Influence of trauma induced by judo practice on postural control

Scand J Med Sci Sports 2000: 10: 292–297 Printed in Denmark ¡ All rights reserved

COPYRIGHT C MUNKSGAARD 2000 ¡ ISSN 0905-7188

Influence of trauma induced by judo practice on postural control C. Perrot1, J. M. Mur2, D. Mainard3, D. Barrault4, Ph. P. Perrin1,2,5 1

Equilibration et Performance Motrice, UFR STAPS, University Henri Poincare´-Nancy 1, Villers-le`s-Nancy, 2National Institute for Health and Medical Research (INSERM), U 420, Vandoeuvre-le`s-Nancy, 3Department of Orthopaedics, University Hospital, Nancy, 4University Hospital Cochin, Paris, 5Department of ENT, University Hospital, Nancy, France Corresponding author: Prof Philippe P. Perrin, MD, PhD, Universite´ Henri Poincare´ – Nancy 1, Equilibration et Performance Motrice, UFR STAPS – Faculte´ du Sport, 30, rue du Jardin Botanique, 54 600 Villers-le`s-Nancy, France

Accepted for publication 6 April 2000

Although high-level sports develop specific physiological and sensorimotor abilities involved in balance control, they also increase the risk of injuries. The influence on postural control of lower limb trauma induced by judo practice was examined in healthy and previously injured judoists (PIJ). During static and dynamic tests, performed with or without vision, PIJ achieved the best performances in maintaining proper balance, except for those with the most se-

vere antecedents of trauma. The severity of the pathology appeared to be the most important parameter prejudicial to balance control while the location, frequency and diversity of trauma had only a modest impact. This shows that PIJ develop excellent sensory and cognitive adaptation abilities to constraints involving new patterns of compensation and of body scheme.

The performance of high athletic skills, whatever the discipline, implies that sportsmen adopt appropriate physiological and biomechanical postures as well as a specific psychological perception. However, proper balance control in the achievement of complex sports is mainly based on good antagonistic and postural muscle coordination (Winearls 1972, Barrault et al. 1991, Perrot et al. 1998). Because of the specifics of each sport, athletes have to possess or develop such muscular qualities as endurance, strength, stretch, elasticity and speed. These qualities are enhanced and/or acquired through intensive training, and condition the athlete’s motor skill level, which derives from the aptitude of the sportsman to reach his maximal physical potential at the right time. Yet, specific athletic techniques and postural adjustments have to be integrated in the central nervous system (CNS) according to the sensory inputs involved, which constitute the reference for coordinated muscular responses (Enbom et al. 1988, Konradsen et al. 1997, Perrot et al. 1998). In difficult training conditions, implying the performance of high balance skills, sportsmen will moreover rely on redundancy among sensory systems (i.e. vestibular, visual and proprioceptive) in order to develop and improve postural, motor and mental abilities (Diener & Dichgans 1988, Magnusson et al. 1990, Hu & Woollacott 1994, Lephart et al. 1997). Proprioception is a particular and complex system in which information from various joints, spindles

and cutaneous receptors contributes to the appreciation of the immediate position of corporal segments and mechanical strains on the skin and muscles (Nardone et al. 1990, Borsa et al. 1997, Lephart et al. 1997). A transcortical and cerebellar modulation of proprioceptive cues is then undertaken in the CNS. Proprioception thus contributes to the neuromuscular control required for precision and reflex movements, providing joint stability (Lephart et al. 1997). In judo face-to-face fights (i.e. randori) when judoists attempt to throw each other to the ground, all muscular, articular and cutaneous mechanoreceptors are stimulated because of the constant modifications of posture, support, ground and partner contact, articular angles, joint positions, muscular tensile strength and spindle activity. This rigorous posture control, crucial for the precision and efficiency of judo-specific techniques, therefore heavily depends on proprioceptive afferent performance. However, the brief and violent efforts sustained during judo fights may lead sportsmen to incur various injuries, including severe trauma such as abrupt musculoskeletal tension, muscle strains, joint injuries or ligament lesions (Ekblom 1987, McGinty et al. 1991, Shoilev 1992, Buckwalter & Lane 1997). Such trauma is then likely to interfere with postural control strategies (Perrin et al. 1997). Muscular and capsulo-ligamentous damage as well as post-traumatic scar tissue have indeed been reported to yield mechanical instability and functional limitations, partial deafferentation resulting in

292

Trauma and postural control in judoists diminished reflex joint stabilisation and/or decreased sensitivity in the damaged tissues (Tropp et al. 1985, Shoilev 1992, Pintsarr et al. 1996, Lephart et al. 1997, Lysholm et al. 1998, Melham et al. 1998). The experiment reported here aimed first to analyse the topocinetical performances of judoists with traumatic antecedents and those of healthy judoists by means of static and dynamic posturographic tests, and then to determine the influence on balance control of lower limb trauma induced by judo practice in order to establish a relationship between the perceived severity of trauma and the measurement of balance control. Material and methods Subjects Thirty high-level judoists (mean age 25.9∫6.4 years, range 18– 42 years), from three different clubs of Nancy (France) and suburbs, were submitted to postural control investigation. They were selected after spontaneously responding to an advertisement. The sportsmen selected had to fulfil the following criteria: black or brown belt male judoists, submitted to the same athletic learning and training, involved in national and international athletic tournaments with a minimum of five years of

practice and without mechanical or functional instability subsequent to ligamentous, articular or muscle trauma or injury in the past three months. None of the subjects enrolled had suffered obvious retinal lesions (which may be secondary to intense efforts or to vascular strangling), neurological pathology or plantar sole contact irritant dermatitis. Among these 30 judoists, 11 had no past history of injury, and were considered healthy judoists (control groupΩCG). Conversely, 19 of them, dubbed previously injured judoists (PIJ), reported various trauma incurred during training and/or competitions. The most recent injuries which had occurred within the past five years, from 1992 to 1997, are detailed in Table 1 and had been treated as appropriate. By means of a questionnaire with a complementary interview about the occurrence and severity of lower limb trauma, the subjects were assigned to three groups. There were 6 PIJ with only one type of minor foot/ankle trauma that had resolved without requiring physiotherapy (subgroup 1: SG1), 6 PIJ (SG2) who had suffered more extensive minor trauma involving the whole leg (i.e. ankle and knee sprains, tendinitis, muscular tears), and 7 PIJ (SG3) who reported severe lesions, first set in plaster and then cured by means of physiotherapy and/or surgery. All subjects gave written informed consent prior to the study. Experimental set-up A vertical force platform, fitted with four strain gauges (Toennies, GmbH, Freiburg, Germany) was used to perform posturographic recordings in a soundproof room. Each subject, stand-

Table 1. Lower limb trauma induced by judo practice in the group of PIJ Knee

Ankle

Foot

SG1: Subject 1 Subject Subject Subject Subject Subject

5th toe fracture, calcaneus osteopathy (1997)

2 3 4 5 6

SG 2: Subject 7 Subject 8 Subject 9 Subject 10 Subject 11

n n n 2 3 Patellar tendinitis (1996) Cartilage inflammation, meniscal tear (1996) Patellar tendinitis, bursitis (1997)

Subject 12 SG3: Subject 13

benign benign benign benign benign

sprains sprains sprains sprains sprains

(1994) (1993) (1996) (1993) (1997)

1 benign sprain Big toe fracture 3 benign sprains 1 benign sprain n benign sprains

Tibial tuberosity fracture (1995) Several contusions and tears of lower limb muscles (1997) Muscular contusions and tears

n benign sprains (1994) 3 benign sprains, meniscal tears, ACL disruption ±ligamentoplasty πphysiotherapy

n benign sprains (1992)

Subject 14

Shinbone fatigue fracture (1994)

Subject 15 Subject 16

1 severe sprain, ACL disruption ±ligamentoplastyπphysiotherapy

Subject 17 Subject 18 Subject 19

Other

Patellar subluxations (1995)

3 severe sprains ±plaster πphysiotherapy (1995) 3 benign sprains (1996) 2 benign sprains, 1 severe sprain ±plasterπphysiotherapy (1996) 2 severe sprains ±plaster πphysiotherapy Lateral malleolus fracture ±plaster (1996)

Big toe fracture

n indicates more than 5 events. The year of the most recent accident is noted in brackets.

293

Perrot et al. Results For static tests, in eyes open (EO) condition, no significant difference was observed between PIJ and CG, judoists being involved in the same fighting training. However, after eye closure (EC), significant differences were noted between PIJ and CG, the latter being less perturbed by the loss of visual afference (Table 2). This resulted in significantly different Romberg’s quotients of respectively 1.56∫0.24 for CG and 1.33∫0.3 for PIJ (PΩ0.034). In order to appreciate whether the severity of injuries had any impact on the postural control of PIJ,

Fig. 1. Set-up of the slow sinusoidal test. The platform is rocked in regular anterior-posterior sinusoidal displacements.

ing upright on the platform, barefooted, arms along the body, was instructed to stare straight ahead at a white dot located at eye level at a distance of 2 m. Static and dynamic tests were then performed in the same session. In the static test, displacements of centre of foot pressure (CFP) are recorded over 20 s, with eyes open, then with eyes closed. The resulting statokinesigrams allow measurement of the sway path, or way (W), and area (A) travelled by the CFP per second. Low values for sway path and area parameters are representative of good posture control. The role of visual afferences was evaluated individually. Comparison of the performance between tests achieved with eyes open or closed was assessed by calculating Romberg’s quotient for the way, i.e. eyes closed-Way/eyes open-Way ratio. The second test was a slow sinusoidal dynamic test performed during 20 s. The movement imposed by the platform consisted of slow sinusoidal anterior-posterior oscillations with a 4æ amplitude, at a frequency of 0.5 Hz (Fig. 1). The graphs obtained, by recording CFP displacements over time, can be analysed by comparison with the sinusoid yielded by the movement of the platform or as fast Fourier transformations (FFT), as reported elsewhere (Perrin et al. 1997). Fig. 2 shows two typical recordings indicating different responses to the platform sinusoidal oscillations. Regularity and homogeneity of the linear CFP displacements and isofrequency, revealed by one single peak at 0.5 Hz on the FFT, are the three main recording characteristics that suggest a bottom-up strategy (defined as an ankle strategy), with good ability of the subject to maintain his posture during the test (type 1 graph). Any other type of record (called type 2), with numerous peaks and higher amplitude, reflects a top-down strategy or hip strategy, i.e. the difficulty of the subject to compensate for the imbalance induced by the platform’s movement (Dichgans & Diener 1989, Perrin et al. 1997, Perrin et al. 1998, Gauchard et al. 1999). The same instructions given to PIJ and CG induced sufficiently similar behaviour that inter-individual comparisons were possible. Statistical methods Data were fed into a Macintosh computer and the statistical significance of comparisons between eyes open and eyes closed tests, between PIJ and CG, were assessed using Student-Fisher’s t-test, ANOVA and c2 test (Statview). A 0.05 significance level was used for all analyses.

294

Fig. 2. Typical recordings of centre of foot pressure (CFP) displacements and fast Fourier transformations obtained consecutively to as low sinusoidal movement of the platform (Stim: ∫4æ, 0.5 Hz, 20 s) in the anterior-posterior plan (A/P). Type 1 graph: regular graphs where CFP displacements have the same frequency and are in reverse phase with the movement of the platform (upper part). Type 2 graphs: irregular graphs where the frequency recorded is different from that of the platform and CFP movements are out of phase with the stimulus (lower part).

Trauma and postural control in judoists Table 2. Mean values and standard deviation of posturographic data from static tests performed with eyes open or closed by judoists with traumatic antecedents (PIJ) and healthy judoists (CG) Eyes open Way (cm)/s PIJ 0.71∫0.13 CG 0.77∫0.18 Student-Fisher’s PΩ0.287 t-test NS

Eyes closed

Area (cm2)/s

Way (cm)/s

Area (cm2)/s

0.14∫0.08 0.21∫0.17 PΩ0.148 NS

0.99∫0.22 1.29∫0.32 PΩ0.007 **

0.22∫0.08 0.58∫0.4 P∞0.001 **

NSΩnot significant.

we compared the value of the W and A parameters. Statistically significant differences (P∞0.001) were noted exclusively between the mean values of W in subgroups SG1 (0.57∫0.08 cm/s), SG2 (0.71∫0.03 cm/s) and SG3 (0.88∫0.13 cm/s). The increase in W therefore appeared related to the severity of trauma in PIJ, as shown in Fig. 3 where subjects are classified according to these traumas. A similar trend was noted for the static test performed EC, but lacked statistical significance (data not shown). During the sinusoidal test performed with EO, all subjects yielded type 1 recordings. However, fewer were able to reproduce the same performance after eye closure. Seventy-nine percent of PIJ succeeded in compensating for the imbalance induced by the platform with EC, while only 63.6% of CG managed to keep their balance in the same conditions, this difference being statistically significant (c2 test: PΩ0.001). Discussion In this study comparing the balance control of judoists with none or various traumatic antecedents, we observed a relationship between the perceived severity of previous pathology and the measured parameters of postural control of high-level judoists. Elite judoists with minimal trauma antecedents were the group displaying the best postural control. This is consistent with the fact that athletic training, whatever the discipline, tends to improve balance control, particularly when training conditions are difficult (Hu & Woollacott 1994, Perrin et al. 1998, Perrot et al. 1998). This is indeed the case for judo, and the good results of the best judoists confirm the redistribution of postural control processing developed by high-level sport. In order to appreciate the impact of previous trauma on balance control, we had to compare individuals with similar skills, which allowed us to demonstrate an effect related to the severity of reported antecedents. Minor capsulo-ligamentous and moderate anatomical lesions, while inducing immediate mechanical and functional instability as well as abnormal body positioning, decreased postural reflex

Fig. 3. Way (cm) per second of centre of foot pressure displacements of each individual in the 3 subgroups of injured elite judoists from static tests performed in eyes open condition. SG1: subjects from 1 to 6, SG2: subjects from 7 to 12, SG3: subjects from 13 to 19.

responses and, sometimes, impaired postural control (Tropp & Odenrick 1988, Shoilev 1992, Pintsarr et al. 1996, Borsa et al. 1997, Lysholm et al. 1998), did not seem to alter balance control over time, i.e. after the clinical resolution of their injuries (SG1). Conversely, such lower limb pathologies as sprains, tendinitis, or muscular tear, appeared to be correlated with a moderate degradation of balance control (SG2). Furthermore, traumatic pathologies having required rigid braces and physiotherapy and/or surgery (SG3) led to EO posturographic results significantly worse than for judoists with less severe antecedents. Thus, severe and/or numerous injuries leave sportsmen with persistent pain and dysfunction (Lysholm et al. 1998) that prevent them from returning to full activity without limitation (Renstro¨m 1996, Melham et al. 1998). These observations are consistent with previous reports from our group showing differences in balance control for basketball players with traumatic pathology compared to controls (Perrin et al. 1997), suggesting that proprioception plays a major role in maintaining a stable upright stance under static circumstances (Bles & De Wit 1976). Haematoma, oedema, contusions, microtrauma, muscle tears or joint sprains do not seem to affect the dynamic balance control of PIJ nor their sensorimotor strategies several months after these traumas had occurred. A significant deficit in proprioception and sensorimotor functions has been reported after injury in sportsmen (McGinty et al. 1991, Shoilev 1992, Perrin et al. 1997), seemingly efficiently compensated for by ankle movements and vestibular inputs (Kapteyn 1972, Nardone et al. 1990, Do & Roby-Brami 1991, Horak et al. 1994). It might be

295

Perrot et al. slightly different for judoists, who perform barefooted on soft tatami, which improves the sensitivity of plantar mechanoreceptors (Barrault et al. 1991) rather than that of the vestibular system. Judoists are trained to constant movement and would therefore heavily rely on plantar variations of pressure distribution to control their balance (Okubo et al. 1980, Magnusson et al. 1990, Barrault et al. 1991, Borsa et al. 1997). The most severe trauma, likely to result in scar tissue, would therefore be involved in a slightly impaired ability to compensate according to proper signals transmitted by proprioceptive afferences. The differences observed between PIJ and CG cannot be related to expertise as the two groups of judoists were submitted to the same kind of fighting training. The discrepancy noted could be related to psychological reasons, sportsmen considering their injuries as a new source of motivation, challenge or commitment, rather than a threat to set attainable goals (Winearls 1972, Iso-Ahola 1992). Focused attention, vigilance and cognitive awareness, initially used to avoid re-injury or to protect the damaged limbs from shock, could lead PIJ to acquire new sensorimotor strategies. The more automated and adjusted stabilising motor activation in PIJ, compared to that of CG, could suggest that PIJ develop new patterns of body scheme and of compensation leading to excellent sensory and cognitive adaptation to new constraints, i.e. environmental or subsequent to trauma (Barrault et al. 1991, Lysholm et al. 1998, Perrin et al. 1998, Perrot et al. 1998, Holme et al. 1999). The most appropriate sensorimotor strategy seems thus to rely on the afference(s) selected and on sensory information integrated during previous tests or experiences of the subject (Proteau 1992, Handford et al. 1997, Perrin et al. 1998, Perrot et al. 1998). An important observation was the excellent performance of PIJ in eyes closed conditions, both in static and dynamic tests. By their easier adaptation to the tasks and their mental representation of the fixed purpose, which is probably more rapid and adequate than in CG, PIJ identify cue patterns, select few afferent signals and concentrate directly on rel-

evant sensory information to avoid imbalance (Perrot et al. 1998). In other words, PIJ could judge the suitability of external and internal inputs for postural control and decide whether they use them or not to reach an optimal solution. Otherwise, the facilitation to integrate proprioceptive cues appears as an essential component for judo practice (Barrault et al. 1991). This confirms that proprioceptive information becomes predominant for posture control, as judo practice and skills improve (Barrault et al. 1991, Perrin et al. 1998, Perrot et al. 1998). In conclusion, although traumatic pathologies are induced by judo practice, this martial art leads injured sportsmen to acquire new physiological and biomechanical abilities, allowing a better balance regulation. Our results indicate that judo training leads to the favouring of somatosensory afferences as an essential component of balance regulation. Only severe trauma, likely leading to persistent anatomical scars, appears to impair the strategies of balance control developed by high-level judo practice. Perspectives Static and dynamic posturographic tests could be used to appreciate the efficiency of rehabilitation treatment (Perrin et al. 1997, Gauchard et al. 1999, Holme et al. 1999) and explore sensorimotor strategies developed by sport practice in previously injured subjects, or to allow them to return to full activity. In the case of healthy sportsmen, these kinds of tests could be included in the medical follow-up to evaluate psychomotor skill levels, or the influence of training and competition on balance control. Furthermore, strategies and techniques learned by highlevel PIJ should be carefully analysed to determine whether these sensorimotor abilities could be incorporated into treatment programmes for non-sportsmen with balance instability and for injured subjects, or into training programmes for competitors who want to improve their performances. Key words: postural control; musculo-skeletal injuries; judo; adaptation; compensation.

References Barrault D, Brondani JC, Rousseau D. Me´decine du Judo. Paris: Masson, 1991. Bles W, De Wit G. Study of the effects of optic stimuli on standing. Agressologie 1976: 17C: 1–5. Borsa PA, Lephart SM, Irrgang JJ, Safran MR, Fu FH. The effects of joint position and direction of joint motion

296

on proprioceptive sensibility in anterior cruciate ligament-deficient athletes. Am J Sports Med 1997: 25: 336–340. Buckwalter JA, Lane NEL. Athletics and osteoarthritis. Am J Sports Med 1997: 25: 873–881. Dichgans J, Diener HC. The contribution of vestibulo-spinal mechanisms to the

maintenance of human upright posture. Acta Otolaryngol (Stockh) 1989: 107: 338–345. Diener HC, Dichgans J. On the role of vestibular, visual and somatosensory information for dynamic postural control in humans. Prog Brain Res 1988: 76: 253–262.

Trauma and postural control in judoists Do MC, Roby-Brami A. The influence of a reduced plantar support surface area on the compensatory reactions to a forward fall. Exp Brain Res 1991: 84: 439–443. Ekblom B. External and internal factors influencing physical performance. Med Sport Sci 1987: 26: 90–97. Enbom H, Magnusson M, Pyykko¨ I, Schale`n L. Presentation of a posturographic test with loading of the proprioceptive system. Acta Otolaryngol (Stockh) 1988: 455 (Suppl): 58–61. Gauchard G, Jeandel C, Tessier A, Perrin Ph. Beneficial effect of proprioceptive physical activities on balance control in elderly human subjects. Neurosci Lett 1999: 273: 81–84. Handford C, Davids K, Bennett S, Button C. Skill acquisition in sports: some applications of an evolving practice ecology. J Sports Sci 1997: 15: 621–640. Holme E, Magnusson SP, Becker K, Aagaard P, Kjaer M. The effect of supervised rehabilitation on strength, postural sway, position and re-injury after acute ankle ligament sprain. Scand J Med Sci Sports 1999: 9: 104– 109. Horak FB, Shupert CL, Dietz V, Horstmann G. Vestibular and somatosensory contributions to responses to head and body displacements in stance. Exp Brain Res 1994: 100: 93–106. Hu MH, Woollacott MH. Multisensory training of standing balance in older adults: I. Postural stability and one-leg stance balance. J Gerontol 1994: 49: M52–M61. Iso-Ahola SE. Mental training. In: Karvonen J, Lemon PWR, Iliev I, eds. Medicine in sports training and coaching. Basel: Kargel, 1992: 35: 215– 234. Kapteyn TS. Data processing of

posturographic curves. Agressologie 1972: 13B: 29–34. Konradsen L, Voigt M, Hojsgaard C. Ankle inversion injuries. Am J Sports Med 1997: 25: 54–58. Lephart SM, Pincivero DM, Giraldo JL, Fu FH. The role of proprioception in the management and rehabilitation of athletic injuries. Am J Sports Med 1997: 25: 130–137. ¨ dkvist LM, Good Lysholm M, Ledin T, O L. Postural control – a comparison between patients with chronic anterior cruciate ligament insufficiency and healthy individuals. Scand J Med Sci Sports 1998: 8: 432–438. Magnusson M, Enbom H, Johansson R, Wiklund J. Significance of pressor input from the human feet in lateral postural control. Acta Otolaryngol (Stockh) 1990: 110: 321–327. Mc Ginty JB, Sarmiento A, Hensinger R, et al. Athletic training and sports medicine. 2nd edn. Park Ridge: American Academy of Orthopaedic Surgeons, 1991. Melham TJ, Sevier TL, Malnofski MJ, Helfst RH Jr. Chronic ankle pain and fibrosis successfully treated with a new noninvasive augmented soft tissue mobilization technique (ASTM): a case report. Med Sci Sports Exerc 1998: 30: 801–804. Nardone A, Giordano A, Corra T, Schieppati M. Responses of leg muscles in humans displaced while standing: Effects of types of perturbation and of postural set. Brain 1990: 113: 65–84. Okubo J, Watanabe I, Baron JB. Study on influences of plantar mechanoreceptor on body sways. Agressologie 1980: 21D: 61–69. Perrin Ph, Be´ne´ MC, Perrin C, Durupt D. Ankle trauma significantly impairs posture control – A study in basketball players and controls. Int J Sports Med 1997: 18: 387–392. Perrin Ph, Schneider D, Deviterne D,

Perrot C, Constantinescu L. Training improves the adaptation to changing visual conditions in maintaining human posture control in a test of sinusoidal oscillation of the support. Neurosci Lett 1998: 245: 155–158. Perrot C, Deviterne D, Perrin Ph. Influence of training on postural and motor control in a combative sport. J Hum Mov Studies 1998: 35: 119–136. Pintsarr A, Brynhildsen J, Tropp H. Postural corrections after standardised perturbations of single limb stance: effect of training and orthotic devices in patients with ankle instability. Br J Sports Med 1996: 30: 151–155. Proteau L. On the specificity of learning and the role of visual information for movement control. In: Proteau L, Elliott D, eds. Vision and motor control. Amsterdam: Elsevier Science, 1992: 67–102. Renstro¨m P. Effects of training, inactivity, remobilization and prevention of sport injuries. Me´decine du Sport 1996: 70: 141–150. Shoilev, D. Etiology, general treatment and rehabilitation of sports injuries. In: Karvonen J, Lemon PWR, Iliev I, eds. Medicine in sports training and coaching. Basel: Kargel, 1992: 35: 104– 114. Tropp H, Odenrick P, Gillquist J. Stabilometry in functional and mechanical instability of the ankle joint. Int J Sports Med 1985: 6: 180– 182. Tropp H, Odenrick P. Postural control in single-limb stance. J Orthop Res 1988: 6: 833–839. Winearls J. Posture: its function in efficient use of the human organism as a total concept. Agressologie 1972: 13B: 99–102.

297