Gait & Posture 26 (2007) 214218 www.elsevier.

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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 2.4 years, height: 173.7 3.6 cm, weight: 63.3 7.9 kg). During each session, one set of muscle groups was fatigued using isokinetic contractions: ankle plantar/dorsi exors, ankle evertor/invertors, hip exor/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 signicant 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 [316]. Muscular fatigue is a key factor argued to impair proprioception and postural control [515,17,18]. Recent studies by Ochsendorf et al., Ramsdell et al., and Joyce et al. indicated that isokinetic fatigue of the ankle plantar exors and dorsiexors was associated with signicant 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: moj_moghadam@yahoo.com (M. Moghadam).

postural sway [1012]. Yaggie and McGregor found similar results following fatigue of the ankle plantar exors, dorsiexors, invertors and evertors [6]. 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 ndings have shown that proprioceptive inputs from the hip region are important for postural control [19]. Nevertheless, there has been no previous attempt to evaluate the effects of fatigue of muscles that move joints in

0966-6362/$ see front matter # 2006 Elsevier B.V. All rights reserved. doi:10.1016/j.gaitpost.2006.09.001

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different planes on the ability to maintain stability in those planes. The purpose of this investigation is to compare changes in postural stability following isokinetic fatigue of frontal and sagittal movers, acting on either proximal or distal segments of the lower extremities.

2. Methods 2.1. Subjects Twenty healthy male college students (age: 22.6 2.4 years, height: 173.7 3.6 cm, weight: 63.3 7.9 kg) volunteered to participate. Participants were excluded if they had any history of lower extremity injury within the past year, visual problems, dizziness and vertigo, any deformity in lower extremities or spine, previous history of surgery, neurological or systemic disorders. 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 [911]. Previous studies showed that physical activity level and specicity may inuence balance ability and thus must be considered in examining balance [20]. A sample of convenience of eligible subjects gave informed consent to participate. The Institutional Review Board of University of Social Welfare and Rehabilitation Sciences approved the study. 2.2. Testing procedure A repeated measures design was used to test the primary research question, which was the effect of fatigue of frontal and sagittal movers acting on either hip or ankle on postural stability. The dependent variable was postural stability, as measured by overall, anteriorposterior, and mediallateral stability indices (OSI, APSI and MLSI, respectively). The independent variable was local muscle fatigue with four levels: (1) distalsagittal (ankle plantardorsi exors), (2) distalfrontal (ankle evertorinvertors), (3) proximalsagittal (hip exorextensors), and (4) proximalfrontal (hip abductoradductors). 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. During each session, postural stability was assessed before and after completing an isokinetic fatigue protocol. For all subjects, assessments and interventions were performed with the dominant lower extremity. 2.3. Muscle fatigue Distal segment and sagittal plane: Peak torque measurements and fatigue protocols were performed using the Biodex System III isokinetic dynamometer (Biodex Inc., Shirley, NY, USA). In order to determine the initial peak

torque (IPT) values two sets of concentric/concentric ankle plantar/dorsiexion movements were performed at 608/s and 1208/s, respectively. The rst set was a familiarization task and consisted of three submaximal and three maximal contractions. In the second set, three trials of maximal effort were performed with no rest. The highest peak torque of three repetitions was recorded as IPT. After a 23 min rest, the fatigue protocol was initiated, during which subjects performed continuous concentric/concentric plantar/dorsiexion movements at 608/s and 1208/s, respectively. Fatigue was judged to have occurred when the torque output in both directions dropped below 50% IPT for three consecutive movements [6,1012,14,15]. Distal segment and frontal plane: In order to induce fatigue in the ankle invertors and evertors, a similar procedure was performed for ankle eversion and inversion with contraction speeds of 608/s and 1208/s. Proximal segment and sagittal plane: Flexors and extensors of the hip joint were fatigued by performing a similar fatigue protocol, at 608/s and 908/s. Proximal segment and frontal plane: To induce fatigue in the hip abductors and adductors, a similar fatigue protocol was performed at 608/s and 908/s. Verbal encouragement was given throughout all tests and fatigue protocols using standard procedures [12,21]. Because there were different fatigabilities of the antagonistic muscle groups around the ankle and hip joints, we used test speeds that we had found during our pilot studies to cause fatigue in both muscle groups almost simultaneously. After completing the fatigue protocols, subjects were removed from the dynamometer and tested for postural stability with a delay of no more than 60 s. This time interval was based on the results of our pilot testing which showed no recovery of fatigue within 24 min after the isokinetic fatigue protocol. Recovery was dened as the return of peak torque for two consecutive contractions above 80% IPT. Schwendner et al. used a similar criterion to determine fatigue recovery [21]. 2.4. Postural stability assessment In order to measure postural stability we used the Biodex Stability System (Biodex Inc.). 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 18, with 1 representing the greatest instability. The Biodex Stability System was shown to be reliable in several previous studies. Pincivero et al. reported intraclass correlation coefcient (ICC) values of .6 (for stability level 8) to .95 (for stability level 2) in healthy subjects [22]. Schmitz and Arnold reported ICC values for dominant single limb stance ranging from .8 to .43, using a decreasing stability level from 8 to 2 over 30 s [23]. We conrmed

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Fig. 1. The condition segment interaction for: (A) mean APSI (F (1, 19) = 13.52, p = .00) and (B) mean MLSI (F91, 19) = 6.63, p = .01).

Fig. 2. The condition plane interaction for: (A) mean APSI (F (1, 19) = .54, p = .46) and (B) mean MLSI (F (1, 19) = 4.71, p = .04).

reliability during our pilot study, with ICC values ranging from .77 to .99. For all trials, the platform was set and remained at stability level 7. Subjects were asked to maintain single leg stance on the platform with both arms folded across their chest. The unsupported limb was held in a position of hip neutral extension with partial abduction and 908 of knee exion, so as not to contact the test limb. To perform the dynamic balance test, subjects were instructed to keep the moving platform as level as possible for 20 s, while they were barefoot and their eyes were closed [8,9]. For each test a report was generated providing values of OSI, APSI, and MLSI. These indicated the variance of platform displacements from level in all planes, the sagittal plane and frontal plane. 2.5. Statistics To determine the effects of fatigue, fatigue segment and fatigue plane on postural instability, separate 2 2 2 analyses of variance (ANOVAs) with repeated measures for condition (pre-fatigue and post-fatigue), fatigue segment (distal and proximal) and fatigue plane (sagittal and frontal) were conducted for OSI, APSI, and MLSI. The alpha level was set at .05 for all analyses.

3. Results The means and standard deviations for pre-fatigue and post-fatigue measurements of all stability indices are presented in Table 1. The results of the repeated measures ANOVAs showed that fatigue had a signicant effect on all stability indices (OSI: F (1, 19) = 87.01, p = .00; APSI: F (1, 19) = 71.91, p = .00; MLSI: F (1, 19) = 39.23, p = .00). A signicant condition by segment interaction was also found for OSI (F (1, 19) = 24.11, p = . 00), APSI (F (1, 19) = 13.52, p = . 00) and MLSI (F91, 19) = 6.63, p = . 01). 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. 1). There was also a signicant condition by plane interaction for MLSI (F (1, 19) = 4.71, p = .04). Fatigue of the frontal movers resulted in a signicantly greater increment in MLSI, compared to fatigue of the sagittal movers (Fig. 2).

4. 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 5.47(1.47) 5.29(1.19) 5.41(1.39) 5.30(1.11) Post-fatigue 6.89(1.90) 6.58(1.66) 8.23(2.61) 8.73(2.53) APSI Pre-fatigue 4.61(1.31) 4.61(1.20) 4.25(1.16) 4.48(1.11) Post-fatigue 5.98(1.83) 5.58(1.50) 7.00(2.60) 7.17(1.97) MLSI Pre-fatigue 3.13(1.00) 2.74(.61) 3.42(1.30) 2.95(.84) Post-fatigue 3.52(1.04) 3.56(1.40) 4.32(1.35) 4.84(2.53)

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healthy young men. These ndings are consistent with Ochsendorf et al. Ramsdell et al., Joyce et al., Yaggie and Mcgregor, and Gribble and Hertel [6,1012,14,15]. These studies examined postural stability using static forceplates. 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. It is possible that the results reect proprioceptive deciencies associated with muscle fatigue [17,18], increased muscle reaction time or inappropriate efferent muscle responses [18,24,25]. Although our results do not pinpoint which aspects of the neuromuscular loop were affected by muscle fatigue, we attempted to increase reliance on proprioceptive feedback by instructing participants to perform the dynamic balance tests without foot wear and with closed eyes [9]. Fatigue in proximal musculature of the lower extremity was associated with the greater deterioration in postural stability in either the sagittal or frontal planes. Although these ndings are consistent with those reported by Gribble and Hertel, we found deterioration of postural stability in both sagittal and frontal planes, following fatigue of the ankle evertors and invertors. This was not observed in the study of Gribble and Hertel [15] who reported that fatigue of the ankle plantar exors and dorsiexors impaired postural stability in the sagittal plane only. The different ndings may have occurred due to the use of different measurement protocols. The dynamic balance tests used in the present study may be more challenging and sensitive test to detect small changes in postural stability, compared to measuring center of pressure excursion velocity as performed by Gribble and Hertel [14,15]. On the other hand, Nyland et al. suggested that eccentric activation of ankle joint musculature might affect subtalar joint control and proprioception. Muscle spindles of peroneal muscles might also affect joint position sense at both the ankle and subtalar joints [25]. It is possible that participants in the present study employed a hip strategy to maintain stability, due to the difcult and challenging conditions of dynamic balance test, especially after fatigue induction. Shumway-Cook suggested that stance on pliant surfaces caused an increased reliance on a hip strategy [26]. Riemann et al. compared the corrective actions of the ankle, knee, hip, and trunk during single-leg stance on rm, foam, and multiaxial surfaces and concluded that the ankle is of primary importance during single-leg stance on rm, foam, and multiaxial surfaces, with proximal joints having an increased role under more challenging conditions [27]. Further kinematic analyses are necessary to determine the effects of segmental muscle fatigue on movement strategies used to maintain postural stability. Fatigue of the frontal movers of the lower extremities reduced postural stability in frontal plane to a greater extent than for the sagittal plane. The specic effects of fatigue plane on the direction of postural stability impairment may be due to the known directionally

sensitive activity of postural muscles [19]. However, such an effect was not seen in the case of fatigue in sagittal plane movers. This may be related to the single-leg stance as the position of dynamic balance test in our study. In contrast to the domination of sagittal plane control in double-leg stance, it is hypothesized that the frontal plane is more important during single-leg stance control. For single-leg stance on a xed surface, Hoogvliet et al. explained two frontal plane strategies. The rst was foot tilt due to the movements of the subtalar joint. The second was similar to the known hip strategy, except that it occured in the frontal plane [27,28]. In conclusion, we have demonstrated that fatigue of proximal musculature of the lower extremity has a greater effect on postural stability than the more distal muscles. In addition, fatigue of the frontal movers of the lower extremity was associated with greater postural instability in the frontal plane. In the real world, situations whereby local muscle fatigue occurs after sports or daily activities might be associated with disturbances in balance. Further investigations are needed to clarify the effects of local muscle fatigue on postural stability in health and disease.

Acknowledgments The authors would like to acknowledge Dr. Anoushirvan Kazemnejad for statistical counseling, Dr. Kayvan Davatgaran for his contribution to language editing and the Research Committee of University of Social Welfare and Rehabilitation Sciences, for ongoing support of their work. The helpful comments and suggestions of the anonymous reviewers were greatly appreciated. Partially supported by the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.

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