a dynamic balance protocol using the Biodex Stability System.308:103–6. Gait Posture 1998. J Electromyogr Kinesiol 2004. foam and multiaxial surfaces.78:284–9.  Taylor JL. Euro J Appl Physiol 2000. Proprioceptive control of posture: a review of new concepts. Med Sci Sports Exerc 1998. Dorsiﬂexor and plantar ﬂexor muscle fatigue decreases postural control. 84:90–5. J Athl Train 1995. van Duyl WA. Henry TJ. J Athl Train 2000. J Athl Train 2001. Effect of orthotics on postural sway after fatigue of the plantar ﬂexors and dorsiﬂexors. Effects of two ankle fatigue models on the duration of postural stability dysfunction.  Schmitz R. Cawley PW. JOSPT 2001.36:S32. Lo IKY.85:589–92. Hertel J. Hertel J. Shapiro R. Horak FB. hip. Fowler PJ. knee. Malone TR. Hulliger M.  Riemann BL. McCroy JL. Effect of lower extremity muscle fatigue on postural control. / Gait & Posture 26 (2007) 214–218  Allum JHJ. Effect of hip and ankle muscle fatigue on unipedal postural control. Philadelphia: LWW. Ireland ML. motoneurons and motor drive during muscle fatigue. Lephart SM.  Hiemstra LA.  Johnston RB. Learning effects and reliability of the Biodex Stability System. Gansneder BM.16:185–9. Huston LJ. Losse GM. Effect of muscular fatigue on knee joint laxity and neuromuscular characteristics of male and female athletes. Horn TS.36:S32. Relationship of fatigued run and rapid stop to ground reaction forces.  Hahn T. Variations in foot breadth: effect on aspects of postural control during oneleg stance.88:106–15. Uhl TL.  Nyland JA. and muscle activation.24:615–21. Changes in muscle afferents. Woollacott M. Am J Sports Med 1996.8:441–7. Scand J Med Sci Sports 1999. Motor control: therapy and practical applications. Onelegged standing balance and sports activity.  Schwendner KI. Stam HJ. Arch Phys Med Rehabil 2003.218
M. Bakker JV. Hadders-Algra M. Arnold B. Foldspang A. Int J Sports Med 1995. Effect of fatigue on knee proprioception: implications for dynamic stabilization.8:214–42. 2nd ed. Rehabilitation strategies for patients with vestibular disorders. and trunk corrective action shown during single-leg stance on ﬁrm. Arch Phys Med Rehabil 1997.20:132–7. JOSPT 1994. Recovery of dynamic muscle function following isokinetic fatigue testing.30:1703–7.  Gribble PA. Mattacola CG.35:26–30. Ingermann-Hansen T. Carpenter MG. Mattacola CG. Howard ME.7:95–101.