EFFECT OF DIFFERENT FOOTWEAR TYPES AND SLEEPING DURATION ON FALL RISK AND POSTURAL STABILITY IN YOUNG ADULTS

Mohamed Mohamed Ibrahim Salem, Gihan S. Mousa, Abrar Abdulrahim Aldowiri, Lama Mohammed Faden, Leen Salah Ashgar, Lina Assim Alduais, Leen Mater Alsaedi, Ali A. El-Monsif Thabet, Kadrya H. Battecha and Anwar A. Ebid

Keywords

Saudi western sandals (Sharqi), Fall Risk, Postural Stability, Sleeping Duration, Biodex Stability System.

Introduction

Falls can cause serious injuries, including fractures and dislocations (1). Preventing falls is a crucial sign of high-quality medical attention. Wearing suitable footwear is one way to avoid it (2). The danger of falling is correlated with feet, shoes, and everyday activities. As the primary means of contact between feet and ground, shoes are essential for maintaining proper posture (3). Shoes have been demonstrated to impact balance, making them an essential aspect to consider while aiming to prevent falls (4).

Balance can be known as the capacity to stay upright, the capacity of an individual to keep their center of gravity (COG) inside the base of support (BOS) is known as postural stability, postural stability can be classified into two types: static, like being in stand position without any motion and dynamic, like walking. Many factors contribute to our balance and stability (5), although footwear is an important factor to maintain balance, both in static and dynamic, it is crucial for minimizing the risk of injuries (6). It also plays a vital role in preventing falls and contributes to protect our feet (7).

One of the main factors contributing to workplace and transportation-related deaths and injuries is sleep deprivation. Evidence indicates that everyone, including young and healthy people, is susceptible to both acute and chronic sleep deprivation in terms of postural balance, Paillard (8) stated that the effects of sleep deprivation on postural balance are exacerbated or emphasized by pathologies, age, and the circadian rhythm, it’s because the affection of each  instance; the vestibulo-ocular reflex, sensory reweighting, oculomotricity system sensitivity of visual perception, and visuospatial ability are all impaired affecting our balance system. So, we considered taking its effects on postural stability and fall risk.

our research contained various types of footwear such as: thick socks, silicone socks, Saudi western sandals “sharqi” for males and slippers for females, we tested each footwear through two standardized types of tests; postural stability and fall risk tests using Biodex balance system machine. The Biodex balance system (BBS) is an evaluation tool for stability in a variety of populations, the (BBS) has lately drawn interest from the balance training field, since there is only a little amount of published data about its use is available, it is a relatively new device (9). Thus, the purpose of this study was to assess the impact of different footwear and sleeping duration on postural stability and fall risk in young, healthy people.

Materials and Methods

Study Design: This was a repeated measures study.

Participants

Forty-eight participants (n = 44 females, 4 males) were selected from Umm Al-Qura University students. The study included students aged 20-30 years with normal BMI. Those with abnormal BMI or any lower extremity musculoskeletal or neurological impairments were excluded. Informed consent was obtained from all participants prior to their participation. This study protocol was reviewed and approved by the ethical committee, Umm Al-Qura University (HAPO-02-K-012-2023-12-1915).

Methods

A single group repeated measures design was used. Each participant underwent both postural stability and fall risk tests using Biodex balance system. It’s an affordable, reliable platform that is used to evaluate balance in various populations (10), under three footwear conditions: [1] barefoot, [2] wearing Saudi western sandals (Sharqi) for males and slippers for females and [3] wearing various types of socks (thick, non-slip silicon socks). The order of testing was randomized to prevent any potential order effects. Additionally, we aimed to investigate any possible relationship between balance and sleeping habits. As part of the sample characterization process, we will initially collect information on participants’ names, ages, heights, weights, and BMIs. All participants will be asked to complete a questionnaire regarding their sleep patterns.

Footwear

Subjects were evaluated barefooted as well as with three different types of footwears. The selection of footwear in this study was focused on types commonly used in the Kingdom of Saudi Arabia, which are Saudi western sandals (Sharqi) for males and (slippers) for females, thick socks, and non-slip silicon socks (Figure1).

Balance Testing

The Biodex Balance Stability System (Biodex Medical Systems, Shirley, New York, USA), featuring a circular platform functioning as a conventional force plate, was utilized for balance assessment by calculating anteroposterior (AP), mediolateral (ML) and overall (OA) indices. There are 12 levels of stability, with level 1 being the most volatile and level 12 being the most stable level (11). In this study, the indices were computed during both the postural stability test at platform stability level 6 and the fall risk test from platform stability levels 12 to 6. Throughout the assessments, subjects were tested with their eyes open.

Procedures

Postural stability assessment

Participants will stand on the Biodex balance locked platform, to assess the feet position coordination and establish the ideal feet positioning for testing.  The platform will be unlocked to allow movement.  Subjects were instructed to adjust the feet position unit, they find a position at which they can maintain platform in ideal position. The platform is locked, and the feet position coordination will be recorded; the feet position is constant throughout the tests.It contains 3 trials, When  the  test begin,  the  platform  is  released  for  20  seconds  and  subjects  were  asked  to  maintain  an  upright position  standing  for  calculating  anteroposterior  (AP),  mediolateral  (ML) and overall (OA) indices of postural stability test at platform stability of level 6 , and rest for 10 seconds between trials (12).

Participants were asked to complete the test barefooted, and with wearing thick socks and non-slip silicone socks, Saudi Western sandals (sharqi) for men and as an alternative, slippers for women.

Falls Risk Assessment

Fall risk was measured by using the Biodex Balance unlocked platform. The participants stood on the unlocked platform to allow movement with bear feet and different footwear types, including Saudi western sandals (Sharqi) for males, slippers for females, and different types of socks (thick and non-slip silicone socks). The feet are supposed to be adjusted by participants until they discover a position where they are able to maintain the platform in the optimal position. To calculate the total stability index of the fall risk test at platform stability levels 12 to 6, the platform is released for 20 seconds at the start of the test, and participants must remain in an upright position. Low results on these tests suggest the participant is steady, while high results suggest an imbalance and a greater risk of falling (13).

Tested participants always keep their eyes open. Utilizing the foot's midline and the platform's grid as reference points, the locations of the left foot, left heel, right foot, and right heel will be documented. During the test, the feet' position remains unchanged. The platform is unlocked, the lever is raised, and the coordination of the foot position was recorded.

Questionnaire

A self-questionnaire was utilized with participants, which included basic information like name, age, height, weight, gender, BMI, and the sleep length has been classified into three categories: short (<7 hours), average (7-8 hours), and long (>8 hours) (14).

Finally, a brief inquiry was posed concerning about the participants’ preferred footwear.

Statistical Analysis

The data analysis was conducted using the Statistical Package for the Social Sciences (SPSS) version 25. The mean and standard deviation (SD) were calculated for all demographic characteristics including age, height, weight, and BMI. Prior to inferential analysis, all data underwent exploration for normality using Shapiro-Wilk test to ensure adherence to assumptions. To assess significant differences among the three footwear conditions [1] barefoot, [2] wearing Saudi western sandals (Sharqi) for males and slippers for females, and [3] wearing various types of socks (thick, non-slip silicon socks), Wilcoxon Signed Ranks tests were employed. These non-parametric tests were chosen due to potential violations of normality. The level of balance was evaluated in both Postural stability and Fall risk tests. Furthermore, the influence of sleep hours on balance was investigated using Kruskal-Wallis tests. This allows the determination of significant differences in balance level across varying sleep durations. For all tests conducted, the alpha level was set at P < 0.05 to determine statistical significance.

Results

The anthropometric characteristics of study volunteers

The 48 participants in this study were (n = 44 females, 4 males) with an overall mean (SD) of age, height, weight, and BMI were 21.08(0.86), 157.40(6.48), 54.31(6.82), 21.87(1.97) respectively, (Table 1). Flow Chart of the study design, (Figure 2).

Values are numbers (n) or mean          SD: standard deviation

The postural Stability index for three footwear conditions

The results from Wilcoxon Signed Ranks test confirmed a significant differences (p < 0.05) between the level of balance in the Postural stability test for Barefoot and each of the following tests, Thick socks (p=0.002), Slipper (p=0.000), Non-slip silicone socks (p=0.000). However there were no significant differences in the Postural stability test between (Thick Socks * Slipper, Thick Socks * Non-slip silicone socks, and Slipper * Non-slip silicone socks) could be seen at (Table 2).

SD: standard deviation    ٭= significant ٭٭     = non-significant

The fall risk test index in degrees for three footwear conditions

The results from Wilcoxon Signed Ranks test confirmed a significant differences (p < 0.05) between the level of balance among Umm Al-Qura University students on the Fall risk test between Barefoot and Non-slip silicone socks (p=0.016) and no significant differences with other footwear (Thick socks, Slipper) could be seen at (Table 3).

SD: standard deviation   ٭= significant ٭٭     = non-significant

The effects of three sleep hours conditions

The results from Kruskal-Wallis test was conducted to determine if there were significant differences in the level of balance among Umm Al-Qura University students based on the sleep hours variable, the results indicated no significant differences between Postural Stability and Fall risk index in degrees for three sleep hours conditions at (p < 0.05) presented in (Table 4).

SD: standard deviation   ٭= significant ٭٭     = non-significant

Discussion

This study aimed to examine the effects of different types of footwear and sleep duration on postural stability and fall risk tests in young healthy adult's females and males of Umm Al-Qura University.

The findings of the current investigation indicated that the postural stability was enhanced during wearing various types of footwear such as slippers, thick socks and non-slip silicone socks compared to being barefooted with the best stability with slippers, this agreed with Rodríguez et al. (2) who recommended to wearing appropriate footwear to prevent falls on the ground and this could be explained by Alghadir etal. (3) who stated that shoes are essential for maintaining proper posture as they were the primary means of contact between feet and ground. The danger of falling is correlated with feet, shoes, and everyday activities. However, wearing a slipper compared to thick socks and non-slip silicone socks did not have any significant changes in postural stability.

our findings suggested that wearing non-slip silicone socks and slipper improved the postural stability compared to other conditions. Also, our results were supported by Smith et al. (15) who concluded that wearing vibram five fingers or being barefoot did not improve postural stability as much as wearing an athletic shoes, OA and AP static balance were improved by wearing vibram five fingers compared to being barefooted, although static balance in vibram five fingers would be similar to that in bare feet. Our research findings were encouraged by  Menz  et al. (16) who studied 3 types of footwear: socks, backless slipper and enclosed slipper. Their results depended on, walking speed, cadence, and step length measurements, their results showed that the best gait patterns and balance occurred when wearing the enclosed slippers, intermediate results when wearing backless slippers, and the worst results while wearing socks. Findings suggest that enclosed slippers may be the most appropriate footwear for older women with an increased risk of falling. In contrast to the previous, Alghadir et al. (3) found that in healthy young adult males, wearing a sandal considerably increased postural sway and decreased stability when compared to bare feet.

The results of our current study appeared that there was a significant difference between bare feet and non-slip silicone socks in the fall risk test and not significantly difference with other conditions, so wearing the non-slip silicone socks could reduce the risk of fall in the participants.

Reduced sleep duration and quality, increases weariness, impairs productivity at work, reduces physical activity, and may cause balance issues (17). Although our research outcomes demonstrated that there were no significant differences between postural stability and fall risk ndividual’s sleeping hours either male or female, a previous study by Ołpińska-Lischka et al. (18) found that there is a difference between the two genders although the men faced a deterioration in their postural stability unlike women, their sleep hours did not affect their postural control at all. In contrast to our findings, Paillard (8) stated that the sleep deprivation affects our postural balance.

Conclusion

The tested footwear types improved postural balance in young healthy people compared to being barefooted.  The non-slip silicone socks could reduce the fall risk in healthy young adults. Regarding the sleep hours duration, the results of the present study showed no significant differences for Postural Stability and Fall risk index between the three sleep hours conditions. Additionally, there was no significant differences for Postural Stability and Fall risk index between males and females.

Recommendations

• Wearing the non-slip silicone socks could reduce the risk of fall in the participants.
• For more challenging situations, modify the platform stability level to level 1for both postural stability and fall risk
• To enhance the result generalization, we recommend increasing the number of participants in these tests.

Ethical approval: This protocol received approval from the “Biomedical Ethics Committee at Umm Al Qura University, Saudi Arabia (HAPO-02-K-012-2023-12-1915).

Conflict of interest:

None

Author contributions

All authors contribute in concept and design of the study, data analysis, critical revision of the manuscript and final approval of the version to be submitted

References

Karasawa S, Yamamoto M, Sakurai J, Kawasaki S, Kobayashi H (2022). The Impact of Footwear on Posture, Gait and Balance, DOI: 10.4236/health.2022.142016.

Rodríguez RM, Solas Gómez B, gallego Marcuello L, Diaz Martinez Md C (2023). Observational Prospective Study to Determine the Efficacy of ‘Non-Slip Socks’ vs. ‘Adequate Footwear’ Regarding the Number of Falls Observed among Admitted Patients DOI:10.3390/healthcare11192605

Alghadir A, Zafar H, Shahnawaz A (2018). Effect of Footwear on Standing Balance in Healthy Young Adult Males. J. Musculoskeletal Neuronal Interact PMID: 29504581 PMCID: PMC5881131

Nor Azhar A, Munteanu S, Hylton M (2023). Effects of supportive and minimalist footwear on standing balance and walking stability in older women DOI: 10.1186/s13047-023-00634-y

Rogers ME, Page P, Takeshima N (2013). Balance Training For The Older Athlete, PMCID: PMC3812830 PMID: 24175135

Notarnicola A, Maccagnano G, Pesce V, Tafuri S, Mercadante M, Fiore A, Moretti B. (2015). Effect of different types of shoes on balance among soccer players. Muscles Ligaments Tendons J 20;5(3):208-13. doi: 10.11138/mltj/2015.5.3.208.

Kim IJ, Hegazy F (2024). Enhancing footwear safety for fall prevention in older adults: A comprehensive review of design features. Ann Geriatr Med Res. 2024 Jan 22. doi: 10.4235/agmr.23.0167. Epub ahead of print. PMID: 38246912.

Paillard T (2023). Detrimental effects of sleep deprivation on the regulatory mechanisms of postural balance: a comprehensive review. Front Hum Neurosci. 13; 14:1146550. doi: 10.3389/fnhum.2023.1146550.

Parsa M, Rahimi A, Noorizadeh Dehkordi S (2019). Studying the correlation between balance assessment by Biodex Stability System and Berg Scale in stroke individuals. J Bodyw Mov Ther. 2019 Oct;23(4):850-854. doi: 10.1016/j.jbmt.2019.04.014.

Ramos G & Batista C & Palma B & Ugrinowitsch C (2021). Risk of falls using the Biodex Balance System in non-faller patients with Parkinson Disease. https://doi.org/10.1080/08990220.2021.2018295

Aly FA, Fawzy E, Ibrahim M, Mohamed. A (2007). Assessment of stability deficits in patients with diabetic peripheral neuropathy. https://scholar.google.com/scholar_lookup?journal=Bull+Fac+Ph+Th+Cairo+Univ&title=Assessment+of+stability+deficits+in+patients+with+diabetic+peripheral+neuropathy&volume=12&publication_year=2007&pages=31-42&

Krzykała M, Karpowicz K, Karpowicz M, Bartkowiak S, Demuth A, Czerniak U, et al (2023).  Somatic characteristics, morphological asymmetry and postural stability of youth male canoesist compared to control. A cross-sectional study. PMID: 37216383 PMCID: PMC10202277 DOI: 10.1371/journal.pone.0285997

El-Bagalaty A, Mohamed M, Abdelraouf O, Abdel Ghafar M, Abdelaal A, Abdelgalil. A, Mousa G (2023). Balance and Fall Risk Assessment in Community-Dwelling Older Adults after Recovery from COVID-19: A Cross-Sectional Study. Sports (Basel, Switzerland), 11(2), 28. https://doi.org/10.3390/sports11020028

Hublin C, Partinen M, Koskenvuo M, Kaprio J (2007). Sleep and mortality: a population-based 22-year follow-up study. Sleep, 30(10), 1245–1253. https://doi.org/10.1093/sleep/30.10.1245

Smith BS, Burton B, Johnson D, Kendrick S, Meyer E, Yuan W (2015). Effects of wearing athletic shoes, five-toed shoes, and standing barefoot on balance performance in young adults. PMID: 25709865; PMCID: PMC4325290.

Menz HB, Auhl M, Munteanu SE (2016). Effects of Indoor Footwear on Balance and Gait Patterns in Community-Dwelling Older Women. Gerontology. 2017;63(2):129-136. doi: 10.1159/000448892. Epub 2016 Sep 3. PMID: 27592333.

Semanur D, Aras Bayram G (2024). Evaluating the effect of daytime sleepiness and sleep quality on balance, fatigue and life quality if shift workers. DOI:10.3233/WOR-220700

Ołpińska-Lischka M, Kujawa K, Maciaszek J. (2021). Differences in the Effect of Sleep Deprivation on the Postural Stability among Men and Women. Int J Environ Res Public Health. 2021 Apr 5;18(7):3796.  doi: 10.3390/ijerph18073796