Study of Neuromuscular and Proprioceptive Training Program on Postural Stability in Active Middle-Aged Men

authors:

avatar Mohammadreza Rezaeipour ORCID 1 , * , avatar Vladimir Ivanovich Nychyporuk 2

Department of Sports Sciences, University of Sistan and Baluchestan, Zahedan, Iran
Ukrainian Center for Sports Medicine, Kiev, Ukraine

how to cite: Rezaeipour M, Nychyporuk V I. Study of Neuromuscular and Proprioceptive Training Program on Postural Stability in Active Middle-Aged Men. Middle East J Rehabil Health Stud. 2019;6(1):e84958. https://doi.org/10.5812/mejrh.84958.

Abstract

Background:

The risk of falling increases with age, and the outcome might sometimes be severe injury or even death.

Objectives:

This study was designed to determine whether a 12-week neuromuscular and proprioceptive training (NPT) plan was impressive on postural stability of active middle-aged men.

Methods:

The study had a quasi-experimental design with a control group. In 2016, 50 middle-aged males of the Ukrainian Sports Medicine Center (Kiev) were randomly divided to experimental (performed the NPT program, rather than general warm-up routines) and control groups (maintained the general warm-up routines). The mean center of pressure (CoP) fluctuations of postural stability was assessed during eyes open (EO) and closed (EC) using a force platform in the two directions, before and after the 12-week study.

Results:

The intervention leads to a significant improvement in the mean CoP velocity in both planes (P < 0.05) in the experimental group compared to the control. All CoP parameters used in this study showed very large correlations.

Conclusions:

The NPT program had a positive effect on postural stability. This may have a direct impact on reducing lower limb injury in middle-aged men.

1. Background

Elderly people population have increased over the recent years (1). Older age leads to stability problems more than younger people because of the decline in proprioception and motor skills (2-4). Falling is an everyday occurrence, and severe injury or even death can sometimes be the result (5, 6). Regular exercise is one of the main measures to improve the postural balance (7, 8). For example, physical exercise, including aerobics (9), anaerobic (10), and aquatic exercise (11, 12) has been shown to increase postural stability in grown-up people. neuromuscular and proprioceptive training (NPT) contains a combination of balancing, strengthening, plyometrics, agility, running, and stretching exercises (13).

Integrating the NPT into the warm-up (14-16) is widely used in some young athletes. It has not been established whether integrating the NPT program in routine exercise sessions improves the balance ability of older men and reduces the incidence of lower extremity injuries. There was no evidence in this regard. Therefore, the current study was conducted to determine the effectiveness of NPT rather than general warm-up routines in reducing the postural instability in middle-aged men. Postural stability is typically analyzed using a force platform during static conditions (quiet standing) by quantitative measurement of displacements of the center of pressure (CoP) of the body in the mediolateral (med-lat) plane and anteroposterior (ant-post) planes (17-19). The parameters of CoP (i.e. CoP velocity) can be classified as related to postural motion in order to maintain stability (20).

It was hypothesized that a 12-week NPT program improves men’s postural stability in the middle age category. If the hypothesis of the study proves to be true, there will be another option to improve postural stability in older adults.

2. Methods

This study had a quasi-experimental design with random and parallel groups. Fifty active men aged from 45 to 65 years old (56.5 ± 3.6 years) were voluntarily enlisted among the Ukrainian Sports Medicine Center (Kiev), who had at least three sessions of exercise a week. Participants were randomly divided to two groups, including experimental and control groups (22 participants in each group). They were excluded if they had notified any of the succeeding states: Parkinson's symptoms, neurologic diseases, diabetes, cardiovascular diseases, and diseases of the musculoskeletal device, such as waist pains and lower extremity pains. Ethics approval was obtained, and informed consents were approved by the institutional research ethics committee [NMAPE, (2016) No. 04112-12]. Every participant was informed of this research and provided a signed informed consent before data collection. During the study, participants, who had an illness and those, who were taking medications were excluded from the study.

The NPT program consists of a combination of different types of exercises, such as balancing, dynamic, plyometrics, strengthening, stretching and agility exercises, not taking in account special sports exercises (21). The experimental group performed the NPT protocol, 20 minutes from the beginning of every exercise session (rather than general warm-up routines) and were then followed by 45 minutes of weight training exercises similar to the control group. Parts of the NPT program are presented in Table 1.

Table 1.

Components of the Neuromuscular and Proprioceptive Training Program

ExerciseDistanceRepetitions/Time
Warm-up
Shuttle run45 m1
Backward running45 m1
Stretching
Calf stretch-2 × 30 s
Quadriceps stretch-2 × 30 s
Hamstring stretch-2 × 30 s
Inner thigh stretch-2 × 30 s
Hip flexor stretch-2 × 30 s
Strengthening
Walking lunges18 m2 passes
Single-toe raises-30, bilaterally
Plyometrics
Lateral hops2- to 6-in cone30 s
Forward hops2- to 6-in cone30 s
Single-legged hops2- to 6-in cone30 s
Vertical jumps-30 s
Scissors jumps-30 s
Agilities
Diagonal runs36 m1
Bounding runs41 m1

Members of the control group maintained their past exercise program (20-minute general warm-up routines comprising of dynamic, strength, and stretching exercises for the whole body and then 45 minutes of weight training exercises). These participants performed the exercise with another instructor during the intervention period. Exercise sessions conducted in both groups were similar and three times a week. Both groups performed a 10-minute cool-down. The 45-minute weight training exercise was based on the guidelines of American College of Sports Medicine (ACSM) and American Heart Association (AHA), which were modified with respect to the age of participants (22, 23).

Postural stability was checked in med-lat, ant-post plans under quiet standing on a foam mat with a force plate (Kistler Instrumente AG, Winterthur, Switzerland) before and after the 12-week intervention period for every participant. Subjects stood on the force plate with shoes and were instructed to stand normally as they would at home or at work (18, 19). Each participant performed a total of two trials of quiet stance with eyes open (EO) and closed (EC) within 30 seconds, and CoP was registered with a frequency of sampling of 200 Hz (18, 19). During the test, the participant observed front of himself a quadrilateral black symbol (2 × 2 cm) at a distance of two meters for the eyes open measurement. There was a five-minute rest period between each trial. The research method did not change during the study. To avoid losing participants, they were interviewed by using a questionnaire every month during the intervention. Participants were instructed to report any problems that could affect their involvement in the study.

Average of the two tests have been applied to statistical analysis (18, 19). Kolmogorov-Smirnov's test confirmed the normality of the distribution of data. For comparison of experimental and control groups, an independent t-test was used. The repeated measure analysis of variance (ANOVA) was carried out to assess the combined effect of the NPT program (experimental and control). The significance level was set at P < 0.05. Effect size was calculated and was interpreted to assess the impact of the NPT on the postural stability as ‘large’ (d > 0.8), ‘medium’ (0.2 < d < 0.5), and ‘small’ (d < 0.2) by Cohen (24, 25). intra-class correlations (ICC), coefficient of variation (CV) values and 95% confidence interval (CI) were calculated to assess intra/inter-session reliability. The ICC was categorized as follows: Excellent (0.75 to 1), moderate (0.4 to 0.74), and poor (0 to 0.39) (24). The statistical analysis was performed with SPSS (version 24.0; SPSS Inc.; USA) for windows.

3. Results

The sample size was obtained by Cochran's sample size formula for 0.05 (error of 5%). Forty-four (22 in the experimental and 22 in the control group) of 50 participants underwent the 12-week intervention (88%). Mean age, height, body weight, and body mass index (BMI) in the experimental group at baseline were 57.3 ± 2.3 years, 1.68 ± 0.1 m, 71.1 ± 8.8 kg, and 25.3 ± 2.8 kg/m2, respectively, and those of the control group were 55.2 ± 4.8 years, 1.7 ± 0.1 m, 73.5 ± 7.4 kg, and 26.1 ± 2.4 kg/m2, respectively. Significant differences in initial characteristics of participants between groups weren't found (P > 0.05). Researcher’s pre-test and post-test were identical. Before the study, no significant difference was found between experimental and control groups for mean CoP velocity in med-lat and ant-post planes (P > 0.05). Postural data are presented in Table 2.

Table 2.

Postural Parameters in the Form of Mean (SD) in Different Sensory Conditions (Eyes Open and Eyes Closed)

ParameterConditionGroupPretestPost-testCohen's d Effect SizeICC Value
Med-Lat mean velocity, cm/sEOExperimental0.99 (0.11)0.81 (0.07)0.61aVery large
Control0.92 (0.19)0.87 (0.12)
ECExperimental1.02 (0.11)0.87 (0.08)0.72aVery large
Control1.01 (0.12)0.94 (0.11)
ANT-POST mean velocity, cm/sEOExperimental0.93 (0.15)0.85 (0.17)0.18Very large
Control0.95 (0.16)0.88 (0.15)
ECExperimental1.23 (0.15)0.95 (0.16)0.19Very large
Control1.19 (0.13)0.98 (0.14)

The med-lat results proved a significant difference between the two groups in the post-test, under EO and EC (P < 0.05). In comparison, both groups were significantly different from their baseline (P < 0.05). Furthermore, Cohen’s effect size value during the two conditions suggested a moderate to high powerful significance.

Comparisons of ant-post results between the two groups did not show a significant difference in the post-test and in EO and EC (P ≥ 0.05). In comparison, the two groups were significantly different from their baseline (P < 0.05). Furthermore, Cohen’s effect size value during both conditions suggested a low powerful significance.

3.1. Intra-Session Reliability of COP Parameters

Med-lat average speeds in both visual conditions were substantially reliable (ICC = 0.60 to 0.91) and obtained very large ICC values. The CVs for this parameter was between 16% and 22% in eyes open and eyes closed (mean CV = 17 to 22%). Ant-post average speed also proved reliable (ICC = 0.62 to 0.81) in this study and had a very large correlation values in the eyes open and eyes closed. The CVs for this parameter ranged from 19% to 28% in both visual conditions (mean CV = 19 to 22%). A minimum difference was seen in the eyes open (ICC = 0.73 t0 0.83) and eyes closed (ICC = 0.73 to 0.86) throughout all CoP parameter's intra-sessions.

3.2. Inter-Session Reliability of COP Parameters

Average speeds of med-lat and ant-post (ICC = 0.57 to 0.91 & 0.66 to 0.91, respectively) were the most reliable parameters and obtained very large ICC values in both visual conditions. The CV values of these two parameters followed a similar trend to that seen in intra-sessions, varying from 17% to 22%. All CoP parameters showed consistently higher ICC values when eyes were closed inter-sessions (ICC in EC = 0.79 to 0.86, ICC in EO = 0.74 to 0.81).

4. Discussion

The present study results confirmed the hypothesis that 12 weeks of NPT will benefit middle-aged men. Numerous studies have shown that CoP mean velocity increases in biological aging, and aging is known to cause impaired postural stability (25-27). The slowdown recognized in this research is opposed to be age-related changes in CoP. As the average velocity of CoP is reliable (28) and a sensitive (29, 30) measure of CoP velocity displacement, the extant results are likely show that NPT positively affects postural stability, thereby validating the hypothesis of this research.

The training program and the time of each exercise session were the same in both groups, except the warm-up. Therefore, members of both groups had the same measurement conditions after each exercise session. The slowdown of CoP fluctuation after NPT occurred mainly in the med-lat plane. Earlier investigations showed that improved postural fluctuations in the med-lat plane are more strongly connected with balance deficiency following an increase and fall in age than postural fluctuation in the ant-post plane (31). Therefore, the present outcomes provide additional support of the idea that the NPT has positive effects on postural stability.

The sensorimotor system is due to the integration of sensory information (vestibular, visual and somatosensory systems) and provides stability of posture in quiet standing (32, 33). Amid these systems, it is assumed that proprioception of the lower extremity is one of the principal factors in control of the equilibrium in quiet standing (33, 34). Proprioception sensitivity of the lower extremity worsens with usual aging (35), and this deterioration has resulted in rising postural fluctuations and falls (35, 36). The velocity of nervous conductivity also reduces in normal aging (26, 37), and this reduction contributes to slow down of muscle reactions to postural perturbation, consequently increasing postural fluctuation (37, 38).

Some researchers consider that one of the factors promoting the rise in proprioceptive sensitivity (11, 26, 39) and velocity of nervous conductivity (11, 26, 40) by physical exercises is the temperature increase of the body. In this way, the beneficial effects of exercises may not last very long. The results of the present study are not consistent with these findings. The study groups performed a 20-minute warm-up for each exercise session, yet their results were different after 12-week. This suggests the NPT has more positive effects than the rise in body temperature. It could potentially compensate age-deterioration in mechanisms of postural control, thereby the postural stability improved and remained for a long time. Paillard Thierry also believed that non-intensive general and local exercises can also disturb postural control due to muscle fatigue (41), yet the participant's results were different in this study after 12 weeks. There were no trial restrictions, such as potential bias, analytical multiplicity, and so on.

4.1. Research limitation

The limitations of the study were that this study was conducted only for middle-aged men, and the allocation was at the time of randomization blinded for participants and investigators; yet due to the nature of the study, an allocation could not continue to be blind.

4.2. Conclusions

The NPT program makes sharp progressive impacts on the stability of posture in men of middle age and slowing down of CoP fluctuations during quiet standing. Thus, physicians, fitness counselors, and coaches will have a new choice when presenting sports programs for middle-aged men. Future studies should examine the effects of the NPT program on another gender and age group.

References

  • 1.

    Lutz W, Sanderson W, Scherbov S. The coming acceleration of global population ageing. Nature. 2008;451(7179):716-9. [PubMed ID: 18204438]. https://doi.org/10.1038/nature06516.

  • 2.

    Abrahamova D, Hlavacka F. Age-related changes of human balance during quiet stance. Physiol Res. 2008;57(6):957-64. [PubMed ID: 18052683].

  • 3.

    Khayat O, Zargarchi M, Razjouyan J, Siahi M, Nowshiravan Rahatabad F. [Age effect on static balance: Center-of-pressure analysis in chaotic and frequency domains]. J Paramed Sci Rehabil. 2014;3(1):53-60. Persian.

  • 4.

    Kinsella-Shaw JM, Harrison SJ, Turvey MT. Interleg coordination in quiet standing: Influence of age and visual environment on noise and stability. J Mot Behav. 2011;43(4):285-94. [PubMed ID: 21774605]. https://doi.org/10.1080/00222895.2011.580389.

  • 5.

    Błaszczyk JW, Czerwosz L. [Postural stability in the process of aging]. Gerontolog Polska. 2005;13(1):25-36. Polish.

  • 6.

    Hsieh RL, Lee WC, Lo MT, Liao WC. Postural stability in patients with knee osteoarthritis: Comparison with controls and evaluation of relationships between postural stability scores and International Classification of Functioning, Disability and Health components. Arch Phys Med Rehabil. 2013;94(2):340-6. [PubMed ID: 23041145]. https://doi.org/10.1016/j.apmr.2012.09.022.

  • 7.

    Jefferis BJ, Merom D, Sartini C, Wannamethee SG, Ash S, Lennon LT, et al. Physical activity and falls in older men: The critical role of mobility limitations. Med Sci Sports Exerc. 2015;47(10):2119-28. [PubMed ID: 25668406]. [PubMed Central ID: PMC5131688]. https://doi.org/10.1249/MSS.0000000000000635.

  • 8.

    Sherrington C, Lord SR, Finch CF. Physical activity interventions to prevent falls among older people: Update of the evidence. J Sci Med Sport. 2004;7(1 Suppl):43-51. [PubMed ID: 15214601]. https://doi.org/10.1016/S1440-2440(04)80277-9.

  • 9.

    Brooke-Wavell K, Athersmith LE, Jones PR, Masud T. Brisk walking and postural stability: A cross-sectional study in postmenopausal women. Gerontology. 1998;44(5):288-92. [PubMed ID: 9693261]. https://doi.org/10.1159/000022028.

  • 10.

    Orr R, de Vos NJ, Singh NA, Ross DA, Stavrinos TM, Fiatarone-Singh MA. Power training improves balance in healthy older adults. J Gerontol A Biol Sci Med Sci. 2006;61(1):78-85. [PubMed ID: 16456197]. https://doi.org/10.1093/gerona/61.1.78.

  • 11.

    Fukusaki C, Masani K, Miyasaka M, Nakazawa K. Acute positive effects of exercise on center-of-pressure fluctuations during quiet standing in middle-aged and elderly women. J Strength Cond Res. 2016;30(1):208-16. [PubMed ID: 26691411]. https://doi.org/10.1519/JSC.0000000000001062.

  • 12.

    Resende SM, Rassi CM. [Effects of hydrotherapy in balance and prevention of falls among elderly women]. Brazil J Phys Therap. 2008;12(1):57-63. Portuguese.

  • 13.

    Mandelbaum BR, Silvers HJ, Watanabe DS, Knarr JF, Thomas SD, Griffin LY, et al. Effectiveness of a neuromuscular and proprioceptive training program in preventing anterior cruciate ligament injuries in female athletes: 2-year follow-up. Am J Sports Med. 2005;33(7):1003-10. [PubMed ID: 15888716]. https://doi.org/10.1177/0363546504272261.

  • 14.

    Bird SP, Stuart W. Integrating balance and postural stability exercises into the functional warm-up for youth athletes. Strength Conditioning J. 2012;34(3):73-9. https://doi.org/10.1519/SSC.0b013e31824f175e.

  • 15.

    Ondra L, Natesta P, Bizovska L, Kubonova E, Svoboda Z. Effect of in-season neuromuscular and proprioceptive training on postural stability in male youth basketball players. Acta Gymnica. 2017;47(3):144-9. https://doi.org/10.5507/ag.2017.019.

  • 16.

    Pasanen K, Parkkari J, Pasanen M, Kannus P. Effect of a neuromuscular warm-up programme on muscle power, balance, speed and agility: A randomised controlled study. Br J Sports Med. 2009;43(13):1073-8. [PubMed ID: 19622526]. https://doi.org/10.1136/bjsm.2009.061747.

  • 17.

    Menegoni F, Galli M, Tacchini E, Vismara L, Cavigioli M, Capodaglio P. Gender-specific effect of obesity on balance. Obesity (Silver Spring). 2009;17(10):1951-6. [PubMed ID: 19325540]. https://doi.org/10.1038/oby.2009.82.

  • 18.

    Rezaeipour M. Evaluation of postural stability in overweight and obese middle-aged men. Turk J Med Sci. 2018;48(5):1053-7. [PubMed ID: 30384575]. https://doi.org/10.3906/sag-1709-108.

  • 19.

    Rezaeipour MR, Apanasenko GL. Effects of overweight and obesity on postural stability of aging females. Middle East J Rehabil Health. 2018;5(4). https://doi.org/10.5812/mejrh.81617.

  • 20.

    Hue O, Simoneau M, Marcotte J, Berrigan F, Dore J, Marceau P, et al. Body weight is a strong predictor of postural stability. Gait Posture. 2007;26(1):32-8. [PubMed ID: 16931018]. https://doi.org/10.1016/j.gaitpost.2006.07.005.

  • 21.

    Risberg MA, Mork M, Jenssen HK, Holm I. Design and implementation of a neuromuscular training program following anterior cruciate ligament reconstruction. J Orthop Sports Phys Ther. 2001;31(11):620-31. [PubMed ID: 11720295]. https://doi.org/10.2519/jospt.2001.31.11.620.

  • 22.

    Alves AJ, Viana JL, Cavalcante SL, Oliveira NL, Duarte JA, Mota J, et al. Physical activity in primary and secondary prevention of cardiovascular disease: Overview updated. World J Cardiol. 2016;8(10):575-83. [PubMed ID: 27847558]. [PubMed Central ID: PMC5088363]. https://doi.org/10.4330/wjc.v8.i10.575.

  • 23.

    Haskell WL, Lee IM, Pate RR, Powell KE, Blair SN, Franklin BA, et al. Physical activity and public health: Updated recommendation for adults from the American College of Sports Medicine and the American Heart Association. Circulation. 2007;116(9):1081-93. [PubMed ID: 17671237]. https://doi.org/10.1161/CIRCULATIONAHA.107.185649.

  • 24.

    Fleiss JL. Design and analysis of clinical experiments. 73. Columbia: John Wiley & Sons; 2011.

  • 25.

    Ghahramani M, Naghdy F, Stirling D, Naghdy G, Potter J. Impact of age on body postural sway. TENCON 2015-2015 IEEE Region 10 Conference. IEEE; 2015. p. 1-6.

  • 26.

    St George RJ, Lord SR. Neurophysiological, sensory and motor changes with ageing. The ageing brain. CRC Press; 2014. p. 73-84.

  • 27.

    Teasdale N, Simoneau M. Attentional demands for postural control: The effects of aging and sensory reintegration. Gait Posture. 2001;14(3):203-10. [PubMed ID: 11600323]. https://doi.org/10.1016/S0966-6362(01)00134-5.

  • 28.

    Lin D, Seol H, Nussbaum MA, Madigan ML. Reliability of COP-based postural sway measures and age-related differences. Gait Posture. 2008;28(2):337-42. [PubMed ID: 18316191]. https://doi.org/10.1016/j.gaitpost.2008.01.005.

  • 29.

    Maki BE, Holliday PJ, Fernie GR. Aging and postural control. A comparison of spontaneous- and induced-sway balance tests. J Am Geriatr Soc. 1990;38(1):1-9. [PubMed ID: 2295764]. https://doi.org/10.1111/j.1532-5415.1990.tb01588.x.

  • 30.

    Prieto TE, Myklebust JB, Hoffmann RG, Lovett EG, Myklebust BM. Measures of postural steadiness: Differences between healthy young and elderly adults. IEEE Trans Biomed Eng. 1996;43(9):956-66. [PubMed ID: 9214811]. https://doi.org/10.1109/10.532130.

  • 31.

    Melzer I, Kurz I, Oddsson LI. A retrospective analysis of balance control parameters in elderly fallers and non-fallers. Clin Biomech (Bristol, Avon). 2010;25(10):984-8. [PubMed ID: 20696509]. https://doi.org/10.1016/j.clinbiomech.2010.07.007.

  • 32.

    Ivanenko Y, Gurfinkel VS. Human postural control. Front Neurosci. 2018;12:171. [PubMed ID: 29615859]. [PubMed Central ID: PMC5869197]. https://doi.org/10.3389/fnins.2018.00171.

  • 33.

    Toledo DR, Barela JA. Age-related differences in postural control: Effects of the complexity of visual manipulation and sensorimotor contribution to postural performance. Exp Brain Res. 2014;232(2):493-502. [PubMed ID: 24212256]. https://doi.org/10.1007/s00221-013-3756-1.

  • 34.

    Samuel AJ. A critical review on the normal postural control. Physiotherap Occup TheraP J. 2015;8(2):71-5. https://doi.org/10.21088/potj.0974.5777.8215.4.

  • 35.

    Nnodim JO, Yung RL. Balance and its clinical assessment in older adults - A review. J Geriatr Med Gerontol. 2015;1(1). [PubMed ID: 26942231]. [PubMed Central ID: PMC4773046].

  • 36.

    Johansson J, Jarocka E, Westling G, Nordström A, Nordström P. Predicting incident falls: Relationship between postural sway and functional limits of stability in older adults. 2018.

  • 37.

    Cattagni T, Scaglioni G, Cornu C, Berrut G, Martin A. [What are the effects of the aging of the neuromuscular system on postural stability?]. Geriatr Psychol Neuropsychiatr Vieil. 2015;13(4):363-80. French. [PubMed ID: 26707554]. https://doi.org/10.1684/pnv.2015.0570.

  • 38.

    Huisinga JM, St George RJ, Spain R, Overs S, Horak FB. Postural response latencies are related to balance control during standing and walking in patients with multiple sclerosis. Arch Phys Med Rehabil. 2014;95(7):1390-7. [PubMed ID: 24445088]. [PubMed Central ID: PMC4331055]. https://doi.org/10.1016/j.apmr.2014.01.004.

  • 39.

    Mense S. Effects of temperature on the discharges of muscle spindles and tendon organs. Pflugers Arch. 1978;374(2):159-66. [PubMed ID: 566425]. https://doi.org/10.1007/BF00581297.

  • 40.

    Dioszeghy P, Stalberg E. Changes in motor and sensory nerve conduction parameters with temperature in normal and diseased nerve. Electroencephalogr Clin Neurophysiol. 1992;85(4):229-35. [PubMed ID: 1380909]. https://doi.org/10.1016/0168-5597(92)90110-W.

  • 41.

    Paillard T. Effects of general and local fatigue on postural control: A review. Neurosci Biobehav Rev. 2012;36(1):162-76. [PubMed ID: 21645543]. https://doi.org/10.1016/j.neubiorev.2011.05.009.