Foot And Ankle Proprıoceptıve Exercıse Program

Participants will be divided into two groups: an intervention (exercise) group and a control group. Based on the assumption that the difference in pre- and post-intervention changes between groups will be significantly in favor of the intervention group (effect size: Cohen's d = 0.80), a power analysis was conducted using Student's t-test with a Type I error rate of 5% and a power of 80%. The study by Mat et al., conducted on geriatric individuals, was used as a reference in the literature (8). The required number of participants was calculated as 17 for the intervention group and 18 for the control group.

Considering the high risk of mortality and morbidity in the elderly population, the study is planned to be carried out with 20 participants in the intervention group and 20 in the control group to account for potential attrition. Group randomization will be based on stratification by gender and age, as these factors are considered likely to affect fall risk in the geriatric population. Participants included in the study sample will be stratified according to these two criteria.

Additionally, each participant will be assigned a unique identification number. Data collection will be conducted face-to-face. The data will be collected by Assoc. Prof. Bahar Külünkoğlu and Ayşegül Atlı.

Demographic Information Descriptive data including participants' age, gender, weight, height, Body Mass Index (BMI), education level, medications used, medical history, family history, marital status, history of falls, and fall-related injuries will be collected using a sociodemographic form.

Cognitive Assessment

Standardized Mini Mental State Examination (MMSE):

This test will be used to assess cognitive functions and to determine the suitability of individuals for participation in the study. Developed by Folstein et al. (9) and validated in Turkish by Güngen et al. in 2005 , the MMSE scores are interpreted as follows:

28-30: Normal cognitive function

24-27: Mild cognitive impairment

0-23: Significant cognitive impairment

Foot Posture Assessment

The following measurements will be performed:

Navicular Drop Test

Metatarsal Width

Foot Length

Navicular Drop Test:

This test assesses the degree of pronation in the foot by calculating the difference in navicular height between non-weight-bearing and weight-bearing positions. Participants will be seated barefoot while the navicular tuberosity is marked. The same mark will be recorded on a card placed on the floor. Then, participants will stand up with full weight bearing, and the new mark will be recorded. The distance (in mm) between the two marks is recorded as the navicular drop .

Metatarsal Width:

Using a digital caliper, the distance between the medial and lateral heads of the metatarsals will be measured with slight compression.

Foot Length:

Foot length will be measured as the distance between the tip of the longest toe and the most posterior part of the heel using a measuring tape.

Physical Performance Assessment

Short Physical Performance Battery (SPPB):

This battery evaluates physical and functional health in older adults, particularly those living in nursing homes. It consists of three objective tests: 4-meter walk test, chair stand test, and balance tests.

Scoring:

4-meter walk:

8.70 seconds = 1 point

6.21-8.70 seconds = 2 points

4.82-6.20 seconds = 3 points

<4.82 seconds = 4 points

Chair stand:

≥16.7 seconds = 1 point

13.7-16.6 seconds = 2 points

11.2-13.6 seconds = 3 points

<11.2 seconds = 4 points

Balance tests:

Side-by-side and semi-tandem stance:

Stand for 10 seconds = 1 point

Unable to stand for 10 seconds = 0 points

Tandem stance:

≥10 seconds = 2 points

3-9 seconds = 1 point

<3 seconds = 0 points

Fear of Falling Assessment

Falls Efficacy Scale-International (FES-I):

Developed by Yardley et al., the FES-I measures fear of falling during activities of daily living. It consists of 16 items, each rated on a 4-point Likert scale:

• = Not at all concerned
• = Somewhat concerned
• = Fairly concerned
• = Very concerned Total scores range from 16 (no fear) to 64 (severe fear). According to Delbaere et al. , score ranges are categorized as:16-19: Low concern

20-27: Moderate concern

28-64: High concern The Turkish validity and reliability study was conducted by Ulus et al.

Plantar Sensation Assessment

Semmes-Weinstein Monofilament Test:

This test evaluates light touch and pressure thresholds by determining the minimal stimulus required to depolarize cell membranes. Sensation at 9 plantar regions (heel, medial midfoot, lateral midfoot, heads of the 1st, 3rd, and 5th metatarsals, and tips of the 1st, 3rd, and 5th toes) will be assessed. Participants will be tested first with eyes open, then closed. Upon sensing contact, they will be asked to respond verbally. Testing will start with the thinnest monofilament and progress to thicker ones. Each filament will be applied three times per site for 2 seconds at a perpendicular angle until it bends.

Interpretation of Monofilament Numbers:

Monofilament No. Interpretation 2.36-2.83 Normal 3.22-3.61 Decreased light touch 3.84-4.31 Decreased protective sensation 4.56-6.65 Loss of protective sensation No response No sensation

Ankle Proprioception Assessment

Joint Position Reproduction Test:

Participants will be seated with hips and knees at 90° flexion. The target joint angles are 10° dorsiflexion and 20° plantar flexion. The evaluator will demonstrate the angle using a goniometer, and participants will attempt to replicate the angle. The test will be repeated three times, and the mean value will be recorded.

Exercise Program A specially designed foot and ankle proprioceptive exercise program will be implemented. The intervention will consist of 24 sessions over 8 weeks (3 days per week). Exercises will be performed in groups of five participants under the supervision of a physiotherapist in the exercise room of the nursing home. The exercises are tailored to the elderly population, focusing on low to moderate intensity to ensure accessibility and safety.

Intervention Group: In addition to their routine physiotherapy, participants will perform foot and ankle proprioceptive exercises.

Control Group: Will continue only with their standard physiotherapy program, which includes strength, balance, and posture training-but not proprioceptive exercises or study-specific materials.

Assessments will be conducted at baseline, post-intervention, and 3 months after the intervention. Each session will include 10 minutes of warm-up and cool-down exercises. Safety measures will be taken throughout the program. Since all exercises are performed in a seated position, the program is designed to avoid excessive stress on the participants' vital functions.

Each exercise will be performed as one set of 10 repetitions, with each repetition lasting 5 seconds. A rest period of 45 seconds will be provided between sets.

After the final (3rd month) evaluation, the control group will also be offered the opportunity to participate in the same proprioceptive training. The exercises will be conducted using spiky balls and spiky balance balls in a seated position.

Inclusion criteria

• Individuals aged 65 years and older
• A score of 24 or higher on the Standardized Mini-Mental State Examination (MMSE)
• Ability to read and write in Turkish
• Voluntary participation in the study with signed informed consent
• Ability to stand independently and take at least two steps without assistance
• Ability to walk independently in the community without the use of lower extremity orthoses or

Exclusion criteria

• Uncorrected visual impairments that cannot be resolved with glasses
• Uncorrected hearing loss despite the use of hearing aids
• A score of 23 or below on the Mini-Mental State Examination
• Any surgical procedure affecting balance within the last 6 months
• Presence of deformities in the lumbar spine, hip, or knee joints
• Lower extremity amputation
• Malignancy involving the lower extremities
• Diagnosis of moderate to severe congenital heart disease, coronary artery disease, or cerebrovascular disease
• Any medical contraindications to exercise
• Inability to establish cooperation with the participant