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Toe functions have little effect on dynamic balance ability in elderly people

Discussion in 'Biomechanics, Sports and Foot orthoses' started by scotfoot, Mar 23, 2017.

  1. scotfoot

    scotfoot Well-Known Member


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    I recently came across a paper below (1) which looked at the foot and balance in the elderly . The authors used a machine which measured the ability of the toes to apply force whilst curled around a bar as one of their main measures of toe function .

    It is my understanding that toe curls do not measure the toe flexing strength of the intrinsic muscles of the foot ,which are known to be recruited in response to postural demand and also vestibular (balance related ) efferents .

    In my opinion ,what results of this paper seems to be suggesting is that differences in the strength of the EXTRINSIC toe flexors have little effect on the dynamic balance ability in elderly people . It says nothing about the INTRINSIC toe flexors .


    Gerry


    (1)
    Toe functions have little effect on dynamic balance ability in elderly people


    Yoshinobu Yoshimoto, RPT, PhD,1,* Yukitsuna Oyama, RPT,2 Mamoru Tanaka, PhD,3 and Asuka Sakamoto, RPT, MA1 2017
    LINK
    Toe functions have little effect on dynamic balance ability in elderly ...

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300830/
    by Y Yoshimoto - ‎2017
    30 Jan 2017 - Maintaining and increasing dynamic balance ability are important factors in fallprevention. Toe function is one factor that relates to dynamic ...
     
  2. scotfoot

    scotfoot Well-Known Member

    With regard to toe flexor function and the intrinsic foot muscles ,it would appear from the evidence presented by two recent papers , (1) and (2) , that many exercises commonly used to strengthen the intrisic flexors cannot be described as being clearly effective . These commonly used exercises ,of no clear clinical value , include the short foot exercise ,toe curls and calf raises . It would seem that the only truly effective exercise to strengthen the intrinsic toe flexors , in a partially isolated fashion , involves the movement of the toes around the MTFJ against increasing resistance . (1)

    (1)
    Efficacy of a progressive resistance exercise program to increase toe ...

    https://www.ncbi.nlm.nih.gov/pubmed/27780109
    by KJ Mickle - ‎2016 - ‎Related articles
    Mickle KJ(1), Caputi P(2), Potter JM(3), Steele JR(4). ... resistance training program, focused specifically on the foot muscles, could improve toe flexor strength in ...

    (2)
    Strength Training for Plantar Fasciitis and the Intrinsic Foot Musculature

    https://www.ncbi.nlm.nih.gov/labs/articles/27692740/18 Aug 2016 - Strength Training for Plantar Fasciitis and the Intrinsic Foot Musculature: A ... in the treatment of plantar fasciitis and improving intrinsic foot musculature strength. A search ofPubMed, CINHAL, Web of Science, SPORTSDiscus, ...
     
  3. scotfoot

    scotfoot Well-Known Member

    If toe curling type exercises ,particularly against increasing levels of resistance resistance , produce strengthening of the external toe flexors and quadratus plantae but not of any of the other intrinsic toe flexor muscles , then is their not a possibility that this type of exercise will produce or exacerbate the sort of muscle imbalances thought to be associated with toe deformities ?
     
  4. scotfoot

    scotfoot Well-Known Member

    With regard to marble pick ups as a strengthening exercise for the toes I feel a relevant question might be as follows. Do the toes need to exert more force to grip and pick up a marble than they do to crush a grape ? If the answer is no then , in my opinion , you really have to question the value of this exercise for some applications .

    Gerry
     
    Last edited: Apr 6, 2017
  5. scotfoot

    scotfoot Well-Known Member

    So looking at the posts above ,and Mickle apart ,its mostly a bit negative . So what else does work ? What exercise provides strengthening of the intrisic toe flexors as well as the extrisic toe flexors and does not involve a toe curling action ?

    Very obviously this paper (1) shows an isometric hold exercise which works ( see below - a full PDF can be downloaded by following the link .

    A quote from their abstract is " TFM responded highly to increased loading within a few weeks. The increased force potential made a contribution to an athlete's performance enhancement. " Note TFM -toe flexor muscles

    Link to researchgate were PDF can be downloaded
    (1)
    The Potential of toe flexor muscles to enhance performance (PDF ...

    https://www.researchgate.net/.../232736221_The_Potential_of_toe_flexor_muscles_to_e...The Potential of toe flexor muscles to enhance performance. Article (PDF Available) ..... isometricplantar flexion contractions of toe flexor. muscles (MPJ angle at ...
     
    Last edited: Apr 8, 2017
  6. scotfoot

    scotfoot Well-Known Member

    With regard to the timed up and go test commonly used to assess an older persons static and dynamic balance ,should some weighting not be given to trials in which the subject would have fallen but for researcher intervention (fall events )? My understanding is that ,at present , it is common to ignore trials which result in " fall events " and give the subject another go .
    Generally ,older people will proceed at a pace that they know suites their abilities . If you put the clock on them and tell them that "fall events" won't count then they will press and falls are more likely . Would it not make more sense to include these "falls events" in the test results ?

    After all , if you are testing for the likely-hood of falls in older people ,should the test you use expressly ignore falls ??
     
  7. scotfoot

    scotfoot Well-Known Member

    With regard to the timed up and go test , and the paper included below , and after a bit of digging around on the internet , things are a good deal clear to me with regard to the timed test used by the researchers in this case .
    In general the timed up and go test involves asking the subject to stand ,walk a certain distance ,turn ,walk back and sit down . In every example I can find the subject is told to complete the test at a comfortable pace which makes falling unlikely . However in the paper (below ) the instruction given to the subjects was " A researcher instructs the participant to walk as fast as possible without falling. "
    Why the departure from the norm ?


    Paper
    Toe functions have little effect on dynamic balance ability in elderly ...

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5300830/
    by Y Yoshimoto - ‎2017
    30 Jan 2017 - Maintaining and increasing dynamic balance ability are important factors in fallprevention. Toe function is one factor that relates to dynamic ...
     
  8. efuller

    efuller MVP

    I'm having visions of old folks training to beat the record for timed up and go test. Another vision of young people lying about their age so they could steal the trophy. Another vision of scientists analyzing the up and go test to see what factors are most important for time improvement to help their seniors beat the record. I bet they would find that ankle plantar flexor strength is a lot more important than toe flexor strength. Especially at the critical turn, before returning to the chair.
     
  9. scotfoot

    scotfoot Well-Known Member

    Eric ,
    I would argue that in terms of exercise based interventions in the elderly designed to reduce falls , the ankle plantar flexors are much less important than the intrinsic muscles of the foot . For example the REFORM project ,which included ankle strengthening exercises but not intrinsic strengthening exercises , did not really make much of an impression on falls in the elderly subject group ( the ball squeeze and pick up can be discounted as a progressive strengthening exercise ) .

    Regardless of their relative overall contributions to balance , and in terms of of falls prevention , I strongly suspect that you will get far more bang for your buck from PROGRESSIVE strengthening of the intrinsics than you will from all the intervention methods included in the reform trial combined . And that is based on the REFORM results .

    Cohort Randomised Controlled Trial of a ... - University of York

    https://pure.york.ac.uk › Research › York Research Database › Publications 20 Jan 2017 - Cohort Randomised Controlled Trial of a Multifaceted Podiatry Intervention for thePrevention of Falls in Older People (The REFORM Trial).
     
  10. scotfoot

    scotfoot Well-Known Member

    To clarify the above , the REFORM trial looked at falls in two groups of older people ,one with the intervention (orthitics ,new shoes if required and ankle and foot exercise ) and one group without . Both groups also had normal podiatry care and a falls leaflet . In the final analysis there was little difference between the two with regard to falls .

    My main focus here is on the exercise program used in the intervention . Progressive strengthening exercises were used for the ankle but not for the intrinsic muscles of the foot . Based on the Reform results ,I believe that progressive strengthening exercises for the ankle will have little effect on falls .However , since recent experimentation has indicated that at least two of the intrinsic foot muscles can be regarded as organs of balance , with direct links to the vestibular apparatus , it seems very likely that strengthening these , sarcopenia affected muscles ,will have a big impact on balance and on falls reduction in older people .

    The conclusions of Yoshinobu Yoshimoto, et al (above ) , that toe function has little effect on dynamic balance ability , and that this is likely to be a factor in falls ,is contradicted in the literature by more direct evidence . The link between toe function and falls has been clearly demonstrate by Dr Karen Mickle and her co workers .

    Mickle has also recently shown that the toe flexor strength of older adults can be restored to levels comparable to younger adults by progressive resistance training ( but NOT by traditional exercises such as towel curls .marble pick ups ,calf raises and the short foot exercise ) and so ,in my opinion ,restoring their ability to act effectively as organs of balance .

    With regard to podiatry based interventions for falls prevention in the elderly , progressive intrinsic muscle strengthening is the elephant in the room .
     
  11. Cyrilg

    Cyrilg Member

     
  12. Cyrilg

    Cyrilg Member

    How about a good old fashioned exercise. I used to get my patients to find a table or chair. Then push down with their arms which brings them up on the toes. Strengthens the whole of the foot muscles and the leg muscle. Now a pensioner myself I do this every day . Keeps my balance and improves my walking.
     
  13. efuller

    efuller MVP

    My comment was directed at improving timed up and go test. Which is correlated with falls, but not the same thing as prevention of falls.

    Falls are multi factorial. There is the vestibular system, and eyesight, which lets you know that you are falling and then there is having the strength to move your limbs quickly enough to prevent the falls.


    You seem to be making the claim that strengthening the muscles makes them a better organ of balance. Practice at proprioception might make the foot a better sensory organ, but I don't see how strengthening the muscle would make it a better sensor. Did the study you referred to, where two muscles could be considered as sensory organs show that those two muscles were better than other muscles or just that those muscles provided sensory feed back. You would think that all muscles provide sensory feedback. I would make the case that sensing sway at the ankle would be more important for balance than sensing motion at the MPJ's.
     
  14. scotfoot

    scotfoot Well-Known Member

    Without meaning any disrespect the evidence strongly suggests that the exercise you suggest does little if anything for balance , ( the REFORM protocol includes unassisted calf raises ) , and does not strengthening the intrinsic muscles of the foot .
     
  15. scotfoot

    scotfoot Well-Known Member

    Hi Eric
    " My comment was directed at improving timed up and go test. Which is correlated with falls, but not the same thing as prevention of falls. " Fair enough .

    My understanding is the the recently established direct link between the vestibular apparatus (VA) and the abductor hallucis and the digiti minimi muscles does not involve the said muscles in a sensory capacity but as force generating agents of balance modulated by the VA . If these muscles are not strong enough do the job asked of them then it stands to reason that this aspect of balance will be impaired .


    PAPER -----
    VESTIBULAR MODULATION OF THE ABDUCTOR
    HALLUCIS AND THE ABDUCTOR DIGITI MINIMI
    MUSCLES IN RESPONSE TO CHANGES IN HEAD
    POSITION, VISUAL CUES, AND COGNITIVE DEMAND
    by
    JONATHAN W. WALLACE
    A THESIS
    Presented to the Department of Human Physiology
    and the Robert D. Clark Honors College
    in partial fulfillment of the requirements for the degree of
    Bachelor of Science
    June 20
    Link
    VESTIBULAR MODULATION OF THE ABDUCTOR HALLUCIS AND ...

    https://scholarsbank.uoregon.edu/xml...dle/1794/20383
    by J Wallace - ‎2016
    7 days ago - The purpose of this experiment was to determine if intrinsic foot musclesare modulated by vestibular activity and to elucidate any changes in the association ...
     
  16. efuller

    efuller MVP

    What job do you expect these muscles to do? These are relatively small muscles that may not change the location of the center of pressure under the foot when they are at their strongest. Also this paper did not look to see if other muscles are also modulated by stimuli affecting the vestibular system. There still could be the same modulation in other muscles that were not examined.
     
  17. scotfoot

    scotfoot Well-Known Member

    "What job do you expect these muscles to do?" and " There still could be the same modulation in other muscles that were not examined" .
    I would be very surprised if other intrinsic muscles did not also have direct control from the vestibular apparatus and the quote ,below, from the paper is worth considering .
    page 7

    "Muscles which are tonically active, but not involved in
    maintaining balance do not exhibit a vestibular myogenic response (Britton et al. 1993;
    Forbes et al. 2015). Therefore, it appears that vestibular-evoked muscle responses only occur in those muscles important to maintaining the upright postural task. "
     
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