EFFECTS OF FLEXIBLE FLAT FEET ON ELECTROMYOGRAPHIC ACTIVITY OF ERECTOR SPINAE

CONCLUSION

Flexible flat feet produce significant increase in EMG activity of erector spinae muscle compared with normal people who hadn’t flat feet.

RECOMMENDATION

A similar study should be conducted on a large  number of patients to provide  a wide representation of the population. Further studies should be done for using other methods of assessment of erector spinae and flat foot .

EFFECTS OF FLEXIBLE FLAT FEET ON ELECTROMYOGRAPHIC ACTIVITY

OF ERECTOR SPINAE

Mohamed H. Rashad*  ;Samah S. Zahran **

andAbdallah M.Kamel ***

* Lecturer in Department of Neurology , faculty of Medicine ,AL-Azhar University

**Lecturer of Physical Therapy for Musculoskeletal Disorders and their Surgeries, Faculty of Physical Therapy, Cairo University; 

*** Demonstrator of  Physical Therapy for Musculoskeletal Disorders and their Surgeries, Faculty of Physical Therapy, Cairo University.

Key Words: Flexible flat feet-Erector spinae –SEMG

ABSTRACT

Background: Flatfoot deformity is a very common deformity among the musculoskeletal deformities, as twenty percent of the populations have a planus or low arched foot.Objective: to determine effect of flexible flat feet on electromyographic  activity of Erector spinae. Methods: forty subjects twenty with flexible flat feet and twenty normal people included in the study ; from students of the faculty of physical therapy ,Cairo University .they were assigned in two groups ; group A (flat foot  subjects ) group B (normal subjects ). Their mean ± SD age, weight, height and BMI were 23.75 ± 2.91 years , 74.85 ± 6 kg , 171.55 ± 5.07 cm, 25.51 ± 2.69 kg/m² and 23.15 ± 1.75 years , 73.2 ± 7.4 kg , 172.1 ± 4.01 cm, 24.73 ± 2.62 kg/ m². Navicualr drop test was used to assess subjects to determine who was flexible flat feet and who had not .Results : There was a significant increase in EMG activity of multifidus in group (A) compared with group( B ).Conclusion :Flexible flat feet  produce significant increase in  EMG activity of Erector spiane muscle compared with normal people who hadn’t flat feet.

INTRODUCTION

Flatfoot deformity is a very common deformity among the musculoskeletal deformities, as twenty percent of the populations have a planus or low arched foot (Williams and Dorsey, 2000;Farokhmanesh et al., 2014). The incidence of flatfoot is high both in children and adolescents which occur as a consequence of various factors such as hypokinesis, overweight, and hereditary factors (Milenkovic et al., 2011).  The most common form of flatfoot is termed a flexible flatfoot (FFF) and is marked by an arch that reappears when the foot is in the non-weight bearing (Letafatkar et al., 2013). It is present in most infants, children and many adults (Leunge et al., 1998; Mosca, 2010; Harris, 2010). Harris and Beath (1947) found that at least 20% of adult have flatfoot and that flexible

flatfoot accounts for approximately two-thirds of all flatfoot.  Lately, the term abnormal or excessive pronation has been utilized to describe a flexible pes-planus that results in hypermobility upon weight bearing (Donatelli,  1996). In the flatfoot, the head of the talus is displaced medially and planter ward from    the navicular, resulting in the loss of the medial longitudinal arch (MLA) (Franco, 1987; Rodgers, 1995; Van Boerum and Sangeorzan, 2003).Excessive foot pronation may contribute to structural and performance deficiencies in standing and walking (Pinto et al., 2008). In standing, subtalar joint pronation is correlated with internal rotation of the tibia (Raming et al., 1980; Klingman et al., 1997; Stergiou and Bates, 1997; Khamis and Yizhar, 2007), that is correlated with knee valgus and flexion which leads to internal rotation of the femur (Cote et al., 2005; Souza et al., 2009; Souza et al., 2010; Resende et al., 2014) and consequently results in increased pelvic ante version (Khamis and Yizhar, 2007;  Pinto et al., 2008). Pelvic posture, acting as an intermediate between the spinal column and the lower extremities, is the main key to suitable postural alignment (Poussa et al., 2005) and has a significant association with lumbar vertebral posture (Levine and Whittle, 1996). Abdel-Raoof et al. (2013) found that subjects with bilateral flexible flatfoot have more pelvic anteversion and lumbar lordosis and Tateuchi et al. (2011) and Farokhmanesh et al. (2014) found that with increased bilateral foot pronation, lumbar lordosis and thoracic kyphosis increase as well. Maintained excessive foot pronation during weight-bearing activities causes internal rotational stresses at the lower extremity that may alter movement patterns and muscle balance at proximal joints (Tiberio, 1988; Fonesca et al., 2007) .  It is widely believed that a person with a postural pes-planus foot type has an increased susceptibility to mechanical overloading of their leg and/or foot structures (Hunt and Smith, 2004). Pes-planus and its associated relatively low medial longitudinal arch have been linked to a range of conditions including metatarsal stress fractures (Simkin et al., 1989), plantar fasciitis (Heil, 1992), achilles tendinitis (Clement et al., 1981), tibialis anterior inflammation (Wallensten and Eriksson, 1984), patellofemoral joint pain and medial tibial stress syndrome (Neal et al., 2014) and  low back pain (LBP) (Cibulka, 1999; Menz et al., 2013).. Bogduk (2005) postulated that erector spinae muscles are more likely to act to stabilize the lumbar region against ‘the unwanted flexion unavoidably produced by the abdominal muscles’ during rotation of the thorax.  Imaging studies of the erector spinae  and other muscles have demonstrated pathological changes that are associated with other spinal abnormalities such as chronic LBP (Flicke et al., 1993; Parkkola et al., 1993) disc herniation (Zhao et al., 2000 ) scoliosis (Chan et al., 1999) and degenerative lumbar kyphosis( Kang et al., 2007).Kader et al. (2000) found that 80% of LBP patients examined had atrophy of lumbar erector spinae muscle. It is thus evident to us the importance of early assessment and then treatment of erector spinae.

The purpose of the study   is To investigate the effect of the flexible flat foot on electromyographic activity of erector spinae muscle during standing.

METHODS

Design of the study:

Forty subjects (male and female) were recruited to share in this study. Sample size calculation was performed using G*POWER statistical software (version 3.1.9.2; Franz Faul, Universitȁt Kiel, Germany) (Faul et al, 2009) and revealed that the appropriate sample size for this study was N=40 which gave observed power equal to 0.8. Calculations were made using α=0. 05, β=0.2 and an effect size of 0.8. Twenty flexible flatfeet patients will be assigned to group A (experimental) and twenty normal subjects were assigned to group B (control). All subjects read and signed a consent form prior to the beginning of testing for ethical issues. Subjects were recruited based on the following inclusion and exclusion criteria: 

Inclusion criteria:

• Age of the subjects between 18-35 years.
• BMI will be less than 30 kg/ m2, as the amplitude, time and frequency domain properties of the SEMG signal are affected by the thickness of overlying skin and adipose tissue. The more superficial the muscle and the lesser the amount of subcutaneous adipose, the greater the SEMG amplitude (Gerdle et al., 1999).
• Subjects in group A will be included if they have more than 10 mm difference on navicular drop (ND) Test.
• Subjects in group B will be included if they have less than 10 mm difference on ND Test.

Exclusion criteria:

Subjects will be excluded if they have:

• History of congenital deformity or surgery in the lower extremities and trunk.
• Recent injury to the lower extremities or back
• Regular practice of physical activity, in a frequency of 3 times a week or greater.
• Neurological diseases

Instrumentation and procedures

Navicular Drop Test (NDT) ;Brody (1982) introduced the static ND as a measure to evaluate the MLA. ND has a goodintrarater reliability (Muller et al., 1993 and Vauhnik et al., 2006). Sell et al. (1994) found high intraclass correlation coefficients (ICC) reported for both intertesterand intratester reliability (0.83and 0.73 respectively). When compared to X-ray examination of the foot, the ND showed good intratester reliability and moderate intertester reliability (Hanningan-Downs et al., 2000). ND has been found to be a valid indicator of radiographic arch height indices (Saltzman et al., 1995) and a valid clinical predictor of dynamic rearfoot motion (McPoul and Cornwall, 1994). Muller et al. (1993) suggested that 10mm is the upper limit for the normal ND; Leodon et al. (1996) stated that ND of 6-9 mm was considered to be within the normal range and that ND greater than 10 mm was considered abnormal.

Procedures of Navicular Drop Test:

• The subject were placed in a sitting position with their feet flat on a firm surface and with the knee flexed to 90° and ankle joints in neutral position.
• The most prominent point of the navicular tubercle while maintaining subtalar neutral position will be identified and marked with a pen.
• Subtalar neutral position was established when talar depressions were equal on medial and lateral side of the ankle
• While maintaining subtalar neutral position, index card will be placed on the inner aspect of the foot, with the card placed on the floor in a vertical position passing the navicular bone. The level of the most prominent point of the navicular tubercle was marked on the card .
• The individual was then asked to stand without changing the position of the feet and to distribute equal weight on both feet. In the standing position, the most prominent point of the navicular tubercle relative to the floor was again identified and marked on the card.
• Finally, the difference between the original height of the navicular tubercle in sitting position and weight-bearing positions was  assessed with a ruler rendering the ND amount in millimeters.

Surface Electromyography (SEMG)

To assess muscular activation patterns in musculoskeletal disorders by measuring amplitude of muscle activity (Lehman et al., 2004; Lewis et al., 2009).

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Procedures for measuring  muscles activity

Participant’s position and electrode placement:

           Participants will be asked to stand erect with their arms at their side and the head was in the midline .The skin will be shaved, rubbed and cleaned with alcohol, fixation of the electrode using elastic band /rings or tape. To record muscle activity, Surface electrodes will be placed in direction of muscle fibers. Electrodes placement to collect EMG signals were as follow:

The surface electrodes for  Erectorspinae right and left sides (RES, LES) were placed parallel to the L3 level of the spine, 3 cm lateral from the spine.

• Bipolar electrode with interelectrode distance 20mm, reference electrode will be placed on the right wrist (Ghofrani et al., 2017).

RESULTS

          Normal distribution of data was checked using the Shapiro-Wilk test for all variables. Subject characteristics were compared between both groups using t test. Chi- squared test was used for comparison of sex distribution between groups. Unpaired t test was carried out for comparison of navicular drop and EMG amplitude of erector spinae between both groups. The level of significance for all statistical tests was set at p <0 .05. All statistical analysis was conducted through the statistical package for social studies (SPSS) version 19 for windows (IBM SPSS, Chicago, IL, USA).

Subject characteristics:

          Table 1 showed the subject characteristics of the flat foot and normal groups. There was no significant difference between both groups in the mean age, weight, height and BMI (p > 0.05). Also, there was no significant difference in sex distribution between groups (p = 0.7).

Table 1.Subject characteristics.

, Mean; SD, standard deviation; MD, Mean difference; χ², Chi squared value; p-value, level of significance. *Non significant

- Comparison of navicular drop between flat foot and normal groups:

There was a significant increase in the right and left navicular drop in the flat foot group compared with that in normal group (p < 0.001).

Table 2. Comparison of navicular drop between flat foot and normal groups:

, Mean; SD, standard deviation; MD, Mean difference; p-value, level of significance; ** Significant.

-  Comparison of EMG amplitude of Erector spinae between flat foot and normal groups:

There was a significant increase in the EMG amplitude of erector spiane in the flat foot group compared with that of normal group (p < 0.001).

Table 3. Comparison of mean EMG amplitude of erector spinae between flat foot and normal groups:

, Mean; SD, standard deviation; MD, Mean difference; p-value, level of significance; ** Significant.

DISCUSSION

        This study was conducted To investigate the effect of the flexible flat foot on electromyographic activity of Erector spinae muscle during standing.

The results of the present study  showed that there was significantincrease in EMG amplitude of Erector spiane in the flat foot group compared with that of normal group.the results of our study explained by  the results of Trontelj (1993), there are changes in latency and propagation velocity of muscle fiber responses induced by changes in their length, in which, there is an increase in propagation velocity on shortening of the muscle fiber and a slowing on its lengthening. ). Abdel-Raoof et al. (2013) found that subjects with bilateral flexible flatfoot have more pelvic anteversion and lumbar lordosis and Tateuchi et al. (2011) and Farokhmanesh et al. (2014) found that with increased bilateral foot pronation, lumbar lordosis and thoracic kyphosis increase as well .Sarti et al. (1996) demonstrated that the position of the pelvis influences the activation of the trunk and hip muscles.. Our results agreed with  Bird et al (2003)  showed  that foot wedging can produce changes in muscle activity within the low back and pelvis during the gait cycle, trunk muscles had  significantly earlier onset of muscle activity with bilateral heel lifts and the bilateral lateral forefoot wedge conditions.and  also with Barton CJ¹et al,(2009 ) showed that  A significant increase in activity of trunk muscles was found immediately upon application of the heel lifts following heel strike.on the other hand  Zahran et al.(2017) were the first to evaluate the changes in proximal muscle torque of the trunk and hip in subjects with bilateral FFF, they found a significant decrease in their hip muscles torque compared to normal controls but they failed to find a significant effect on trunk muscles. They recommended assessing the trunk muscles with different methods.

CONCLUSION

Flexible flat feet produce significant increase in EMG activity of erector spinae muscle compared with normal people who hadn’t flat feet.

RECOMMENDATION

A similar study should be conducted on a large  number of patients to provide  a wide representation of the population. Further studies should be done for using other methods of assessment of erector spinae and flat foot .

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تأثیر القدم المسحاء اللینة على رسم  العضلات الناصبه للفقار

محمد حامد رشاد * ، سماح سعد زهران ** ، عبدالله محمد کامل ***

*مدرس بقسم الاعصاب کلیه الطب جامعه الازهر

** مدرس العلاج الطبیعی لاضطرابات الجهاز العضلى الحرکى وجراحته ، کلیة العلاج الطبیعی ، جامعة القاهرة.

*** معید بقسم الاضطرابات الجهاز العضلی الحرکی وجراحته .کلیه العلاج الطبیعی.جامعه القاهره

نبذه مختصره

خلفیه : القدم المسحاء اللینه  تعتبر تشوه شائع من ضمن تشوهات الجهاز العضلی الحرکی حیث ان نسبه عشرین بالمئه من البشر یوجد عندهم هذا التشوه.

الهدف : تحدید تاثیر القدم المسحاء اللینه علی رسم العضلات ناصبه للفقار. 40 شخص تم تقسیهم الی مجموعتین  مجموعه أ( ثنائیه قدم مسحاء) ومجموعه ب ( اشخاص طبیعین ) والاشخاص تم ضمهم من طلیه کلیه العلاج الطبیعی جامعه القاهره . بلغ متوسط ​​العمروالوزنوالطولومؤشرکتلةالجسمالمتوسطة 34.75   ±2.91 سنه ‘ 74.85 ± 6 کجم ‘ 171.55 ± 5.07 سم  ‘ 25.51 ± 2.69 کجم /  متر مربع و  23.15 ± 1.75 سنه ‘ 73.2 ± 7.4 کجم ‘ 172.1 ± 4.01 سم  ‘   24.73 ± 2.62 کجم /  متر مربع . تم عمل اختبار سقوط العظمه الزورقیة فی القدم للتفریق بین المجموعتین.

النتائج : هناک زیاده فی رسم العضلات للعضلات  النصابه للفقار فی القدم المسحاء اللینه مقارنه بالمجموعه ذات القدم الطبیعیه .

الخلاصه : القدم المسحاء اللینه تسبب فی زیاده رسم العضلات للعضلات الناصبه للفقار

الکلمات الداله : القدم المسحاء اللینه – العضلات الناصبه للفقار – رسم العضلات