Sarath Krishnan K.T

Sarath Krishnan K.T

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES
BANGALORE, KARNATAKA.

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECT FORDISSERTATION
1 / Name of the candidate
And Address /
SARATH KRISHNAN K.T.
SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, PANDESHWAR, MANGALORE-575001.
2 /

Name of the Institute

/ SRINIVAS COLLEGE OF PHYSIOTHERAPY AND RESEARCH CENTER, MANGALORE.
3 /

Course of study and Subject

/ Master of Physiotherapy (MPT)
2 years Degree Course.
“Musculoskeletal disorder and Sports
physiotherapy”
4 /

Date of Admission To course

/ 15/06/2009
5 /

Title of the Topic

/ “Effect of Textured Foot Orthotics on Static and Dynamic Postural Stability in Chronic Ankle Instability Patients”.
Brief resume of the intended work:
6.1 Need for the study:
Postural stability is dependent on the position of center of mass of body and its displacement within the base of support.1
Sensory processes in balance involve interaction among orientation inputs from somatosensory, visual, and vestibular system. For healthy adults, the preferred sensory input for the control of balance is somatosensory information from the feet in contact with the support surface.2
Functional ankle instability following a lateral ankle instability is a common disability that can affect both athletic performance and activities of daily life. It has been reported that residual symptoms, such as a feeling of instability or giving away, occurs in approximately 40% of ankle sprain.3
Following lateral ankle sprain, ligamentous tissue is thought to heal effectively but mechanoreceptor disruption within the lateral ligaments and talocrural joint capsule results in reduced ability to detect changes in joint position sense.4
Mechanical instability and functional ankle instability have been hypothesised as underlying causes of recurrent ankle sprains. Functional ankle instability is defined as joint motion that do not necessarily exceed normal physiological limits but is beyond voluntary control. Mechanical instability is defined as laxity and excessive joint motion of talocrural, subtalar and/or inferior tibiofibular joints due to structural damage of the supporting ligamentous tissues.4
Functional instability is a common complication following an acute ankle sprain .Three potential contributing factors underlying the ankle which chronically gives way are propriocepive deficits, muscle weakness, and ligamentous laxity. Deficits in passive movement sense and anatomic stability are greater concerns than strength deficits when managing the ankle with functional instability.5
Patients can have a history of recurrent inversion sprains with concomitant functional limitations and still present clinically with mechanically stable ankles.
Damage to mechanoreceptors following ankle sprain could interrupt the flow of afferent impulses into the central nervous system, thus leading to balance deficits, and ultimately contributing to the development of FI
Proprioception is the term used to describe a group of sensations including the sensation of movement and position of the joints and sensation related to the muscle force.7
In normal functioning, proprioceptive information such as kinaesthesia and joint position sense are obtained from mechanoreceptors upon detection of joint displacements and perturbations. This elicits complex responsive reflex neural muscle activation,to increase muscle stiffness and resist these displacements, to maintain postural stability.8
Tactile sensitivity within the foot has a strong influence on maintenance of postural stability, as evidenced when this sensory input is lost in patients with diabetic neuropathy.9,10
Shoe inserts and foot orthotics are thought to affect sensory feedback from the feet and aid postural control.11
Footwear may influence the quality of sensory feedback from the feet and may be act as a sensory filter between the feet and the external environment.12,13,14
Adding textured insoles to the shoes was found to improve movement discrimination. This was interpreted in terms of enhanced cutaneous feed back from the sole.15
Aspects of footwear especially insoles have substantial relevance to injury research, but other than as a shock absorber, the potential role of sport shoe as an interface between the moving body and the support surface has received little attention in sports medicine and podiatric literature in the perspective of postural control. The plantar sole is a important interface as the point of contact with the playing surface.16
Since there are inconclusive literatures revealing the effects of textured insoles on postural stability in patients with ankle sprain where postural stability is affected, purpose of this study is to find out the effect of insoles on postural stability in chronic ankle sprain patients.
6.2 Review of Literature:
  1. Konradsen L et al(19991) reported significantly altered postural sway(as measured by average distance from the mean center of pressure position) in patients with functional ankle instability.17
  1. Palluel E et al(2008) did a study on elderly population and found out that using spike insoles improved quite standing when there is relatively intact plantar cutaneous sensation.18
  1. Corbin DM et al(2007)conducted a study to find the effect of textured insoles on postural control in double and single limb stance and proved increased afferent information from textured insoles improves postural control in bilateral stance when compared with non textured insoles.19
  1. Meyer PF et al(2004)did a study on role of plantar cutaneous sensation in unperturbed stance in patients with peripheral neruopathies and concluded that the impact of reduced plantar sensitivity on postural control is expected to increase with the loss of additional sensory modalities such as the concomitant proprioceptive deficits commonly associated with peripheral neuropathies.20
  1. Matthew A. Nurse et al(2001) did a study on the effect of changes in foot sensation following attenuation of sensory input from plantar surface on plantar pressure and muscle activity and concluded that cutaneous feedback is important in regulation and modification of gait patterns as the muscle patterns were significantly altered and sensory input needs to be included in any model that attempts to predict motion.21
  1. Hijmans JM et al(2006) did a systematic review and concluded that insoles with tubing or vibratory elements may improve balance, whereas thick or soft soles may deteriorate balance.22
  1. Matthew A. Nurse et al(2005) conducted a study on texture of footwear and its effect on gait patterns and concluded that changes in gait pattern associated with altered muscle activity were due to change in sensory feedback caused by textured shoe insert.23
6.3 Objectives of the study:
To find out the effect of textured insoles on static and dynamic postural stability in chronic ankle instability patients
6.4 Hypothesis:
Experimental hypothesis:
Textured foot orthotics will improve the static and dynamic
Postural stability in adults patients with chronic ankle
instability.
Null hypothesis:
There will be detrimental or no effect by textured foot
orthotics on static and dynamic postural stability in adults
with chronic ankle sprain.
Material and Methods:
7.1 Source of data:
chronic ankle instability patients selected from various sports academies in Mangalore.
7.2 Method of collection of data:
Subjects interested to participate will be asked to visit Srinivas Collage Of Physiotherapy and Research Center and a written consent will be obtained stating voluntary acceptance of the subject to this study. Subjects will be explained about the testing procedure.
Testing Procedure:
Cumberland Ankle Instability Tool is used to measure the functional instability of ankle. A cut off score of 27.5 out of 30 points is used as an inclusion criteria, subjects with score less than the cut off value is considered to have functional ankle instability.24 Control group will consist of same age group healthy subjects without any history of chronic ankle instability, fracture of lower extremity, musculoskeletal injury, neurological or vestibular impairments.
Subjects fulfilling this criterion are selected for posturo-graphic analyses at SCPTRC. To familiarise the research setting with force plate and shoe with insoles 30 minutes warm-up session will be given.
Foot placements:
Prior to the testing, force plate will be marked for exact placement of foot for all trials and testing conditions.
Static balance measurements:
Subjects will be asked to stand on the force plate with single leg support and instructions will be given to stand as still as possible while focusing on a visual target placed 1m in front of them for 10 seconds.
Dynamic balance measurements:
Functional reach test (FRT): Subjects will be asked to stand on both legs and with their feet shoulder-width apart. Then they will be asked to raise their right(dominant) arm horizontal to the ground, The finger location at the starting position of the first trial was recorded and recreated in each trial. Then they will be instructed to extend their right arm and reach as far as they can and come back to standing position at their own speed.
Function reach test (modified single leg) FRTSL:
Wilkerson Et al25 suggested more dynamic method to detect functional instabilities of ankle rather than using one legged balance test which is relatively static task. They further recommended to use the tasks that demand more activation of joint receptors that would be occur in near the end range of motion of joints and where the necessary for neural discharge of joint mechanoreceptors. Hence the functional reach test was modified to single leg reach test
Then they will be asked to stand on one leg(dominant leg in controls and affected leg in patients)and raise their same side arm horizontal to ground. The finger location at the starting position of the first trial was recorded and recreated in each trial. Then they will be instructed to extend their arm and reach as far as they can and come back to standing position at their own speed.
During FRT and FRTSL, COP measures of limits of stability will be measured on the forceplate the simultaneously and cumulated for condition wise. Testing will be done in three conditions as mentioned below:
  1. Barefoot
  2. With plain insole
  3. With grid insole.
The schematic outline of the tasks included in our study is given below:
Static balance:
1] single leg stance
Dynamic balance:
1] functional reach test
2] functional reach test with single leg.
Sampling: Convenient sampling.
Materials to be used:
  1. Bertec force plate
  2. Insoles
  3. Shoes
  4. Modeled foot diagram on forceplate
  5. Pen
  6. Cumberland ankle instability tool
INCLUSION CRITERIA:
  1. Male subjects with history of 2≥ unilateral inversion sprain in the age group of 20-40
  2. Cumberland Ankle Instability Tool score should be less than cutoff value of 27.5
EXCLUSION CRITERIA:
  1. Incidence of ankle sprain in past 3 weeks
  2. Any neurological deficit or other injury to leg that may interfere with proprioceptive acuity
  3. Any medications that can affect the balance.
  4. Visual or vestibular impairments
SATISTICAL ANALYSIS:
  1. Repeated measure ANOVA.
STUDY DESIGN: Experimental study.
7.3 Does the study require any investigations or interventions to be conducted on patients or other humans or animals? If so please describe briefly.
YES. This study intends to find the effect of foot insoles on balance of ankle injured athletes.
7.4 Has ethical clearance been obtained from your institution in case of 7.3?
YES.
Consent has been taken from the college.
8 / List of references:
  1. Gatev P, Thomas S, Kepple T, Hallet M.Feed forward strategy of balance during quite stance in adults.J physiol 1999;513.3:915-28
  2. Anne Shumway Cook. Assessing the influence of sensory interaction on balance. Physical therapy vol 66,number 10,October
  3. Verhegen RAW, de Keizer G, van Dijk CN. Long term follow up of inversion trauma of the ankle. Arch Orthop Trauma Surg. 1995;114;95-96
  4. Hertel J. Functional instability following lateral ankle sprain.Sports Medicine,29,361-371
  5. Tropp H, Odenrick P, Gillquist J. stabilometry recordins in functional and mechanical instability of the ankle joint. International Journal of Sports Medicine 6,180-182.
  6. Birmingham T.B, Chesworth B.M. Peak passive resistive torque at maximum inversion range of motion in subjects with recurrent ankle inversion sprains
  7. Lentell G,Katzman L,Walters M.The relationship between muscle function and ankle stability.JOSPT, 11,605-611
  8. G Waddington, R Adams. Football boot insoles and sensitivity to extent of ankle inversion movement.Br J Sports Med 2003;37:170-175
  9. Solveig A, Vicki S Mercer. Effects of footwear on measurements on balance and gait in women between the ages of 65 and 93 years.physical therapy vol 80,jan 2000
  10. Anne Mundermann, Darren J, Stefanyshyn, Benno M Nigg. Relationship between footwear comfort of shoe inserts and antropometric and sensory factors. Med.Sci.Sports Exerc 2001
  11. Wadddington G, Adams R. Textured insole effects on ankle movement discrimination while wearing athletic shoes
  12. Benno Nigg, Matthew A Nurse. shoe inserts and orthotics for sport and physical activity. Med Sci. Sports Exerc1999,vol31,No7,S421-428
  13. Paiiuel E, Nougier V, Oliver I.Do spike insoles enhance postural stability and plantar-surface cutaneous sensitivity in the elderly.Age(DODR) 2008 Mar;30(1):53-61.
  14. Corbin DM, Hart JM, McKeon PO, Ingersoll CD, Hertel J. The effect of textured insoles on postural control in double and single limb stance. J sports.Rehabil.2007 NOV;16(4)
  15. E Delahant. Neuromuscular contributions to functional instability of the ankle joint. Journal of Bodywork and Movement Therapies, Volume 11, Issue 3, Pages 203-213
  16. Freeman M.A, Dean M.R, Hanham I.W. The etiology and prevention of functional instability of foot. Journal of Bone and Surgery Britain 47,678-685.

Signature
of the candidate
/ 10 /
Remarks of the guide
11 / 11.1 Guide’ name
Designation of the Guide
11.2 Signature
/
DR. RAMPRASAD M.
Assistant Professor in Physiotherapy
11.3 Co-Guide (If Any)
Designation of co guide
11.4 Signature /
DR. RAMA PRABHU K.R.
Lecturer in physiotherapy
11.5 Head of the Department
Designation

11.6 Signature

/
DR.T.JOSELEY SUNDERRAJ PANDIAN
Associate Professor in Physiotherapy
And P.G Coordinator
12 /
12.1 Remarks of Chairman and Principal
12.2 Signature /
DR. RAMPRASAD M.
Principal and associated
professor in physiotherapy

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