International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194

Original Research Article doi: 10.5455/ijtrr.000000262

International Journal of Therapies & Rehabilitation

E-ISSN
Research
2278-0343
http://www.scopemed.org/?jid=12

Improved postural and gait performances by ankle rehabilitation program

among people have lower limb ulcers
Eman M. Othman 1, Radwa E. Sweif 2
and Mahmoud Y. El Zanaty 3

Department of Physical Therapy for Surgery 1, Biomechanics 2 and Neurological disorders 3, Faculty of
Physical Therapy, Cairo University.
Correspondence to Dr. Eman M. Othman, PhD, Ahmed Elzayat, Dokki, Giza 12613, Egypt, Tel: 00202 3761
7691; fax: 00202 3761 7692; e-mail: dr.emanothman@yahoo.com

ABSTRACT
Purpose: This study was designed to investigate the effect of ankle rehabilitation program on improving
gait performance and dynamic balance in lower limb ulcer cases. Subjects: Thirty patients with lower limb
ulcers (18 females and 12 males) were included in this study. Their ages ranged from 45 to 55 years. They
were randomly divided into two equal groups in numbers. Procedures: Group (A) (N=15) received 6 weeks
of ankle rehabilitation program for 30 to 45 min, 3 times per week in addition to selected balance exercise
and routine medical treatment while, group (B) (N=15) received only selected balance exercise and routine
medical treatment. Biodex Balance test were used to measured dynamic balance through stability index
(SI) and dynamic limit of stability (LOS) values, also, tandem walk test were used to measured gait
performance by step width, speed and end sway values just before treatment (Pre) and after 6 weeks of
treatment (Post). Results: This study showed significant improvement (P ⩽ 0.05) in both SI (3±0.25) and
LOS (21.4±2.44) in group (A) more than in group (B), as well as there were significant improvement of
tandem walk test in both step width (7.52±3.8) and speed (21.58±4.47) in group (A), while in end-sway
(6.16±2.23) there was no significant difference (P > 0.05) between both groups of the study. Conclusion:
The suggested exercise program produced improvement in balance disturbance, gait performance and
considered as a golden tool in the management of imbalance as well as abnormal gait in the cases of lower
limb ulcers.
Keywords: Ankle training program, Biodex balance system, Dynamic balance, Gait & Lower limb ulcer.

INTRODUCTION Postural control is the ability to maintain

upright posture, which comprises the use of most of the
body’s major muscle groups; the visual, vestibular, and
Chronic lower limb ulcer is a significant
sensory systems and sometimes the auditory system.
problem for both patients and health care providers [1].
Postural control is fundamentally a matter of achieving
Foot and leg ulcers are dangerous complications
postural stability [7]. Somatosensory pathway from the
because they frequently lead to lower-limb amputations
[2] lower extremities is one of the main input sources that
. A study by Graham et al., demonstrated that lower
ensure and adjust postural control [8]. The muscles
limb ulcer occurrence increases with age [3]. The most
around ankle region play an important role in supporting
important leading factor to lower extremity ulcer is
the foot during different postures. Both plantarflexors
peripheral neuropathy [4]. Diabetic peripheral
and dorsiflexors are reciprocally activated to maintain
neuropathy (DPN) is the main cause of sensory and
body’s balance over the foot [9]. Postural sway originally
motor insufficiencies of the feet; as a consequence,
is a small amplitude motion; it can be an intimidation to
motor control of gait which compromised nerve
balance and hence becomes a challenge for posture
degeneration may cause muscle weakness and
control. Studying dynamic postural control needs further
atrophy, as well as plantar ulcers [5]. The loss of
exploration of proprioception, strength, and range of
sensation accompanied with DPN thought to contribute
motion to maintain an upright and steady posture [10].
to impaired balance, abnormal patterns of gait, and
The Biodex Balance System (BBS) has been used to
increase the incidence of falling [6].
evaluate postural balance in recent years [11]. There is
high reliability for BBS to evaluate dynamic postural
balance [12].
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
Exercise that improves lower extremity
balance and strength (Force-generating capacity
exercises) has been revealed to be effective in
improving risk of falling in older adults [13, 14, 15].
Nevertheless, people who are inactive and /or with
insensible feet have an increased risk of falling [16]. On power and reflexes).
the other hand, there is an evidence suggesting that
daily weight-bearing activity may decrease foot
ulceration [17].
Researchers had been focused toward
creating ankle-foot exercise program focused on
proprioceptive, strengthening, balance and coordination
[18]
. Short-term exercise showed an improvement in
sensory perfusion in uncritical peripheral arterial
disease . [19]
Previous studies assessed the effect of
exercise training on balance have shown that; after
exercise training the length of time of the first fall
increased, balance improved which acquired by other
balance training [20,21]. Consequently, the current study study group (Group A) the patients completed 6 weeks
was carried out to determine the effect of ankle training of selected ankle rehabilitation programs.
program on balance and gait in lower limb ulcer cases.
METHODOLOGY
SUBJECTS:
Thirty volunteers (18 females and 12 males)
who had chronic unhealed unilateral lower limb ulcers
grade II and grade III according to Wagner-Meggitt
classification of ulcer [22] (Located on the sole of the
foot) with duration about 3 months after onset of ulcer,
associated with postural sway symptoms and selected
from the Outpatient Clinics of Kasr El-Aini Hospital. The
patients participated in the study after signing an
informed consent form prior to data collection. The
subjects were chosen under the following criteria: The
age of the patients ranged from 45 to 55 years, their
weight ranged from (60 kg -90 kg) and height from (155
cm – 175 cm). All patients were examined by physician
before the study and were free from any pathological
conditions that might affect the results. Patients were
received the same medical care and were under
controlled diet therapy described by their physicians. All
patients should be conscious, ambulant, understand
and follow the instructions. However, the exclusion
criteria included the following: Patients with previous
surgical procedures in lower limb which may affect the
study. Evidence of any other neurological disorders
which causes disturbance of balance affection (i.e.
Hemi paresis, myelopathy, cerebellar ataxia, vertigo,
visual impairment and so on). Patient with congenital
musculoskeletal deformity especially in foot (i.e. Pes
caves, hallux valgus… etc). Lower extremity arthritis or
pain that limits standing or weight-bearing exercise.
After a physician checked the inclusion and exclusion
criteria, eligible participants were randomly assigned to
group (A) (N=15) who received 6 weeks of ankle
rehabilitation program for 30 to 45 min, 3 times per
week in addition to selected balance exercises and their
routine medical treatment while, group (B) (N=15)
received only the selected balance exercises and their
routine medical treatment.
PROCEDURES
The evaluation was started with personal, present
and past history taking, full general, medical and
ophthalmologic examination. The neurological
examination consists of:
1- Motor system, evaluation of (Muscle tone, muscle
2-Sensory system, evaluation of deep sensation (Joint
sense and vibration sense) and superficial sensation
(Pain and touch).
3- Co-ordination and balance tests.
4- Activity of daily living (ADL) tests.
Both groups underwent identical tests for two times:
Just before treatment application (Pre), and after 6
weeks of treatment application (Post). Those tests were
Biodex Balance test to measure dynamic balance
through both stability index (SI) and dynamic limit of
stability (LOS) values. The other test was tandem walk
test which used to measure gait performance by step
width, speed and end sway values. The patients in both
groups received the selected balance exercises and
their routine medical treatment. Additionally, in the
A) Evaluation procedures:
1- Biodex Balance System (BBS):
This test was performed at the Research
Laboratory Unit of the Faculty of Physical Therapy,
Cairo University, Egypt. Dynamic balance was
measured by using the BBS (Biodex corporation,
Shirley, N.Y) (Model 945-470) which was performed to
test the patient’s ability to control the platform angle of
tilt. This system provides a numerical stability index that
reflects the body sway variation around the body’s
center of gravity so that the lower the index, the higher
the level of stability [22]. BBS helps to test and improve
patient’s balance through the use of a computerized
"wobble board". Patients must use the feet and ankles
to control the on screen cursor while the wobble board
becomes unsteady. The computer analyzes the
patient's movements and determines in which
directions the patient is reluctant to move or is having
difficulty moving. These directional weaknesses may be
due to limited range of motion, muscle weakness or
vestibular dysfunction. The degree of surface instability
is controlled by a microprocessor-based actuator. The
measurement procedures were taken as follow: All
patients were given an explanatory session before the
evaluation procedure based on the protocols set in the
Biodex system operation manuals to be aware about
the different test steps of Biodex system. Each patient
was asked to stand on the center of the locked platform
with two legs stance with affected leg dressed and the
other undressed. All patients were tested on stability
level (8) (Most stable platform) initially and at the end,
all patients were tested for 30 seconds. The patient was
instructed to try to achieve a centered position on the
platform (Once the platform set to motion). This was
accomplished by shifting the position of his feet to a
position which is easy to keep the cursor on the visual
feedback screen in the center of the screen grid. This
followed by recording feet angles and heels coordinate
from the platform. The platform X coordinate was
marked in numbers, whereas the platform Y coordinate
was marked in letters, the platform was also marked in
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
degree angles from 0° to 45°. The patients heel patient medial malleoli centered over the wide stripe
coordinates were measured from the center of the back running from the left to right on the footpads. This
of the heel, while his foot angle was determined by position centers the patient's weight with respect to the
finding a parallel line on the platform to the center line force plate. There are three lateral foot position for
of the foot. After introducing feet angles and heels patients of different heights: (S) short: 76.140 cm; (M)
coordinates into the Biodex system the test then Medium: 141. 165 cm; T Tall: 166. 203 cm. It quantifies
initiated and system started recording participants characteristics of gait as the patient walks (Heel to toe)
sway. The recording screen divided into four quadrants from one end of the force plate to the other through
and four circular zones, so that deviations from initial three trials. The patient was instructed to stand at the
centered position recorded together with its' direction end of the force plate in a tandem stance (Heel to toe)
and extent. Results expressed as percentage of total position. When the test started the patient would see
test time participant spent on each zone and quadrant, the (Hold steady) sign. The patient stands upright as
from which the device calculates an overall balance, steady as possible. When the (Go) sign appear the
mediolateral and anteroposterior indexes. According to patient walk quickly heel to toe, to the end of the force
evaluation patients categorized into four levels of plate. Parameters of Tandem walk test are: step width:
stability according to the percentage of time each It is the lateral distance between the left and right feet
patient takes in each of the zones A, B, C and D on successive steps (In centimeters), the speed: It is
respectively, where A the most stable and D least the velocity during the forward progression (In
stable level. The aim of centering process was to centimeters per-second) and the end sway: It is the
position the center of gravity (COG) over the point of velocity of the anterior/posterior component of COG
the vertical group reaction force. Once centering sway for five seconds beginning when the patient
achieved and the cursor in the center of the display terminates walking (In degrees per-second).The
target, instruction given to the patients to maintain his shaded area on each graphic represents performance
feet position till stabilizing the platform. Each subject’s outside of the normative data range. Green bars
feet position coordinates on the platform were recorded indicate performance within the normal range; red bars
after the first stability measurement, and the same indicate performance outside the normal range. A
coordinates were used throughout the study to obtain numerical value is given at the top of each bar.
consistency between the tests [23]. At the end of each
test trial a print out report obtained. This report included
information as regard: Over all stability index (SI):
Represented the patient’s ability to control their balance
in all directions. High values represent patient had
difficulty to maintain balance [8], and also, motor control
skills at 50 % limits of stability (LOS). The LOS is
defined as the maximum angle that a person can incline
from the upright position in any direction without falling
or altering his or her base of support (BOS) (Normal
range is 8º on each side) [22]. The overall dynamic limit
of stability score calculated by the stability system that
is the average of the eight individual dynamic limits of
stability scores generated by the device for each trial
[24]
. Dynamic LOS testing on BBS does not measure the
maximal angle one can lean, but rather how quickly and
accurately subjects return to original place from the
leaning position. The ability to regain balance after
functional fatigue has been examined for LOS [23].

2- Tandem Walk Test (TW):

This test was performed at the Kasr El-Aini
Hospital, Cairo University, Egypt. The test was
Fig. (1): Tandem walk test (TW)
performed on the long force plate part (Figure 1) of the
Computerized Posturography (CP): Neurocom
international, inc., 9570 SE Lawn field Road.
Clackamas OR 97015-9611 USA (Version 7.0
software), The device consists of system software, dual
force plate, force plate apron, IBM compatible
computer, flat panel LCD monitor, color printer, wireless
mouse, mobile computer cart and electrical isolation
transformer (Figure 2). The force plate was covered
with a pair of non-slip footpads with the following three-
foot placement guidelines: anterior, posterior stripes,
lateral stripes (S, M, and T) and gridlines. The foot
placement was adjusted carefully before performing
standardized testing on the computerized
posturography to ensure accuracy and reproducibility of
results, and to allow comparison to normative data. The
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
move. This exercise applied from two to three
minutes.

2- Ankle joint mobility program:

The study group only (Group A) performed the

following selected exercises for 30 to 45 min, 3 times
per week for a total period of 6 weeks.

a) Active free exercises for dorsiflexor muscles:

While the patient lying supine he or she actively
moved the involved ankle into dorsiflexion several times
(5-10) times, holding few seconds and then relax.

b) Active free exercises for planter flexor muscles:

While the patient lying supine he or she actively
moved the involved ankle into planter flexion several
times (5-10 times), holding few seconds and then relax.

c) Ankle stretching exercises to planter flexor

muscles stretching of the gastrocnemius muscle
(To increase dorsiflexion of the ankle with the knee
extended):
Fig. (2): Long force plate
(1) Hand placement: Grasped the patient's heel
(Calcaneus) with one hand.
B) Therapeutic procedures:
(2) Stabilize the anterior aspect of the tibia with the
other hand.
The exercises were tailored to the individual
(3) Pulled the calcaneus downward with the thumb
abilities of the patients, in that patients were allowed to
and fingers, then gently pushed upward on the heads
perform some exercises in a sitting instead of standing
of the metatarsals.
position because of fatigue or poor balance control.
d) Stretching of the soleus muscle (To increase
1- Balance Training Program:
dorsiflexion of the ankle with the knee flexed):
This training performed 3 times per week for both
(1) In order to eliminate the effect of the two-joint
groups (Group A& B) for a total period of 6 weeks. Each
gastrocnemius muscle, the knee must be flexed.
subject stood without shoes. The balance exercise
(2) Hand placement, stabilization and stretch force
timed with a digital stopwatch. This program included
were the same as when did stretching the
these balancing exercises:
gastrocnemius.
A) Sit to stand from a chair: each participant seated
Precaution: Avoid placing too much pressure
comfortably in a straight-back chair without arm
against the heads of metatarsals and stretching the long
rests, supported the back well on the back of a
arch of the foot. Overstretching of the long arch of the
chair, placed both hands on thighs, then the
foot can cause a rocker-bottom foot.
patient leaned forward, placed both foot under the
push up until standing in upright posture with hips
e) Gastrocnemius muscle self- stretching:
and knees extended and shoulders back.
Can be performed in a long sitting position with a
Repeated this exercise from five to ten times.
towel or similar object positioned around the forefoot.
B) Standing with eyes open and close: Each patient
The patients was instructed to actively dorsiflex the
was stood with feet together and arms held beside
talocrural joint and then apply graded overpressure into
the body. Each subject was asked to open eyes
dorsiflexion using the towel. Exercise was performed 3-
and maintained this position from two to three
5 times, holding twenty seconds then relax. The
minutes. Repeated this exercise with eye closed,
clinician must ensure proper patient positioning,
and maintained this position from two to three
avoiding posterior pelvic tilt and lumbar flexion due to
minutes.
short hamstrings. A cushion under the pelvis improved
C) Reaching forward with stretch arms: From stride
the patient’s position.
standing position, arms at ninety degree shoulder
flexion, and each subject was asked to reach
f) Soleus muscle self-stretching:
forward with both arm stretch as much as possible
Ankle dorsiflexion range of motion can be
without moved feet from their place, relaxed. This
performed in a long sitting position, but a pillow was
exercise repeated from two to three minutes.
placed under the knee to minimize the gastrocnemius
D) Standing on one foot: Each patient stood on a
and hamstring stretch. The soleus was stretched in this
dominant foot, tried to balance without bracing the
position if the talocrural joint has adequate dorsiflexion
non-weight bearing on the weight bearing one or
mobility. Exercise was performed 3-5 times, holding
moving the weight bearing limb. Maintained this
twenty seconds and then relax.
position from two to three minutes.
E) Marching in place: Each participant was stood and g) Passive stretching of gastrocnemius:
marched in the same place with both arms free to
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
The patient stood arm's length plus approximately 6
inches away from the wall, the involved foot was
positioned with its lateral border perpendicular or
slightly toe-in to the wall. The patient moved the
uninvolved foot to the wall and then leaned toward the
wall while maintaining a vertically oriented trunk
position. The involved knee was maintained in full
extension and the heel was held flat on the floor. The
use of a small hand towel folded under the medial
longitudinal arch may help to support the subtalar joint
and mid tarsal joint during stretching. Exercise was
performed 2-3 times, holding thirty seconds and then
relax.
h) Step-down training exercises (Strengthening
planter flexion and active free exercises
dorsiflexion):
Can be used to facilitate controlled eccentric
lengthening of the calf muscle. Patient stood on a 2- or
4-inch box and was instructed to maintain involved side
heel contact while lowering the uninvolved heel to the
floor. This exercise is progressed by increasing the step
height. The exercise was performed 3-5 times, holding
for twenty seconds and then relax.
i) Planter flexion strengthening:
Can be achieved in a long sitting position with the
elastic band wrapped around the planter surface of the
forefoot. While holding the opposite end of the band,
the patient performed the planter flexion against the
resistance of the band. The exercise was performed 3-5
times, holding for twenty seconds and then relax.
j) Dorsiflexion strengthening:
Can be completed with an elastic band looped
around a table leg or similar secure structure. The
patient performed the dorsiflexion movement against
the resistance of the band. The exercise was performed
3-5 times, holding for twenty seconds then relax.
C) Data analysis:
All statistical measures were carried out using the
Statistical Package for Social Studies (SPSS) version
17 for Windows (Armonk, NY: IBM Corp). In this study,
the mean and the standard deviation was calculated for
all patients after the detected time of the study.
Descriptive statistics and a t-test were used for
comparison of the mean demographic data between
both groups.
• Paired t-test to compare the variable within each
group to detect level of significance in each group.
• Unpaired t-test to compare the variable between
groups was used to detect significance level
between the two groups (Comparison).
Both the descriptive and the analytic statistical were
used to examine, describe and analyze the collected
data in order to detect if there were any inter group
differences before and after treatment application. A
value of P<0.05 was considered statistically significant
[23]
. significant difference in speed item with P ≤ 0.05. There
RESULTS
a. Patient demographic data:
As reflected from table (1), Comparison of mean
values of demographic data (Age, weight and height)
indicated that there were no significant difference in
both groups of the study in their demographic data
(P>0.05).
Table (1): The descriptive analysis for demographic
data of for both groups (A& B).
Group Group (A) Group (B)
Mean±SD Mean±SD T- P-
Item Value Value
Age
(Years) 49.23±2.5 48.70±2.1 0.59 0.55
Weight
(Kilograms) 75.60 ±6.2 75.47±5.76 1.27 0.21
Height
(Centimeters) 166.53±5.15 163.63±7.2 0.06 0.95
SD = Standard deviation, P-Value=Probability level,
P > 0.05 = Non-significant.
b. Results of Stability Indices (SI) & (LOS):
As reflected from table (2), there were
statistical significant reduction (P<0.05) in stability index
(SI) and dynamic limit of stability (LOS) at the end of
training program (Post), when compared with (Pre test)
in the study group (Group A). The percentage of
improvement in stability index (SI) was 36.84% and
dynamic limit of stability (LOS) of 58.87%. While with
concerning control group (Group B) there were no
significant difference in stability index (SI) at the end of
training program (Post), when compared with (Pre test)
in the control group. However, there was a statistical
significant reduction (P<0.05) in the dynamic limit of
stability (LOS) in group (B) with (P= 0.01). The
percentage of improvement in stability index (SI) was
3.37% and dynamic limit of stability (LOS) of 14.18% in
the control group.
Comparison between both groups of the study:
As revealed form table (2), that the SI had a
highly significant decrease after the end of training
program (Post) for study group (Group A) (P= 0.001)
when compared with the control group (Group B) (P=
0.02), also the LOS had a highly significant increase
after the end of training program (Post) for study group
(Group A) (P= 0.001) when compared with the control
group (Group B) (P= 0.03).
c. Results of Tandem Walk Test (TW):
The values of pre and post-tests in study group
(Group A) indicated that there is significant difference of
all variables of tandem walk test (step width, speed and
end sway) with P ≤ 0.05.
While, it was revealed that the values of pre and post-
tests in control group (Group B) indicated that there is
is no significant difference between other different items
(step width and end sway) of test with P > 0.05.
Comparison between both groups of the study:
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
As reflected from table (3), the values of pre control group (Group B) indicated that there was
and post-tests in study group (Group A) indicated that significant difference in speed item with P ≤ 0.05. There
there were significant difference of all variables of TW were no significant difference between other different
(Step width, speed and end sway) with percentage of items (Step width and end sway) (P > 0.05) with
improvement in step width was 31.57% , speed was percentage of improvement in speed was 9.71% and
42.91% and end sway of 30.16% (P ≤ 0.05). While, it end sway of 4.42%.
was revealed that the values of pre and post-tests in

Table (2): Comparative analysis of stability index (SI) and dynamic limit of stability (LOS) between the two groups of
the study (A & B) as well as between pre and post-treatment of each group:

Stability Index (SI) for Dynamic Limit of Stability Index (SI) for Dynamic Limit of
Study Group (A) Stability (LOS) for Control Group (B) Stability (LOS) for
Study Group (A) Control Group (B)
Pre- Post- Pre- Post- Pre- Post- Pre- Post-
treatment treatment treatment treatment treatment treatment treatment treatment
Means ±SD 4.75±0.58 3.00±0.25 13.47±4.75 21.40±2.44 3.86±0.76 3.73±0.69 16.93±2.09 19.33±2.38
% of 36.84% 58.87% 3.37% 14.18%
improvement
T-value 13.14 -10.45 0.855 -11.23
P-value 0.01* 0.01* 0.4 0.01*
T-value -3.64 3.89 2.59 -2.35
between
groups
P-value 0.001** 0.001** 0. 02* 0.03*
between
groups

± SD= Standard deviation, P-Value=Probability level, P ≤ 0.05 = Significant*.

%=Percentage, P > 0.05 = Non-significant. P < 0.01 = Highly significant**.

Table (3): Compare the mean values of Tandem Walk test (TW) (Step width, speed and end sway) between pre and
post-treatment of each group.

Study Group (Group A) T-Value P-Value Control Group (Group T-Value P-Value
Mean±SD B) Mean±SD

Pre- Post- Pre- Post-

treatment treatment treatment treatment

Step 10.99±3.47 7.52±3.8 3.01 0.009** 13.25± 3.9 13.2±4.35 0.05 0.96
Width
(cm)
Speed 15.1±2.35 21.58±4.47 -10.26 0.000** 15.35±3.61 16.84±1.15 -2.17 0.05*
(cm/sec.)

End Sway 8.82± 3.67 6.16±2.23 2.77 0.015* 7.91±3.17 7.56±2.55 0.33 0.74
(deg/sec.)
± SD= Standard deviation, P-Value=Probability level, P ≤ 0.05 = Significant*.
%=Percentage, P > 0.05 = Non-significant. P ≤ 0.01 = Highly significant**.

Table (4): Compare the mean values of Tandem Walk test (TW) (Step width, speed and end sway) of control and
study groups.
Study Control T-Value P-Value Study Control T-Value P-Value
Group Group Group Group
(Group A) (Group B) (Group A) (Group B)
Mean±SD Mean±SD Mean±SD Mean±SD
(Pre) (Pre) (Post) (Post)
Step 10.99±3.47 13.25± 3.9 1.67 0.106 7.52±3.8 13.2±4.35 3.80 0.001**
Width
(cm)
Speed 15.1±2.35 15.35±3.61 0.26 0.799 21.58±4.47 16.84±1.15 -3.97 0.001**
(cm/sec.)
End Sway 8.82± 3.67 7.91±3.17 -0.73 0.470 6.16±2.23 7.56±2.55 1.60 0.121
(deg/sec.)
 International Journal of Therapies and Rehabilitation Research 2017; 6 (2): 184-194
± SD= Standard deviation, P-Value=Probability level, P ≤ 0.05 = Significant*.
%=Percentage, P > 0.05 = Non-significant. P ≤ 0.01 = Highly significant**.
Comparison between both groups of the study:
As revealed form table (4), it was clear that the
values of pre-treatment TW (Step width, speed and end
sway) in the study and control groups (Group A& B)
indicated that there was no significant difference
between different items of the test with P > 0.05. On the
other hand, the values of post-treatment test of both
groups (Group A& B) indicated that there were
significant difference of TW (Step width and speed) with
P ≤ 0.05. However, there was no significant difference
of end sway item between both groups with P > 0.05.
DISCUSSION
The postural control system needs a
complicated processes involving both sensory and
motor components. Maintenance of postural equilibrium
requires sensory recognition of body motions,
incorporation of sensorimotor information within the
central nervous system (CNS) and execution of
relevant musculoskeletal response [24]. Numerous
factors found to have variable effects on the postural
stability such as mechanoreceptors, proprioception,
amputation, fatigue, the effect of diseases, and reduced
balance confidence [12].
Association between strength, force and
exercise are essential for balance, the ability to
sufficiently contract postural control muscles, and to
maintain the center of mass over the base of support.
Lower limb strength, particularly ankle strength,
frequently accompanying with reduced balance control
in elderly [25]. On the other hand, ankle strategy is
normally used to lessen the small anterior-posterior
sway perturbations. The ankle strategy requires
acceptable ankle range of motion and force in ankle
muscles and it’s effective when alternations of
equilibrium are slow and small. The ankle muscles
provide proprioceptive data for postural sway through
monitoring the sum of ankle moments, consequently
regulating the body's center of gravity and reserve the
center of mass within the base of support [26]. Dynamic
balance refers to the ability to control, keep and regain
the center of gravity within the base of support in
response to external changes or voluntary movements.
Dynamic balance is required for daily life activities as
walking, running, stair climbing and sports [27].
It was revealed that, the lower limb ulcers can
cause one or more of the following factors that affect
the balance: loss of mechanoreceptors in the sole of
the foot; loss of proprioception in the lower limb,
decreased balance confidence, and easily fatigue of
lower limb muscles. Furthermore, lower limb ulcers can
result from peripheral neuropathy especially diabetic
peripheral neuropathy, which considered as one of the
main causes of balance disorders, therefore the
patients with lower limb ulcers have problems in on
balance and gait. This finding is in consistent with that
reported by Gribble and Hertel, [28].
In the present study, ankle rehabilitation in the
form of combination of leg stretching exercises, ankle
active free exercises, leg strengthening and balance
exercises were used in lower limb ulcer cases. It was
declared that balance and gait performance were
augmented significantly. This finding is supported by
Nitz and Low, [29].
In the current study the improvement in balance
had been resulted after 6 weeks of the ankle exercise
program. This improvement was in consistent with
previous study by Lord et al., [30] who showed
significant enhanced performance in the test of dynamic
balance post eight weeks of an exercise program
included flexibility and balance in addition to gentle
aerobic exercise. Another study, in accordance with the
current one, investigated the improvement in medio-
lateral balance control after six weeks of training
program [31]. A study supports this results, where it
stated that a ten weeks program of strengthening
exercise for tibialis anterior and gastrocnemius
muscles, contributed to an improvement balance ability
for elderly subjects of males and females with average
age around 74 to 96 years [32].
In the current study the comparison between
pre- and post-treatment of both groups (A & B) revealed
that there were significant improvements in each group
at accomplished of treatment except for stability index
(SI) of control group (Group B). However, the
comparisons between results of post-treatment for both
groups (A & B) indicated that there were significant
improvement in ankle training group (Group A). It may
be attributed to the effect of ankle exercises. The
percentage of improvement from the control group in
the stability index and dynamic limit of stability (LOS)
with the study group was 19.57% and 10.7%
respectively. This improved value of stability index and
dynamic limit of stability (LOS) was consistent with that
observed by Gillespie et al., and Wolf et al., [14,33].
The percentage of improvement in the current
study for the control group in the step width, speed and
end sway with the study group was 43.03%, 28.15%
and 18.52% respectively. This results showed
significant improvements in step length and speed
parameters by tandem walk test (TW) between both
groups. In a biomechanical study in accordance with
the current one done by Dingwell et al., [6] who proved
that the patients with neuropathic ulcer walk with slow
speeds, shortened stride lengths, greater double
support times, decreased ankle moments powers, and
decreased ground reaction forces compared to
matched controls. This finding is supported by Noel et
al., [34].
The differences in dynamic stability were
significantly anticipated by differences in walking speed,
but not by differences in sensory status. These results
may be supported by the hypothesis that clearly
reductions in walking speed are a compensatory
strategy used by ulcer patients to maintain dynamic
stability during walking. The improvement in present
study can be also explained from the biomechanical
point of view as Kaminski [35] mentioned that target
distance increased; the reach and postural synergies
became coupled resulting in the arms, legs and trunk
working together as one functional unit to move the
whole body forward.
The ankle strategy considered one of main
possible strategies for preventing a fall in the event of a
destabilizing perturbation. It was suggested that
balance control responses involve a combination of
ankle and hip strategies and the selection of a specific
balance response look as if it is depend mainly on
biomechanical variables such as strength and reaction
time [36].
In the present study, the improvement of
balance at end of treatment in the ankle training group
(Group A) may be explained from biomechanical point
of view, that motor system generates motor responses
according to the mechanical load received by the foot to
attenuate the load. Plantar area is the first to touch the
floor during standing and plays an extremely important
role in supplying the nervous system with pressure and
proprioception information as Gutierrez et al., [37]
views. Also the improvement may be related to the fact
that stability mainly depends on muscles activity of
ankle dorsiflexors susceptible to weakness and
dysfunction related to presence and severity of DPN
and ulcer. This supported by Baker et al., [38].
Lafond et al., [39] explained that biomechanical
inverse dynamics to the activation of the ankle plantar
dorsiflexors motor control. This was in agreement with
Andersen et al., [40] who declared that patients may
have weakness of the extensors and flexors at the
ankle and of knee flexors with preservation of strength
of the knee extensors and of muscles at the wrist and
elbow. The distribution of muscular weakness confirmed
that a distal neuropathic process is the cause of the
impaired motor performance.
The exercise designed to increase rapidly
available strength of ankle musculatures and balance
improved measures of balance. These results of the
present study were in a close agreement with
Pijnappels et al., [41] who concluded that strengthening
exercises have a benefit effect on muscles power and
transfer effects to balance recovery seems to be
achievable. Amiridis et al., [42] found that dorsiflexors
electrical stimulation training could reduce postural
sway and the use of ankle muscles, more characteristic
of young peoples, might be helpful in the elderly
patients as well. Dawn and Stephen, [43] suggested
that differences in ability to recover balance between
subjects associate with variables related to strength
and speed of response.
From the previous discussion of these results,
and according to the reports and researches of other
investigators in the field related to the present study,
authors can appealed that lower limb ulcers leads to
decrease postural stability and gait performance. Also
using ankle rehabilitation program, which is easily
applied for lower limb ulcer patients, induced a greater
improvement of overall stability index, the dynamic limit
of stability and gait performance in lower limb ulcer
cases.
CONCLUSION
On the basis of the present data, it is possible to
conclude that ankle training is an effective method in
treatment of balance disturbance, improvement of gait
performance and consequently possibly decrease risk
of fall in lower limb ulcer patients.
*Financial support and sponsorship: None.
*Conflicts of interest: None.
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