|Year : 2017 | Volume
| Issue : 2 | Page : 173-177
Assessment of static and dynamic balance in overweight and obese children with and without flatfoot: A cross-sectional study
Pallavi Sharma, Deepa Metgud
Department of Pediatric Physiotherapy, KLE University's Institute of Physiotherapy, Belgaum, Karnataka, India
|Date of Web Publication||30-May-2017|
Bharatpur 10, Syaulibazaar, Chitwan, Nepal
Source of Support: None, Conflict of Interest: None
Background: Childhood obesity and overweight have been referred by health organization as serious epidemic and global problems that are on the rise. The consequence of being overweight in children is the greater impairment of mobility which may result in several orthopedic conditions. The foot dimensions of overweight children and obese children will be larger than those of normal weight children. Balance is defined as an ability to maintain the center of mass over base of support. Balance as a sensorimotor ability helps in maintaining static and dynamic equilibrium. The presence of abnormalities in the foot structures may affect the displacement of the body, function in static, and dynamic position.
Methodology: This was a cross-sectional study done in overweight and obese children with and without flatfoot. A total of 1165 children were screened out of which 87 were found to have obesity between the age group of 6–12 years from 11 schools. Static balance of children was measured using balance error scoring system (BESS) and stork balance stand test (SBST), and dynamic balance was measured using four square step test (FSST) and modified bass test of dynamic balance (MBTDB).
Results: The static balance was significantly affected in obese children with and without flatfoot and also in overweight children with flatfoot whereas dynamic balance was affected in obese children with flatfoot. BESS (P = 0.001), MBTDB (P = 0.006), and FSST (P = 0.001) were statistically significant. There was no significant difference found on SBST (P = 0.0657) when compared within and between the groups.
Conclusion: Obese children with flatfoot had poor static and dynamic balance compared to overweight children with flatfoot when it was tested on BESS and MBTDB and FSST.
Keywords: Balance, childhood, obese, overweight, postural control
|How to cite this article:|
Sharma P, Metgud D. Assessment of static and dynamic balance in overweight and obese children with and without flatfoot: A cross-sectional study. Indian J Health Sci Biomed Res 2017;10:173-7
|How to cite this URL:|
Sharma P, Metgud D. Assessment of static and dynamic balance in overweight and obese children with and without flatfoot: A cross-sectional study. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2022 Dec 4];10:173-7. Available from: https://www.ijournalhs.org/text.asp?2017/10/2/173/207268
| Introduction|| |
Childhood obesity and overweight have been referred by health organization as serious epidemic and global problems that are on the rise., It has been estimated that 10% of school going children becomes overweight. Nearly, 22 million children are estimated to be overweight under the age of five. In the USA, the prevalence of overweight in children was increased from 5% to 11%. India has reported a high prevalence of obese and overweight children both in adults as well as children. Increase in prevalence is due to the availability of high fat fast foods, urbanization, and mechanization. Efforts should be taken to prevent overweight, including improved diets, physical activities which should be begin in early childhood. In children, overweight and obesity are defined using age- and sex-specific normograms for body mass index (BMI). BMI above the 85th percentile on the age-gender specific chart is level as overweight and those with BMI exceeding 95th percentile to be obese.
Body weight is regulated by various physiological mechanisms which maintain a balance between energy expenditure and energy intake. Studies have revealed differences in foot structure, plantar pressure, and foot mechanics in obese compared to nonobese individuals. Some of the foot problems due to obesity are pronated foot, heel spurs, painful arches, bunions, and plantar fasciitis.
Balance is very essential for doing any voluntary movement. Balance is defined as an ability to maintain the center of mass over base of support., Static and dynamic balance are the most frequently used technique to evaluate postural stability. It is the measurement of position and displacement of center of pressure. These two measures are the used for the identification of lower extremity function. Balance is important in development and performance of many motor skills. It is one of the associated problems in obese children. Numerous studies have assessed the balance in children with obesity. Excess body mass in obese children contributes to reduce stability and lead to need to seek posture adaptation mechanisms.
Literature has been reported on balance issue in overweight and obese children considering factors such as posture, praxis, hypertension, and gait  but the variation of balance in overweight and obese children with and without flatfoot has not been evaluated.
Hence, the present study intends to determine the static and dynamic balance in overweight and obese children with and without flatfoot.
| Methodology|| |
This was a cross-sectional study conducted in children between the age group of 6–12 years. Totally, 1165 children were screened out of which 87 were found to be obese. A total of 87 Children were found to be overweight and obese. Among these children, 54 were overweight and 33 were obese. Among them, overweight children 25 were with flatfoot and 29 were without flatfoot whereas among the obese children 17 were with flatfoot and 16 were without flatfoot. An approval for the study was obtained from Institutional Ethical Committee. List of 250 schools were obtained from District Education Office. Stratified sampling was done for selection of schools. Out of which 11 schools were screened for overweight and obese children with and without flatfoot children with any recent injury or surgery to lower extremities, acquired or congenital deformity of lower limbs, any neurological deficits, disabled and physically challenged children were exclusion criteria.
The baseline data regarding height, weight, waist and hip circumference, chippaux index, and leg dominance were recorded. The static balance of all the children was evaluated on balance error scoring system (BESS) and stork balance stand test (SBST). For BESS, the children were measured on the firm surface followed by on foam surface in double leg stance, single leg stance on the nondominant leg and in tandem stance with the nondominant leg behind. The scores according to the BESS were recorded. For SBST, children were made to stand comfortably on both feet with their hands on their hips and lifted his nondominant leg and were asked to hold this position was for as long as possible. The best of three attempts was recorded. This was followed by evaluation of the dynamic balance of obese children. The dynamic balance was evaluated using Modified Bass Test for dynamic balance and four square step test (FSST). For modified bass test for dynamic balance, the course was marked. The children were made to stand on the right foot on the starting point square and then the child was asked to hop to first tape mark with the left foot and hold a static position for 5 s. The children continued the same until the course was completed. For each successful landing, the children were given five points. For each second hold, the children were given one point.
The children were then tested on FSST. For FSST, the square was formed using four canes resting flat on the floor. The children were made to stand in square number one, facing square number two and were asked to complete a course of a test clockwise and anticlockwise. The best of two attempts was recorded.
| Results|| |
The results of the study were analyzed in terms of age, gender, anthropometric measurements such as weight, height, waist circumference, hip circumference, waist: hip ratio, BMI, chippaux index, dominant Leg [Table 1], static balance on BESS and SBST, dynamic balance on modified bass test of dynamic balance (MBTDB) and FSST [Table 2]. Statistical analysis for the present study was done using Statistical Package for Social Science (SPSS) version 16. One-way ANOVA test was used to find the significance of the study parameters within the groups. Tukeys post hoc test was performed to find the significance of study parameters between the two groups (intergroup comparison). P< 0.05 was considered as statistically significant [Table 3].
|Table 1: Demographic characteristics of overweight and obese children in the age group of 6.12 years|
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|Table 2: Comparison of Balance Error Scoring System, Stork Balance Stand Test, Modified Bass Test of Dynamic Balance and Four Square Step Test scores between the groups|
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|Table 3: Pair wise comparison of Balance Error Scoring System, Stork Balance Stand Test, Modified Bass Test of Dynamic Balance and Four Square Step Test scores within the group|
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Obese with flatfoot had a poor static balance compared to overweight children with flatfoot when it was tested on BESS (P = 0.001). SBST score was not found to be significant when it was compared with overweight and obese children with and without flatfoot (P = 0.0657). Obese children with flatfoot had poor or lower dynamic balance compared to overweight children with flatfoot when tested on MBTDB (P = 0.006). Obese children with flatfoot showed poor performance on FSST (P = 0.001).
| Discussion|| |
Obesity is a multifactorial problem, and its development is due to multiple interactions between genes and environment. In the present study, numbers of girls were found to be more in both the overweight and obese group as compared to number of boys. Studies on Indian population have reported that Indian girls (61%) had higher obesity than boys (54%). Our findings were in accordance to this study as we found 64.37% of girls as compared to 35.63% of boys out of 1165 children screened. In a study, it was found that obese girls were less physical active than boys. A physical activity is a form of prevention against obesity for reduction of body fat. Researchers count the following reasons to be most important limitation causing less physical activity in overweight and obese girls such as body related barriers, cultural factors which decrease the opportunity and motivation and low level of parents support. It was noticed that during weekdays and weekends girls had a significantly higher indoor than boys who were more involved in sports.
Adiposity in children increases rapidly in the 1st year of life and then again it decreases till the age of 6 years, and it again develops. The study reports a considerable increase of obesity among 6–11 years from 5% to 13% over a period. Some researches attribute the increasing prevalence among these children is decreased physical activity as a result of television watching. Another reason could be the positive relation between the birth weight and BMI. Hence, we look for children in age group of 6–12 years in the study. Overweight among school children is a concern, because it may have long-term health consequences.
In this study, there was significance difference found in overweight children with flatfoot and obese children with flatfoot on total BESS scores both on firm and foam surface. Obese children with flatfoot showed poor performance when it was compared with overweight children with flatfoot. In a systemic review of the BESS, it has been found that scores increases with concusion, functional ankle stability, external ankle bracing, fatigue, and age.
In this study, single leg stance on firm surface was more affected in obese children with flatfoot. In obese children with flatfoot, it was more challenging to lift one leg. This could be because of the overuse of the one leg over the other which develops limb asymmetry. Significance difference on BESS score on firm surface was found between the groups for tandem stance. Overweight children without flatfoot performed well as compared to children with flatfoot. Tandem stance was found to be more affected in obese children with flatfoot. The results of our study are consistent with the study which was done on functional balance abilities of children which showed difficulties in an upright stance, when the base of support was narrowed and in situ ations where the center of gravity approaches the edge of the base of support.
Obese children with flatfoot showed poor balance control in double leg stance, single leg stance, and tandem stance on firm surface. Ankle instability could be one of the reason for increased BESS scores in obese children with flatfoot on firm surface and the authors also suggested that obese children were more dependent on the visual system to postural stability than nonobese children and also there was greater center of pressure displacement when obese children stood on the foam support surface.
There was no significance difference found in SBST in between the groups and within the groups. This could be because of the impact of leg dominance where BESS measures balance on nondominant leg and SBST measures balance on dominant leg. Vision provides the orientation of the body in space and movement in the environment. Children for stork stand balance test stood with eyes opened whereas in BESS eyes were closed.
Obese children with flatfoot had a poor or lower dynamic balance compared to overweight children with flatfoot when tested on MBTDB. Based on mean score of each group, children with flatfoot had a good balance as the score range was above 65.
It has been said that obese children will have greater absolute strength but low relative strength and power. Because of increased segment mass greater muscle force is required to move segments. Increased ankle torque required to correct postural sway. These children will have decreased functional capacity due to increased fatigue over repetition of task.
Obesity reduces relative muscular strength and decreases muscular fatigue resistance. These limitations may lead to motor delays and insufficient corrective torque. As a result, it contributes to an inability to affect an appropriate response to perturbation which allows for the maintenance of postural control.
The dynamic balance of the children on Foursquare step test was found to be poor in obese children with flatfoot. It has been said that obese individual with flatfoot has poor motor planning and an inability to adapt motor plans during the action and these children being less responsive to perturbation than normal weight children. One potential explanation for this could be decreased sensitivity to the increase in mean pressure that the mechanoreceptors – the body's sensory receptors for pressure are under, due to an elevation in body weight.
| Conclusion|| |
Our study concludes that 7% of children were found to have obesity out of 1165 children screened. The static balance and dynamic balance was affected in obese children with flatfoot and static balance was affected in overweight with flatfoot. However, when compared Static balance was affected more in obese children with flatfoot based on BESS and dynamic balance was fairly affected in obese children with flatfoot on Modified Bass Test and FSST.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Shultz SP, Anner J, Hills AP. Paediatric obesity, physical activity and the musculoskeletal system. Obes Rev 2009;10:576-82.
Raj M, Sundaram KR, Paul M, Deepa AS, Kumar RK. Obesity in Indian children: Time trends and relationship with hypertension. Natl Med J India 2007;20:288-93.
Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, Johnson CL. Prevalence of overweight among preschool children in the United States, 1971 through 1994. Pediatrics 1997;99:E1.
Ramachandran A, Snehalatha C, Vinitha R, Thayyil M, Kumar CK, Sheeba L, et al.
Prevalence of overweight in urban Indian adolescent school children. Diabetes Res Clin Pract 2002;57:185-90.
O'Donovan SM, O'B Hourihane J, Murray DM, Kenny LC, Khashan AS, Chaoimh CN, et al.
Neonatal adiposity increases the risk of atopic dermatitis during the first year of life. J Allergy Clin Immunol 2016;137:108-17.
Hills AP, Hennig EM, Byrne NM, Steele JR. The biomechanics of adiposity – Structural and functional limitations of obesity and implications for movement. Obes Rev 2002;3:35-43.
Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: Current theories and assessment tools. Phys Ther 1997;77:629-45.
Shumway Cook A, Wollacott MH. Motor Control Practice. 3rd
ed. Baltimore: Lippincott Williams and Wilkins; 2007.
Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: A review. Neurobiol Aging 1989;10:727-38.
Aleixo AA, Guimarães EL, de Walsh IA, Pereira K. Influence of overweight and obesity on posture, overall praxis and balance in schoolchildren. J Hum Growth Dev 2012;22:239-45.
Mota J, Santos P, Guerra S, Ribeiro JC, Duarte JA. Differences of daily physical activity levels of children according to body mass index. Pediatr Exerc Sci 2002;14:442-52.
Planinsec J, Matejek C. Differences in physical activity between non-overweight, overweight and obese children. Coll Antropol 2004;28:747-54.
Bac A, Wozniacka R, Matusik S, Golec J, Golec E. Prevalence of overweight and obesity in children aged 6-13 years-alarming increase in obesity in Cracow, Poland. Eur J Pediatr 2012;171:245-51.
Frankel S, Elwood P, Sweetnam P, Yarnell J, Smith GD. Birthweight, body-mass index in middle age, and incident coronary heart disease. Lancet 1996;348:1478-80.
Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al.
Health consequences of obesity. Arch Dis Child 2003;88:748-52.
Bell DR, Guskiewicz KM, Clark MA, Padua DA. Systematic review of the balance error scoring system. Sports Health 2011;3:287-95.
Baeker C. Fundamental Motor Skills: A Manual for Classroom Teachers. Victoria: Department of Education; 1996.
Horak FB. Postural orientation and equilibrium: What do we need to know about neural control of balance to prevent falls? Age Ageing 2006;35 Suppl 2:ii7-11.
Sharkey JR, Ory MG, Branch LG. Severe elder obesity and 1-year diminished lower extremity physical performance in homebound older adults. J Am Geriatr Soc 2006;54:1407-13.
Hassinen M, Komulainen P, Lakka TA, Väisänen SB, Rauramaa R. Associations of body composition and physical activity with balance and walking ability in the elderly. J Phys Act Health 2005;2:298.
Wolpert DM, Miall RC. Forward models for physiological motor control. Neural Netw 1996;9:1265-79.
Lustig RH. The neuroendocrinology of childhood obesity. Pediatric Clinics of North America 2001;48:909-30.
[Table 1], [Table 2], [Table 3]