Embed Size (px)
Citation preview
Human Movement Science 31 (2012) 1247–1252
Contents lists available at SciVerse ScienceDirect
Human Movement Science
journal homepage: www.elsevier .com/locate/humov
Interference of high-heeled shoes in static balance amongyoung women
Susana Bacelete Gerber a, Rafael Vital Costa a, Luanda André Collange Grecco a,Hugo Pasini a, Nádia Fernanda Marconi b, Claudia Santos Oliveira a,⇑a Nove de Julho University, São Paulo, SP, Brazilb Paulista University, São Paulo, SP, Brazil
a r t i c l e i n f o a b s t r a c t
Article history:Available online 27 June 2012
PsycINFO classification:2330
Keywords:High-heeled shoesStatic balanceForce plate
0167-9457/$ - see front matter � 2012 Elsevier B.http://dx.doi.org/10.1016/j.humov.2012.02.005
⇑ Corresponding author. Address: Endereço paraSão Paulo, SP, Brazil. Tel./fax: +55 11 3868 1681.
E-mail addresses: [email protected] (S.B. G(L.A.C. Grecco), [email protected] (H. PaOliveira).
The aim of the present study was to assess the effect of the use ofhigh-heeled shoes on static balance in young adult women. Fifty-three women between 18 and 30 years of age and accustomed towearing high-heeled shoes participated in the study. None of theparticipants had any orthopedic or neurologic alterations. Staticbalance was assessed using a force plate. Oscillations from the cen-ter of pressure in the mediolateral and anteroposterior directionswere measured both when barefoot and when wearing high-heeled shoes [7 centimeters (cm) in height and 1 cm in diameter]under the conditions of eyes open and eyes closed. Two-way anal-ysis of variance was employed for the statistical analysis, with thelevel of significance set at 5% (p < .05). The results revealed statis-tically significant differences between tests when barefoot andwhen wearing high-heeled shoes as well as with eyes open andeyes closed (p < .01). With the use of high-heeled shoes, therewas a significant increase in mediolateral oscillation with eyesclosed (p < .01). The present study demonstrates that the use ofseven-cm high heels altered static balance in the healthy youngwomen analyzed, increasing the oscillation of the center of pres-sure, regardless of visual restriction.
� 2012 Elsevier B.V. All rights reserved.
V. All rights reserved.
Correspondência – Rua Itapicuru, 380, apart. 111 – Perdizes, CEP 05006-000,
erber), [email protected] (R.V. Costa), [email protected]), [email protected] (N.F. Marconi), [email protected] (C.S.
1248 S.B. Gerber et al. / Human Movement Science 31 (2012) 1247–1252
1. Introduction
From the mid 20th century to the current day, human behavior has undergone considerablechanges. In various regions of the world, the social behavior of women and their representativity insociety are reflected in changes in habits and ways of dressing, with a particular emphasis on foot-wear, especially high-heeled shoes, considered to characterize beauty, self-assurance and elegance.However, maintaining the body on a support base that has been modified in physical terms (diameterand height) presupposes changes in the sensory information necessary for the maintenance of pos-tural control (Barela, 2000; Duarte, 2000; Thompson & Coughlin, 1994; Winter, 1995).
Postural control is defined as the process by which the central nervous system produces muscleactivity patterns necessary to the relationship between the center of mass and support base. The vi-sual, vestibular and proprioceptive systems are involved in sending information to the postural con-trol system (balance), thereby forming an afferent mechanism. Vision is the most important sensoryinformation system and can compensate for a lack or non-reliability of other sensory stimuli (Bug-nariu & Fung, 2007; Cenciarini & Peterka, 2006; Mochizuki & Amadio, 2006).
The nervous system has the capacity to repair maladjustments, allowing dynamic postural efficacy(Schmid, Bottaro, Sozzi, & Schieppati, 2011). Despite maintaining an apparently immobile orthostaticposture, an individual constantly oscillates in the anteroposterior and mediolateral directions. Theseoscillations are the result of hip and ankle motor strategies performed to maintain static balance.The ankle strategy requires a small range of motion and considerable ankle muscle strength, whichare fundamental when the disturbance to balance is slight and the support base is firm (Horak, Nash-ner, & Diener, 1990; Nashner, 1977; Runge, Shupert, Horak, & Zajac, 1999).
The reason for undertaking the present study was based on the fact that the use of high-heeledshoes alters variables that affect the stability of the body, such as friction on the ground, the formof the support base, the center of pressure (COP) of the feet on the ground and the height of the centerof gravity in relation to the support base (Ko et al., 2009; Pezzan, Sacco, & João, 2009). As these ele-ments contribute toward maintaining the body in static equilibrium, a change in any one of them con-sequently leads to a change in the balance of the body in bipedal stance (Cho & Choi, 2005; Hansen &Childress, 2004; Iunes, Monte-Raso, Santos, Castro, & Salgado, 2008; Joyce, 2000).
The aim of the present study was to assess the effect of the use of high-heeled shoes on the staticbalance of young adult women, comparing the degree of anteroposterior and mediolateral oscillationwhen barefoot and when wearing these shoes, and to analyze the interference of visual restriction.
2. Methods
The present study received approval from the Human Research Ethics Committee of the Universid-ade Nove de Julho (Brazil) under process number 201862/2008, in compliance with the guidelines ofResolution 196/96 of the Brazilian Health Board. Written informed consent was obtained from allparticipants.
A non-controlled, cross-sectional study was carried out involving 53 women between 18 and30 years of age. The eligibility criteria were the ability to remain in an orthostatic position withoutsupport, experience of at least three weeks in wearing high-heeled shoes seven centimeters (cm) inheight and an absence of orthopedic or neurologic alterations that might compromise balance. Obesewomen (based on the classification of the World Health Organization), those with uncorrected visualimpairment and those with inner-ear conditions were excluded from the study.
The participants were assessed on a single day. Anthropometric measurements were taken. Theassessment of static balance in the orthostatic position was assessed using a force plate (OR-6 model,Advanced Mechanical Technology, Inc) at a frequency of 1000 Hz. The force plate has a series of forcesensors arranged to measure the three force components (Fx, Fy and Fz) and three torque components(Mx, My and Mz). This device measures movements in the anteroposterior (x), mediolateral (y) andvertical (z) directions. The Fz moments in relation to the x and y axes were calculated using equations1 (Mx = Fz � COPy) and 2 (My = Fz � COPx).
S.B. Gerber et al. / Human Movement Science 31 (2012) 1247–1252 1249
The oscillation of the COP was measured under four separate conditions: (1) barefoot eyes open(EO); (2) barefoot eyes closed (EC); (3) in high heels EO; and (4) in high heels EC. Each conditionwas measured for 60 s. The women were first instructed to remain barefoot with arms alongsidethe body, staring at a point marked at a distance of one meter at the height of the glabellar point, withunrestricted width of the foot base and the heels in alignment. The participants were then evaluatedwhile using high-heeled shoes (Scarpin model) seven cm in height and one cm in diameter.
The data from the force plate were processed and calculated using the Matlab program (Math-works�). The results were expressed as mean and standard deviation values. Two-way analysis of var-iance was employed for the statistical analysis. Levene’s test was used to determine the homogeneityof variance. The level of significance was set at 5% (p < .05). The data were organized and tabulatedusing the SPSS program (v.19.0).
3. Results
Table 1 displays the anthropometric data on the 53 participants of the present study.Oscillations in the anteroposterior direction were greater than oscillations in the mediolateral
direction under all four conditions analyzed (p < .001). The least amount of anteroposterior oscillationoccurred under the barefoot condition with EO in comparison to the other conditions: barefoot EC(p = .009), in high heels EO (p < .001), and in high heels EC (p < .001). Fig. 1 displays the mean and stan-dard deviation values for anteroposterior oscillation under all four experimental conditions.
Fig. 2 displays the results of the oscillations in the mediolateral direction under the four experi-mental conditions. No statistically significant differences were detected in the comparison of the bare-foot EO and EC or barefoot EO and in high heels EO (p > .05). However, statistically significantdifferences were found in the comparison of the condition of high heels EC and all other conditions(p < .001).
Table 1Anthropometric data of participants, expressed as mean and standard deviation.
Age (years) Height (cm) Body mass (kg) BMI (kg/m2)
Mean 23.3 164.6 59.3 21.9Standard deviation 3.7 6.4 8.1 3.1
BMI = body mass index.
Fig. 1. Oscillation in anteroposterior position barefoot with eyes open (APBEO), anteroposterior position barefoot with eyesclosed (APBEC), anteroposterior position in high heels with eyes open (APHHEO) and anteroposterior position in high heels witheyes closed (APHHEC); ⁄p = .009; ⁄⁄p < .001.
Fig. 2. Oscillation in mediolateral position barefoot with eyes open (MLBEO), mediolateral position barefoot with eyes closed(MLBEC), mediolateral position in high heels with eyes open (MLHHEO) and mediolateral position in high heels with eyes closed(MLHHEC).
1250 S.B. Gerber et al. / Human Movement Science 31 (2012) 1247–1252
4. Discussion
The purpose of the present study was to assess oscillations in the COP with and without the use ofhigh-heeled shoes with eyes open and eyes closed. The results draw attention to two aspects: the ef-fect of high heels on the health of the osteo-ligament system in women and the relationship betweenalterations in postural receptors (feet and eyes) in maintaining balance.
The foot has characteristics that allow it to perform its function adequately, such as flexibility,stiffness and stability (Rodgers, 1995). These characteristics allow the foot to absorb biomechanicalimbalance within the limits of its adaptation threshold. However, surpassing this threshold com-promises function (Csapo, Maganaris, Seynnes, & Narici, 2010). When attempting to establish har-mony through adaptation, the body takes on positions that can overload the bone-muscle-ligamentsystem and lead to postural deviations, such as the posterior lean of the head, straightening of thespinal column, verticalization of the sacrum and flexion of the hip and knee, as evidenced by theevaluation of posture and the instability it can create (Gefen, Megido-Ravid, Itzchak, & Arcan,2002).
Electromyographic and COP analyses have demonstrated the women who wear high-heeled shoesexperience fatigue of the medial and lateral gastrocnemius and peroneus longus muscles. Such alter-ations cause the inversion of the ankle and instability of the foot, thereby contributing toward an in-crease in the oscillation of the COP in the mediolateral direction (Gefen et al., 2002). According to theauthors cited, the prolonged raising of the hindfoot greater than 5 cm leads to a reduction in the num-ber of fibers activated in the medial gastrocnemius and an increase in the number of fibers activated inthe lateral gastrocnemius, resulting in instability of the ankle.
A number of authors (Ebbeling, Hamill, & Crussemeyer, 1994; Jahss, 1982; Opila, Wagner, Schio-witz, & Chen, 1988; Palastanga, Field, & Soames, 2000) warn about the functional problems that canbe caused by the use of high-heeled shoes, such as alterations in the posterior chain of the lower limbsstemming from prolonged flexion of the ankle (Ebbeling et al., 1994), the position of the metatarsalbones, the insertion angles of the intrinsic muscles of the feet (Opila et al., 1988) and altered plantarpressure distribution (Nyska, McCabe, Linge, & Klenerman, 1996). These alterations exert an influenceover the gait pattern (Han, Paik, & IM, 1999; Snow & Williams, 1994). High heels maintain the foot insupination, causing distention of the ligaments of the lateral compartment of the ankle and foot andincreasing instability in this region (Jahss, 1982). Moreover, when the foot is in plantar flexion, whichis the position of least ankle stability, postural adjustments occur, displacing the center of gravity inthe posterior direction (Palastanga et al., 2000).
The results of the present study demonstrate that alterations in the adequate positioning of propri-oceptive receptors affect the maintenance of posture and balance. All participants were accustomed towearing high-heeled shoes and exhibited oscillations on the mediolateral and anteroposterior axes.
S.B. Gerber et al. / Human Movement Science 31 (2012) 1247–1252 1251
Even with the aforementioned adaptations, the body still finds itself in a situation of disequilibriumand instability when such shoes are worn.
Proprioception or sensory perception represents information from muscle, skin and joint receptors.These receptors are involved in the conscious monitoring of posture, determining where the limbs arein space as well as the range and speed of their movements (Cohen, 2001). The somatosensory propri-oceptive system furnishes information to the central nervous system regarding the position andmovement of the body in relation to the support base (Shumway-Cook, Woollacott, & de Lourdes Gia-nini, 2003). Proprioceptors provide specific spatial details and temporal information on the contactpressure of the feet that facilitates the compensatory control of the reaction to the ground (Perry, McIl-roy, & Maki, 2000). These receptors signal the extreme positions of the joints in order to prevent injury(Proske, Schaible, & Schmidt, 1988) and furnish information on the length and velocity of muscle alter-ations (Jami, 1992). These peripheral receptors are the first to detect a change in body position andplay an extremely important role in maintaining posture (Jeka, Schöner, Dijkstra, Ribeiro, & Lackner,1997). The results of the present study corroborate these concepts, as the mere change in the position-ing of the ankle compromised the control of the COP.
Another important aspect of the present findings was the increase in oscillation with the loss ofvisual information. The visual system is made up of photoreceptors that allow the recognition of ob-jects in space and the coordination of movement. Exteroceptive information determines the positionof the body in space as well as the relationships between the different parts of the body, which isdenominated visual proprioception (Shumway-Cook et al., 2003). By means of three-dimensionalimages, one study found a reduction in postural balance when the subjects looked at images of objectsthat appeared to be moving, which demonstrates the influence of vision in the maintenance of posture(Kelly, Loomis, & Beall, 2005). In the present study, there was an increase in postural instability witheyes closed in comparison to eyes open, demonstrating that the interruption of the visual systemcauses a specific directional oscillation in posture, which is in agreement with the findings of previousstudies (Diener, Dichgans, Bacher, & Gompf, 1984; Warren, Kay, & Yilmaz, 1996).
5. Conclusion
The use of high-heeled shoes had a negative influence over balance in the women evaluated, lead-ing to an increase in oscillation in the anteroposterior and mediolateral directions, which was accen-tuated when visual information was removed. We believe that high-heeled shoes altered the quality ofafferent proprioceptive information, directing interfering in balance and postural control.
References
Barela, J. A. (2000). Estratégias de controle em movimentos complexos: Ciclo percepção-ação no controle postural. RevistaPaulista de Educação Física, 3, 79–88.
Bugnariu, N., & Fung, J. (2007). Aging and selective sensorimotor strategies in the regulation of upright balance. Journal of NeuroEngineering and Rehabilitation, 4, 19.
Cenciarini, M., & Peterka, R. J. (2006). Stimulus-dependent changes in the vestibular contribution to human postural control.Journal of Neurophysiology, 95, 2733.
Cho, W., & Choi, H. (2005). Center of Pressure (COP) during the postural balance control of high-heeled woman. Engineering inMedicine and Biological Society, 3, 2761–2764.
Cohen, H. (2001). Neurociência para fisioterapeutas: Incluindo correlações clínicas. Manole.Csapo, R., Maganaris, C., Seynnes, O., & Narici, M. (2010). On muscle, tendon and high heels. Journal of Experimental Biology, 213,
2582.Diener, H. C., Dichgans, J., Bacher, M., & Gompf, B. (1984). Quantification of postural sway in normals and patients with
cerebellar diseases. Electroencephalography and Clinical Neurophysiology, 57, 134–142.Duarte, M. (2000). Análise estabilográfica da postura ereta humana quasi-estática. São Paulo: Escola de Educação Física e Esporte,
Universidade de São Paulo.Ebbeling, C., Hamill, J., & Crussemeyer, J. (1994). Lower extremity mechanics and energy cost of walking in high-heeled shoes.
The Journal of Orthopaedic and Sports Physical Therapy, 19, 190.Gefen, A., Megido-Ravid, M., Itzchak, Y., & Arcan, M. (2002). Analysis of muscular fatigue and foot stability during high-heeled
gait. Gait and Posture, 15, 56–63.Han, T. R., Paik, N. J., & IM, M. S. (1999). Quantification of the path of center of pressure (COP) using F-scan in-shoe transducer.
Gait and Posture, 10, 248–254.Hansen, A. H., & Childress, D. S. (2004). Effects of shoe heel height on biologic rollover characteristics during walking. Journal of
Rehabilitation Research and Development, 41, 547–554.
1252 S.B. Gerber et al. / Human Movement Science 31 (2012) 1247–1252
Horak, F., Nashner, L., & Diener, H. (1990). Postural strategies associated with somatosensory and vestibular loss. ExperimentalBrain Research, 82, 167–177.
Iunes, D., Monte-Raso, W., Santos, C., Castro, F., & Salgado, H. (2008). A influência postural do salto alto em mulheres adultas:Análise por biofotogrametria computadorizada. Revista Brasileira de Fisioterapia, 12, 441–446.
Jahss, M. H. (1982). Disorders of the foot and ankle. Saunders.Jami, L. (1992). Golgi tendon organs in mammalian skeletal muscle: Functional properties and central actions. Physiological
Reviews, 72, 623.Jeka, J., Schöner, G., Dijkstra, T., Ribeiro, P., & Lackner, J. R. (1997). Coupling of fingertip somatosensory information to head and
body sway. Experimental Brain Research, 113, 475–483.Joyce, P. (2000). Women and their shoes: Attitudes, influences and behaviour. British Journal of Podiatry, 3, 111–115.Kelly, J. W., Loomis, J. M., & Beall, A. C. (2005). The importance of perceived relative motion in the control of posture.
Experimental Brain Research, 161, 285–292.Ko, P. H., Hsiao, T. Y., Kang, J. H., Wang, T. G., Shau, Y. W., & Wang, C. L. (2009). Relationship between plantar pressure and soft
tissue strain under metatarsal heads with different heel heights. Foot & ankle international/American Orthopaedic Foot andAnkle Society [and] Swiss Foot and Ankle Society, 30, 1111.
Mochizuki, L., & Amadio, A. C. (2006). As informações sensoriais para o controle postural. Fisioterepia em Movimento, 19, 11–18.Nashner, L. (1977). Fixed patterns of rapid postural responses among leg muscles during stance. Experimental Brain Research, 30,
13–24.Nyska, M., McCabe, C., Linge, K., & Klenerman, L. (1996). Plantar foot pressures during treadmill walking with high-hell and low-
hell shoes. Foot Ankle International, 17, 662–666.Opila, K. A., Wagner, S. S., Schiowitz, S., & Chen, J. (1988). Postural alignment in barefoot and high-heeled stance. Spine, 13, 542.Palastanga, N., Field, D., & Soames, R. (2000). Anatomia e movimento humano: Estrutura e função. 3a ed., Manole, São Paulo.Perry, S. D., McIlroy, W. E., & Maki, B. E. (2000). The role of plantar cutaneous mechanoreceptors in the control of compensatory
stepping reactions evoked by unpredictable, multi-directional perturbations. Brain Research, 877, 401–406.Pezzan, P. A. O., Sacco, I. C. N., & João, S. M. A. (2009). Postura do pé e classificação do arco plantar de adolescentes usuárias e não
usuárias de calçados de salto alto. Revista Brasileira de Fisioterapia, 13, 398–404.Proske, U., Schaible, H. G., & Schmidt, R. (1988). Joint receptors and kinaesthesia. Experimental Brain Research, 72, 219–224.Rodgers, M. (1995). Dynamic foot biomechanics. The Journal of Orthopaedic and Sports Physical Therapy, 21, 306.Runge, C., Shupert, C., Horak, F., & Zajac, F. (1999). Ankle and hip postural strategies defined by joint torques. Gait and Posture, 10,
161–170.Schmid, M., Bottaro, A., Sozzi, S., & Schieppati, M. (2011). Adaptation to continuous perturbation of balance. Progressive
reduction of postural muscle activity with invariant or increasing oscillations of the center of mass depending onperturbation frequency and vision conditions. Human Movement Science, 30, 262–278.
Shumway-Cook, A., Woollacott, M. H., & de Lourdes Gianini, M. (2003). Controle motor: Teoria e aplicações práticas. Manole.Snow, R. E., & Williams, K. R. (1994). High heeled shoes: Their effect on center off mass position, posture, three-dimensional
kinematics, rearfoot motion and groud reaction forces. Archives of Physical Medicine and Rehabilitation, 75, 568–576.Thompson, F. M., & Coughlin, M. J. (1994). The high price of high-fashion footwear. The Journal of Bone and Joint Surgery, 76, 1586.Warren, W. H., Kay, B. A., & Yilmaz, E. H. (1996). Visual control of posture during walking: Functional specificity. Journal of
Experimental Psychology: Human Perception and Performance, 22, 818.Winter, D. A. (1995). Human balance and posture control during standing and walking. Gait and Posture, 3, 193–214.
