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Effects of Plyometric Exercises versus Flatfoot Corrective Exercises on Postural Control and Foot Posture in Obese Children with a Flexible Flatfoot

Effects of Plyometric Exercises versus Flatfoot Corrective Exercises on Postural Control and Foot... Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 3635660, 8 pages https://doi.org/10.1155/2021/3635660 Research Article Effects of Plyometric Exercises versus Flatfoot Corrective Exercises on Postural Control and Foot Posture in Obese Children with a Flexible Flatfoot 1,2 1 1 3 Hatem H. Allam, Alsufiany Muhsen, Mosfer A. Al-walah, Abdulmajeed N. Alotaibi, 4 5 Shayek S. Alotaibi , and Lamiaa K. Elsayyad Department of Physical Therapy, College of Applied Medical Sciences, Taif University, Saudi Arabia Faculty of Physical Therapy, Misr University for Sciences and Technology, Egypt Children Hospital, Taif Health Affairs, Ministry of Health, Saudi Arabia Department of Medical Rehabilitation and Physiotherapy, Children Hospital, Ministry of Health, Taif, Saudi Arabia Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Egypt Correspondence should be addressed to Lamiaa K. Elsayyad; hatem.lamiaa@gmail.com Received 20 September 2021; Revised 8 October 2021; Accepted 18 October 2021; Published 31 October 2021 Academic Editor: Fahd Abd Algalil Copyright © 2021 Hatem H. Allam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Obesity contributes to the acquired flatfoot deformity which in turn impairs balance. Aim. The purpose of the current study was to compare the effect of plyometric exercises with flatfoot corrective exercises on balance, foot posture, and functional mobility in obese children with a flexible flatfoot. Methods. Forty-seven children participated in the study. Their age ranged from 7 to 11 years. Participants were randomly divided into 3 groups: experimental group I (EGI), experimental group II (EGII), and the control group (CG). The EGI received plyometric exercises and the EGII received corrective exercises, 2 sessions weekly for 10 weeks. The control group did not perform any planned physical activities. The Prokin system was used to assess balance, the timed up and go test (TUG) was used to assess functional mobility, and the navicular drop test (NDT) was used to assess foot posture. Results. EGI showed significant improvement in all balance parameters, foot posture, and TUG. EGII showed improvement in the ellipse area and perimeter in addition to foot posture and TUG. Conclusion. Plyometric exercises and foot correction exercises had a positive effect on foot posture, balance, and functional mobility in obese children with flatfeet. 1. Introduction by many factors such as sensory impairment, abnormal muscle response, poor muscle strength, and the presence of Obesity appeared among children and adults as one of the certain foot abnormalities such as a flatfoot [4]. Some studies critical and major community health worries within the past have confirmed that the impaired balance may affect the quality of life, many skills, and many daily living activities century [1]. The prevalence of childhood obesity has been noticed over the last 3 decades [2]. Moreover, obesity also in children and adults [5]. affects all daily living activities like walking or standing skills Riccio et al., [6] mentioned that rehabilitation therapy, and negatively affects balance and ability to alter positions. which includes the constant proprioceptive stimulation of Additionally, it is one of the main factors that causes an the foot, is likely to achieve improvement in the plantar arch and correct the flexible flatfoot. Additionally, there is evi- acquired flat foot deformity which in turn impairs the bal- ance strategy [3]. Balance is considered as multiple processes dence that exercises have a crucial role in improving balance. that require mechanical, sensory, and kinetic elements of It strengthens the muscles that enhance balance, walking motion to be coordinated. It may be negatively influenced ability, and correct deformities [7]. Published research has 2 Applied Bionics and Biomechanics participants were randomly assigned into three groups: demonstrated that balance has improved by applying certain stretching procedures, proprioceptive stimulation techniques, experimental group I (EGI) contained 16 participants, exper- and strengthening exercises [8]. One of the approaches that imental group II (EGII) contained 16 participants, and the enhance balance in children is plyometric exercises [9]. Plyo- control group (CG) contained 15. The stratification was done metric exercise indicates a quick and strong interaction move- using sealed envelopes. The children were not aware of the ment between both eccentric and concentric contractions [10]. group that they belonged to. This type of exercise is secure and efficient in adults and chil- Demographic data collection was as follows: a specially dren for enhancing balance, jumping skills, reaction time, designed survey was used to collect demographic data for all participants such as age, weight, and height. bone mineral density, endurance, muscle power and strength, energy production, motor performance, and coordination 2.4. Body Mass Index Percentile for Boys. BMI percentile is a [11]. Certain studies concluded that there were some improve- screening tool used to classify the participant’s degree of ments in postural stability after the application of a 15-minute obesity in children according to the American Academy of plyometric exercise [12]. To date, little is known about the Pediatrics recommendations. To calculate the BMI percen- effect of plyometric exercises on foot posture in obese children tile, at first, obtain accurate height and weight measurements with flexible flatfeet. Thus, the purpose of the current study for each child. The subjects’ body weight in bare feet and was to compare the effect of plyometric exercises with with minimal clothing was measured. Standing height was flatfoot-corrective exercises on balance, foot posture, and measured with the children standing straight without foot- functional mobility in obese children with a flexible flatfeet. wear. The height and weight were measured twice to mini- The current study could help the obese children to benefit mize errors. The body mass index (BMI)was then from the different exercise protocols which may contribute calculated by dividing the weight (kg) by height (m) squared. to improvements in their quality of life. 2.5. Balance Assessment. The static balance was assessed by 2. Materials and Methods using the Prokin system (PK 252, TecnoBody S.r.l., Italy). The balance assessment is based on the degree of postural 2.1. Study Setting. The study was conducted at the balance sway using a tilting board. Before the actual assessment, all lab of the Faculty of Applied Medical Sciences. It was started participants were engaged in certain practical sessions and on 15 January 2021. the whole procedures were illustrated to them to be familiar- ized with the testing procedures and balance device. 2.2. Subjects. A sample of 47 male children participated in the current study without having female participants due 2.5.1. Starting the Test. In the first step, the system was to the cultural issues and order of the society in Saudi Ara- opened and calibrated and the demographic data was bia. The sample size was detected by using statistical power entered (name, age, height, and weight). The next step is analysis—G ∗ power (power, 0.85; α =0:05;effect size = 0:5, selecting the type of stability test, and the participant stands Pillai V =0:2). The participants were selected randomly comfortably on the tilting board and was asked to look from different elementary schools in Taif, Saudi Arabia. Par- towards at the screen keeping his hands beside the body ticipants were enrolled by contacting their parents by phone while his eyes are focused on the fixed target on the screen. using the phone numbers in the schools’ database. Their age Each participant applied three trials with eyes opened (EO) ranged from 7 to 11 years. Initially, a specialist examiner and the mean score was recorded. The participants had a conducted a comprehensive evaluation of all participants. five-minute break after each trial, and we tried to avoid He was blinded about the groups’ division. Inclusion criteria any distractions. There are four variables that were mea- are as follows: all children were classified as obese (their sured for all participants at the beginning and at the end of body mass index percentile is equal to or greater than the the study with EO: perimeter area (mm), ellipse area 95th percentile). The participants were not involved in (mm ), standard backward-forward deviation, and standard strength, balance training, or competitive sports aiming to medial-lateral deviation. enhance muscular strength or balance. All participants had balance impairments and a mobile flat foot. Their degree 2.6. The Navicular Drop Test. (NDT) was used to assess the of flatfoot deformity according to NDT was ranged from degree of flatfoot deformity. The NDT revealed excellent 16 to 19 millimeters in all participants. The exclusion criteria reliability, with ICC values reaching 0.945 and standard were as follows: the children were excluded when they had a error of measurement < 1 mm [13]. Firstly, the subtalar previous injury to the lower limb which required medical neutral position was accustomed while the child was in the care or had other confounding conditions, such as deformity sitting position with both hips and knees at 90 , and then, of or surgery in the lower limb or visual impairment. Addi- the navicular tuberosity was palpated and marked. The tionally, they were excluded if they engaged in obesity treat- distance between the navicular tuberosity and the floor was ment programs three months prior to the study. The written measured in millimeters using a stainless-steel high- informed consent (from parents or children’s guardians) was accuracy electronic digital display slide caliper. After that, obtained before they enrolled in the study. the participant was instructed to stand in a relaxed foot pos- ture and the navicular tuberosity was palpated and marked 2.3. Randomization. A simple randomization technique again to avoid any error due to skin shifting and then the was used. After gathering the baseline measurements, the height of the mark measured from the floor. The ND was Applied Bionics and Biomechanics 3 Table 1: The repetition of plyometric exercises during the intervention period. Repetitions The exercise Weeks 1 and 2 Weeks 3 and 4 Weeks 5 and 6 Weeks 7 and 8 Weeks 9 and 10 Jump jacks 6 7 8 9 10 Skipping 8 9 10 11 12 Jump side to side 6 7 8 11 12 Jump front and back 6 8 10 11 13 Vertical jump 6 8 10 11 13 Hopping forwards and backwards on the right foot 6 7 8 9 10 Hopping forwards and backwards on the left foot 6 7 8 9 10 Short jump forwards and backwards 6 7 8 9 10 Total repetitions 50 60 70 80 90 Table 2: Corrective exercises and activities for the flexible flatfoot adopted from Riccio et al. [6]. Aim Exercises and activities Passive range of motion exercises and global movement of the ankle and all foot joints; stretching of the Flexibility calf and peroneus brevis muscles Anterior and posterior tibialis muscles and the flexor hallucis longus (to neutralize valgus), intrinsic, Strengthening, proprioception, interosseus plantaris muscles, and the abductor hallucis (to prevent anterior arch flattening); global and balance activation/movement of the muscles involved in maintaining the medial longitudinal arch and the varus; single-leg weight bearing (with pronation control); toe and heel walking; descending an inclined surface Table 3: MANOVA results for the study variables. the difference in the navicular tuberosity height between both marks [14]. Effect Test FP Variables ∗ groups 3.384 0.000 2.7. Functional Mobility. Functional mobility was assessed Time ∗ groups 7.477 0.000 using the timed up and go (TUG) test to detect participants’ Wilks’ lambda functional mobility. It is a valid and reliable test. At first, a Variables ∗ time 13.952 0.000 sign was placed 3 meters away from the chair. A seat with Variables ∗ time ∗ groups 6.693 0.002 back support without arms was chosen from the children’s environment. The seat should allow the feet to be flat on the ground and the knee and hip to bend 90 degrees. Then, spongy mat for shock absorption. We emphasized that all the child was asked to stand up, walk at his free gait, touch participants should get down from jumping on tiptoes and the mark, and return to sit down on the chair. The time the weight-bearing activities should be done with foot prona- was counted as the child left the seat and stopped when tion control. The jumps were divided into five sets and two- the child returned to the sitting position using a stopwatch. minute rests were given in between each set and the other. The test was run three times and the average value was The selected corrective exercises and activities are illustrated taken [15]. in Table 2 according to Riccio et al. [6]. 2.8. The Intervention. The EGI received a plyometric exercise 2.9. Ethical Considerations. The ethical committee at the program. The EGII received the corrective exercises. The research and studies department, directorate of health control group was not involved in any planned physical affairs, Taif, Saudi Arabia (IBR registration number with activity during the intervention period but persisted in their KACST, KSA HAP-02-T-067), approved the current study traditional physical activities. The designed exercises were on 11 November 2020 with approval number 452. applied two sessions per week with three days of rest in between for 10 weeks. The session started with 5 minutes 2.10. Study Design and Data Analysis. A randomized con- warming up and ended with 5 minutes cooling down in trolled trial was used to investigate the effect of plyometric the form of gentle stretching of the lower limb muscles. All exercises with flatfoot-corrective exercises on balance, foot participants were engaged in certain practical sessions at posture, and functional mobility in obese children with the beginning of the study to be familiarized for all interven- flexible flatfoot. This was a randomized clinical trial of the tion procedures. Additionally, the supervisor emphasized parallel-group design. The study was registered and posted the correct application of the exercises. The selected plyo- on the Clinical Trials.gov public website with ID metric exercises and their repetitions are illustrated in (NCT05026294). The study was double blinded, the exam- Table 1 according to Johnson et al. [16]. It was done on a iners and participants were blinded about the group division. 4 Applied Bionics and Biomechanics Table 4: Bonferroni pairwise comparisons for demographic characteristics and the study variables of the three groups at the beginning of the study. M ±SD MD Variables EGI EGII CG EGI-EGII P EGI-CG P EGII-CG P 9:48 ± 1:12 9:74 ± :95 9:07 ± 1:22 Age −0.27 1 0.407 0.92 0.67 0.28 45:37 ± 8:14 41:44 ± 6:02 42:04 ± 8:55 Weight 3.93 0.46 3.34 0.69 −0.60 1 Height 1:37 ± :17 1:35 ± :14 1:25 ± :12 0.022 1 0.12 0.09 0.09 0.24 23:71 ± 2:06 22:71 ± 3:06 22:01 ± 2:05 BMI 1.003 0.76 1.7 0.18 0.69 1 529:64 ± 81:35 614:05 ± 125:58 581:02 ± 184:98 Ellipse area −84.41 0.26 −51.38 0.89 33.03 1 706:33 ± 170:5 631:33 ± 192:22 570:13 ± 112:99 Perimeter 75.001 0.6 136.2 0.074 61.2 0.9 BFD 7:96 ± 1:58:62 ± 1:47:95 ± 1:93 −0.67 0.76 0.001 1 0.67 0.78 4:64 ± 1:16 4:03 ± 1:03 4:07 ± 1:39 MLD 0.61 0.48 0.56 0.59 −0.043 1 17:25 ± 3:55 16:94 ± 1:81 18:47 ± 2:9 ND 0.31 1 −1.21 0.72 −1.53 0.43 7:53 ± :58163 7:26 ± :397 7:27 ± :36 TUG 0.27 0.31 0.26 0.37 −0.011 1 EGI: experimental group 1; SD: standard deviation; MLD: mediolateral deviation; EGII: experimental group 2; MD: mean difference; ND: navicular drop test; CG: control group; M: mean; TUG: time up and go test; BFD: backward-forward deviation. All statistical measures were performed through the Statisti- 4. Discussion cal Package for Social Studies (SPSS) version 26 for Win- dows. The MANOVA test was conducted to determine if The study is aimed at investigating the effect of plyometric there were any significant differences in the mean values of exercises on foot posture, balance, and functional mobility age, weight, height, and BMI between both groups. Addition- in obese children with mobile flatfeet. We have selected the ally, repeated measures MANOVA was used to compare the balance parameters to be investigated in obese children within- and between-subject effects of both interventions because appropriate balance control is necessary for routine (Table 3). The alpha level was set at 0.05. activities of daily living and obesity has a tremendous nega- tive effect on balance [17]. The results of the study revealed that there was significant improvement in all balance param- 3. Results eters, foot posture, and TUG in EGI. EGII showed improve- ment in the ellipse area and perimeter in addition to foot 3.1. Baseline Comparison. There were no significant differ- posture and TUG without improvement in the backward- ences among the three groups at the beginning of the study forward and mediolateral deviation. either in the demographic data or in the study variables Concerning preintervention balance assessment, the (Table 4). results of the study revealed that obese children have defi- cient balance skills. This comes in agreement with Deforche et al. [18] who mentioned that obese prepubertal males have 3.2. Postintervention (within-Subject Comparisons). The EGI decreased both static and dynamic balance and postural showed a significant improvement in all assessed balance skills. Moreover, obese children have deficits in the torque parameters (ellipse area, perimeter, backward-forward devi- of the ankle muscles needed for stability when they are ation, and mediolateral deviation) in addition to the signifi- subjected to any oscillations [17]. Additionally, deficits in cant improvement in foot posture (as indicated by navicular balance strategies in obese children preintervention had height) and TUG. Regarding EGII, there was a significant impaired functional mobility as represented by the TUG test improvement in the previous items except for the score [18]. backward-forward deviation and the mediolateral deviation Concerning the effect of plyometric exercises on balance, which showed nonsignificant improvement. On the other the results of the current study revealed that the balance was hand, there were no significant changes in the CG (Table 5). improved significantly in the EGI postintervention. This comes in consistency with Arazi and Asadi [19] who men- 3.3. Postintervention (between-Subject Comparison). Con- tioned that muscle strength and balance skills were improved cerning EGI, it showed a significant difference in all assessed after 8 weeks of aquatic and land plyometric exercises in parameters when it was compared to the EGII and CG young athletes. Moreover, Myer et al. [20] mentioned that except the improvement in foot posture and TUG which the balance performance was improved after the application showed a nonsignificant difference between EGI and EGII. of the plyometric training program. Additionally, Chaouachi EGII showed significant improvement in all parameters et al. [21] were in line with our findings when they reported when compared to the CG except for the backward- that plyometric training improved balance, jumping skills, forward deviation which showed nonsignificant improve- and squat strength measures like the combined training pro- ment in the EGII (Table 6). gram. The improvement in balance skills after plyometric Applied Bionics and Biomechanics 5 Table 5: Bonferroni pairwise comparisons for within-subject effect. EGI EGII CG Variables M ±SD MD PM ±SD MD PM ±SD MD P Pre Post Pre Post Pre Post 529:64 ± 81:35 401:02 ± 98:98 614:05 ± 125:58 504:99 ± 105:44 581:02 ± 184:98 616:47 ± 99:4 EA 128.62 0.012 109.05 0.031 −35.45 0.487 706:33 ± 170:5 449 ± 75:08 631:33 ± 192:22 531:17 ± 102:45 570:13 ± 112:99 619:71 ± 84:99 PR 257.32 0.000 100.16 0.022 −49.58 0.260 7:96 ± 1:56:6±1:43 8:62 ± 1:48:2±1:27 7:95 ± 1:93 8:47 ± 1:35 BFD 1.34 0.024 0.42 0.463 −0.52 0.386 MLD 4:64 ± 1:16 2:9±0:54 1.74 0.000 4:03 ± 1:03 3:35 ± 0:56 0.68 0.054 4:07 ± 1:39 4:21 ± 0:39 −0.14 0.698 17:25 ± 3:55 13:69 ± 1:49 16:94 ± 1:81 14:63 ± 1:96 18:47 ± 2:917:73 ± 1:16 ND 3.56 0.000 2.31 0.006 0.73 0.381 7:53 ± 0:58 8:44 ± 0:64 7:26 ± 0:48:68 ± 0:72 7:27 ± 0:36 7:15 ± 0:43 TUG −0.91 0.000 −1.41 0.000 0.13 0.344 EGI: experimental group 1; SD: standard deviation; PR: perimeter; EGII: experimental group 2; MD: mean difference; BFD: backward-forward deviation; CG: control group; EA: ellipse area; MLD: mediolateral deviation; M: mean; ND: navicular drop test; TUG: time up and go test. 6 Applied Bionics and Biomechanics Table 6: Bonferroni pairwise comparisons for between-subject effect. M ±SD MD Variables EGI EGII CG EGI-EGII P EGI-CG P EGII-CG P 401:02 ± 98:98 504:99 ± 105:44 616:47 ± 99:4 Ellipse area −103.97 0.017 −215.44 0.000 −111.47 0.011 Perimeter 449 ± 75:08 531:17 ± 102:45 619:71 ± 84:99 −82.17 0.035 −170.7 0.000 −88.53 0.023 6:62 ± 1:43 8:2±1:27 8:47 ± 1:35 BFD −1.579 0.006 −1.85 0.001 −0.28 1.0 2:9±0:54 3:35 ± 0:56 4:21 ± 0:39 MLD −0.449556 0.047 −1.31 0.000 −0.86 0.000 13:69 ± 1:49 14:63 ± 1:96 17:73 ± 1:16 ND −0.938 0.302 −4.05 0.000 −3.11 0.000 8:44 ± 0:64 8:68 ± 0:72 7:15 ± 0:43 TUG −0.237 0.840 1.29 0.000 1.53 0.000 EGI: experimental group 1; SD: standard deviation; MLD: mediolateral deviation; EGII: experimental group 2; MD: mean difference; ND: navicular drop test; M: mean; BFD: backward-forward deviation; TUG: time up and go test. exercises may be related to the rapid stretch-shortening cycle walking after each set). They related the navicular drop to and combines shifts of the center of gravity in both vertical muscle fatigue after exercise. Concerning the effect of corrective exercises on the foot and horizontal directions that may improve postural control and equilibrium [22]. Furthermore, enhanced cocontraction arch, the results of the study revealed that there was a signif- icant improvement in the foot posture in EGII postinterven- of the lower extremity muscles and the improvement in proprioception and neuromuscular control after plyometric tion. Halabchi et al. [31] confirmed our findings when they training played a role in balance improvement [23]. have stated that the use of a suitable rehabilitation program may improve the flexible flatfoot posture in children. Their On the other hand, Twist et al. [24] contradict our find- ings when they mentioned that unilateral balance perfor- rehabilitation program included flexibility, strength, and mance was impaired 24 hours after plyometric exercise. proprioceptive training exercises which come in consistency This contradiction may be related to fact that they had used with our corrective exercise program. Furthermore, Riccio a high-intensity plyometric exercise program (200 jumps et al. [6] agreed with our results when they mentioned that rehabilitation therapy, which depends on the constant per session). They reported that this designed intensive plyo- metric program may induce symptoms of muscle damage proprioceptive stimulation of the foot, is likely to achieve and muscle soreness that negatively affected the balance improvement in the plantar arch and correct the calcaneoval- performance. gus deformity in a flexible flatfoot. The proprioceptive train- Concerning the effect of plyometric exercises on foot pos- ing is essential in the improvement of the reflex circuits, which is vital for proper confidence in both static and ture, the results of the current study revealed that there was a significant improvement in the foot posture in EGI after dynamic foot placements, which in turn improves balance plyometric training. We can attribute this improvement to and functional mobility. On the other hand, Namsawang the improvement in plantar flexor strength and mechanical et al. [32] contradict our results as they found that exercises properties after plyometric exercises. Kubo et al. [25] support for foot muscles did not improve the ND. Their results may be due to the short duration of the program (only 4 weeks) this idea when they found a significant increase in plantar flexor muscle activity during the concentric phase of vertical that is considered as one of their study’s limitations. jumps. Furthermore, the results obtained by Kyröläinen et al. Concerning the effect of corrective exercises on balance, [26] denoted a significant improvement in both maximum the results of the study revealed that there was a significant voluntary contraction and muscular activity and strength of improvement in all balance measures in EGII postinterven- tion except for the backward-forward and mediolateral devi- plantar flexors after plyometric exercises. Moreover, Weist et al. [27] confirmed the relation between the plantar flexors ation. The improvement in the balance measures may be and the medial longitudinal arch (MLA) when they con- attributed to an increase in the strength of the intrinsic mus- cluded that fatigue of plantar flexors reduces its supination cles of the foot, which in turn improves the arch height and action and increases foot pronation. Additionally, Fourchet postural control as reported by Kim and Kim [33]. More- over, Sudhakar et al. [34] added that the runners with low et al. [28] found that decreased calf muscle activity due to fatigue was associated with an increase in the contact area arches had less balance than those with normal arches, under the MLA. Kamalakannan and Swetha [29] came in which means that the increase in the arch height improves agreement with our results when they concluded that robe the balance strategy. skipping activities improved the foot arch and functional Regarding the improvement in functional mobility, the results of the current study showed that there was a signifi- activities of the lower limb. On the other hand, Klaikaew and Panichaporn [30] con- cant improvement in the TUG test scores in both EGI and tradict our results when they reported dropping down of the EGII when it was compared with CG at the endpoint. The navicular and a decrease in the height of the MLA after improvement may be related to the improvement in balance repetitive hopping. However, they used a vigorous hop tech- skills, muscle strength, and foot posture that occurred in both experimental groups. nique (hopped 60 times/minute/set for 3 sets with 30 sec Applied Bionics and Biomechanics 7 [4] N. Teasdale, O. Hue, J. Marcotte et al., “Reducing weight 4.1. Limitations. Only male children were examined without increases postural stability in obese and morbid obese men,” having female participants because of cultural values in International Journal of Obesity, vol. 31, no. 1, pp. 153–160, Saudi Arabia. Additionally, foot posture was assessed using the ND test only. [5] L. D. Jelsma, Dynamic control of balance in children with developmental coordination disorder, Diss. University of 5. Conclusion Groningen, 2017. [6] I. Riccio, F. Gimigliano, R. Gimigliano, G. Porpora, and Both plyometric exercises and foot correction exercises had a G. Iolascon, “Rehabilitative treatment in flexible flatfoot: a positive effect on foot posture, balance, and functional perspective cohort study,” Musculoskeletal Surgery, vol. 93, mobility in obese children with flatfeet. Both should be no. 3, pp. 101–107, 2009. considered in the rehabilitation of children with obesity. [7] P. G. Vassão, R. L. Toma, H. K. M. Antunes, and A. C. M. Renno, “Photobiomodulation and physical exercise on Data Availability strength, balance and functionality of elderly women,” Fisio- terapia em Movimento, vol. 31, 2018. The data used to support the findings of this study are avail- [8] H. W. Wallmann, K. R. Player, and M. Bugnet, “Acute Effects able from the corresponding author upon request. of static stretching on balance in young versus Elderly adults,” Physical & Occupational Therapy in Geriatrics, vol. 30, no. 4, Conflicts of Interest pp. 301–315, 2012. [9] F. Fischetti, S. Cataldi, and G. Greco, “A combined plyometric The authors declare that there is no conflict of interest and resistance training program improves fitness performance regarding the publication of this article. in 12 to 14-years-old boys,” Sport Sciences for Health, vol. 15, no. 3, pp. 615–621, 2019. Authors’ Contributions [10] D. McKay and N. Henschke, “Plyometric training pro- grammes improve motor performance in prepubertal chil- Conceptualization was done by HA, LE, AM, MA, AA, and dren,” British Journal of Sports Medicine, vol. 46, no. 10, SA. Writing of the original draft was done by HA and LE. pp. 727-728, 2012. Statistical designing was done by HA and LE. Formal analy- [11] S. Shah, “Plyometric exercises,” Int J Health Sci Res, vol. 2, sis was done by HA and LE. Investigation was done by MA, pp. 115–126, 2012. SA, and AA. The methodology was done by HA, LE, AM, [12] N. Romero-Franco and P. Jiménez-Reyes, “Unipedal postural MA, AA, and SA. Project administration was done by HA, balance and countermovement jumps after a warm-up and LE, AM, MA, AA, and SA. The software was prepared by plyometric training session: a randomized controlled trial,” HA and LE. Supervision was done by HA, LE, AM, MA, The Journal of Strength & Conditioning Research, vol. 29, AA, and SA. Writing of the discussion was done by HA, no. 11, pp. 3216–3222, 2015. LE, and AM, Writing, reviewing, and editing were done by [13] J. C. Zuil-Escobar, C. B. Martínez-Cepa, J. A. Martín-Urrialde, HA, LE, AM, MA, AA, and SA. and A. Gómez-Conesa, “Medial longitudinal arch: accuracy, reliability, and correlation between navicular drop test and footprint parameters,” Journal of Manipulative and Physiolog- Acknowledgments ical Therapeutics, vol. 41, no. 8, pp. 672–679, 2018. [14] M. Kirmizi, M. A. Cakiroglu, A. Elvan, I. E. Simsek, and We thank all study’s participants and their guardians for S. 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Effects of Plyometric Exercises versus Flatfoot Corrective Exercises on Postural Control and Foot Posture in Obese Children with a Flexible Flatfoot

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Copyright © 2021 Hatem H. Allam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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10.1155/2021/3635660
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Hindawi Applied Bionics and Biomechanics Volume 2021, Article ID 3635660, 8 pages https://doi.org/10.1155/2021/3635660 Research Article Effects of Plyometric Exercises versus Flatfoot Corrective Exercises on Postural Control and Foot Posture in Obese Children with a Flexible Flatfoot 1,2 1 1 3 Hatem H. Allam, Alsufiany Muhsen, Mosfer A. Al-walah, Abdulmajeed N. Alotaibi, 4 5 Shayek S. Alotaibi , and Lamiaa K. Elsayyad Department of Physical Therapy, College of Applied Medical Sciences, Taif University, Saudi Arabia Faculty of Physical Therapy, Misr University for Sciences and Technology, Egypt Children Hospital, Taif Health Affairs, Ministry of Health, Saudi Arabia Department of Medical Rehabilitation and Physiotherapy, Children Hospital, Ministry of Health, Taif, Saudi Arabia Department of Biomechanics, Faculty of Physical Therapy, Cairo University, Egypt Correspondence should be addressed to Lamiaa K. Elsayyad; hatem.lamiaa@gmail.com Received 20 September 2021; Revised 8 October 2021; Accepted 18 October 2021; Published 31 October 2021 Academic Editor: Fahd Abd Algalil Copyright © 2021 Hatem H. Allam et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Obesity contributes to the acquired flatfoot deformity which in turn impairs balance. Aim. The purpose of the current study was to compare the effect of plyometric exercises with flatfoot corrective exercises on balance, foot posture, and functional mobility in obese children with a flexible flatfoot. Methods. Forty-seven children participated in the study. Their age ranged from 7 to 11 years. Participants were randomly divided into 3 groups: experimental group I (EGI), experimental group II (EGII), and the control group (CG). The EGI received plyometric exercises and the EGII received corrective exercises, 2 sessions weekly for 10 weeks. The control group did not perform any planned physical activities. The Prokin system was used to assess balance, the timed up and go test (TUG) was used to assess functional mobility, and the navicular drop test (NDT) was used to assess foot posture. Results. EGI showed significant improvement in all balance parameters, foot posture, and TUG. EGII showed improvement in the ellipse area and perimeter in addition to foot posture and TUG. Conclusion. Plyometric exercises and foot correction exercises had a positive effect on foot posture, balance, and functional mobility in obese children with flatfeet. 1. Introduction by many factors such as sensory impairment, abnormal muscle response, poor muscle strength, and the presence of Obesity appeared among children and adults as one of the certain foot abnormalities such as a flatfoot [4]. Some studies critical and major community health worries within the past have confirmed that the impaired balance may affect the quality of life, many skills, and many daily living activities century [1]. The prevalence of childhood obesity has been noticed over the last 3 decades [2]. Moreover, obesity also in children and adults [5]. affects all daily living activities like walking or standing skills Riccio et al., [6] mentioned that rehabilitation therapy, and negatively affects balance and ability to alter positions. which includes the constant proprioceptive stimulation of Additionally, it is one of the main factors that causes an the foot, is likely to achieve improvement in the plantar arch and correct the flexible flatfoot. Additionally, there is evi- acquired flat foot deformity which in turn impairs the bal- ance strategy [3]. Balance is considered as multiple processes dence that exercises have a crucial role in improving balance. that require mechanical, sensory, and kinetic elements of It strengthens the muscles that enhance balance, walking motion to be coordinated. It may be negatively influenced ability, and correct deformities [7]. Published research has 2 Applied Bionics and Biomechanics participants were randomly assigned into three groups: demonstrated that balance has improved by applying certain stretching procedures, proprioceptive stimulation techniques, experimental group I (EGI) contained 16 participants, exper- and strengthening exercises [8]. One of the approaches that imental group II (EGII) contained 16 participants, and the enhance balance in children is plyometric exercises [9]. Plyo- control group (CG) contained 15. The stratification was done metric exercise indicates a quick and strong interaction move- using sealed envelopes. The children were not aware of the ment between both eccentric and concentric contractions [10]. group that they belonged to. This type of exercise is secure and efficient in adults and chil- Demographic data collection was as follows: a specially dren for enhancing balance, jumping skills, reaction time, designed survey was used to collect demographic data for all participants such as age, weight, and height. bone mineral density, endurance, muscle power and strength, energy production, motor performance, and coordination 2.4. Body Mass Index Percentile for Boys. BMI percentile is a [11]. Certain studies concluded that there were some improve- screening tool used to classify the participant’s degree of ments in postural stability after the application of a 15-minute obesity in children according to the American Academy of plyometric exercise [12]. To date, little is known about the Pediatrics recommendations. To calculate the BMI percen- effect of plyometric exercises on foot posture in obese children tile, at first, obtain accurate height and weight measurements with flexible flatfeet. Thus, the purpose of the current study for each child. The subjects’ body weight in bare feet and was to compare the effect of plyometric exercises with with minimal clothing was measured. Standing height was flatfoot-corrective exercises on balance, foot posture, and measured with the children standing straight without foot- functional mobility in obese children with a flexible flatfeet. wear. The height and weight were measured twice to mini- The current study could help the obese children to benefit mize errors. The body mass index (BMI)was then from the different exercise protocols which may contribute calculated by dividing the weight (kg) by height (m) squared. to improvements in their quality of life. 2.5. Balance Assessment. The static balance was assessed by 2. Materials and Methods using the Prokin system (PK 252, TecnoBody S.r.l., Italy). The balance assessment is based on the degree of postural 2.1. Study Setting. The study was conducted at the balance sway using a tilting board. Before the actual assessment, all lab of the Faculty of Applied Medical Sciences. It was started participants were engaged in certain practical sessions and on 15 January 2021. the whole procedures were illustrated to them to be familiar- ized with the testing procedures and balance device. 2.2. Subjects. A sample of 47 male children participated in the current study without having female participants due 2.5.1. Starting the Test. In the first step, the system was to the cultural issues and order of the society in Saudi Ara- opened and calibrated and the demographic data was bia. The sample size was detected by using statistical power entered (name, age, height, and weight). The next step is analysis—G ∗ power (power, 0.85; α =0:05;effect size = 0:5, selecting the type of stability test, and the participant stands Pillai V =0:2). The participants were selected randomly comfortably on the tilting board and was asked to look from different elementary schools in Taif, Saudi Arabia. Par- towards at the screen keeping his hands beside the body ticipants were enrolled by contacting their parents by phone while his eyes are focused on the fixed target on the screen. using the phone numbers in the schools’ database. Their age Each participant applied three trials with eyes opened (EO) ranged from 7 to 11 years. Initially, a specialist examiner and the mean score was recorded. The participants had a conducted a comprehensive evaluation of all participants. five-minute break after each trial, and we tried to avoid He was blinded about the groups’ division. Inclusion criteria any distractions. There are four variables that were mea- are as follows: all children were classified as obese (their sured for all participants at the beginning and at the end of body mass index percentile is equal to or greater than the the study with EO: perimeter area (mm), ellipse area 95th percentile). The participants were not involved in (mm ), standard backward-forward deviation, and standard strength, balance training, or competitive sports aiming to medial-lateral deviation. enhance muscular strength or balance. All participants had balance impairments and a mobile flat foot. Their degree 2.6. The Navicular Drop Test. (NDT) was used to assess the of flatfoot deformity according to NDT was ranged from degree of flatfoot deformity. The NDT revealed excellent 16 to 19 millimeters in all participants. The exclusion criteria reliability, with ICC values reaching 0.945 and standard were as follows: the children were excluded when they had a error of measurement < 1 mm [13]. Firstly, the subtalar previous injury to the lower limb which required medical neutral position was accustomed while the child was in the care or had other confounding conditions, such as deformity sitting position with both hips and knees at 90 , and then, of or surgery in the lower limb or visual impairment. Addi- the navicular tuberosity was palpated and marked. The tionally, they were excluded if they engaged in obesity treat- distance between the navicular tuberosity and the floor was ment programs three months prior to the study. The written measured in millimeters using a stainless-steel high- informed consent (from parents or children’s guardians) was accuracy electronic digital display slide caliper. After that, obtained before they enrolled in the study. the participant was instructed to stand in a relaxed foot pos- ture and the navicular tuberosity was palpated and marked 2.3. Randomization. A simple randomization technique again to avoid any error due to skin shifting and then the was used. After gathering the baseline measurements, the height of the mark measured from the floor. The ND was Applied Bionics and Biomechanics 3 Table 1: The repetition of plyometric exercises during the intervention period. Repetitions The exercise Weeks 1 and 2 Weeks 3 and 4 Weeks 5 and 6 Weeks 7 and 8 Weeks 9 and 10 Jump jacks 6 7 8 9 10 Skipping 8 9 10 11 12 Jump side to side 6 7 8 11 12 Jump front and back 6 8 10 11 13 Vertical jump 6 8 10 11 13 Hopping forwards and backwards on the right foot 6 7 8 9 10 Hopping forwards and backwards on the left foot 6 7 8 9 10 Short jump forwards and backwards 6 7 8 9 10 Total repetitions 50 60 70 80 90 Table 2: Corrective exercises and activities for the flexible flatfoot adopted from Riccio et al. [6]. Aim Exercises and activities Passive range of motion exercises and global movement of the ankle and all foot joints; stretching of the Flexibility calf and peroneus brevis muscles Anterior and posterior tibialis muscles and the flexor hallucis longus (to neutralize valgus), intrinsic, Strengthening, proprioception, interosseus plantaris muscles, and the abductor hallucis (to prevent anterior arch flattening); global and balance activation/movement of the muscles involved in maintaining the medial longitudinal arch and the varus; single-leg weight bearing (with pronation control); toe and heel walking; descending an inclined surface Table 3: MANOVA results for the study variables. the difference in the navicular tuberosity height between both marks [14]. Effect Test FP Variables ∗ groups 3.384 0.000 2.7. Functional Mobility. Functional mobility was assessed Time ∗ groups 7.477 0.000 using the timed up and go (TUG) test to detect participants’ Wilks’ lambda functional mobility. It is a valid and reliable test. At first, a Variables ∗ time 13.952 0.000 sign was placed 3 meters away from the chair. A seat with Variables ∗ time ∗ groups 6.693 0.002 back support without arms was chosen from the children’s environment. The seat should allow the feet to be flat on the ground and the knee and hip to bend 90 degrees. Then, spongy mat for shock absorption. We emphasized that all the child was asked to stand up, walk at his free gait, touch participants should get down from jumping on tiptoes and the mark, and return to sit down on the chair. The time the weight-bearing activities should be done with foot prona- was counted as the child left the seat and stopped when tion control. The jumps were divided into five sets and two- the child returned to the sitting position using a stopwatch. minute rests were given in between each set and the other. The test was run three times and the average value was The selected corrective exercises and activities are illustrated taken [15]. in Table 2 according to Riccio et al. [6]. 2.8. The Intervention. The EGI received a plyometric exercise 2.9. Ethical Considerations. The ethical committee at the program. The EGII received the corrective exercises. The research and studies department, directorate of health control group was not involved in any planned physical affairs, Taif, Saudi Arabia (IBR registration number with activity during the intervention period but persisted in their KACST, KSA HAP-02-T-067), approved the current study traditional physical activities. The designed exercises were on 11 November 2020 with approval number 452. applied two sessions per week with three days of rest in between for 10 weeks. The session started with 5 minutes 2.10. Study Design and Data Analysis. A randomized con- warming up and ended with 5 minutes cooling down in trolled trial was used to investigate the effect of plyometric the form of gentle stretching of the lower limb muscles. All exercises with flatfoot-corrective exercises on balance, foot participants were engaged in certain practical sessions at posture, and functional mobility in obese children with the beginning of the study to be familiarized for all interven- flexible flatfoot. This was a randomized clinical trial of the tion procedures. Additionally, the supervisor emphasized parallel-group design. The study was registered and posted the correct application of the exercises. The selected plyo- on the Clinical Trials.gov public website with ID metric exercises and their repetitions are illustrated in (NCT05026294). The study was double blinded, the exam- Table 1 according to Johnson et al. [16]. It was done on a iners and participants were blinded about the group division. 4 Applied Bionics and Biomechanics Table 4: Bonferroni pairwise comparisons for demographic characteristics and the study variables of the three groups at the beginning of the study. M ±SD MD Variables EGI EGII CG EGI-EGII P EGI-CG P EGII-CG P 9:48 ± 1:12 9:74 ± :95 9:07 ± 1:22 Age −0.27 1 0.407 0.92 0.67 0.28 45:37 ± 8:14 41:44 ± 6:02 42:04 ± 8:55 Weight 3.93 0.46 3.34 0.69 −0.60 1 Height 1:37 ± :17 1:35 ± :14 1:25 ± :12 0.022 1 0.12 0.09 0.09 0.24 23:71 ± 2:06 22:71 ± 3:06 22:01 ± 2:05 BMI 1.003 0.76 1.7 0.18 0.69 1 529:64 ± 81:35 614:05 ± 125:58 581:02 ± 184:98 Ellipse area −84.41 0.26 −51.38 0.89 33.03 1 706:33 ± 170:5 631:33 ± 192:22 570:13 ± 112:99 Perimeter 75.001 0.6 136.2 0.074 61.2 0.9 BFD 7:96 ± 1:58:62 ± 1:47:95 ± 1:93 −0.67 0.76 0.001 1 0.67 0.78 4:64 ± 1:16 4:03 ± 1:03 4:07 ± 1:39 MLD 0.61 0.48 0.56 0.59 −0.043 1 17:25 ± 3:55 16:94 ± 1:81 18:47 ± 2:9 ND 0.31 1 −1.21 0.72 −1.53 0.43 7:53 ± :58163 7:26 ± :397 7:27 ± :36 TUG 0.27 0.31 0.26 0.37 −0.011 1 EGI: experimental group 1; SD: standard deviation; MLD: mediolateral deviation; EGII: experimental group 2; MD: mean difference; ND: navicular drop test; CG: control group; M: mean; TUG: time up and go test; BFD: backward-forward deviation. All statistical measures were performed through the Statisti- 4. Discussion cal Package for Social Studies (SPSS) version 26 for Win- dows. The MANOVA test was conducted to determine if The study is aimed at investigating the effect of plyometric there were any significant differences in the mean values of exercises on foot posture, balance, and functional mobility age, weight, height, and BMI between both groups. Addition- in obese children with mobile flatfeet. We have selected the ally, repeated measures MANOVA was used to compare the balance parameters to be investigated in obese children within- and between-subject effects of both interventions because appropriate balance control is necessary for routine (Table 3). The alpha level was set at 0.05. activities of daily living and obesity has a tremendous nega- tive effect on balance [17]. The results of the study revealed that there was significant improvement in all balance param- 3. Results eters, foot posture, and TUG in EGI. EGII showed improve- ment in the ellipse area and perimeter in addition to foot 3.1. Baseline Comparison. There were no significant differ- posture and TUG without improvement in the backward- ences among the three groups at the beginning of the study forward and mediolateral deviation. either in the demographic data or in the study variables Concerning preintervention balance assessment, the (Table 4). results of the study revealed that obese children have defi- cient balance skills. This comes in agreement with Deforche et al. [18] who mentioned that obese prepubertal males have 3.2. Postintervention (within-Subject Comparisons). The EGI decreased both static and dynamic balance and postural showed a significant improvement in all assessed balance skills. Moreover, obese children have deficits in the torque parameters (ellipse area, perimeter, backward-forward devi- of the ankle muscles needed for stability when they are ation, and mediolateral deviation) in addition to the signifi- subjected to any oscillations [17]. Additionally, deficits in cant improvement in foot posture (as indicated by navicular balance strategies in obese children preintervention had height) and TUG. Regarding EGII, there was a significant impaired functional mobility as represented by the TUG test improvement in the previous items except for the score [18]. backward-forward deviation and the mediolateral deviation Concerning the effect of plyometric exercises on balance, which showed nonsignificant improvement. On the other the results of the current study revealed that the balance was hand, there were no significant changes in the CG (Table 5). improved significantly in the EGI postintervention. This comes in consistency with Arazi and Asadi [19] who men- 3.3. Postintervention (between-Subject Comparison). Con- tioned that muscle strength and balance skills were improved cerning EGI, it showed a significant difference in all assessed after 8 weeks of aquatic and land plyometric exercises in parameters when it was compared to the EGII and CG young athletes. Moreover, Myer et al. [20] mentioned that except the improvement in foot posture and TUG which the balance performance was improved after the application showed a nonsignificant difference between EGI and EGII. of the plyometric training program. Additionally, Chaouachi EGII showed significant improvement in all parameters et al. [21] were in line with our findings when they reported when compared to the CG except for the backward- that plyometric training improved balance, jumping skills, forward deviation which showed nonsignificant improve- and squat strength measures like the combined training pro- ment in the EGII (Table 6). gram. The improvement in balance skills after plyometric Applied Bionics and Biomechanics 5 Table 5: Bonferroni pairwise comparisons for within-subject effect. EGI EGII CG Variables M ±SD MD PM ±SD MD PM ±SD MD P Pre Post Pre Post Pre Post 529:64 ± 81:35 401:02 ± 98:98 614:05 ± 125:58 504:99 ± 105:44 581:02 ± 184:98 616:47 ± 99:4 EA 128.62 0.012 109.05 0.031 −35.45 0.487 706:33 ± 170:5 449 ± 75:08 631:33 ± 192:22 531:17 ± 102:45 570:13 ± 112:99 619:71 ± 84:99 PR 257.32 0.000 100.16 0.022 −49.58 0.260 7:96 ± 1:56:6±1:43 8:62 ± 1:48:2±1:27 7:95 ± 1:93 8:47 ± 1:35 BFD 1.34 0.024 0.42 0.463 −0.52 0.386 MLD 4:64 ± 1:16 2:9±0:54 1.74 0.000 4:03 ± 1:03 3:35 ± 0:56 0.68 0.054 4:07 ± 1:39 4:21 ± 0:39 −0.14 0.698 17:25 ± 3:55 13:69 ± 1:49 16:94 ± 1:81 14:63 ± 1:96 18:47 ± 2:917:73 ± 1:16 ND 3.56 0.000 2.31 0.006 0.73 0.381 7:53 ± 0:58 8:44 ± 0:64 7:26 ± 0:48:68 ± 0:72 7:27 ± 0:36 7:15 ± 0:43 TUG −0.91 0.000 −1.41 0.000 0.13 0.344 EGI: experimental group 1; SD: standard deviation; PR: perimeter; EGII: experimental group 2; MD: mean difference; BFD: backward-forward deviation; CG: control group; EA: ellipse area; MLD: mediolateral deviation; M: mean; ND: navicular drop test; TUG: time up and go test. 6 Applied Bionics and Biomechanics Table 6: Bonferroni pairwise comparisons for between-subject effect. M ±SD MD Variables EGI EGII CG EGI-EGII P EGI-CG P EGII-CG P 401:02 ± 98:98 504:99 ± 105:44 616:47 ± 99:4 Ellipse area −103.97 0.017 −215.44 0.000 −111.47 0.011 Perimeter 449 ± 75:08 531:17 ± 102:45 619:71 ± 84:99 −82.17 0.035 −170.7 0.000 −88.53 0.023 6:62 ± 1:43 8:2±1:27 8:47 ± 1:35 BFD −1.579 0.006 −1.85 0.001 −0.28 1.0 2:9±0:54 3:35 ± 0:56 4:21 ± 0:39 MLD −0.449556 0.047 −1.31 0.000 −0.86 0.000 13:69 ± 1:49 14:63 ± 1:96 17:73 ± 1:16 ND −0.938 0.302 −4.05 0.000 −3.11 0.000 8:44 ± 0:64 8:68 ± 0:72 7:15 ± 0:43 TUG −0.237 0.840 1.29 0.000 1.53 0.000 EGI: experimental group 1; SD: standard deviation; MLD: mediolateral deviation; EGII: experimental group 2; MD: mean difference; ND: navicular drop test; M: mean; BFD: backward-forward deviation; TUG: time up and go test. exercises may be related to the rapid stretch-shortening cycle walking after each set). They related the navicular drop to and combines shifts of the center of gravity in both vertical muscle fatigue after exercise. Concerning the effect of corrective exercises on the foot and horizontal directions that may improve postural control and equilibrium [22]. Furthermore, enhanced cocontraction arch, the results of the study revealed that there was a signif- icant improvement in the foot posture in EGII postinterven- of the lower extremity muscles and the improvement in proprioception and neuromuscular control after plyometric tion. Halabchi et al. [31] confirmed our findings when they training played a role in balance improvement [23]. have stated that the use of a suitable rehabilitation program may improve the flexible flatfoot posture in children. Their On the other hand, Twist et al. [24] contradict our find- ings when they mentioned that unilateral balance perfor- rehabilitation program included flexibility, strength, and mance was impaired 24 hours after plyometric exercise. proprioceptive training exercises which come in consistency This contradiction may be related to fact that they had used with our corrective exercise program. Furthermore, Riccio a high-intensity plyometric exercise program (200 jumps et al. [6] agreed with our results when they mentioned that rehabilitation therapy, which depends on the constant per session). They reported that this designed intensive plyo- metric program may induce symptoms of muscle damage proprioceptive stimulation of the foot, is likely to achieve and muscle soreness that negatively affected the balance improvement in the plantar arch and correct the calcaneoval- performance. gus deformity in a flexible flatfoot. The proprioceptive train- Concerning the effect of plyometric exercises on foot pos- ing is essential in the improvement of the reflex circuits, which is vital for proper confidence in both static and ture, the results of the current study revealed that there was a significant improvement in the foot posture in EGI after dynamic foot placements, which in turn improves balance plyometric training. We can attribute this improvement to and functional mobility. On the other hand, Namsawang the improvement in plantar flexor strength and mechanical et al. [32] contradict our results as they found that exercises properties after plyometric exercises. Kubo et al. [25] support for foot muscles did not improve the ND. Their results may be due to the short duration of the program (only 4 weeks) this idea when they found a significant increase in plantar flexor muscle activity during the concentric phase of vertical that is considered as one of their study’s limitations. jumps. Furthermore, the results obtained by Kyröläinen et al. Concerning the effect of corrective exercises on balance, [26] denoted a significant improvement in both maximum the results of the study revealed that there was a significant voluntary contraction and muscular activity and strength of improvement in all balance measures in EGII postinterven- tion except for the backward-forward and mediolateral devi- plantar flexors after plyometric exercises. Moreover, Weist et al. [27] confirmed the relation between the plantar flexors ation. The improvement in the balance measures may be and the medial longitudinal arch (MLA) when they con- attributed to an increase in the strength of the intrinsic mus- cluded that fatigue of plantar flexors reduces its supination cles of the foot, which in turn improves the arch height and action and increases foot pronation. Additionally, Fourchet postural control as reported by Kim and Kim [33]. More- over, Sudhakar et al. [34] added that the runners with low et al. [28] found that decreased calf muscle activity due to fatigue was associated with an increase in the contact area arches had less balance than those with normal arches, under the MLA. Kamalakannan and Swetha [29] came in which means that the increase in the arch height improves agreement with our results when they concluded that robe the balance strategy. skipping activities improved the foot arch and functional Regarding the improvement in functional mobility, the results of the current study showed that there was a signifi- activities of the lower limb. On the other hand, Klaikaew and Panichaporn [30] con- cant improvement in the TUG test scores in both EGI and tradict our results when they reported dropping down of the EGII when it was compared with CG at the endpoint. The navicular and a decrease in the height of the MLA after improvement may be related to the improvement in balance repetitive hopping. However, they used a vigorous hop tech- skills, muscle strength, and foot posture that occurred in both experimental groups. nique (hopped 60 times/minute/set for 3 sets with 30 sec Applied Bionics and Biomechanics 7 [4] N. Teasdale, O. Hue, J. Marcotte et al., “Reducing weight 4.1. Limitations. Only male children were examined without increases postural stability in obese and morbid obese men,” having female participants because of cultural values in International Journal of Obesity, vol. 31, no. 1, pp. 153–160, Saudi Arabia. Additionally, foot posture was assessed using the ND test only. [5] L. D. Jelsma, Dynamic control of balance in children with developmental coordination disorder, Diss. University of 5. Conclusion Groningen, 2017. [6] I. Riccio, F. Gimigliano, R. Gimigliano, G. Porpora, and Both plyometric exercises and foot correction exercises had a G. Iolascon, “Rehabilitative treatment in flexible flatfoot: a positive effect on foot posture, balance, and functional perspective cohort study,” Musculoskeletal Surgery, vol. 93, mobility in obese children with flatfeet. Both should be no. 3, pp. 101–107, 2009. considered in the rehabilitation of children with obesity. [7] P. G. Vassão, R. L. Toma, H. K. M. Antunes, and A. C. M. Renno, “Photobiomodulation and physical exercise on Data Availability strength, balance and functionality of elderly women,” Fisio- terapia em Movimento, vol. 31, 2018. The data used to support the findings of this study are avail- [8] H. W. Wallmann, K. R. Player, and M. Bugnet, “Acute Effects able from the corresponding author upon request. of static stretching on balance in young versus Elderly adults,” Physical & Occupational Therapy in Geriatrics, vol. 30, no. 4, Conflicts of Interest pp. 301–315, 2012. [9] F. Fischetti, S. Cataldi, and G. Greco, “A combined plyometric The authors declare that there is no conflict of interest and resistance training program improves fitness performance regarding the publication of this article. in 12 to 14-years-old boys,” Sport Sciences for Health, vol. 15, no. 3, pp. 615–621, 2019. Authors’ Contributions [10] D. McKay and N. Henschke, “Plyometric training pro- grammes improve motor performance in prepubertal chil- Conceptualization was done by HA, LE, AM, MA, AA, and dren,” British Journal of Sports Medicine, vol. 46, no. 10, SA. Writing of the original draft was done by HA and LE. pp. 727-728, 2012. Statistical designing was done by HA and LE. Formal analy- [11] S. Shah, “Plyometric exercises,” Int J Health Sci Res, vol. 2, sis was done by HA and LE. Investigation was done by MA, pp. 115–126, 2012. SA, and AA. The methodology was done by HA, LE, AM, [12] N. Romero-Franco and P. Jiménez-Reyes, “Unipedal postural MA, AA, and SA. Project administration was done by HA, balance and countermovement jumps after a warm-up and LE, AM, MA, AA, and SA. The software was prepared by plyometric training session: a randomized controlled trial,” HA and LE. Supervision was done by HA, LE, AM, MA, The Journal of Strength & Conditioning Research, vol. 29, AA, and SA. Writing of the discussion was done by HA, no. 11, pp. 3216–3222, 2015. LE, and AM, Writing, reviewing, and editing were done by [13] J. C. Zuil-Escobar, C. B. Martínez-Cepa, J. A. Martín-Urrialde, HA, LE, AM, MA, AA, and SA. and A. Gómez-Conesa, “Medial longitudinal arch: accuracy, reliability, and correlation between navicular drop test and footprint parameters,” Journal of Manipulative and Physiolog- Acknowledgments ical Therapeutics, vol. 41, no. 8, pp. 672–679, 2018. [14] M. Kirmizi, M. A. Cakiroglu, A. Elvan, I. E. Simsek, and We thank all study’s participants and their guardians for S. 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Published: Oct 31, 2021

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