|
Effectiveness of Neuromuscular Exercises on Static and Dynamic Balance in Male Adolescents with Genu Valgum Deformity
|
Nima Djavadi1    , Mohammadhosein Alizadeh *2 , Amirhosein Barati3 |
1- Ph.D Candidate in Sports Injury and Corrective Exercises, Department of Sport Sciences, Kish International Campus, University of Tehran, Tehran, Iran.
2- Professor, Faculty of Sport and Health Sciences, Department of Sports Injury and Biomechanics, University of Tehran, Tehran, Iran. , alizadehm@ut.ac.ir
3- Associate Professor, Sports Medicine Specialist, Department of Health and Rehabilitation, Shahid Beheshti University, Tehran, Iran. |
|
Keywords: Genu Valgum [MeSH], Exercise Therapy [MeSH], Postural Balance [MeSH]
Article ID: Vol27-13 |
|
|
Full-Text [PDF 833 kb]
(4729 Downloads)
| Abstract (HTML) (5314 Views)
|
|
Type of Study: Original Articles |
Subject:
Sport Medicine and Corrective Exercises
|
|
|
|
|
|
|
Abstract: (716 Views) |
Extended Abstract
Introduction
Genu valgum deformity is a prevalent knee joint anomaly characterized as a structural misalignment of the tibia relative to the femur. Identifying effective methods for preventing its secondary complications and improving the efficiency of the knee-area musculature is crucial. An increased knee angle, or genu valgum deformity, alters natural body alignment, leading to shifts in the body's center of gravity and imposing limitations on the proper control of both static and dynamic balance. Static and dynamic balance, defined as the ability to maintain a body position, such as standing or sitting, or to control posture during movements like reaching for an object or walking, both are essential and important for motor abilities. Studies report that individuals with genu valgum deformity exhibit poorer performance in balance recovery. Given that impairments in both static and dynamic balance can heighten the risk of injury during physical activities, this finding is particularly significant.
The passive (osseous-ligamentous), active (muscles), and control (nervous system responsible for sensorimotor control) subsystems are defined as three influential subsystems affecting balance. The complications of genu valgum deformity vary within each of these subsystems. The passive subsystem involves misalignment of bones from the pelvis to the ankle, encompassing femoral anteversion, ankle pronation, reduced medial longitudinal arch (pes planus), patellar dislocation, joint instability, cartilage degradation, and ultimately, premature osteoarthritis. Complications related to the active subsystem in genu valgum deformity include weakness of the hip abductor muscles (gluteal and fascia lata muscles), increased quadriceps force on the patella, increased inward tensile force, increased compressive force, and premature fatigue during gait. Complications of genu valgum deformity within the neuromuscular subsystem include a decrease in balance index, altered center of pressure, modified muscle activation patterns, altered motor patterns, and impaired motor performance. In essence, any alteration in the alignment of the knee joint, or its proximal and distal joints, can negatively impact knee alignment and motor patterns, resulting in deviations from normal motor patterns.
There are various approaches to prevent, reduce potential complications, and rehabilitate injuries associated with this malalignment, including surgical methods, orthoses, and exercise-based interventions, such as resistance band exercises and corrective movements and games. Among these methods, exercise programs are considered among the safest and most effective corrective approaches. Due to their efficacy, ease of instruction, and low cost, exercise programs can be utilized for correcting certain musculoskeletal disorders and their resulting complications. Due to the presence of chain reactions, the entire body should be regarded as a single, unified system, and instead of focusing locally on one area, attention should be directed toward muscle chains based on the sensorimotor system. This study was conducted to determine the effectiveness of neuromuscular exercises on static and dynamic balance of male adolescents with genu valgum deformity.
Methods
This quasi-experimental study was conducted in 2023 on 24 non-athlete students aged 12 to 14 years with genu valgum deformity. The participants were recruited from corrective exercise centers in District 1 of Velenjak and District 20 of Shahr-e-Rey, Tehran.
The tools used in this study comprised a checkerboard (for initial screening), a stadiometer, a scale, calipers, a stopwatch, a Y-balance test kit, a consent form, TheraBand resistance bands, and tennis balls.
Subject height was measured to the nearest millimeter using a stadiometer. A consent and personal information form was employed to gather information concerning age, height, weight, and injury history, and to obtain informed consent from the subjects. For the clinical measurement of genu valgum deformity using calipers, the subject was positioned standing without shoes or socks, enuring their knees and thighs were visible and there was no contraction in the thigh muscles. The knees were in full extension, with both patellae facing forward. The distance between the medial malleoli of the ankles was then measured and recorded using a caliper. Values less than 2.5 cm were classified as Grade 1, 2.5-5 cm as Grade 2, 5-7.5 cm as Grade 3, and greater than 7.5 cm as Grade 4.
Static Balance Measurement: Static balance was assessed using the single-leg stance test, measured with a stopwatch.
Dynamic Y-Balance Test: To evaluate the participants' dynamic balance, the Y-balance test was utilized. The objective of this test is to maintain single-leg balance while reaching with the elevated leg in three directions: Anterior, posteromedial, and posterolateral.
Exercise Program: The neuromuscular exercise program emphasized three phases: Non-weight-bearing exercises, weight-bearing exercises, and functional exercises. The primary goal of phase one, i.e., non-weight-bearing exercises, which spanned weeks one to four, was to familiarize the sujects with the exercises and elicit initial, low-intensity contractions from the aforementioned muscle groups, thereby engaging these muscles. This phase saw the least amount of progression, as its objective was to alleviate contractions in specific muscles and to facilitate the learning of correct motor patterns for each muscle group. Phase one exercises were discontinued after the fourth week (considering the principle of exercise progression and exercise variety), and the subjects entered phase two, performing new exercises. The phase two, spanning weeks 4 to 8, aimed to implement weight-bearing exercises. This phase encompassed the core of the exercise program and incorporated progressive exercise aiming at fostering adaptation and correcting abnormalities. Similar to phase one, the emphasis in phase two was on the quality of exercise execution (performing exercises without errors and progressing from simple to complex). Exercise progression also involved increasing the duration and repetitions of exercises, with the most significant increases aimed at improving muscle strength and control over lower extermity movements. During this phase, an effort was made to engage the muscle groups activated in the previous stage in the correct sequence (utilizing muscles involved in correcting genu valgum deformity, such as the gluteal muscles and the medial knee musculature) and in the proper chain. Finally, in phase three, i.e., functional exercise, spanning weeks 9 to 12, aimed to maximize the impact on neuromuscular control, improve movement control (progressing from simple to complex exercises), and maintain proper alignment (requiring activation of the entire lower extermity, pelvic, and trunk musculature during more complex and challenging exercises) in the participants when performing functional tests. The exercise design was based on the American College of Sports Medicine (ACSM) guidelines for children aged 6 to 17 years, which recommend a minimum of 60 minutes of daily physical activity at moderate to vigorous intensity. The exercise program was structured into three phases, including preparatory, advanced, and maintenance, spanning the initial four weeks and the subsequent eight weeks, with an ideal frequency of three to four sessions per week. The intensity of resistance exercises was set within the range of six to twelve repetitions, up to the threshold of endurance exercises. Contraction and stretching exercises were standardized at 10 to 20 seconds per repetition for two to four repetitions, accumulating to 60 seconds per movement. The ideal exercise duration was planned to be 20 to 40 minutes, excluding warm-up and cool-down, with a safe range of 2 to 4 sets. Participants were instructed to discontinue the exercise and inform the instructor if they experienced fatigue exceeding 60%, culminating in their exclusion from the study. In the present study, no participant encountered this condition.
Results
A significant difference and change were observed in the static balance post-tests between the control and exercise groups when comparing their post-tests (after controlling for pre-test scores as confounding variables) (P < 0.001). Similarly, a significant difference and increase were noted in the dynamic balance post-tests between the control and exercise groups (after controlling for pre-test scores as confounding variables) in the anterior (P < 0.004), posteromedial (P < 0.001), and posterolateral (P < 0.020) directions.
Intragroup analysis revealed that the exercise group exhibited a significant increase in static balance when comparing pre-test to post-test scores (P < 0.001). In contrast, the control group did not demonstrate any significant differences or changes in static balance between pre-test and post-test scores. According to the intragroup analysis of dynamic balance between the control and exercise groups, the exercise group demonstrated greater reach in the post-test compared to the pre-test in the anterior (P < 0.005), posteromedial (P < 0.001), and posterolateral (P < 0.017) directions, leading to significant differences and changes. However, the control group showed no significant change or difference in dynamic balance in any of the anterior, posteromedial, or posterolateral directions when comparing pre-test to post-test scores.
Conclusion
Based on the findings of the current study, intragroup analysis of static balance between the two groups revealed that the exercise group demonstrated improved performance and recorded longer times in the post-test of static balance compared to the pre-test, ultimately leading to a significant increase in their static balance. Furthermore, a significant difference and change were observed between the control and exercise groups in the post-test scores of dynamic balance in the anterior, posteromedial, and posterolateral directions.
According to the Sensory Organization Hypothesis, the central nervous system is able to regulate balance by processing data from the visual, vestibular, and proprioceptive systems. This implies that maintaining balance in a closed kinetic chain relies on coordinated motor strategies and feedback among the femoral, knee, and ankle joints. Consequently, a reduction in afferent feedback or a decrease in the strength and mechanical stability of any single joint, or the entire lower extermity kinetic chain, can impair balance. Thus, disruptions in sensory data (often resulting from changes in knee alignment) that provide information about body position and orientation, can ultimately give rise to instability and imbalance. The effectiveness of neuromuscular exercises on balance may be attributed to the fact that the closed kinetic chain neuromuscular exercises employed stimulate mechanoreceptors in the lower extremity joints and muscles. The probable improvement in both static and dynamic balance is likely due to enhanced mechanoreceptor function and subsequent improvement in neuromuscular control.
Given the impact of genu valgum deformity on mechanical deviation, the neuromuscular corrective exercise program in the present study focused not only on strengthening muscles involved in the condition (specifically, the lower segments of the inverter and supinator muscles, particularly the tibialis posterior, and the upper segments of the external rotators and abductors) but also aimed to enhance neuromuscular control through exercise incorporating neuromuscular components. The program avoided solely concentrating on strengthening specific muscle groups. To achieve this, the present neuromuscular exercise program was implemented with an emphasis on three phases: Non-weight-bearing exercises, weight-bearing exercises, and functional exercises. Indeed, by comprehensively engaging both the distal and proximal muscles and joints of the affected area, the aim was to induce adaptation and correct abnormalities.
Ethical Statement
This study received approval from the Research Ethics Committee at the Sports Sciences and Physical Education Research Institute (IR.SSRC.REC.1402.178). Written informed consent was obtained from the parents of all participants prior to their participation in the study.
Funding
This article has been extracted from the doctoral dissertation of Dr. Nima Javadi in Sport Pathology and Corrective Exercises from Kish International Campus, University of Tehran. This study received no institutional funding.
Authors' Contributions
Nima Djavadi: Project execution, data collection, data analysis, and drafting of the initial manuscript.
Mohammadhosein Alizadeh: Project administration and design, interpretation of the results, and approval of the final manuscript.
Amirhosein Barati: Project administration and design, interpretation of the results, and approval of the final manuscript.
Conflicts of Interest
No conflicts of interest.
Acknowledgments
We would like to thank all participants in the study and those who assisted us in conducting it.
Key Message: The findings of this study indicate that 12 weeks of neuromuscular corrective exercises can be effective in improving both static and dynamic balance in male adolescents with genu valgum deformity. Given that these individuals are still in their growth phase, it appears essential to prioritize preventative measures, rehabilitation, and correction of genu valgum deformity to further enhance and promote their balance.
|
|
| References |
1. Tharmaseelan S, Kamisan N, Ismail II. Growth modulation in genu valgum secondary to multiple hereditary exostosis. Med Sci Discov. 2024;11(1):36-39. http://dx.doi.org/10.36472/msd.v11i1.1108. [ Link] [ DOI] 2. Gupta R, Nayyar AK, Ghatak S. Clinical measurement of intermalleolar distance in Western Indian population. IJRMS. 2021;9(2):494-97. https://doi.org/10.18203/2320-6012.ijrms20210430. [ Link] [ DOI] 3. Ashraf S, Viveiros R, França C, Ornelas RT, Rodrigues A. Association between Body Composition, Physical Activity Profile, and Occurrence of Knee and Foot Postural Alterations among Young Healthy Adults. Future. 2024;2(1):16-29. https://doi.org/10.3390/future2010002. [ Link] [ DOI] 4. Prakash J, Boruah T, Mehtani A, Chand S, Lal H. Experience of supracondylar cheveron osteotomy for genu valgum in 115 adolescent knees. J Clin Orthop Trauma. 2017 Jul-Sep;8(3):285-92. https://doi.org/10.1016/j.jcot.2017.05.017. [ DOI] [ PubMed] 5. Rabiei M, Jafarnejhad-Gre T, Binabaji H, Hosseininejad E, Anbarian M. [Assessment of postural response after sudden perturbation in subjects with genu valgum]. J Shahrekord Univ Med Sci. 2012;14(2):90-100. [Article in Persian] [ Link] 6. Tuncer D, Gurses HN, Senaran H, Uzer G, Tuncay I. Evaluation of postural control in children with increased femoral anteversion. Gait Posture. 2022 Jun;95:109-14. https://doi.org/10.1016/j.gaitpost.2022.04.011. [ DOI] [ PubMed] 7. Hodges PW, Cholewicki J, van Dieen JH. Spinal Control: The Rehabilitation of Back Pain: State of the art and science. 1st ed. London: Churchill Livingstone. 2013; pp: 1-327. 8. Mathew SE, Milbrandt TA, Young ML. Lateral Opening Wedge Osteotomy of the Distal Femur for Genu Valgum. J Pediatr Soc North Am. 2022;4(3):465. https://doi.org/10.55275/JPOSNA-2022-0033. [ Link] [ DOI] 9. Yoon JU, Yoo KT, Lee HS. [Evaluation of Muscle Activity and Foot Pressure during Gait, and Balance Test in Patients with Genu Valgum]. J Korean Soc Phys Med. 2022;17(1):127-37. https://doi.org/10.13066/kspm.2022.17.1.127. [Article in Korean] [ Link] [ DOI] 10. Theisen BJ, Larson PD, Chambers CC. Optimizing Rehabilitation and Return to Sport in Athletes With Anterior Knee Pain Using a Biomechanical Perspective. Arthrosc Sports Med Rehabil. 2022 Jan;4(1):e199-e207. https://doi.org/10.1016/j.asmr.2021.10.028. [ DOI] [ PubMed] 11. Ghaznavi A, Mohammadpour M, Taheri N, Cheraghiloohesara S, Aslani M. Temporary hemiepiphysiodesis for correction of genu valgum due to cystinosis: A preliminary interventional study in children. Curr Orthop Pract. 2022;33(5):424-27. https://doi.org/10.1097/BCO.0000000000001149. [ Link] [ DOI] 12. Sahrmann S, Azevedo DC, Dillen LV. Diagnosis and treatment of movement system impairment syndromes. Braz J Phys Ther. 2017 Nov-Dec;21(6):391-99. https://doi.org/10.1016/j.bjpt.2017.08.001. [ DOI] [ PubMed] 13. National Academy of Sports Medicine (NASM). NASM Essentials of Corrective Exercise Training. 1st ed. Jones & Bartlett Learning. 2013; pp: 342-43. 14. Page P, Frank C, Lardner R. Assessment and Treatment of Muscle Imbalance: The Janda Approach. 1st ed. Human Kinetics, Champaign. 2010; pp: 128-29. 15. Baldon Rde M, Lobato DF, Carvalho LP, Wun PY, Santiago PR, Serrão FV. Effect of functional stabilization training on lower limb biomechanics in women. Med Sci Sports Exerc. 2012 Jan;44(1):135-45. https://doi.org/10.1249/mss.0b013e31822a51bb. [ DOI] [ PubMed] 16. Barendrecht M, Lezeman HC, Duysens J, Smits-Engelsman BC. Neuromuscular training improves knee kinematics, in particular in valgus aligned adolescent team handball players of both sexes. J Strength Cond Res. 2011 Mar;25(3):575-84. https://doi.org/10.1519/jsc.0b013e3182023bc7. [ DOI] [ PubMed] 17. Nagano Y, Ida H, Akai M, Fukubayashi T. Effects of jump and balance training on knee kinematics and electromyography of female basketball athletes during a single limb drop landing: pre-post intervention study. Sports Med Arthrosc Rehabil Ther Technol. 2011 Jul;3(1):14. https://doi.org/10.1186/1758-2555-3-14. [ DOI] [ PubMed] 18. Pamboris GM, Pavlou K, Paraskevopoulos E, Mohagheghi AA. Effect of open vs. closed kinetic chain exercises in ACL rehabilitation on knee joint pain, laxity, extensor muscles strength, and function: a systematic review with meta-analysis. Front Sports Act Living. 2024 Jun;6:1416690. https://doi.org/10.3389/fspor.2024.1416690. [ DOI] [ PubMed] 19. Kopack JK, Cascardi KA. Principles of Therapeutic Exercise for the Physical Therapist Assistant. 1st ed. New York: Routledge. 2023; pp: 81-126. 20. Waldon KV, Stout A, Manning K, Gray L, Wilson DG, Kang GE. Dual-task interference effects on lower-extremity muscle activities during gait initiation and steady-state gait among healthy young individuals, measured using wireless electromyography sensors. Sensors. 2023 Oct;23(21):8842. https://doi.org/10.3390/s23218842. [ Link] [ DOI] 21. Ghani Zadeh Hesar N, Moradi B, Azarpur S. [Comparison of Balance and Core Stability between Female Students with Genu Recurvatum and Their Healthy Counterparts]. J Gorgan Univ Med Sci. 2022;24(4):76-84. [Article in Persian] [ Link] 22. Blodgett JM, Ventre JP, Mills R, Hardy R, Cooper R. A systematic review of one-legged balance performance and falls risk in community-dwelling adults. Ageing Res Rev. 2022 Jan;73:101501. https://doi.org/10.1016/j.arr.2021.101501. [ DOI] [ PubMed] 23. Bennett H, Chalmers S, Milanese S, Fuller J. The association between Y-balance test scores, injury, and physical performance in elite adolescent Australian footballers. J Sci Med Sport. 2022 Apr;25(4):306-311. https://doi.org/10.1016/j.jsams.2021.10.014. [ DOI] [ PubMed] 24. Ries MA. The Effect of a Twelve-Week Neuromuscular Training Program on Female High School Multi-Sport Athletes' Balance, Strength, and Knee Valgus. Thesis. Adams State University. 2020. 25. American College of Sports Medicine. ACSM's guidelines for exercise testing and prescription. 9th ed. Philadelphia: Lippincott williams & wilkins. 2013; pp: 168-73. 26. Moradi B, Letafatkar A, Hadadnezhad M, Hosseinzadeh M, Khalghi M. The effect of neuromuscular training on kinetic variables in male athletes with trunk control defects. Sport Sciences and Health Research. 2023, 15(1): 53-66. https://doi.org/10.22059/sshr.2024.363547.1102. [ Link] [ DOI] 27. Mohanty T, Pattnaik M, Sethy GC, Jee RN. Hybrid External Fixator for Correction of Genu Valgum in an Adult. Journal of Orthopedics, Traumatology and Rehabilitation. 2022; 14(1):86-89. https://doi.org/10.4103/jotr.jotr_61_21. [ Link] [ DOI] 28. Palmer K, Hebron C, Williams JM. A randomised trial into the effect of an isolated hip abductor strengthening programme and a functional motor control programme on knee kinematics and hip muscle strength. BMC Musculoskelet Disord. 2015 May;16:105. https://doi.org/10.1186/s12891-015-0563-9. [ DOI] [ PubMed] 29. Rahmani Nia F, Daneshmandi H, Irandoust K. Prevalence of Genu Valgum in Obese and Underweight Girls. World J Sport Sci. 2008;1(1):27-31. [ Link] 30. Soheilipour F, Pazouki A, Mazaherinezhad A, Yagoubzadeh K, Dadgostar H, Rouhani F. The Prevalence of Genu Varum and Genu Valgum in Overweight and Obese Patients: Assessing the Relationship between Body Mass Index and Knee Angular Deformities. Acta Biomed. 2020 Oct;91(4):e2020121. https://doi.org/10.23750/abm.v91i4.9077. [ DOI] [ PubMed] 31. Patel K. Corrective exercise: a practical approach: a practical approach. Chap 14. 1st ed. London: Routledge. 2005; pp: 1-51. 32. Wu KW, Lee WC, Ho YT, Wang TM, Kuo KN, Lu TW. Balance control and lower limb joint work in children with bilateral genu valgum during level walking. Gait Posture. 2021 Oct;90:313-19. https://doi.org/10.1016/j.gaitpost.2021.09.187. [ DOI] [ PubMed] 33. Park SR, RoHL, Namkoong S. The Effect of Stretching and Elastic Band Exercises Knee Space Distance and Plantar Pressure Distribution during Walking in Young Individuals with Genu Varum. J Korean Soc Phys Med. 2017;12(1):83-91. https://doi.org/10.13066/kspm.2017.12.1.83. [ Link] [ DOI] 34. Komatsu T, Tateuchi H, Hirono T, Yamagata M, Ichihashi N. Influence of ankle invertor muscle fatigue on workload of the lower extremity joints during single-leg landing in the sagittal and frontal planes. Gait Posture. 2024 May;110:29-34. https://doi.org/10.1016/j.gaitpost.2024.02.021. [ DOI] [ PubMed] 35. Salekar B, Patil R, Patil M, Mankar S. Association of Foot Deviations with Foot Functional Activity and Dynamic Balance in Female Kathak Dancers. IJHSR. 2024;14(4):35-43. http://dx.doi.org/10.52403/ijhsr.20240406. [ Link] [ DOI] 36. Dimitriou D, Meisterhans M, Geissmann M, Borpas P, Hoch A, Rosner J, et al. The effect of experimentally induced gluteal muscle weakness on joint kinematics, reaction forces, and dynamic balance performance during deep bilateral squats. J Orthop Res. 2024 Jan;42(1):164-71. https://doi.org/10.1002/jor.25644. [ DOI] [ PubMed] 37. Ichikawa S, Kumai T, Akiyama Y, Okunuki T, Maemichi T, Matsumoto M, et al. Relationship between Dynamic Balance and Physical Characteristics and Functions in Elite Lifesaving Athletes. J Funct Morphol Kinesiol. 2024 Aug;9(3):134. https://doi.org/10.3390/jfmk9030134. [ DOI] [ PubMed] |
|
| Send email to the article author |
|
|
|
Djavadi N, Alizadeh M, Barati A. Effectiveness of Neuromuscular Exercises on Static and Dynamic Balance in Male Adolescents with Genu Valgum Deformity. J Gorgan Univ Med Sci 2025; 27 (2) :21-32 URL: http://goums.ac.ir/journal/article-1-4537-en.html
|
