Efficacy of Comprehensive Foot Strengthening Program on Foot Biomechanics and Plantar Pressure to Reduce Lower Limb Injury Risk in Male Bhangra Dancers: A Randomized Controlled Trial Protocol

Abstract

Background:

Bhangra dance is vibrant and energy demanding art form involving dynamic footwork, jumps, kicks and rapid movements. Poor biomechanics and uneven plantar pressure is a crucial factor for injury among dancers thus, this study protocol aimed at evaluating the efficacy of comprehensive foot strengthening program in improving faulty foot biomechanics and plantar pressure distribution to reduce the risk of lower limb injuries among male Bhangra dancers.

Methods:

A single-blinded randomized controlled trial (RCT) will be performed. One hundred forty professional dancers will be recruited for this study based on G* power calculations. Seventy participants will be randomly allocated to the experimental group, undergoing a structured intrinsic foot strengthening program (IFSP; 12 weeks, 5 days/week, 30-60 minutes, mild-severe intensity). Seventy participants will be allocated to the waitlist control group, which will follow their exercise regime and dance training (randomization 1:1 ratio). Outcome measures to assess biomechanical characteristics of the foot and plantar pressure distribution will be foot posture index, navicular drop test, feiss line, arch height index, foot print parameters (Clark’s Angle, Chippaux-Smirak Index, Staheli Index), and baropodometer at baseline (0 week), and at the end of the exercise program (after 12th week). Injury incidence and type will also be recorded using a self-designed questionnaire.

Discussion:

This study aims at evaluating the efficacy of comprehensive foot strengthening program in improving foot biomechanics and plantar pressure distribution to reduce the risk of lower limb injuries among male Bhangra dancers. The findings of this RCT will have implications for dance training protocols and injury prevention strategies.

Trial status:

Recruitment has not yet started.

Keywords

dancing foot injury foot posture plantar pressure prevention randomized controlled trial strengthening program

Key Points

This study will evaluate a 12-week intrinsic foot strengthening program (IFSP) to improve foot health in Bhangra dancers.

This study will aim to improve foot biomechanics and plantar pressure distribution, which are considered crucial factors in lower limb injury risk.

The ultimate goal of this study will be to determine if the foot strengthening program can effectively reduce the incidence of lower limb injuries in this high-impact dance population.

Introduction

Dancers are often considered performing athletes due to the repetitive movements they undertake. Bhangra dance, a traditional folk dance of Punjab, India, holds significant cultural importance.¹ This dynamic dance form demands considerable energy and stamina, as participants frequently engage in repetitive movements, adopt extreme positions, and perform high-impact activities.² Consequently, these physical demands place substantial strain on the lower extremities, particularly the knee, ankle, and foot.³

While the prevalence of injury among Bhangra dancers remains unknown, Sun and Liu⁴ have reported an injury prevalence rate of 82% among modern and contemporary dancers. Additionally, Rinonapoli et al⁵ assert that lower extremity injuries are the most common of all dance-related injuries, specifically affecting the ankle and foot regions. Several researchers have further indicated that approximately 70% of all dance-related injuries involve the lower limbs.^6
-10

The unique physical demands of Bhangra dance necessitate a comprehensive understanding of the biomechanixcal aspects of the feet and their impact on injury risk. Consequently, it is crucial to explore strategies for mitigating these risks to enhance the longevity of dancers’ careers.¹¹ Despite the widespread popularity of Bhangra dance, there is a notable gap in the current academic literature regarding specific injuries that Bhangra dancers may incur and the strategies that can be implemented to mitigate these risks.

Therefore, this study protocol aims to investigate the effectiveness of the comprehensive foot strengthening program in improving faulty foot biomechanics and reducing the injury risk among male Bhangra dancers through a randomized controlled trial (RCT).

Method/Design

Study Design and Settings

This study is a pragmatic, single centric (Department of Physiotherapy, Lovely Professional University, Phagwara, Punjab-144411), stratified, single blinded and RCT employing a pre-test and post-test control group design. This protocol testing experiment will be carried out after the identification of population in the first phase of the study. The first phase of this trial will involve population identification by analyzing Foot Posture Index, Navicular drop, Feiss line, Arch height Index, foot print variables and Plantar pressure (static and dynamic). Those dancers who exhibit faulty biomechanics and an uneven pressure distribution on the soles will be included in the study conducted during the second stage (Figure 1).

Figure 1.

Consolidated Standards of Reporting Trials (CONSORT) flow chart for study.¹²

Objective

The primary objective of our study is to test the efficacy of the designed comprehensive foot strengthening program (IFSP) in improving faulty foot biomechanics (static and dynamic) and uneven plantar pressure distribution to reduce the risk of lower limb injuries in male Bhangra dancers.

Hypothesis

Null Hypothesis

The experimental group will not show significant improvement over the control group in improving foot biomechanics and unevenly distributed plantar pressure, and will not reduce the risk of lower limb injuries in male Bhangra dancers.

Alternate Hypothesis

The experimental group will show significant improvement over the control group in improving foot biomechanics and unevenly distributed plantar pressure, thereby reducing the risk of lower limb injuries in male Bhangra dancers.

Ethical Considerations

This trial will be continued as a second phase of the study undertaken for the PhD program, which has received ethical approval on 20 April 2023 from the Genebandhu Independent Ethics Committee, duly referenced as Ref-ECG005/2023. Furthermore, it has been registered in the Clinical Trials Registry-India, with a distinctive trial number: CTRI/2023/05/52343. Our commitment lies in upholding ethical principles and ensuring the safety and well-being of all participants. Each participant will be required to provide informed consent. The execution of this study will be conducted in accordance with the Helsinki Declaration, and adherence to the SPIRIT guidelines for Randomized Controlled Trials (Table 1).¹³ The exercise protocols to be used in this study have been thoroughly reviewed after designing and have garnered approval from the appropriate Institutional Review Board. The protocol has been copyrighted under registration number: L- 137234/2023.

Table 1.

Study Period According to the Guidelines of SPIRIT.¹³

Study period
	Enrollment	Allocation	Baseline	Post allocation	Close-out
Time-point	2025	2025	2025 (0 week)	2025 (after 12th week)	2025
Enrollment	✓
Screening	✓
Informed consent	✓
Allocation		✓
Intervention			✓
Assessment
FPI			✓	✓
NDT			✓	✓
FL			✓	✓
AHI			✓	✓
CA			✓	✓
CSI			✓	✓
SI			✓	✓
PP static			✓	✓
PP dynamic			✓	✓
Data analysis					✓

Abbreviations: FPI, foot posture index; NDT, navicular drop test; FL, feiss line; AHI, arch height index; CA, Clark’s angle; CSI, Chippaux Simrak index; SI, Staheli index; PP, plantar pressure.

Participants

The study will recruit 140 male Bhangra dancers from various academies, selected based on specific inclusion and exclusion criteria (Table 2). The sample size of 128 was estimated using G* Power 3.1.9.7 (Heinrich-Heine-Universität Düsseldorf, Düsseldorf, Germany),¹⁴ and after addition of 10% drop out, Total sample calculated is 140, ensuring a medium effect size (0.50) and power (0.80). Participants will be randomly divided into 2 equal groups of 70 (experimental and control). The study will be single-blinded, with participants unaware of their group allocation. The experimental group will receive predesigned foot-specific strengthening program and control group will be receiving regular exercise and dance training routines. Both the training program will be structure carefully ensuring both sets of training material looks similar in appearance, format and instructions. Group allocation will be disclosed only after the final database is locked, and assessments and training will be conducted by certified Physiotherapist. The sequence of participant allocation will be by randomization (1:1) using the SNOSE (Sequentially Numbered, Opaque, Sealed Envelope) method.¹⁵ The sample will be randomly divided into 2 equal groups of 70 participants in each group (experimental and control group). Further dropout in the study will be analyzed using last reading carry forward mechanism (Intention-to-treat-analysis).

Table 2.

Eligibility Criteria for the Study.

Eligibility criteria
A. Patients will be included in the RCT if they are:
➢ Male Bhangra Dancer with changes in the foot biomechanical characteristics
➢ Age ≥18 ≤ 45
➢ Having dancing experience of more than 5 years
➢ Physically/psychologically/cognitive fit to participate in the study (PARQ for physical fitness and WHO wellbeing index-5 for mental wellness and MOCA for assessment of psychological and cognitive well being
➢ Able to understand and communicate in the respective language
B. Patients will be excluded from the RCT if they are:
➢ Performing any other dance form
➢ Having recent musculoskeletal injury (3 months)
➢ Having diagnosed neurological condition
➢ Having diagnosed balance and coordination issues (ankle, knee, hip instability cases)
➢ Having diagnosed diabetic peripheral neuropathy
➢ Having diagnosed collagen vascular disease
➢ Diagnosed cardiac case
➢ Having diagnosed osteoporosis
➢ Unable to provide written informed consent

Abbreviations: PARQ, physical activity readiness questionnaire; WHO-5, World health Organisation wellbeing index-5; MOCA, Montreal cognitive assessment; RCT, randomized control trial.

Selection Criteria

The eligibility criteria for this Randomized Control Trial include male Bhangra dancers aged 18 to 45 with a minimum of 5 years of experience, ensuring consistent exposure to the physical demands of the dance. This period allows for sufficient adaptation to the repetitive impact forces on the feet, contributing to changes in foot biomechanics and plantar pressure. Such experience increases the likelihood of chronic adaptations or overuse injuries, which are crucial for examining biomechanical changes in the foot through assessments like the Foot Posture Index (FPI),¹⁶ Navicular Drop Test (NDT),¹⁷ Feiss Line (FL),¹⁸ Arch Height Index (AHI),¹⁹ footprint variables,²⁰ and Plantar pressure analysis.²¹ Participants must be physically, psychologically, and cognitively fit to participate, assessed by the Physical assessment readiness questionnaire for everyone (PAR-Q+) for physical fitness,²² the World Health Organization (WHO) Wellbeing Index-5 for mental wellness,²³ and the Montreal Cognitive Assessment (MoCA) for Cognitive impairment.^24,25 Additionally, they must be able to understand and communicate in Hindi, Punjabi or English language. Dancers involved in any other dance form other than Bhangra dance diagnosed neurological conditions, balance and coordination issues, diabetic peripheral neuropathy, collagen vascular diseases, cardiac conditions, osteoporosis or recent surgery of lower limb will not be included and the Individuals unable to provide written informed consent will also be excluded from the study.

Experimental Group

In the experimental group, the participants will engage in a carefully designed program consisting of 10 exercises aiming at strengthening of the intrinsic muscles of the feet. This exercise protocol has been designed as per the guidelines of The American College Sports Medicine (ACSM).²⁶ This intervention will be continuing over a period of 12 weeks, with participants engaging in the program for 5 days each week. The duration of each session will range from 30 minutes initially and progress to 60 minutes. The exercise program will include a range of intensities, from mild to vigorous, as detailed in Appendix 1. Table 2 and Figures 2 to 11 provides the description of the exercises and Table 3 and Table 4 outlines the weekly protocol.

Control Group

In the control group, participants will continue their assigned regular exercise and dance training routines without any additional foot-specific training exercises. This wait-list control group will serve as a comparison group to evaluate the effects of the intervention.

Outcome Measures

Biomechanical Assessments

Baseline and post-intervention assessments of foot biomechanics will be conducted. These assessments will include the Foot posture Index (FPI),²⁷ Navicular Drop test (NDT),²⁸ Feiss Line (FL),²⁹ Arch Height Index (AHI)³⁰ and foot print parameters: Clarks Angle (CA), Chippaux Smirak index (CSI), Staheli Index (SI).³¹

Plantar Pressure Distribution

The plantar pressure distribution will be assessed using Win-track (Medicapteurs France SAS, Balma, France) is a Baropodometer/foot pressure analyzer which provides detailed analysis of static and dynamic plantar pressure distribution within the each foot as well between feet.³²

Injury Incidence

The injury incidence will be recorded using a Self-Structured Questionnaire (Appendix 2), which is copyrighted by the Government of India under copyright number 7838/2023-CO/L. This questionnaire will be used to record dancing experience of dancers and the number of the injuries dancer have experienced in past 1 year, most common part involved, type of injury and side involved. This will allow whether the intervention has a tangible impact on reducing injury rates.

Clinical Trial Registration of the Main Study

Registration number (CTRI/2023/05/052343) registered under Clinical trial registry of India.

Ethical Approval of the Main Study

Genebandhu Independent ethics committee Ref ECG005/2023.

The Copyright Registration Number for Questionnaire

Copyright Registration Number for Protocol

Trial Status

Recruitment has not yet started.

Data Analysis

Statistical analysis will be conducted using software IBM SPSS Statistics 22 (IBM Corp. Armonk, New York, USA.) and MS Excel 2016 (Microsoft, Inc., Redmond, Washington, USA). The normality of the data will be tested by using to Wilk’s Shapiro normal distribution test (sample size < 2000). After testing the normality parametric and non-parametric test will be decided to compare the mean of Experimental and control group to test the hypothesis. The mean will be compared within the group and between the group. Descriptive statistics of the samples will be calculated (mean ± SD and median (range); the confidence interval was 95%). Paired t-test and Independent t-test will be used to compare mean within and between groups. Pearson’s correlation coefficient or spearman rank correlation will be used to detect the relationships among the variables. The test level for statistical significance of differences between both groups is defined as P ≤ .05 for all tests.

Discussion

This study focused to investigate the effectiveness of the comprehensive foot strengthening program in improving faulty foot biomechanics and reducing the injury risk among male Bhangra dancers through a randomized controlled trial. Several biomechanical parameters, including the Foot Posture Index, Navicular Drop Test, and other measures, will be assessed before and after the intervention. These improvements in foot biomechanics are expected to lead to more efficient and safer dance movements.

Plantar Pressure Distribution

Another key aspect of this study is the evaluation of plantar pressure distribution. Understanding how weight is distributed across the feet during dance movements is vital as abnormal pressure distribution can lead to injuries. The study anticipates that the experimental group will show a more even plantar pressure distribution compared to the control group, which can contribute to in reducing the incidence of injuries among dancers.

Injury Incidence

The study will gather data on past injury incidence over the previous year, and monitor injury incidence throughout the intervention period by using self-structured questionnaire. The past injury information will be used as a control variable in the statistical analysis to account for its potential influence on current injury risk or biomechanical outcomes. A follow-up period of 6 months will be included. Participants will continue with or without the training program, and injury incidence will be tracked prospectively during this period. This extended timeframe allows for a more accurate assessment of how biomechanical improvements translate into reduced injury rates. The experimental group is expected to experience fewer foot and lower extremity injuries than compared to the control group. This outcome would provide the long-term effectiveness of foot training exercises on injury prevention among dancers.

Implications for Dance Training Protocols

The findings of this study may have significant implications for the development of dance training protocols. Dancers and their instructors will benefit from evidence-based recommendations on the incorporation of foot muscle strengthening program into their training routines. This can help the Bhangra dancers to prepare and maintain their bodies for the rigors of dance, ultimately enhancing their performance and prolonging their careers.

Contribution to Injury Prevention Strategies

The study’s results will not only benefit the field of dance but also contribute to injury prevention strategies in sports and physical activities. Understanding how targeted training exercises can improve biomechanical characteristics can be applied to other athletic disciplines where lower extremity injuries are prevalent.

Study Limitations

Despite its potential contributions, this study has some limitations. The sample size of 140 participants is relatively small, and the study duration is limited to 12 weeks. Additionally, individual variations may influence the study’s findings. Even this protocol should be tested in other dance forms as the injury rate is high in other dance forms as well.

Trial Status

This clinical trial yet to recruit participants for phase 2. Phase 1 have started to identify the population with problems.

Conclusion

In conclusion, this randomized controlled trial aims to test the efficacy of comprehensive foot strengthening program to improve the faulty foot biomechanical characteristics and uneven plantar pressure distribution in male bhangra dancers. The study’s results have the potential to reshape dance training protocols and injury prevention strategies in the field of dance and beyond.

Footnotes

Appendix 1

Table 4.

Weekly Exercise Protocol as per ACSM Guidelines.

Week	Exercise name	Frequency/intensity	Time per exercise	Hold time	Rest interval	Intensity	Total time per session
Week 1	Fanning of toes with inversion	1 Set × 7 rep each	3.5 min	3 s	1 min	Mild to moderate intensity exercise	30 min per session with 5 to 7 min warmup and 3 to 5 min cool down
	Heel-strike with toe curl
	Heel raise and twist
	Ball hold and press
Week 2	Fanning of toes with inversion	1 Set × 10 rep each	4 min	3 s	1 min	moderate intensity exercise	40 min per session with 5 to 7 min warmup and 3 to 5 min cool down
	Heel-strike with toe curl
	Heel raise and twist
	Ball hold and press
	Theraband pull
	Ball lifts
Week 3	Fanning of toes with inversion	2 Set × 10 rep each	8 min	5 s	1 min	moderate intensity exercise	60 min per session with 5 to 7 min warmup and 3 to 5 min cool down
	Heel-strike with toe curl
	Heel raise and twist
	Ball hold and press
	Theraband pull
	Ball lifts
	Knee folds with ankle flexed
	Theraband pulling with inversion
Week 4	Fanning of toes with inversion	3 Set × 10 rep each	12 min	5 s	1 min	Moderate to vigorous exercise	90 min per session with 5 to 7 min warmup and 3 to 5 min cool down
	Heel-strike with toe curl
	Heel raise and twist
	Ball hold and press
	Theraband pull
	Ball lifts
	Knee folds with ankle flexed
	Theraband pulling with inversion
	Toe dragging with inversion
	Fanning of toes with plantar flexion and toe curl

Appendix 2 Acknowledgements

The authors would like to thank the participant of the present study and also like to extend the thanks to family and friends for constant support and love.

Credit Authorship Contribution Statement

All the authors have distinctive role in formulation of this study protocol;

1. Sakshi sadhu: will take lead role in conceptualization and designing of protocol, ethical consideration, data collection and management responsibility, manuscript preparation, exercise protocol designing and drafting, questionnaire designing and drafting, drafting final version of manuscript and publication responsibility.

2. Dr. Ramesh Chandra patra: conceptualization and designing of protocol, will provides the supervision through the study, revision of manuscript, exercise protocol designing and drafting, questionnaire designing and drafting, drafting final version of manuscript.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval of Main Study

Genebandhu Independent ethics committee Ref ECG005/2023.

Clinical trial Registration of Main Study

Registration number (CTRI/2023/05/052343).

Copyright Registration Number for Questionnaire

7838/2023-CO/L.

Copyright Registration Number for Protocol

L- 137234/2023.

ORCID iDs

Sakshi Sadhu

Ramesh Chandra Patra

References

Schreffler

Situating bhangra dance: a critical introduction. South Asian Hist Cult. 2013;4(3):384-412.

Pramukhtech. Exploring the vibrant world of bhangra: Music, dance, and culture. DanceOdia. July 15, 2023. https://danceodia.com/bhangra-music-dance-and-culture

Adrien

. Biomechanical risks associated with foot and ankle injuries in ballet dancers: a systematic review. Int J Environ Res Public Health. 2022;19(8):4916.

Sun

Liu

. Prevalence and risk factors of musculoskeletal injuries in modern and contemporary dancers: a systematic review and meta-analysis. Front Public Health. 2024;12:1325536.

Rinonapoli

Graziani

Ceccarini

Razzano

Manfreda

Caraffa

. Epidemiology of injuries connected with dance: a critical review on epidemiology. Med Glas. 2020;17(2):256-264.

Huang

Lin

Jankaew

Lin

. Relationship of extrinsic risk factors to lower extremity injury in collegiate ballet dancers. Front Bioeng Biotechnol. 2022;10:878448.

Anagnostopoulou

Argiriadou

Mavrovouniotis

. The examination of injuries in dancers. Eir Argiriadou, Sch Phys Educ Sport Sci. 2017;67(5):67-74.

Nair

Kotian

Hiller

Mullerpatan

R, C

, Survey of musculoskeletal disorders among Indian dancers in Mumbai and Mangalore. J Dance Med Sci. 2018;22(2):67-74.

Hung

RKH

Yung

PSH

Ling

SKK

, et al. Prevalence of dance-related injuries and associated risk factors among children and young Chinese dance practitioners. Medicine. 2023;102(47):e36052.

10.

Sadhu

Chandra Patra

Pal

Prusty

Prinson

. Evaluation of prevalence, location and pattern of musculoskeletal pain and discomfort among dancers. Sport Mont. 2024;22(2):93-99.

11.

Russell

. Preventing dance injuries: current perspectives. Open Access J Sports Med. 2013;30(4):199-210.

12.

Schulz

Moher

Altman

. Guidelines for Reporting Health Research: A User’s Manual. 2014;80-92.

13.

Chan

Tetzlaff

Altman

Dickersin

Moher

. SPIRIT 2013: new guidance for content of clinical trial protocols. Lancet. 2013;381(9861):91-92.

14.

Kang

. Sample size determination and power analysis using the G*Power software. J Educ Eval Health Prof. 2021;18:17.

15.

Sil

Kumar

Das

. Selection of control, randomization, blinding, and allocation concealment. Indian Dermatol Online J. 2019;10(5):601-605.

16.

Redmond

Crane

Menz

. Normative values for the foot posture index. J Foot Ankle Res. 2008;1(1):1-9.

17.

Vinicombe

Raspovic

Menz

. Reliability of navicular displacement measurement as a clinical indicator of foot posture. J Am Podiatr Med Assoc. 2001;91(5):262-268.

18.

Spörndly-Nees

Dåsberg

Nielsen

Boesen

Langberg

. The navicular position test: a reliable measure of the navicular bone position during rest and loading. Int J Sports Phys Ther. 2011;6(3):199-205.

19.

McCrory

Young

Boulton

AJM

Cavanagh

. Arch index as a predictor of arch height. Foot. 1997;7(2):79-81.

20.

Paecharoen

Arunakul

Tantivangphaisal

. Diagnostic accuracy of Harris Imprint Index, Chippaux-Smirak Index, Staheli Index compared with talar-first metatarsal angle for screening arch of foot. Ann Rehabil Med. 2023;47(3):222-227.

21.

Deepashini

Omar

Paungmali

Amaramalar

Ohnmar

Leonard

. An insight into the plantar pressure distribution of the foot in clinical practice: narrative review. Pol Ann Med. 2020;21(1):51-56.

22.

Warburton

DER

Bredin

SSD

Jamnik

Gledhill

. Validation of the PAR-Q+ and ePARmed-X+. Heal Fit J Canada. 2011;4(2):38-46.

23.

Topp

Østergaard

Søndergaard

Bech

. The WHO-5 well-being index: a systematic review of the literature. Psychother Psychosom. 2015;84(3):167-176.

24.

Nasreddine

Phillips

Bédirian

, et al. The Montreal cognitive assessment, MoCA: a brief screening tool for mild cognitive impairment. J Am Geriatr Soc. 2005;53(4):695-699.

25.

Hoops

Nazem

Siderowf

, et al. Validity of the MoCA and MMSE in the detection of MCI and dementia in Parkinson disease. Neurology. 2009;73(21):1738-1745.

26.

Liguori

Feito

Fountaine

Roy

, eds. ACSM’s Guidelines for Exercise Testing and Prescription. 11th ed. Wolters Kluwer; 2022.

27.

Yang

Mao

, et al. Reliability and validity of Foot Posture Index (FPI-6) for evaluating foot posture in participants with low back pain. Sci Rep. 2022;12(1):21168-21210.

28.

Arulsingh

Raj

Adhikari

Pai

. Normative values of navicular drop test and the effect of demographic parameters: a cross-sectional study. Ann Biol Res. 2014;5(7):40-48.

29.

Nilsson

Friis

Michaelsen

Jakobsen

Nielsen

. Classification of the height and flexibility of the medial longitudinal arch of the foot. J Foot Ankle Res. 2012;5(1):1-9.

30.

Drefus

Kedem

Mangan

Scher

Hillstrom

. Reliability of the arch height index as a measure of foot structure in children. Pediatr Phys Ther. 2017;29(1):83-88.

31.

Mohd Shariff

Manaharan

Ahmad Shariff

Merican

. Evaluation of foot arch in adult women: comparison between five different footprint parameters. Sains Malays. 2017;46(10):1839-1848.

32.

Ramachandra

Maiya

Kumar

. Test-retest reliability of the Win-Track platform in analyzing the gait parameters and plantar pressures during barefoot walking in healthy adults. J Foot Ankle Res. 2012;5(5):306-312.