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Relationship Between Balance and Muscle Strength of The LowerExtremities in Healthy Middle-Aged WomenCollage of Applied Medical Sciences Abstract: Background: Most middle- aged women, even the healthy ones, havesome impairments, such as muscle weakness and loss of balance. This increasesthe likelihood of falling, which causes serious complications, deteriorates theoverall health status, impaires their day-to-day functioning, and increasestheir physical dependency and hospitalizations. Purpose: To investigate therelationship between muscle strength of the lower extremities and balance inhealthy middle-aged women. Methods: Muscle strength will be measured usinghand-held dynamometer.

While balance will be measured by one-leg standing testand timed Get-Up and Go test (GUG). Data analysis: Statistical analysis will becarried out using SPSS software. Pearson correlation coefficient test will beused to investigate the relationship between muscle strength and balance andinteraction between participants’ characteristics (Age, BMI). The spearmancorrelation coefficient test will be used to investigate the relationshipbetween other participants’ characteristics, muscle strength and balance. Thevalues will be considered statistically significant at P ? 0.

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???? ??????? ????? ?????? ???????????? ?? ??????? ??? ??? ??????? ???????? ????? ??? ????? ????????? (?????????? ???? ?????) ???? ??????? ????????. ????? ??????? ????? ?????? ????????????? ?? ??????? ??? ????? ????????? ?????? ???? ??????? ????????. ?????????????? ??? ????? ??????? ??? P ? 0.05. Introduction Aging is a normal process that allpeople pass through within their lifespan, but it may differs between individualsdue to genetic and environmental factors (P1 et al.

, 2014). When a person gets older, there is an overall gradual decrease ofphysical capacity, muscle power, sensation, and coordination, which leads tobalance deficits) Oliveira et al., 2014).

An adequate level of balance is required in middle-agedpeople to successfully perform everyday normal activities) Muehlbauer et al., 2012). Researchers define balance as the preservation of ideal bodyposture during dynamic and static states by producing suitable motor responsesto facilitate voluntary movements and recover equilibrium) Lord, 2008; Mancini & Horak, 2010). For instance, isometric and dynamic muscle strength reaches itspeak around age 20-29 years old and deteriorates in persons 50-59 years old dueto a reduction in individual muscle fiber counts, particularly among fasttwitch fibers type II, that reduces overall skeletal muscle size (P1 et al., 2014).  As a result, elderly  people are more prone to depend on others tomaintain their balance and protect themselves from falling )Liu CJ 1,  2017; Muehlbauer, 2015).

In this context, the other factorthat needs to be considered is muscle strength. “Muscle strength should bedistinguished from muscle power: muscle strength is defined as the maximalforce that a muscle can produce against a given resistance, while muscle power(force × velocity) is defined as the product of force and speed.” Thus, toprevent falling, interventions should focus on muscle power enhancement insteadof muscle strength (Winzenberg, 2016(. For more stability, the muscle power of middle-aged peopleshould be equal between the right and left lower extremities.

Differentialmuscle power between the left and right sides leads to instability) Kim MK 1, 2015(.Balance and muscle power arecritical for good health and physical strength and should be improved ormaintained adequately throughout one’s lifespan to be able to play sports andconduct everyday activities without accidents like falling(Muehlbauer, 2015(. Physical fitness is an effective strategy to enhanceequilibrium and decrease sarcopenia (Oliveira et al., 2014). The lower limb muscle strength evaluation is commonly used tostudy balance in middle age. Accordingly, this study will regard musclestrength as a measurement tool for balance (Wang H1,  2016) .Middle-aged people with reducedphysical capacity are more likely to depend on others to conduct everydayactivies.

Liu CJ et al. (2017) studied the effects of physical activity  with decrease physical capacity in elderly with age 75 years or older people and theirrisk of need to care giver in their daily activity . Using a meta-analysis study,their findings showed that multimodal exercises are effective in reducingfalls, increase muscle strength, balance and physical function of the lowerextremities.Two recent studies have reportedthat physical exercise directly affects muscle power and the capacity topreserve balance. Hyo-Cheol Lee et al. (2015) examined the influence ofphysical exercise by elderly women on muscle function and balance in 20 healthyelderly women aged 60 and over by separating them into control group andexercise group. The exercise group subjects participated in an elastic bandexercise program lasting for 8 weeks, exercising for 40 minutes four days aweek with resting periods of 60 seconds.

They measured sit-to-stand capacity toevaluate muscle strength, knees-up exercises for two minutes to measure muscleendurance and standing on one leg with eyes open to test balance. They foundthat strength and endurance of the quadriceps femoris muscle markedly increasedin the exercise group following the intervention. The ability to balancemarkedly improved in the exercise group, exhibiting that the intervention isefficacious at developing balance, muscle strength and endurance of middle agewomen. The other study was conducted by Eckardt (2016) as a randomized controltrial on 75 healthy community-dwelling aged 65-80 years to detect if resistanceexercise of lower extremity on unstable surfaces will affect muscle strengthand balance. The author assigned them to three intervention groups: machine-basedunstable resistance training M-URT, machine-based stable resistance trainingM-SRT, and free-weight unstable resistance training F-URT. For ten weeks,all groups exercised two times per week with each exercising session lasting~60 min. Tests contained assessment of power (e.g.

, chair rise test), legmuscle strength (e.g., maximal isometric leg extension strength) and balance(e.g., functional reach test), carried out pre-and post the training period.The results revealed that lower-extremity resistance training conducted on bothsurfaces markedly increased proxies of strength, power and balance in allgroups. The greatest improvements in leg extension strength produced by M-URT andF-URT in the chair rise test and functional reach test.

Aging correlates with changes in body musculature. Thus, Castro etal. (2014) studied the relationship between physical ability, muscle strengthand muscle mass in 100 physically independent healthy elderly women aged ? 65years old. Dual-energy x-ray absorptiometry (DXA) were assess the bodycomposition and bone mass.

Isokinetic dynamometry was assessed the kneeextension and flexion strength, and physical ability was measured by timed GetUp and Go test (TUG), dynamic Gait index (DGI) and Berg Balance test (BBT). Ageand muscle strength showed a significant association even without a significanteffect of age on muscle mass.Middle-aged individuals, even thehealthy ones, may suffer from instability and impaired balance.

Weirich et al(2010) studied the predictors of balance in young, middle-aged, and latemiddle-aged women in eighty-five female ages between 18 and 64 years in kneeextensor, leg press and knee flexor. Evaluation with maximal muscular strengthfor the lower extremities (knee extensor, leg press, and knee flexor), lowerextremity flexibility (plantar flexion, dorsiflexion, hip flexion, and sit andreach) and total bone mineral density (BMD) and bone mineral content (BMC),total and regional body composition (lean body mass and fat mass), balance andpostural stability. The results showed a significant relationship betweenbalance and age.Most middle-age are face healthproblems. One of the main problems is falling. Therefore, Ding Li et al. (2016)investigated the relevance between muscle weakness and slip-initiated fallsamong community-dwelling in Thirty-six healthy older male adults of age71.3±4.

7 years, in knee extensors and flexors muscles. Evaluation of muscle strengthand slip perturbation muscle strength (torque) was evaluated for the right kneeunder maximum voluntary isometric (flexor and extensor) contractions. They werethen proceed to a specific treadmill. The authors reported a significant relevancebetween muscle weakness and slip-initiated falls among community-dwellingmiddle-aged men.

Other studies have also reported therelation between balance and muscle strength. For instance, F. Wu and hiscolleagues (2016) examined the association between lower limb muscle strengthand its association with poor balance in middle-aged women. The study examinedstrength in quadriceps and hip extensor muscles cross-sectional analysis sampleinvolved of among 345 women of age 36–57. There was a significant associationbetween lower limb muscle strength and poor balance in middle aged women. Inanother study, Chandak and his colleagues (2014) examined balance performanceand lower limb isometric muscle strength, particularly in the hip flexors,extensors, abductors and adductors, knee flexors and extensors, ankle plantar-flexorsand dorsi-flexors in 100 community-dwelling middle-aged women of ages 60 and moreby using the Fullerton Advanced Balance (FAB) scale and handheld dynamometer.They found that knee extensor strength correlated better with balance ascompared to other muscles, while the hip adductors weakly correlated withbalance. That is, women with higher knee extensor strength have better balance.

In addition, Abd El- Kader and Ashmawy (2014) investigated the relationshipbetween ankle dorsi-flexors strength and balance performance improvement infifty healthy middle aged male participants with age ranged between 65 and 75years. Twenty-five participants were exercising group which trained withresisted exercises and electrical nerve stimulation of ankle dorsi-flexorsmuscles three times per week for 2 months. The control group, which contains twenty-fiveparticipants, got encouragement for practicing their regular daily activitiesover the 2 months of the study.

The ankle dorsi-flexors muscles force wasmeasured by handheld dynamometer in kilograms, and the balance control wasmeasured by the Berg Balance Scale (BBS), and timed Get-Up and -Go test (GUG).The Pearson’s correlation coefficients test for the relationship between BBSscores and ankle dorsi-flexor muscles strength in both groups showed a strongdirect relationship. Conversely, there was an inverse direct relationshipbetween GUG and ankle dorsi-flexor muscles strength in both groups.The Most researchers who haveresearched the relationship between lower extremity muscle strength and balancein healthy middle-aged individuals studied subjects ages 60 years old andabove, did not examine females, and/or they did not cover all lower extremitymuscle groups in their studies. The existing literature is deficient in theserespects and requires further investigations to determine the relationshipbetween lower extremity muscle strength and balance in healthy middle-agedwomen, as it has been reported that the likelihood of  falling for middle-aged people increases fromthe age of 50 and onwards years old (P1 et al. , 2014). Therefore, this study aims to cover, first, all lower extremitymuscle groups, and, second, to include healthy middle-aged women of age between45 and 60 years old . The null hypothesis for the proposed study is: there isno relationship between balance and lower extremity strength in middle-agedhealthy women.

The alternative hypothesis is: there is a relationship betweenbalance and lower extremity strength in middle-aged healthy women.  Accordingly, the question of this study willbe: is there a relationship between balance and lower extremity strength inmiddle-aged healthy women? Materialsand methods:Study design: Cross-sectional correlation study.Participants: Forty healthy middle-agedwomen of age from 45 to 60 years old will be covered in this study. They willbe recruited from the community. Participant information sheet will bedistributed in malls of the eastern region and women’s gathering places withcontact details of the researcher. If they are willing to take part in thestudy, they will contact the research team.

They will then be invited to theuniversity and measurement tests will be carried out. Participants will beexcluded if they have neurological disorders, any musculoskeletal problems, cognitivedeficits, any cardiopulmonary diseases, or if they consume medications that affect balance, as these factors mayaffect balance outcomes. They will be included only if they are healthy, ifthey are women, and if they are 45 – 60 years old.

Procedure:The subjects will come to a clinical lab inImam Abdulrahman Bin Faisal University. They will be educated about the entireprocess and should be sign a consent form. Furthermore, they will be requiredto complete a personal information form.The therapist will then perform the followingsteps with the subjects:1-      Measermentof muscle strength of both lower limbs using the hand-held dynamometer. Thisstep will take 5 -10 minutes.2-      Measurementof balance by one-leg-stand test and Time up-and-go test.

These will take 5 -10minutes. 3-      Restbetween the two steps and a snack will be provided.4-      Transportationwill be provided to the subjects to and from the university lab.  To test muscle strength, the followingprocedure will be employed:The therapist will put the participant in aproper comfortable position, then measure muscle strength in both lower limbswith a hand-held dynamometer to see how vigorously the participants cancontract their (hip flexors, extensors, abductors, adductors, externalrotators, internal rotators, knee flexors and extensors, ankle dorsiflexors andplanter flexors). Then therapist will place the device in a proper position andlean over the participant’s leg to provide the appropriate resistance and gainan accurate reading, while asking the participant to try as hard as she can tomove the tested joint as the practitioner exerts force in the oppositedirection with the muscle testing device pressed against the patient’slimb. Once the muscle testing device is in place, the therapist willinstruct the participant to press back against the device as hard as possiblefor 4-5 seconds. The participant will take approximately one to two seconds toexert maximum muscle force.

To test balance, the following procedure willbe employed:1)One leg stands:The therapist will instruct the participant tostand for as long as she can on one leg, or until tell her to stop.Chair/table/counter will be used for initial support. The participant canselect either foot to stand on, hold her foot anywhere, put not brace free legon the standing one. The participant arms should be at each sides while try notto move unless she need to regain her balance. The therapist will start timingwhen participant’s hand leaves the chair/table, and stop timing whenparticipant’s free foot contacts the ground, their hand touches thechair/table, their foot moved, or time passed 30 seconds. Another therapistmust be close enough to guard the participant.

The time must document to atenth of a second. Less than 10 seconds indicate balance problem and less than5 seconds indicate fall risks. 2) timeup-and-go test:Thetherapist will instruct the participant to sit right in arm rest chair. Thechair should be steady and placed so that it will not move when the participantchange position from sit to stand position.

The therapist will put tape orother type of  marker on the ground 3meters away from the chair thus that it is easy to seen by the subject. Theninstruct the subject to stand when hear the term STAERT, walk streak on the ground,turn around, walk back to chair and sit down. The timer will started on the term” STAERT ” and stop when the subject is seated right again in thechair with her back fully resting on the chair.

Normal healthy middle-agedpeople usually do the test in ten seconds or less and the very weak with poormobility middle-aged people, may take 2 minutes or more. Significance of the study:If the findings of the study show arelationship between muscle strength and Balance, educational courses will besugested to be delivered to educate healthy women the importance ofstrengthening their lower limb muscles to maitain balnce .Limitations:The sample size is 40 participants, therefore,the findings of this study will be limited and can not be generalized to allpopulation  in the eastern region ofSaudi Arabia. Outcome measures:Muscle Strength: Many tools arereported in the literature to measure muscle strength such as myometer, sit tostand ex, maximum isometric leg extension strength, isokinetic dynamometry andone repetition maximum assessment (1RM). However, hand-held dynamometer will beused in this study because it is small, accurate, time efficient, provides aquantified measurement of force and is relatively inexpensive compared withisokinetic dynamometry. It is easy to use and has a convenient size which mayjustify widespread clinical use) M 2014; Timothy  Stark  BS, 2011(.

Procedure of data collection: Participants will be instructed tocome to the university’s Lab. Researcher will do the measurements in approximately 20minutes, with 5 minutes rest between each test. Soft drinks will be providedand transportation will be available for the subjects.Ethical considerations: the ethical approval will be take from theethics community within Imam Abdulrahman bin Faisal University. A participationinformation sheet will be distributed among healthy middle-aged womenexplaining all phases of the study. All participants will sign a consent formbefore commencing data collection. Safety of all participants will be ensuredthroughout the study. Data will be kept in hard paper format in secure storageand in digital files, saved on desktop computers accessible only to the primaryinvestigator and the research team.

    Data analysis:  Statistical analysis will be carried out usingSPSS software. Participants’ characteristics will be analyzed using descriptiveanalysis. Pearsons’ correlation coefficient test will be used to investigatethe relationship between muscle strength and balance.

In addition, it will beused to investigate the relationship between participants’ characteristics(Age, BMI), strength and balance. The Spearman correlation coefficient testwill be used to investigate the relationship between participants’ othercharacteristics, muscle strength and balance. The values will be consideredstatistically significant at P ? 0.05.

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