Accelerat ing t he world's research.

Reduced plantar sensation causes a

cautious walking pattern
Dieter Rosenbaum

Gait & Posture

Cite this paper Downloaded from Academia.edu 

Get the citation in MLA, APA, or Chicago styles

Related papers Download a PDF Pack of t he best relat ed papers 

Effect s of changes in plant ar sensory feedback on human gait charact erist ics: a syst emat ic…
Diet er Rosenbaum

Gait Muscle Act ivit y during Walking on an Inclined Icy Surface

Chuansi Gao, Juha Oksa

Changes in muscle act ivit y in children wit h hemiplegic cerebral palsy while walking wit h and wit hout a…
Reinald Brunner
See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/8510105

Reduced plantar sensation causes a cautious

walking pattern

Article in Gait & Posture · September 2004

DOI: 10.1016/S0966-6362(03)00095-X · Source: PubMed

CITATIONS READS

92 144

6 authors, including:

Lothar Thorwesten Klaus Voelker

Universitätsklinikum Münster Universitätsklinikum Münster
84 PUBLICATIONS 872 CITATIONS 17 PUBLICATIONS 598 CITATIONS

SEE PROFILE SEE PROFILE

Dieter Rosenbaum
University of Münster
287 PUBLICATIONS 5,566 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

KNEEMO, an Initial Training Network (ITN) for knee OA research (EU FP7 funding) View project

Early rehabilitation in pediatric oncology: objective assessment of physical activity levels and
evaluation of bone mass View project

All content following this page was uploaded by Dieter Rosenbaum on 12 May 2014.

The user has requested enhancement of the downloaded file. All in-text references underlined in blue are added to the original document
and are linked to publications on ResearchGate, letting you access and read them immediately.
 Gait and Posture 20 (2004) 54–60

Reduced plantar sensation causes a cautious walking pattern

Eric Eils a,∗ , Susann Behrens a , Oliver Mers a , Lothar Thorwesten b ,
Klaus Völker b , Dieter Rosenbaum a
a Funktionsbereich Bewegungsanalytik (Movement Analysis Laboratory), Klinik und Poliklinik für Allgemeine Orthopädie,
University Hospital Münster, Domagkstr. 3, 48129 Münster, Germany
b Lothar Thorwesten, Klaus Völker, Institute of Sports Medicine, University Hospital Münster, Münster, Germany

Received 9 April 2003; received in revised form 20 June 2003; accepted 8 July 2003

Abstract

The aim of this study was to investigate the influence of reduced plantar sensation on gait patterns during walking in 20 healthy subjects
(25.9 ± 1.2 years, 61.6 ± 11.5 kg, 178 ± 9.5 cm) with no history of sensory disorders. Force plate measurements, electromyography (EMG)
measurements and a three-dimensional movement analysis were performed simultaneously during barefoot walking before and after reduction
of plantar sensation using an ice immersion technique. The results show that reduced plantar sensation leads to significant changes in gait
patterns that are present at the ankle, knee and hip joint and indicate a more cautious ground contact and push-off with modified EMG and
motion patterns.
© 2003 Elsevier B.V. All rights reserved.

Keywords: Somatic sensation impairment; Gait analysis; Electromyography; Locomotion; Biomechanics

1. Introduction control still remains unclear because of the difficulties in

Human movement is the result of a complex interaction
of neural, motor and skeletal functions that are controlled
by the central nervous system. Spinal locomotor patterns
are modified by afferent information due to the external
requirements [1,2] and different sensory systems, visual,
vestibular and somatosensory, contribute to the overall
control of human movement. The role of the visual and
the vestibular system have been well documented [3–8],
whereas information about the influence of the somatosen-
sory system is less well described. The consequences of
reduced influence of the somatosensory system in its en-
tirety has been investigated for the regulation of posture
and gait using ischaemic block technique or in patients with
diabetic neuropathy [9–11]. The somatosensory system
consists of different types of sensors providing information
from muscles, tendons, ligaments, and joint capsules, as
well as cutaneous and subcutaneous structures of the skin.
The influence of each single sensory system on movement
∗ Corresponding author. Tel.: +49-251-835-2975;
fax: +49-251-835-2993.
E-mail address: eils@uni-muenster.de (E. Eils).
disabling or reducing these systems selectively.
The plantar afferents of the foot are important for the con-
trol of posture and gait because the foot is usually the only
part of the body that is in direct contact with its environ-
ment. One possibility to impair information from the sole
of the foot is to use an ice immersion approach. It has been
shown that reduced plantar information by such an approach
leads to an increased body sway in standing, an increased
variation in foot contact in gait termination and a modified
pressure distribution pattern in walking [4,12–15]. Eils et al.
showed that roll-over in walking was substantially modified
after ice immersion of the sole of the foot compared with
normal conditions [15]. However, the cause of the modified
roll-over remained unclear because the proximal joints were
not considered.
In general, the complex control mechanisms of body
segments movement under reduced plantar sensation con-
ditions has not been well described. Knowledge of how
information from plantar afferents triggers and modulates
human gait patterns has important implications for the re-
habilitation of gait disorders. Therefore, the aim of this
investigation was to selectively reduce the cutaneous in-
formation from the plantar surface of the foot using an ice
immersion approach to study the effects on ground reaction

0966-6362/$ – see front matter © 2003 Elsevier B.V. All rights reserved.
doi:10.1016/S0966-6362(03)00095-X
 E. Eils et al. / Gait and Posture 20 (2004) 54–60
forces, muscle activation patterns and segment movements
of the lower extremity in barefoot walking. Our hypothe-
sis was that reduced cutaneous information of the plantar
surface of the foot results in a substantially modified gait
strategy by characteristic changes in the horizontal and
vertical components of the ground reaction forces, reduced
electromyography (EMG) activity of specific muscles of
the lower extremities, and modified segment angles of the
lower extremities during the phases of walking.
2. Materials and methods
Twenty healthy subjects (25.9 ± 1.2 years, 61.6 ± 11.5 kg,
178 ± 9.5 cm) participated in the study. All subjects signed
an informed consent form and filled out a short questionnaire
before participation. All experimental procedures were per-
formed in accordance to the principles of the Declaration of
Helsinki. Subjects with a history of neurological disease or
diabetes were excluded. Force plate measurements; (EMG)
measurements and three-dimensional movement analysis
were performed simultaneously during walking before and
after reduction of plantar sensation.
Surface EMG signals of 12 muscles of the right leg were
recorded using bipolar electrodes (Blue sensor (N-50-K),
Medicotest GmbH, Olsstykke, Denmark). The skin was
prepared with abrasive skin prepping gel and alcohol to
minimized impedance below 6 k. The electrodes were
placed with an inter-electrode distance of 2 cm on the mus-
cle bellies of the tibialis anterior, peroneus longus, soleus,
gastrocnemius medialis, biceps femoris, vastus medialis
and lateralis, rectus femoris, adductor longus, tensor faciae
latae, gluteus medius and maximus. All electrode place-
ments were performed by the same investigator using the
SENIAM recommendation [16] and the correct placements
were checked by manual tests and voluntary contractions.
The Noraxon system and software were used to measure and
analyze EMG data (Noraxon Myosystem, Scottsdale, USA).
EMG signals were normalized to maximum voluntary con-
traction values for each muscle. The raw EMG signal was
A/D converted and sampled with 1200 Hz and 12 bit resolu-
tion, filtered (bandpass 10–1000 Hz), rectified and smoothed
(RMS 50).
Three-dimensional movement analysis was performed us-
ing a set of six cameras in combination with reflective mark-
ers that were placed on anatomical landmarks of the subjects
using the “Helen Hayes Marker Set”. The marker placements
were the anterior superior iliac spine (left and right), sacrum,
mid-thigh (left and right—wand markers), lateral knee (left
and right), mid-shank (left and right—wand markers), lat-
eral malleolus (left and right), calcaneus (left and right) and
foot between second and third metatarsal heads (left and
right). The Motion Analysis system and software (Motion
Analysis, Santa Rosa, CA, USA) were used to measure and
analyze three-dimensional motion data. The system had a
sampling frequency of 60 Hz and the dimension of the cali-
55
brated space to detect motion was 2 m long, 1.5 m wide and
1.8 m high.
A three-dimensional force plate was used to measure com-
ponents of the ground reaction force in walking (AMTI, Wa-
tertown, MA, USA). The sampling frequency was 600 Hz
and data was measured and analyzed using Motion Analysis
Eva 5.2 software. Synchronization of force plate, EMG and
motion data was performed using the vertical component of
the ground reaction force that was measured by EMG and
Motion Analysis software simultaneously. The swing phase
was also defined by using a manual trigger that was set at
initial contact of the ipsilateral leg.
Characteristic values of the vertical component of the
ground reaction force (vGRF) were used to subdivide phases
of the EMG and to define parameters of the motion analy-
sis curves (Fig. 1). Angles in the sagittal plane of the ankle,
knee and hip were calculated at the occurrence of the first
peak (loading response peak), relative minimum (mid-stance
valley) and second peak (terminal stance peak) of the vGRF.
Mean EMG activity of the muscles were calculated for four
different phases of the vGRF, i.e. the phase between ground
contact and first peak, the phase between first and second
peak, the phase between second peak and toe off and the
phase between toe off and the end of the swing phase. The
maximum braking and acceleration force peaks of the hor-
izontal component of the ground reaction force were also
used for analysis.
For the reduction of plantar sensation, the right foot was
placed in a cold water container (0 ◦ C) for 10 min. The foot
was placed on a grid that was surrounded by iced water
so that only the plantar aspect of the foot was submerged.
This cooling procedure was reported to sufficiently influ-
ence plantar sensation as confirmed with Semmes–Weinstein
monofilaments [15].
A first-step walking method (subjects stood close enough
to the platform and contacted the platform with their first
step) was chosen to obtain a high repeatability of contact-
ing the platform and to avoid targeting. Before the data
collection, subjects performed several first-step walking tri-
als across the force platform with the complete EMG and
marker setting to familiarize themselves with the equipment
and the testing procedure. After the 10 min cooling proce-
dure, the subjects performed two trials of first-step walking
over the force platform. The high repeatability of contacting
the platform in first-step walking was important because
of the foot warming up which only allowed few measure-
ments. Only two first-step walking trials were measured
directly after the cooling to prevent foot warm-up. The foot
was then submerged for additional 10 min in ice water and
the next two steps were recorded until six steps under iced
conditions were measured.
For statistical analysis, the mean of six trials was calcu-
lated. Differences between normal and iced conditions were
determined using the nonparametric dependent Wilcoxon
signed rank test. The statistical level of significance was set
at P < 0.05.
56 E. Eils et al. / Gait and Posture 20 (2004) 54–60
Fig. 1. Definition of parameters that were used for data analysis. Char-
acteristic values of the vertical ground reaction force (top) were used to
define parameters of the three-dimensional motion analysis (middle) and
the phases of muscle activity (bottom).
3. Results
The analysis of ground reaction force parameters showed
significant changes for almost all parameters under the iced
condition (Table 1). The second peak of the vGRF was sig-
1.4
1.2
1
Bodyweight
0.8
0.6
0.4
normal iced
0.2
0
0 20 40 60 80 100
Ground contact [%]
Fig. 2. An example of the modified vertical component of the ground
reaction force under normal (black line) and iced (gray line) conditions.
A significantly delayed first peak, a significantly increased minimum and
a significantly earlier and decreased second peak were found under iced
conditions.
nificantly decreased and the minimum between peaks was
significantly increased under iced conditions. The absolute
ground contact time did not change significantly between
both normal and iced conditions (744 ms versus 758 ms,
P > 0.05). The timing of first and second peak was signif-
icantly modified under iced conditions. The first peak was
delayed (P = 0.0137), the minimum nearly unchanged and
the second peak occurred earlier (P = 0.0019) under iced
conditions (Fig. 2). Braking (P = 0.0304) and acceleration
(P = 0.0005) force peaks were significantly reduced under
iced conditions. The time of occurrence for braking force
peak was significantly delayed (P = 0.0304) under iced
compared with normal conditions.
Kinematic parameters showed significant changes under
iced conditions during ground contact (Table 2). Dorsi-
flexion of the ankle joint was significantly reduced at the
beginning (P = 0.0025) of ground contact and increased at
the end of ground contact (P = 0.0080) under iced condi-
tions. The knee was significantly less flexed at the end of
ground contact (P = 0.0479), and the hip was significantly
more flexed at push-off (P = 0.0005) and at the end of
ground contact (P = 0.0366) under iced conditions. All
other angles did not change significantly.
The muscle activity in phase 1 showed an increased am-
plitude in the flexor muscles of the shank and the thigh
(soleus, gastrocnemius medialis, biceps femoris) and a de-
creased amplitude for the extensor muscles of the shank and
the thigh (tibialis anterior, vastus medialis and lateralis, rec-
tus femoris) under iced conditions (Table 3). The muscles of
the hip showed a decreased amplitude compared to normal
conditions. The decrease in amplitude under iced conditions
was significant for the tibialis anterior (P = 0.0001), rectus
femoris (P = 0.0479), tensor faciae latae (P = 0.0276) and
glutaeus medius (P = 0.0276).
In phase 2 the mean amplitude decreased for all muscles
of the shank and was nearly unchanged for the muscles of
 E. Eils et al. / Gait and Posture 20 (2004) 54–60 57

Table 1
Ground reaction force parameters under normal and iced conditions
Ground reaction force parameters Normal Iced P-level

First peak (% BW) 107 ± 6 106 ± 5 n.s.

Minimum (% BW) 80 ± 6 82 ± 5 0.0479
Second peak (% BW) 116 ± 6 112 ± 6 0.0012
Instant of first peak (% GC) 27 ± 3 29 ± 4 0.0137
Instant of minimum (% GC) 48 ± 9 48 ± 7 n.s.
Instant of second peak (% GC) 77 ± 2 76 ± 2 0.0019
Braking force peak (% BW) 8.1 ± 2.2 7.2 ± 1.6 0.0304
Acceleration force peak (% BW) 23.4 ± 3.8 21.1 ± 3.9 0.0005
Instant of braking force peak (% GC) 17.5 ± 3.9 19.4 ± 4.2 0.0304
Instant of acceleration force peak (% GC) 85.2 ± 1.4 85.1 ± 1.5 n.s.
First peak, minimum and second peak are derived from the vertical component of the ground reaction force. Braking and acceleration force peaks are
derived from the horizontal component of the ground reaction force (% BW: % bodyweight; % GC: % gait cycle).

Table 2
Angles (sagittal plane) of the ankle, knee and hip at the beginning of ground contact, occurrence of first peak, minimum, second peak and end of ground
contact under normal and iced conditions
Kinematic parameters Ankle angles (◦ ) Knee angles (◦ ) Hip angles (◦ )
(sagittal plane)
Normal Iced P-level Normal Iced P-level Normal Iced P-level
Begin of contact 4.0 ± 3.5 2.3 ± 4.3 0.0025 17.7 ± 5.4 18.3 ± 5.1 n.s. 33.9 ± 7.4 33.9 ± 6.6 n.s.
First peak 9.5 ± 3.2 10.0 ± 3.0 n.s. 25.5 ± 6.8 24.6 ± 6.1 n.s. 24.1 ± 7.2 23.5 ± 7.2 n.s.
Minimum 13.4 ± 3.1 13.4 ± 2.9 n.s. 14.5 ± 4.2 14.8 ± 4.1 n.s. 7.4 ± 6.2 8.5 ± 5.2 n.s.
Second peak 16.2 ± 3.0 15.9 ± 3.1 n.s. 12.0 ± 4.4 11.9 ± 4.9 n.s. −8.7 ± 6.1 −6.7 ± 5.1 0.0005
End of contact −11.6 ± 5.6 −9.6 ± 6.3 0.008 43.8 ± 4.8 42.9 ± 5.8 0.0479 −1.0 ± 6.0 0.4 ± 6.2 0.0366
Neutral positions were derived from straight standing. For the ankle and the hip joint positive values indicate flexion (dorsiflexion at the ankle, hip
flexion), negative values indicate extension (plantar flexion at the ankle, hip extension). For the knee joint values indicate the angle between neutral
position and shank.

the thigh. The hip muscles showed no consistent tendency
(Table 3). The mean amplitudes of the gastrocnemius medi-
alis (P = 0.0080) and tibialis anterior (P = 0.0015) were
significantly decreased under iced conditions.
Mean amplitudes were decreased for the muscles of the
shank and increased for the muscles of the thigh under
iced conditions in phase 3. Muscles of the hip showed
an inconsistent behavior. The decreased amplitude under
iced conditions was significant for the medial gastrocne-
mius (P = 0.0064), peroneus longus (P = 0.0003), biceps
femoris (P = 0.0013), adductor longus (P = 0.00187) and
tensor faciae latae (P = 0.0111).
In the swing phase (phase 4) the mean amplitude of the
muscles of the shank, the thigh and most of the hip muscles
was increased under iced conditions. The increased ampli-
tude under iced conditions was significant for the extensors
of the thigh (vastus medialis (P = 0.0251) and lateralis
(P = 0.0100), rectus femoris (P = 0.0304)) as well as for
the tensor faciae latae (P = 0.0008).
4. Discussion
This investigation has shown that altered plantar sensation
using an ice immersion approach leads to a substantially
modulated gait strategy indicating a more cautious ground
contact and push-off with accordingly modified EMG and
motion patterns. Furthermore, these results explain previous
observations where a characteristically modified roll-over
pattern from pressure distribution measurements was found
under iced conditions [15].
Plantar sensation was reduced using a 10 min ice immer-
sion technique. Although reduced sensitivity after cooling
was not explicitly tested in this investigation, it is well doc-
umented that this technique reduces significantly plantar
sensation by influencing mainly the mechanoreceptors of the
skin [4,13,15]. Apart from reduction of sensory function, the
cooling procedure may produce other effects such as hyper-
or paraesthesia. In a previous investigation, different dura-
tions of cooling were subsequently tested and sensation was
evaluated after cooling with Semmes–Weinstein monofil-
aments. No signs of hyperaesthesia were found during or
directly after cooling and initial sensation returned between
5 and 10 min after cooling [15]. Concerning paraesthesia,
subjects did not report any sensation that would indicate
such an effect. After submerging the sole of the foot in ice
water, subjects initially reported a feeling of discomfort that
decreased and vanished after a few minutes. During and
after subsequent cooling, subjects did not report any further
discomfort.
A first-step walking method was used in this investigation.
It has to be considered that a first-step in walking will be
 58
Table 3
Muscle activity parameters of 12 selected muscles of the lower extremity and the hip in different phases of the gait cycle under normal and iced conditions

E. Eils et al. / Gait and Posture 20 (2004) 54–60

Muscle activity (% MVC) Phase 1 Phase 2 Phase 3 Phase 4
Normal Iced P-level Normal Iced P-level Normal Iced P-level Normal Iced P-level
Soleus 15.6 ± 9.6 16.2 ± 10.1 n.s. 42.2 ± 26.6 40.0 ± 24.7 n.s. 20.5 ± 14.6 18.1 ± 15.7 n.s. 8.0 ± 5.2 9.4 ± 7.1 n.s.
Gastrocnemius medialis 8.8 ± 5.5 9.0 ± 4.9 n.s. 58.3 ± 25.8 51.4 ± 22.2 0.0080 13.7 ± 6.8 11.4 ± 7.0 0.0064 6.7 ± 5.4 7.5 ± 5.4 n.s.
Tibialis anterior 20.5 ± 8.8 13.3 ± 6.6 0.0001 7.7 ± 4.3 5.4 ± 2.6 0.0015 6.5 ± 2.4 6.2 ± 3.2 n.s. 17.8 ± 6.2 18.6 ± 6.2 n.s.
Peroneus longus 15.3 ± 7.3 13.0 ± 7.2 n.s. 24.0 ± 9.3 22.6 ± 11.4 n.s. 12.3 ± 5.4 9.9 ± 5.1 0.0003 9.5 ± 4.8 9.9 ± 4.6 n.s.
Biceps femoris 8.8 ± 5.1 9.3 ± 4.7 n.s. 3.4 ± 2.0 3.7 ± 1.8 n.s. 3.4 ± 2.6 5.8 ± 4.5 0.0013 4.6 ± 3.0 4.8 ± 2.6 n.s.
Vastus medialis 17.9 ± 9.5 16.8 ± 10.4 n.s. 4.6 ± 2.2 4.9 ± 2.4 n.s. 3.2 ± 2.4 3.2 ± 1.8 n.s. 5.0 ± 3.9 6.4 ± 5.2 0.0251
Vastus lateralis 20.1 ± 9.1 19.7 ± 8.7 n.s. 7.3 ± 4.8 7.1 ± 4.1 n.s. 3.0 ± 1.7 3.5 ± 1.8 n.s. 6.0 ± 4.6 7.1 ± 5.1 0.0100
Rectus femoris 8.0 ± 4.0 7.4 ± 3.4 0.0479 3.7 ± 1.4 3.7 ± 1.3 n.s. 3.5 ± 1.4 3.6 ± 1.3 n.s. 3.7 ± 1.5 4.3 ± 1.7 0.0304
Adductor longus 4.4 ± 3.4 4.1 ± 2.5 n.s. 1.9 ± 1.6 1.8 ± 1.1 n.s. 7.9 ± 5.9 9.0 ± 4.8 0.0187 5.5 ± 3.9 4.9 ± 3.3 n.s.
Tensor faciae latae 8.4 ± 5.2 7.4 ± 3.8 0.0276 5.5 ± 3.0 6.0 ± 3.8 n.s. 2.3 ± 1.3 2.7 ± 1.4 0.0111 2.8 ± 1.7 3.3 ± 2.0 0.0008
Glutaeus maximus 18.7 ± 7.6 18.2 ± 6.8 n.s. 6.7 ± 3.1 6.2 ± 2.3 n.s. 4.8 ± 1.9 4.5 ± 1.5 n.s. 5.7 ± 2.5 5.6 ± 2.2 n.s.
Glutaeus medius 23.1 ± 8.9 21.4 ± 6.8 n.s. 11.6 ± 5.7 13.1 ± 7.6 n.s. 3.3 ± 1.7 4.2 ± 2.8 n.s. 5.5 ± 2.3 6.5 ± 3.9 n.s.
 E. Eils et al. / Gait and Posture 20 (2004) 54–60
different from a step during full gait due to differences in
braking and accelerating the centre of mass of the body. A
different strategy between normal and iced conditions for
first-step and full gait is certainly not expected. However, it
should be kept in mind that the presented results are based
on the first-step walking method.
The vertical and horizontal component of the ground
reaction force showed a comparable ground contact time
but marked changes under iced condition. In the loading
response, a reduction of the first peak was measured under
iced condition that was not significantly different from nor-
mal conditions but appeared significantly later in the gait
cycle. The braking force peak was also significantly reduced
under iced condition. This suggests that the initial foot con-
tact with the ground was performed more cautiously than
under normal conditions. A similar strategy is seen for the
second peak indicating a more cautious push-off. After ice
immersion the second and the acceleration force peak were
significantly decreased and the second peak appeared signif-
icantly earlier. In addition to the reduced peak force values,
the significantly increased minimum suggests a diminished
dynamic of the ground contact phase under iced conditions.
These results are in accordance with recently performed
plantar pressure distribution measurements. Nurse and Nigg
and Eils et al. reported significantly reduced peak pres-
sures under the heel and the forefoot at ground contact and
push-off after ice immersion of the sole of the foot [13,15].
In addition, Eils et al. [15] reported a substantially modified
pressure distribution pattern in walking that was also char-
acterized by a significant load shift to the lateral part of the
foot and a more even load distribution over the whole foot
by an early and prolonged foot-flat position.
The three-dimensional movement and EMG analysis also
supports the above-mentioned hypothesis of a more cautious
beginning and end of contact. Significant changes in ankle,
knee, and hip angles were found especially at the beginning
and end of ground contact. At the instant of ground contact,
dorsiflexion of the ankle was significantly reduced leading
to a more flat touch down, whereas knee and hip angles were
similar under iced conditions. At the end of ground contact,
a significantly decreased plantar flexion, knee and hip flex-
ion indicate a less pronounced push-off from the ground. In
the phase between initial contact and first peak of the verti-
cal component of the ground reaction force as well as from
the second peak and end of contact, the mean muscle activ-
ity was significantly reduced for characteristic muscles. The
decreased dorsiflexion at ground contact and the decreased
plantar flexion at push-off were caused by significantly de-
creased amplitudes of tibialis anterior, gastrocnemius medi-
alis and peroneus longus under iced conditions. At ground
contact, the decreased amplitude of the extensors of the knee
and all hip muscles under iced conditions indicated a more
smooth initial contact and weight bearing for the whole leg.
There was a significant decrease in muscle activity for
the tibialis anterior and the medial gastrocnemius muscle in
phase 2. The decreased tibialis anterior activity is the re-
59
sult of the decreased activity at ground contact and weight
bearing (phase 1) that still affected the activity level in
phase 2. The decreased activity of medial gastrocnemius
in phase 2 indicates the start of the observed decreased
muscle activity in the push-off phase (phase 3). Although
the above-mentioned differences between conditions were
found, the contact time did not differ significantly between
the two conditions. This suggests that the observed changes
during ground contact may be counterbalanced in the swing
phase. The results of the EMG analysis in phase 4 reflects
this assumption: the mean activity of the knee extensor in-
creased significantly in this phase and indicated an acceler-
ated swing forward of the lower limb under iced conditions.
This study has shown that there were marked differences
in gait affecting the whole lower limb under iced condi-
tions. In general, sensation from the sole of the foot has
been demonstrated to have an influence on posture and gait
when using patients with diabetic neuropathy as a specific
model, ischaemic block techniques or an ice immersion ap-
proach. For example, Sacco and Amadio, Katoulis et al. and
Mueller et al. studied gait parameters in patients with dia-
betic neuropathy in comparison to healthy controls [17–19].
These authors found reduced peak forces of the vertical
ground reaction force at loading response and push-off,
decreased bracing and acceleration force peaks of the hor-
izontal ground reaction force and reduced plantar flexion
angles in walking when compared with controls. Dickey
and Winter reported substantial modifications in walking
after inducing a unilateral ischaemic block [9]. Changes
in the tibio-talar joint angles as well as decreased activity
of tibialis anterior were found after inducing an ischaemic
block. In diabetic polyneuropathy and ischaemia afferent
information of different systems is impaired causing diffi-
culty of evaluating the influence of information from single
systems. In the above-mentioned studies, the influence of
impaired sensation on gait patterns (angles, muscle activity)
was more pronounced than in the present investigation un-
derlining the decreased afferent input from several different
sensor systems. Ice immersion approaches have also been
used to study the influence of reduced plantar sensation
on posture and gait [13–15,20,21]. Magnusson et al. and
Asai et al. demonstrated that cutaneous information of the
sole of the foot is important in balance regulation during
standing [14,20]. Nurse and Nigg as well as Eils et al.
have shown the important influence of plantar sensation
on roll-over in walking and Perry et al. have shown that
cutaneous sensation contributes to the control of the centre
of mass during gait termination [21]. Although different
aspects of reduced plantar sensation have been studied, a
more complete analysis of the lower extremities has not
been performed previously and the present investigation
provides further insights into the control mechanisms of
gait and posture related to reduced plantar sensation.
In general, decreased tactile sensation, poor balance, in-
creased body sway, and impaired sensory function of the
lower limbs are strongly associated with falls in the elderly
60 E. Eils et al. / Gait and Posture 20 (2004) 54–60
[22,23]. In addition, there is evidence that the control of gait
and posture is a clinically relevant problem in patients with
diabetic neuropathy [24]. The results of the present study
may be of importance concerning the risk of falling in the
elderly population or in patients with diabetic neuropathy.
Elderly patients or those with diabetes mellitus were not in-
vestigated in the present study but the techniques used may
be applicable to these patient groups for future research. In
conclusion, the present investigation showed that short term
reduced afferent information from the sole of the foot sub-
stantially modifies the normal gait pattern.
References
[1] Grillner S. Control of locomotion in bipeds, tetrapods, and fish. In:
Brooks B, editor. Handbook of physiology, vol. II, part 2. Washington,
DC: The American Physiological Society; 1981. p. 1179–236.
[2] Gandevia SC, Burke D. Does the nervous system depend on kines-
thetic information to control natural limb movements? Behav Brain
Sci 1992;15:614–32.
[3] Patla AE. Understanding the roles of vision in the control of human
locomotion. Gait Posture 1997;5:54–69.
[4] Perry SD, Santos LC, Patla AE. Contribution of vision and cuta-
neous sensation to the control of centre of mass (COM) during gait
termination. Brain Res 2001;913(1):27–34.
[5] Wade MG, Jones G. The role of vision and spatial orientation in the
maintenance of posture. Phys Ther 1997;77:619–28.
[6] Straube A, Paulus W, Brandt T. Influence of visual blur on
object-motion detection, self-motion detection and postural balance.
Behav Brain Res 1990;40(1):1–6.
[7] Horak FB, Nashner LM, Diener HC. Postural strategies associated
with somatosensory and vestibular loss. Exp Brain Res 1990;82:167–
77.
[8] Diener HC, Dichgans J, Guschlbauer B, Bacher M. Role of visual
and static vestibular influences on dynamic posture control. Hum
Neurobiol 1986;5:105–13.
[9] Dickey JP, Winter DA. Adaptations in gait resulting from unilateral
ischaemic block of the leg. Clin Biomech 1992;7:215–25.
[10] Simoneau GG, Ulbrecht JS, Derr JA, Cavanagh PR. Role of so-
matosensory input in the control of human posture. Gait Posture
1995;3:115–22.
[11] van Deursen RW, Simoneau GG. Foot and ankle sensory neuropathy,
proprioception, and postural stability. J Orthop Sports Phys Ther
1999;29:718–26.
[12] Eils E, Tewes M, Nolte S, Rosenbaum D. Der Einfluss reduzierter
Fußsohlensensorik auf Schwankungs- und Druckverteilungsparame-
ter beim Stehen und Gehen. Med Orth Tech 2003;4:46–54.
[13] Nurse MA, Nigg BM. The effect of changes in foot sensation on
plantar pressure and muscle activity. Clin Biomech 2001;16:719–
27.
[14] Magnusson M, Enbom H, Johansson R, Pyykko I. Significance of
pressor input from the human feet in anterior-posterior postural
control. The effect of hypothermia on vibration-induced body-sway.
Acta Otolaryngol 1990;110:182–8.
[15] Eils E, Nolte S, Tewes M, Thorwesten L, Rosenbaum D. Modi-
fied pressure distribution patterns in walking following reduction of
plantar sensation. J Biomech 2002;35:1307–13.
[16] Hermens HJ, Freriks B, Disselhorst-Klug C, Rau G. Development
of recommendations for SEMG sensors and sensor placement pro-
cedures. J Electromyogr Kinesiol 2000;10:361–74.
[17] Sacco IC, Amadio AC. A study of biomechanical parameters in gait
analysis and sensitive cronaxie of diabetic neuropathic patients. Clin
Biomech 2000;15:196–202.
[18] Katoulis EC, Ebdon-Parry M, Lanshammar H, Vileikyte L, Kulkarni
J, Boulton AJ. Gait abnormalities in diabetic neuropathy. Diabetes
Care 1997;20:1904–7.
[19] Mueller MJ, Minor SD, Sahrmann SA, Schaaf JA, Strube MJ. Dif-
ferences in the gait characteristics of patients with diabetes and pe-
ripheral neuropathy compared with age-matched controls. Phys Ther
1994;74:299–308, and discussion 309–13.
[20] Asai H, Fujiwara K, Yamashina T, Nara I, Tachino K. The influence
of foot soles cooling on standing posture control. In: Brandt T, Paulus
W, editors. Disorders of posture and gait. Stuttgart: Thieme; 1990.
p. 198–201.
[21] Perry SD, McIlroy WE, Maki BE. The role of plantar cutaneous
mechanoreceptors in the control of compensatory stepping reactions
evoked by unpredictable, multi-directional perturbation. Brain Res
2000;877:401–6.
[22] Lord SR, McLean D, Stathers G. Physiological factors associated
with injurious falls in older people living in the community. Geron-
tology 1992;38:338–46.
[23] Sorock GS, Labiner DM. Peripheral neuromuscular dysfunction and
falls in an elderly cohort. Am J Epidemiol 1992;136:584–91.
[24] Cavanagh PR, Simoneau GG, Ulbrecht JS. Ulceration, unsteadiness,
and uncertainty: the biomechanical consequences of diabetes mellitus.
J Biomech 1993;26(Suppl 1):23–40.