Does Treadmill Training Improve Balance Function of Healthy Untrained Young Adult Male?

Abstract

Background: Number of falls increase among elders and young adults prior to any cause. Occult balance disorder may become one of the morbidity factors that causes fall in young adults and eventually elders. One leg stance test reflects static balance function that might show occult balance disorder in healthy population. Closed eyes crossed arms one leg stance (CECAOLS) used to eliminate balance factors such as visual and arms sways that can elevate limit of stability (LOS). Treadmill used as a dynamic balance exercise with inclination and speed level as its’ component to challenge the balance function.

Aim: to compare CECAOLS value in subjects with gradual increase of speed versus inclination in moderate intensity treadmill exercise.

Methods: Nineteen healthy young adults male with sedentary lifestyle aged from 26 to 37 years old were recruited. Nine people in inclination group, ten people in speed group. Treadmill exercise with moderate intensity (70% maximal heart rate), exercise duration was 30 minutes (5 minutes warming up, 20 minutes core exercise, 5 minutes cooling down), 3 times/week, for 4 weeks. Measurement of CECAOLS value were done prior to first exercise and after completion of exercise in 4th week.

Results: Significant increase of CECAOLS value at right leg inclination group with p=0.038. No significant increase of CECAOLS value in speed group (p>0.05).

Conclusion: Moderate intensity treadmill exercise with gradual inclination increase 30 minutes duration, 3 times/week, for 4 week was proven to increase CECAOLS value in young adult healthy untrained male.

Full text

Surabaya Physical Medicine and Rehabilitation Journal. August 2019 Ed: 1, Vol: 2
44
Original Research
Does Treadmill Training Improve Balance Function of
Healthy Untrained Young Adult Male?
Stephanie Theodora1, Damayanti Tinduh1, Rr I LukitraWardhani1
1Physical Medicine and Rehabilitation Department, Airlangga University, Surabaya, Indonesia.
Abstract
Background: Number of falls increase among elders and young adults prior to any cause. Occult
balance disorder may become one of the morbidity factors that causes fall in young adults and
eventually elders. One leg stance test reflects static balance function that might show occult
balance disorder in healthy population. Closed eyes crossed arms one leg stance (CECAOLS)
used to eliminate balance factors such as visual and arms sways that can elevate limit of stability
(LOS). Treadmill used as a dynamic balance exercise with inclination and speed level as its’
component to challenge the balance function.
Aim: to compare CECAOLS value in subjects with gradual increase of speed versus inclination
in moderate intensity treadmill exercise.
Methods: Nineteen healthy young adults male with sedentary lifestyle aged from 26 to 37 years
old were recruited. Nine people in inclination group, ten people in speed group. Treadmill
exercise with moderate intensity (70% maximal heart rate), exercise duration was 30 minutes (5
minutes warming up, 20 minutes core exercise, 5 minutes cooling down), 3 times/week, for 4
weeks. Measurement of CECAOLS value were done prior to first exercise and after completion
of exercise in 4th week.
Results: Significant increase of CECAOLS value at right leg inclination group with p=0.038. No
significant increase of CECAOLS value in speed group (p>0.05).
Conclusion: Moderate intensity treadmill exercise with gradual inclination increase 30 minutes
duration, 3 times/week, for 4 week was proven to increase CECAOLS value in young adult
healthy untrained male.
Keywords: closed eyes crossed arms one leg stance, CECAOLS, occult balance disorder,
balance function, treadmill training, healthy adult male.
Introduction
Number of falls among young adult at
20-45 years of age has reached 18% of
population and gradually increased according
to age, rising to 35% of 65 years old
population. Balance disorder is one of the
cause of mortality prior to fall.1 Balance is
influenced by neurological system:
somatosensory, sensory-motor integration,
motoric planning; also by musculoskeletal
system: verticality, postural and movement
control. Contextual system integrates all of
those systems, such as environment, support

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45
surface, lighting, gravity, and physical
characteristic.2 One leg stance (OLS) test is a
simple static balance measurement that is
easy to apply with minimal equipment. One
leg stance abnormality relates to frailty,
dependency of daily living activities, and high
risk of fall status.3,4
A brief observation of one leg stance
test in Rehabilitation Medicine Outpatient
Clinic on healthy young subjects aged 26-54
years old showed 78% of 57 subject had < 50
seconds OLS with eyes closed. This balance
disturbance phenomenon of the young and
productive age might contributes to 18% of
falls in young age. Treadmill exercise is an
aerobic training commonly used to improve
gait function. There are two variables of
treadmill exercise, which are inclination and
speed. Steib et al showed perturbation using
treadmill stimulates specific adaptation in
dynamic balance control during ambulation.
Treadmill creates constant challenge of
postural control system during walking.5
Pirouzi et al showed a significant increase of
Berg Balance Score in healthy older adult
population after treadmill exercise.6 Shimada
et al revealed there were increased value of
functional reach test and OLS in older adult
population after bilateral separated treadmill
exercise. This showed an improvement of
stability and mobility in upright position.7 We
found little evidence about OLS test in
healthy young adult and there were no clear
comparison between inclination and speed
treadmill exercise.
Closed eyes crossed arms one leg
stance test (CECAOLS) were proposed to
eliminate visual control over balance, and
provide an active, constant stimulation of
proprioceptive sense especially in both legs
due to decreasing limit of stability. We
hypothesized that moderate intensity treadmill
exercise with gradual increase of inclination
and speed would significantly increase
CECAOLS value, and we also hypothesized
there would be significant difference of
CECAOLS value between inclination group
and speed group. The aim of this study is to
compare CECAOLS test value before and
after moderate intensity treadmill exercise
with gradual speed increase and gradual
inclination increase to young healthy adult
untrained male.
Material and Methods
The design of this study was
randomized pre-test and post-test group.
Twenty young healthy males were recruited
in the study. Subjects were randomized into
two groups: inclination group and speed
group. Inclusion criteria were healthy adults
according to WHO guidelines, aged within
26-37 years old with body mass index (BMI)
18-22,9 kg/m2, and signed the informed
consent form. Participants were excluded if
they had routine aerobic exercise at least 2
times per week, ischemic heart disease
history, restrictive/obstructive respiratory
tract disease history, neuromusculoskeletal
disease history, systole blood pressure exceed
120 mmHg and diastole less than 60 mmHg,
had vestibular and proprioseptive disturbance,
and range of motion of both ankles for plantar
flexion < 45° and dorsoflexion < 30°. This
study wes approved ethically by ethical
committee of Dr. Soetomo General Hospital
Surabaya Indonesia with ethical approval
number 0168/KEPK/IV/2018.
EN-Mill® 2007 Treadmill was used as
walking exercise device in this study. Polar
H10 heartbeat sensor was used for the
heartrate sensor, installed at participants chest
during exercise connected via bluetooth to
smartphone application (Figure 1). Balke
protocol used for Inclination group, and
athlete led protocol was used for speed group.
The duration for each session was 30 minutes
with 5 minutes of warming up period, 20
minutes of core exercise and 5 minutes

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46
cooling down, frequency was 3 times per
week for each group, the program lasted for 4
weeks straight.
All groups were tested for OLS test
prior to exercise. Participants were asked to
close both eyes, crossed their arms on their
chest and raised one of his leg (CECAOLS).
Stopwatch was used to measure the time the
subject could stood on one leg. The test
repeated for the contralateral leg. Normal
value for the test is if participants stood more
than 45 seconds (Figure 3). Inclination group
was subjected to 3 km/h speed with gradual
increase of inclination from 2,5%, 5%, 7,5%,
10%, 12,5%, 15%, 17,5%, 20%, 22%. The
inclination was raised every 1 minute until the
participant reached the target heart rate (70%
maximum heart rate). The heart rate was
recorded every minute during the exercise.
Speed group was subjected with 5 km/h
starting speed and increased 1 km/h every
minute with 0% inclination until participants
reached the target heart rate (70% maximum
heart rate) (Figure 2). After 4 weeks of
training, all participants were tested for
CECAOLS.
Statistical analysis were measured
using Saphiro-wilk, Independent sample test,
Wilcoxon Signed Rank test in IBM SPSS
statistic 23 system.
Result
This study was conducted for 4 weeks
with 20 young healthy untrained male
participants. All participants were divided
into 2 groups. The participants were
employees and resident medical doctors of
Physical Medicine and Rehabilitation in Dr.
Soetomo General Hospital Surabaya, ten were
subjected into the inclination group, and ten
in the speed group. There was one participant
excluded from the inclination goup because of
having an outlier value, leaving 9 participants
remained at the inclination group and 19
participants in total. The demographic data
normality was tested using saphiro-wilk test
and showed normal distribution in both
groups with p<0,05 (Table 1).
We used closed eyes crossed arms one
leg stance test as a dependent variable.
Variable characteristic measurement did not
show normal distribution so we used non-
parametric test. There were no significant
difference of the CECAOLS mean value in
inclination and speed groups (Table 2).We
found significant increase only in inclination
group using Wilcoxon Signed Ranks test with
p value < 0,05 (Table 3).There were no
significant statistical calculation in the
difference (delta) of CECAOLS test in
inclination and speed groups at all variables
(Table 4).
Table 1.Demographic characteristic
Groups
N
Mean ± SD
p
Age (years)
Inclination
9
31.33 ± 3.04
0.443
Speed
10
32.3 ± 2.31
Body weight
(kg)
Inclination
9
64.11 ± 6.62
0.843
Speed
10
64.80 ± 8.15
Height (cm)
Inclination
9
169.22 ± 7.21
0.876
Speed
10
168.7 ± 7.18
BMI (kg/m2)
Inclination
9
22.2 ± 1.14
0.492
Speed
10
22.64 ± 1.54
*Significant if p<0,05 using Independent sample T test
Table 2. Mean CECAOLS test value before training
Groups
N
Mean
(seconds)
SD
p
Closed eyes, crossed arms,
Left, pre
Inclination
9
25,39
± 12,11
0,338
Speed
10
34,44
± 25,78
Closed eyes, crossed arms,
Right, pre
Inclination
9
18,97
± 15,98
0,555
Speed
10
24,51
± 23,02
*Significant if p-value< 0,05 using Independent T test (based on positive ranks)

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Table 3. CECAOLS test value in both groups before and after training
CECAOLS test value (Left),
pre versus post (second)
CECOLS test value (Right),
pre versus post (second)
Inclination
0.515
0.038*
Speed
0.386
0.139
*Significant if p-value <0,05 with Wilcoxon Signed Ranks Test
Table 4. The Difference of CECAOLS test value in both groups
Levene's Test for Equality of
Variances
t-test for Equality of Means
F
Sig.
t
Sig. (2-tailed)
Delta Closed eyes,
Crossed arms, Left
0,005
0,943
0,195
0,847
Delta Closed eyes,
Crossed arms, Right
2,260
0,151
-0,243
0,811
*Sigificant if p-value< 0.05 with independent sample test
Discussion
The demographic characteristic had
normal distribution showing homogenecity of
age, weight, height, and BMI of participants
in both groups (Table 1).There were no
significant differences of CECAOLS in both
groups using the right / dominant leg and left /
non-dominant leg in baseline (Table 2). Our
findings were in accordance with Muehlbauer
et al who reported there was no significant
difference of CECAOLS test results between
non-dominant and dominant leg in healthy
young adult.8 There are findings that showed
the dominant leg are activated at times of
maintaining the stability without visual
involvement faster. Proprioceptive feedback
increased the muscles activation on
Figure 1. Inclination group
participants using Polar H10
(Figure permissions had been
approved by subject)
Figure 2. Speed group
participants using Polar H10
(Figure permissions had been
approved by subject)
Figure 3. One leg stance
measurement (Figure
permissions had been
approved by subject

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maintaining balance through hip and ankle
strategy of the dominant extremity.9 The
baseline of CECAOLS value was homogen in
both groups (table 3).
In inclination treadmill exercise
groups, CECAOLS increased significantly on
the right leg, but not on the left leg, there
were no significant difference of CECAOLS
values when using the left leg. These reports
support the initial hypothesis which was
proposed in relation of postural verticality
towards the leg dominancy reciprocal motor
coordination which in our study was the right
leg. Postural verticality depends on
proprioceptive input, vestibular input, and
vestibular-motor phenomenon (ocular and
postural). Pirouzzi et al reported vestibular
involvement in forward walking as one of
human function.6 Meanwhile, Bisdorf et al
reported that verticality element will be
achieved mostly using the proprioceptive
organs. This evidence might be one of the
reason for the improvement of balance after
inclination treadmill training.10 The dominant
leg were the chosen leg to do functional
activity, usual evaluation were by kicking or
one leg hopping. Our study showed a
significant improvement of the right leg
CECAOLS value more than the left leg, this
might be caused by the dominancy capacity
created along the brain to bones, joints,
muscles, skin to control movement, thus
better stability. Reed et al reported that young
adult commonly used the dominant leg for
stability necessity more than mobility
function11.
Our study were in accordance with
Leroux et al who reported that during
inclination proprioceptive input were enrolled
by the thalamus and cerebellum from various
organs such as ankle, knee, hip joints,
lumbosacral, vertebra body, anterior tibial,
gastrocnemius, hamstring, quadriceps,
iliopsoas, gluteus, and flexor-extensor trunk
muscles.12 Information given were about
trunk orientation, inclination adaptation,
position sense of lower extremity relative to
the trunk and the treadmill. All of which were
integrated to maintain balance. This also
might be the reason during inclination
progress, there were more muscles recruited
than speed treadmill.12 Barbieri et al reported
that vibration stimulation in Achilles tendon
induce backward tilting about 2,7° ± 0,8° with
p < 10-3.13 This evidence concluded that
vibration effect might stimulate static
perturbation through the spontaneous
frequency of lengthening-shortening of
Achilles tendon. Meanwhile, treadmill
exercise using inclination benefits the
constant and active readjustment of Achilles
tendon through the lengthening-shortening
movement that will amplify the dynamic
perturbation function.
Inclination walking with steady speed
benefited from a more efficient energy usage
compared with speed walking although there
were more muscles recuited.14 Postural
adaptation during inclination training comes
from the stimulation of the somatosensory
input to corticospinal, reticulospinal, and
vestibulospinal neurons, through the changes
of neurons amplitude.15
Our study showed speed treadmill
exercise group showed no improvement of
CECAOLS value in both legs (table 3). Speed
walking exercise caused the increasing of
speed, stride length, cadence and decreased
double limb support. Speed walking exercise
affects the centre of gravity of the body
(COG), centre of mass (COM), especially at
lateral border of base of support (BOS) which
will affect the limits of sway.16 Our findings
were in accordance with Goodworth et al who
reported there was significant decrease of
perturbation sensitivity the faster the walk /
speed. The perception of stability were
developed indirect to trunk movement in fast

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walking, however, the stability perception
were significantly triggered by relative trunk
movement that occurred between stable and
unstable condition17, which the condition was
not available in our study. Horizontal
translation that occur during speed treadmill
generated the same amount of forces to both
legs but each had different amplitude, the
forces were results from muscles responses in
individual toward the perturbation angle
produced.15 In our speed study group, there
were no changes of inclination angle during
treadmill exercise, therefore these statements
might cause the unsignificant CECAOLS
value in speed group.
Table 4 showed there were no
significant difference of CECAOLS test in
inclination and speed groups at all variables.
However, the inclination group showed
significant improvement than the speed group
due to constant changes of COG that will
stimulate proprioceptive sense. As for the
speed walking exercise, the gradual speed
changes creates movement pattern in the
brain. Perturbation changes in 0° inclination
angle will only stimulate the central nervous
system to maintain the trunk in upright
position unaffected by the perturbation so that
forward horizontal translation did not need
active readjustment. Disparate to speed,
inclination angle change will evoke responses
in corticospinal, reticulospinal,
vestibulospinal neurons that will produce
amplitude modulation changes and eventually
result in more perturbation challenge.15
Movement controls are arranged
inside the brain somatotopically. Constant
stimulation of precentral gyrus/motoric cortex
leads to coordinated recruitment toward
intracortical synapse to corticospinal neurons
resulting in regular motoric planning.18
Central pattern generators (CPG) are capable
of generating a rhythmic and patterned output
from a tonic input, the pattern provides
framework for motor neuron activation which
coordinates muscles for stereotypic
movements such as breathing, chewing and
swimming.19
Human naturalization of walking
shows that central nervous system regulates
reflex excitability in a way that matches its
functional requirements with respect to the
walking phase, in particular regarding the
stretch reflex response during human
walking.20 Walking automation is developed
through elimination, correction, and external
matters along the ages, consistent learning,
and environment stimulation. Postural
correction is a product of corticofugal
neurons responses from Gaba-ergic
interneurons.15 Gomez-Pinilla et al reported
that actively contracting muscles increase the
brain derived neurotropic factor (BDNF)
modulation, this play a role in inducing
neuroplasticity and neuron growth. BDNF
stimulates the motoric excitability network at
the spinal cord, acetylcholine release in
neuromuscular junction, neuron tenacity,
synapse plasticity, and neural circuit
development.21,22
Conclusion
There were significant increased value
of CECAOLS after moderate intensity
treadmill exercise with gradual inclination
escalation, however there were no significant
increase of CECAOLS value before and after
treadmill exercise with gradual speed
escalation, and also there were no significant
difference (delta) of CECAOLS value
between inclination and speed group after 4
weeks of treadmill training in young adult
healthy untrained male.
Study limitation
There were no objective measurement
or description about the habit, occupation or

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50
the usual physical activity of the participant,
these variables might relate to the occult
balance disorder. It is necessary to have the
understanding of occult balance disturbances
in normal individual because the occult
balance disturbances might increase the
potential risk of falling.
We suggest further study needed to be
conducted about occult balance disturbance.
The treadmill exercise particularly with
gradual inclination increase is beneficial as
balance exercise with frequency 3 times per
week in 4 weeks straight to young adult
healthy untrained male.
Acknowledgment
Author thanked all subjects who was
willingly following all rules during research
that greatly assisted the research.
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