This article was downloaded by: [Heriot-Watt University] On: 07 March 2015, At: 23:17 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sports Sciences Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rjsp20
Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study a
a
a
a
Tina Winter , Heidrun Beck , Achim Walther , Hans Zwipp & Susanne Rein
b
a
Center for Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Germany b
Department of Hand Surgery, Rhoen Klinikum, Germany Published online: 25 Nov 2014.
Click for updates To cite this article: Tina Winter, Heidrun Beck, Achim Walther, Hans Zwipp & Susanne Rein (2015) Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study, Journal of Sports Sciences, 33:8, 831-840, DOI: 10.1080/02640414.2014.964751 To link to this article: http://dx.doi.org/10.1080/02640414.2014.964751
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Sports Sciences, 2015 Vol. 33, No. 8, 831–840, http://dx.doi.org/10.1080/02640414.2014.964751
Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study TINA WINTER1, HEIDRUN BECK1, ACHIM WALTHER1, HANS ZWIPP1 & SUSANNE REIN2 1
Center for Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Germany and 2Department of Hand Surgery, Rhoen Klinikum, Germany
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
(Accepted 9 September 2014)
Abstract The influence of a 12-week-proprioceptive training on functional ankle stability was investigated in young speed skaters. Twenty-eight speed skaters were randomly divided into an intervention (n = 14) and into a control group (n = 14). A 15-min circle training was performed 5 times per week over a 12-week period. Measurements were taken prior to the training, after 6 and 12 weeks of training. Kinaesthesia was evaluated with the Isomed2000 in all movements of the ankle joint. Dynamic balance was tested with the Biodex Stability System at the stable level 8 and at the unstable level 2, measuring the overall stability index, the anterior/posterior and the medial/lateral scores. Static single-leg stance was evaluated using the Kistler force platform. Kinaesthesia of the intervention group improved significantly for plantarflexion of the right foot (P = 0.001) after 12 weeks. Dynamic balance showed significant differences in the intervention group after 12 weeks in comparison with the first measurement for each foot in the overall stability index, the anterior/posterior and the medial/lateral scores (P ≤ 0.017, respectively) at the unstable level 2. Functional ankle stability improved in terms of dynamic balance after 12 weeks of proprioceptive training. Therefore, inclusion of proprioceptive exercises in the daily training programme is recommended for young speed skaters. Keywords: balance, kinaesthesia, proprioception, speed skating, training
Introduction Speed skating is a fast sport with speeds up to 50 km · h−1. So the risk of ankle injuries is high. With 14% it is the second most common injury in speed skating (Fong, Hong, Chan, Yung, & Chan, 2007). Athletes wear skates with a blade thickness of 1.3 to 1.5 mm that ends below the ankle joint, so it does not stabilise it properly. The plantarflexion is restricted to reduce friction during the push-off phase. The blade stands on the inside edge in pronation, while the outside edge of the blade is retouching the ice in a supinated position after the push-off (Haguenauer, Legreneur, & Monteil, 2006). Speed skaters need to position the blade with high precision on the ice in order to avoid ankle sprains. Particularly in the curves, there is a high risk of ankle injuries, as the right ankle is adjusted in a pronated position and the left one is supinated (van Ingen Schenau, de Groot, & de Boer, 1985). Additionally, the risk of injuries is even higher with an increasing frequency of training
sessions in the competitive sports (Rothenberger, Chang, & Cable, 1988). However, there is hardly any literature addressing the functional ankle stability in speed skaters, which is essential to protect them from ankle sprains. Proprioception implies the perception and depth sensitivity of the body, and it influences the planning and modification of intrinsic generated motor control (Jerosch, 1999; Riemann & Lephart, 2002b). Proprioception includes different qualities: the neuromuscular unconscious aspect, including balance, is important for the preparation of joint movement and to reach a functional joint stability (Hagert, 2010; Riemann & Lephart, 2002a; Riemann, Myers, & Lephart, 2002). Balance is the ability to maintain the centre of pressure on a base of support with a maximum of stability and a minor body sway (Horak, 1987). Postural control is investigated statically with force platforms analysing the centre of pressure or dynamically with the Biodex Stability System, which consists of a moving platform. The conscious somatosensory aspect incorporates
Correspondence: Tina Winter, Center for Orthopedic and Trauma Surgery, University Hospital “Carl Gustav Carus”, Fetscherstr. 74, Dresden, 01307, Germany. E-mail: [email protected] © 2014 Taylor & Francis
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
832
T. Winter et al.
kinaesthesia, joint position sense and force sense, and it is influenced by the afferent information from muscle spindles and the cutaneous receptors (Cordo, Gurfinkel, Brumagne, & Flores-Vieira, 2005; Hagert, 2010; Riemann et al., 2002). One possibility to investigate kinaesthesia is measuring the threshold to detect a passive movement. It indicates the smallest change in a joint, which is necessary to detect a conscious movement of the limb (Riemann et al., 2002). Velocities of 0.5° s−1 to 2° s−1 are used to test slow-adapting mechanoreceptors, including the Ruffini endings and the Golgi-like endings. While the Ruffini endings are responsible for registering the joint’s position and its motion due to their ability to detect direction and velocity of active and passive joint movements (Grigg & Hoffman, 1982; Rein et al., 2013; Skoglund, 1956), the Golgi-like endings react to extreme range of motion (Lephart, Pincivero, Giraido, & Fu, 1997; Newton, 1982). Recurring ankle sprains cause damage to these sensory nerve endings, resulting in a functional ankle instability due to the reduced joint position sense, the decreased postural control and the prolonged peroneal reaction time (Arnold, Linens, de la Motte, & Ross, 2009; Glencross & Thornton, 1981; Hertel, 2002; Karlsson & Andreasson, 1992; Konradsen & Bohsen Ravn, 1991; Munn, Sullivan, & Schneiders, 2010; Richie, 2001; Tropp, Askling, & Gillquist, 1985). The risk of recurrent ankle sprains is reduced by proprioceptive training (Eils & Rosenbaum, 2001; Eils, Schröter, Schröder, Gerss, & Rosenbaum, 2010). However, in literature, recommendations for training periods vary between 6 (Bernier & Perrin, 1998; Eils & Rosenbaum, 2001; McKeon & Hertel, 2008; Paterno, Myer, Ford, & Hewett, 2004; Schmidt, Benesch, Bender, Claes, & Gerngross, 2005) and 12 weeks (Gioftsidou et al., 2006). Due to this fact and the lack of knowledge about the functional ankle stability in speed skaters, the aim of this study was to investigate the influence of a 12-week-proprioceptive training programme on functional ankle stability in speed skaters.
Materials and methods Participants Twenty-eight speed skaters from a sport school centre, aged between 11 and 19 years, were recruited. The study took place during the build-up period in spring after the competition season. Participants were divided randomly into two groups by an independent study nurse during the first measurement. The intervention group (n = 14) completed a 12-week training programme 5 times per week for 15 min. The second measurement was performed after 6 weeks
and the third one after 12 weeks of proprioceptive training. The control group (n = 14) just participated in their usual training sessions. Speed skaters who had a frequency of five sport-specific training sessions equivalent to 10 h per week as well as those who participated in regional and national competitions were included in this study. Exclusion criteria were injuries of the lower limb, acute anterolateral rotation instability of the ankle joint as well as neuromuscular or neural diseases. Clinical history and investigations The local ethics committee review board approved this study. Before collecting data, informed consent was obtained from all athletes and their parents. Participants completed a questionnaire with information about weight, height, body mass index, dominant leg, regular medication, general, neurological and orthopaedic disease as well as sportspecific conditions like starting age of training, number of training sessions per week, previous ankle sprains, date and content of the last training session. On the physical examination, participants’ ankle joints were inspected and palpated for areas of tenderness and swelling at the ankle joint by a medical doctor. Vibration sensibility of the lower leg was evaluated over the head of the fibula and the lateral malleolus by a tuning fork (Rydel-Seiffer tuning fork, Model AB-125; C 64vHz frequency, Arno Barthelmes & Co. GmbH, Tuttlingen, Germany) (Martina, van Koningsveld, Schmitz, van der Meche, & van Doorn, 1998). In order to exclude sensory ataxia, Romberg’s test was performed. The active range of motion in plantarflexion, dorsiflexion, pronation and supination was measured on the non-weight-bearing ankle joints with a standard goniometer. To avoid passive load on the ankle joint, the participants laid supine. Kinaesthesia The Isomed2000 (D&R Ferstl GmbH, Hemau, Germany) with the “DualAthletic” software (D&R Ferstl GmbH, Hemau, Germany) was used to evaluate kinaesthesia in plantarflexion, dorsiflexion, pronation and supination. The device consists of a lying surface with an adjustable seat back and a swivelling dynamometer to which a foot adapter was attached. The dynamometer and the swivel arm can be moved 360° around the participant. For pronation and supination tests, the dynamometer was tilted 90°. The athletes sat with their knees flexed at 90° (Figure 1). Plantarflexion and dorsiflexion was performed in a lying position. The foot was placed barefoot and unfixed on the foot adapter in the neutral position. The foot was moved passively by the device with a velocity of 0.5° s−1 from
Influence of a proprioceptive training
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Figure 1. The testing position of pronation and supination on the Isomed2000 is shown. The participant was blindfolded and wore earphones to avoid visual and auditive cues.
the neutral position into the respective ending position, which was reached after 15° and then backwards to the neutral position. To minimise possible vibrations from the device, a relax foam matt (Polyform GmbH & Co. KG, Rinteln, Germany) with a size of 30 × 7 cm and a thickness of 0.75 cm was fixed on the adapter. Participants wore headphones and were blindfolded to avoid visual and auditory influences. They were given a button to press as soon as they realised any movement in the ankle joint. The examiner supervised the movements with a remote control. The measurement procedure was standardised with a randomised beginning of movement. One practice trial was granted prior to each new position in order to reduce learning effects and also to prevent participants to adapt to the next trial. A special developed software (University of Lausitz, Senftenberg, Germany) transformed the raw data into a graph, which showed the displacement in degrees of the movement perception. Mean scores were calculated from three single trials for every foot position and each foot.
Biodex Stability System The ability of dynamic balance was tested with the Biodex Stability System (Biodex Medical Systems, Shirley, New York, USA). This mobile balance platform has a movement range of 360° with a surface tilt of maximal 20°. Eight different levels allow an assessment of different grades of platform instability. In this study, the most stable level 8 and the more unstable level 2 were chosen, measuring three trials over a period of 20 s, which is in accordance with previous studies (Aydoğ, Bal, Aydoğ, & Çakci, 2006; Rein, Fabian, Weindel, Schneiders, & Zwipp, 2011a; Rein, Fabian, Zwipp, Mittag-Bonsch, & Weindel, 2010; Rein, Fabian, Zwipp, Rammelt, & Weindel, 2011b; Testerman & van der Griend,
833
1999). The order of testing was randomised. Participants were tested barefoot with eyes open in a quiet room to avoid auditory influences. Participants stepped on the platform with one foot, slightly flexed in the knees (15°), looking straight ahead to the screen with their arms in a neutral position. Coordinates of the foot position were marked to ensure the same conditions for all participants. Before each new position, the athletes underwent a practice trial to reduce learning effects. The overall stability index, which indicates the variance of foot-platform displacement in degrees from a level position in all motions during the test, the anterior/posterior and the medial/lateral stability scores, representing the variance of foot-platform displacement in degrees for motions in the sagittal and frontal plane, were determined (Arnold & Schmitz, 1998; Rein et al., 2011b). The variance from the neutral position over time expresses the ability of the athletes to control the angle on the tilted platform. A high score indicates poor balance ability, whereas a score of “0 degrees” implies a maximum of postural control. Mean scores of the three trials were calculated for each level and foot. Kistler force platform The Kistler force platform (Kistler Instrumente GmbH, Ostfildern, Germany) was used to assess the static balance ability through the registration of the centre of pressure (D’Hondt et al., 2011; Verhagen et al., 2005). The platform was 35 mm thick with a mass of 18 kg. The minimum body weight required to start the software analysis was 35 kg. Single-leg stance on the right and left leg was performed randomly, barefoot and with eyes open over 20 s with 10 s rest. The participant stood with the tested foot on the platform, maintaining a slight flexion of the knee. The contralateral knee was held in a relaxed 90° flexion. The head was held in a neutral position, and the hands were close to the trunk. The setting took place in a quiet room to reduce auditory influence. The software analysed the centre of pressure of the mediolateral and anteroposterior direction of the foot movement. The mean distance of movement shift was measured over 15 s. A high score indicated poor static balance control. Three trials were recorded for the right and the left foot, followed by the calculation of the mean score. Proprioceptive training The training programme of 15 min took place 5 times per week. Six exercises were done in a circle training of 45 s of practice time and a resting interval of 30 s (Eils, 2003; Eils & Rosenbaum, 2001; Wester, Jespersen,
834
T. Winter et al.
Nielsen, & Neumann, 1996). The exercise programme was done twice to train both feet equally. Strengthening exercises with 45-cm clubs (SportTec Physio & Fitness, Pirmasens, Germany) and the Airex® Balanceboard (Gaugler & Lutz oHG, AalenEbnat, Germany) were performed to secure balance in extreme positions. Kinaesthesia was promoted by using an angle board and a joint position exercise. A wobble board (Jakobs GmbH, Nörvenich, Germany) and the Pedalo® round woods (Holz-Hoerz GmbH, Münsingen, Germany) were used to improve balance by different daily exercises. Exercises varied daily or weekly because different stimuli are required to prevent ankle injuries effectively.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Statistical analysis Three different measurements were analysed separately for the intervention and the control group. The parameters of all three test measurements were compared to each other, respectively. Mean values with standard deviation were selected for descriptive statistics. The Kolmogorov–Smirnov test was used to investigate data distribution. The Kruskal–Wallis test was applied for statistical analysis, which was followed by the Mann–Whitney test with post hoc Bonferroni adjustment. The final level of significance was P = 0.017, because of the three possible tests between the three measurements. Additionally, the difference of the medians was given including their 95% confidence interval (CI).
Results Clinical history and investigations Results of the demographic and anthropometric variables of all speed skaters are reported in Table I. No participant stated a polyneuropathy in the questionnaire. One athlete stated an attention-deficit
Table I. Anthropometric data are shown for the intervention and the control group. Anthropometric data
Intervention
Participants (n) Female (n) Male (n) Age (years) Height (m) Weight (kg) BMI (kg · m−2) Age of training (years) Training sessions/week (n) Frequency distribution Dominant leg right (n) Dominant leg left (n) Ankle sprains (n) Regularly twisting (n) Twisting (frequency/week) Orthopaedic diseases (n) Neurological diseases (n) General diseases (n) Medication
14 6 8 12.6 160.9 49.6 18.9 4 5.2
± ± ± ± ± ±
1.5 13 10 1,3 2.3 1.6
8 6 1 4 0.8 ± 1.5 2 0 2 2
Control 14 5 9 12.9 160.1 46.6 18 6.9 4.6
± ± ± ± ± ±
1.7 10.7 9.2 1.9 2.9 1.2
11 3 3 3 0.6 ± 1.5 2 1 1 1
hyperactivity disorder, which was reported as a “neurological disease”. The only orthopaedic disease that appeared was a mild juvenile idiopathic scoliosis. Regular medication did not alter proprioception and only consisted of salbutamol for asthmatics. Regular twisting included participants who indicated a subjective feeling of “giving away” of the ankle joint without any swelling or tender to palpation of the ankle joint region nor positive anterior drawer test and also nor positive talar tilt test. Tuning fork tests showed no abnormality in all participants. The Romberg test was also negative in all athletes. No pathological condition was found during the foot inspection. Neither local swelling nor tenderness was palpable during the clinical investigation. The results of active range of motion are shown in Figure 2.
Figure 2. Active range of motion of the ankle sprain is shown for the intervention and the control group prior to the proprioceptive training sessions.
Influence of a proprioceptive training Kinaesthesia
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Comparing to the first measurement (mean value = 1.39, s = 0.78°), kinaesthesia improved significantly (P = 0.001, median 0.53°, CI 0.23 to 1.03°) for plantarflexion of the right foot after 12 weeks of training (mean value = 0.69, s = 0.52°) in the intervention group, but not after 6 weeks (Figure 3). Plantarflexion of the left foot as well as dorsiflexion, pronation and supination did not show any significant differences based on the first measurement among the intervention and the control group (Figure 4). Furthermore all movements, starting at the extreme position, were not influenced by proprioceptive training.
Biodex Stability System Dynamic balance control showed no significant differences for each single-leg stance at the stable level 8 among all groups, neither when comparing it with the first to the second and to the third measurement nor when comparing it with the second to the third investigation for the overall stability index, the anterior/posterior and the medial/lateral scores.
835
The intervention group achieved significantly better results for the overall stability index, the anterior/ posterior and the medial/lateral scores at the unstable level 2 after 12 weeks of proprioceptive training compared to the baseline measurement for right (overall stability index: first measurement mean value = 3.4, s = 1.7°; third measurement mean value = 1.7, s = 0.7°; P = 0.001, median 1.37°, CI 0.53 to 2.10°; medial/lateral score: first measurement mean value = 1.9, s = 0.9°; third measurement mean value = 1.2, s = 0.4°; P = 0.012; median 0.57°; CI 0.10 to 1.20°; anterior/posterior score: first measurement mean value = 2.9, s = 1.7°; third measurement mean value = 1.5, s = 0.7°; P = 0.005, median 1.00°, CI 0.33 to 1.73°) and left single-leg stance (overall stability index: first measurement mean value = 3.2, s = 1.7°; third measurement mean value = 1.8, s = 0,7°; P = 0.006, median 0.97°, CI 0.33 to 1.73°; medial/lateral score: first measurement mean value = 1.9, s = 1.5°; third measurement mean value = 1.1, s = 0.4°; P = 0.014, median 0.47°, CI 0.10 to 0.90°; anterior/posterior score: first measurement mean value = 2.5, s = 1.2°; third measurement mean value = 1.5, s = 0.6°; P = 0.006, median 0.72°; CI 0.23 to 1.03°) (Figures 5 and 6).
Figure 3. The kinaesthesia results of the right foot are shown as mean with standard deviation. Only plantarflexion improved significantly (*) in the intervention group (P = 0.001) after 12 weeks of training. Note: 1 = intervention group; 2 = control group.
Figure 4. Means with standard deviation of left-foot kinaesthesia are presented. No significant differences between all three measurements and all foot positions have been seen. Note: 1 = intervention group; 2 = control group.
836
T. Winter et al.
Figure 5. Results of the Biodex Stability System are shown as means with standard deviation for the right single-leg stance at the unstable level 2 for the OSI, ML and AP scores. The intervention group improved significantly (*) after 12 weeks of proprioceptive training for the OSI (P = 0.001), ML (P = 0.014) and AP (P = 0.006) scores.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Note: 1 = intervention group; 2 = control group; OSI = overall stability index; ML = medial/lateral score; AP = anterior/posterior score.
Figure 6. Means with standard deviation for the OSI, ML and AP scores of the Biodex Stability System for the left single-leg stance at the unstable level 2 are demonstrated. The third measurement showed significant improvement of the intervention group for the OSI (P = 0.007), ML (P = 0.015) and AP (P = 0.007) score. Note: 1 = intervention group; 2 = control group; OSI = overall stability index; ML = medial/lateral score; AP = anterior/posterior score.
Kistler force platform Four athletes had to be excluded due to low body weight. The Kistler force platform starts analysing postural control at a weight of 35 kg. Twelve participants for the intervention group and twelve
for the control group finally took part. Static balance assessment did not improve for the right and left single-leg stance after 6 or 12 weeks of training in the intervention and the control group (Figure 7).
Figure 7. Results of the Kistler force platform are shown for the right and the left foot as means with standard deviation. No significant changes were remarked either after 6 or after 12 weeks of proprioceptive training. Note: 1 = intervention group; 2 = control group.
Influence of a proprioceptive training Discussion
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Kinaesthesia The intervention group showed a significant improved kinaesthesia of their right foot’s plantarflexion after 12 weeks of proprioceptive training. No significant differences have been revealed for any other tested movement direction. Speed skaters practice to suppress the plantarflexion in order to reduce friction and to achieve a better gliding phase (de Koning, Thomas, Berger, de Groot, & van Ingen Schenau, 1995). Due to proprioceptive training, the perception of plantarflexion was trained explicitly. Moreover, the right leg performs the major work during the push-off in the curve (van Ingen Schenau et al., 1985). This pronounced role of the right leg might be an explication for improved kinaesthesia in plantarflexion. However, there were no kinaesthetic changes in the supination of the left foot as well as in the pronation of the right foot. This is probably caused by the supination position of the left foot and pronation position of the right foot during skating into the curve (van Ingen Schenau et al., 1985). The young speed skaters in this study represented a healthy study population with a high basic level of motion perception. Therefore, the capacities for improving were limited (Cox, Lephart, & Irrgang, 1993). Surprisingly, movement perception did not improve in motions starting in the extreme position neither after 6 nor after 12 weeks of training. It seems to be that Golgi-like endings, which are activated in extreme position providing information about joint position and movement direction, were not stimulated through proprioceptive training due to the insufficient maximal movement positions (Grigg & Hoffman, 1982; Grigg & Hoffmann, 1993; Newton, 1982; Skoglund, 1956). In order to achieve a standardised examination, it was decided to choose a starting position of 15° in relation to the neutral position for each direction of movement. Out of this limitation not every speed skater reached his individual ending position. There is a probability that Golgi-like endings were not involved in the perception of kinaesthesia. Refshauge, Kilbreath, and Raymond (2000) instructed their participants to signalise a movement perception just when they were sure about the direction of movement. In the present study, the athletes had to press a button when feeling a movement but they did not have to differentiate the direction of movement. Each direction of movement, which was investigated, was known in advance. The time between the three single trials was chosen randomly. However, athletes sometimes anticipated the next movement. Therefore, some of them pressed the button before perceiving a movement, which only
837
could be analysed after the measurement. This limitation has been noted by other researchers as well (Refshauge et al., 2000). Moreover, it is essential to support the awareness of young athletes, that a proprioceptive training, performed additionally to their regular trainings protocol, reduces the risk of injuries. Preventive training achieves the best results in motivated athletes (Myklebust et al., 2003). Children and young adolescents between 10 and 19 years have a high incidence of ankle sprains (Waterman, 2010). Professional athletes spend up to 20 h per week performing their sport activities and competitions (Caine, Maffulli, & Caine, 2008). The burst of growth in this age is combined with physiologically reduced ligament strength causing a higher risk for injuries. Moreover, the bone mineralisation is delayed compared to the bone growth. Hence, the bones are more porous and vulnerable to injuries (Caine et al., 2008). But also overstraining due to extensive training sessions is a possible reason for sport injuries in youth age (Caine et al., 2008). Additionally, unconscious neuromuscular activation of dynamic mechanism to regain joint stability depends on previous experiences with the disturbing stimulus. In order to have an adequate reaction to balance interferences, athletes need a wide range of prior experiences (Riemann & Lephart, 2002a; Taube, Gruber, & Gollhofer, 2008), which obviously young athletes have less of than adults.
Biodex Stability System No significant differences were observed after 6 or 12 weeks of training for each single-leg stance at the stable level 8 in both groups. A low level of difficulty is not challenging enough for athletes with a high acquirement of movements pattern (Hinman, 2000; Perron, Hebert, McFadyen, Belzile, & Regnieare, 2007; Rein et al., 2011a, 2011b). More unstable levels are necessary to achieve significant improvement results (Rahnama, Salavati, Akhbari, & Mazaheri, 2010; Rein et al., 2011a). In the present study, the intervention group showed significant improvement in all tested dynamic balance scores after 12 weeks of proprioceptive training at the unstable level 2. This is in accordance with former studies (Dohm-Acker, Spitzenpfeil, & Hartmann, 2008; Emery, Rose, McAllister, & Meeuwisse, 2007; Franco, MartínezLópez, Lomas-Vega, Contreras, & Amat, 2012; Gioftsidou et al., 2006; Rein et al., 2011a, 2011b; Stasinopoulos, 2004; Wester et al., 1996). No significant differences based on the first measurement were found after 6 weeks. A cumulative effect for balance training is shown, indicating that a longer
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
838
T. Winter et al.
training period leads to a greater preventive effect (McKeon & Hertel, 2008). On the other hand, some studies state a period of 6 weeks equally effective to improve proprioception (Bernier & Perrin, 1998; Eils & Rosenbaum, 2001; Emery, Cassidy, Klassen, Rosychuk, & Rowe, 2005; Hupperets, Verhagen, & van Mechelen, 2009; McKeon & Hertel, 2008; Paterno et al., 2004; Schmidt et al., 2005). The present study demonstrates that 12 weeks of proprioceptive training is required to improve dynamic balance control, due to changes in the neuromuscular control (Eils et al., 2010). Previous experiences influence the compensatory response. Balance training reduces the excitation of spinal reflexes through an elevation of supraspinal-induced presynaptic inhibition (Taube et al., 2008). Subcortical structures have thereby a more important role than the motor cortex to maintain and to control balance. Synaptic efficiency for direct corticospinal projection on the muscles that are surrounding the ankle is improved and is used for voluntary muscle contraction (Taube et al., 2008). Different types of exercises are challenging for the individual and are required to prevent ankle injuries efficiently. Additionally, the previous general training protocol could be used for older athletes as well as for other competitive sports. The more intense athletes are practicing their sport, the more important the role of proprioception gets in order to reduce injuries. Moreover, it was shown that a high level of stability is associated with skating speed in young ice hockey players (Behm, Wahl, Button, Power, & Anderson, 2005).
Static balance tests are easy to perform and useful for clinical integration to evaluate proprioception (Arnold et al., 2009). Nevertheless, it is not a challenge for competitive speed skaters and therefore considered as an inappropriate assessment (Hinman, 2000; McKeon & Hertel, 2008; Perron et al., 2007). Dynamic balance tests are more adequate for the finely graduated ability of postural control in athletes. One limitation is the duration of single-leg stance; 20 s might not be sufficient enough in competitive sports. Cox et al. (1993) have already noticed that an interval of 10 s is not enough for single-leg stance to record differences in a healthy population. The test duration was chosen to achieve equal measurement conditions between static and dynamic balance assessment in the present study. Conclusion Proprioceptive training performed 5 times per week for 15 min improves functional ankle stability after 12 but not after 6 weeks in speed skaters. Aspects of proprioception are influenced differently. Kinaesthesia improved only in the right feet for plantarflexion due to the technical specifics of speed skating. The intervention group achieved significant better results in all tested scores for dynamic balance, but there was no improvement in static singleleg stance. Regular proprioceptive training is recommended for speed skaters to achieve better functional ankle stability. Acknowledgement
Kistler force platform No significant improvement in static balance was achieved either after 6 or after 12 weeks. These results are in accordance with previous studies (Cox et al., 1993; van der Wees et al., 2006; Verhagen et al., 2005). In contrast, other studies have shown significant differences in postural stability after proprioceptive training (Eils et al., 2010; Hoffman & Payne, 1995). These differences might be explained by a different choice of exercises. Hoffman and Payne (1995) explicitly exercised the single-leg stance on the dominant leg with a biomechanical ankle platform system. On the other hand, in the present study, 6 different exercises were used to improve the conscious and the unconscious aspects of proprioception. Interestingly, a recent study has shown that left static balance proficiency correlated with higher cerebellar volume of the vermian lobule VI-VII in female short tracker (Park, Yoon, Kim, & Rhyu, 2013).
The authors thank the following individuals for their contributions to this article: Ursula Range for statistical support, Thomas Albrecht for photographical work as well as Diana Scheibe and Heike Reinwarth for logistic support. Disclosure statement The authors declare that they have no competing interests. The authors disclose any financial conflicts of interest that may influence interpretation of this study and/or results. References Arnold, B. L., Linens, S., de la Motte, S., & Ross, S. (2009). Concentric evertor strength differences and functional ankle instability: A meta-analysis. Journal of Athletic Training, 44(6), 653–662. Arnold, B. L., & Schmitz, R. J. (1998). Examination of balance measures produced by the Biodex Stability System. Journal of Athletic Training, 33(4), 323–327.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Influence of a proprioceptive training Aydoğ, E., Bal, A., Aydoğ, S., & Çakci, A. (2006). Evaluation of dynamic postural balance using the Biodex Stability System in rheumatoid arthritis patients. Clinical Rheumatology, 25(4), 462–467. Behm, D. G., Wahl, M. J., Button, D. C., Power, K. E., & Anderson, K. G. (2005). Relationship between hockey skating speed and selected performance measures. Journal of Strength and Conditioning Research, 19(2), 326–331. Bernier, J., & Perrin, D. (1998). Effect of coordination training on proprioception of the functionally unstable ankle. Journal of Orthopaedic and Sports Physical Therapy, 27(4), 264–275. Caine, D., Maffulli, N., & Caine, C. (2008). Epidemiology of injury in child and adolescent sports: Injury rates, risk factors, and prevention. Clinics in Sports Medicine, 27, 19–50. Cordo, P., Gurfinkel, V., Brumagne, S., & Flores-Vieira, C. (2005). Effect of slow, small movement on the vibrationevoked kinesthetic illusion. Experimental Brain Research, 167, 324–334. Cox, E., Lephart, S., & Irrgang, J. (1993). Unilateral training of non-injured individuals and the effect on postural sway. Journal of Sport Rehabilitation, 2, 87–96. D’Hondt, E., Deforche, B., de Bourdeaudhuij, I., Gentier, I., Tanghe, A., Shultz, S., & Lenoir, M. (2011). Postural balance under normal and altered sensory conditions in normal-weight and overweight children. Clinical Biomechanics, 26(1), 84–89. de Koning, J., Thomas, R., Berger, M., de Groot, G., & van Ingen Schenau, G. (1995). The start in speed skating: From running to gliding. Medicine and Science in Sports and Exercise, 27(12), 1703–1708. Dohm-Acker, M., Spitzenpfeil, P., & Hartmann, U. (2008). Auswirkung propriozeptiver Trainingsgeräte auf beteiligte Muskulatur im Einbeinstand [Effect of proprioceptive trainings tools for the muscles in stance stability]. Sportverletzung Sportschaden, 22(1), 52–57. Eils, E. (2003). The role of proprioception in the primary prevention of ankle sprains in athletes: A review. International Journal of Sports Medicine, 4(5), 1–9. Eils, E., & Rosenbaum, D. (2001). A multi-station proprioceptive exercise program in patients with ankle instability. Medicine and Science in Sports and Exercise, 33(12), 1991–1998. Eils, E., Schröter, R., Schröder, M., Gerss, J., & Rosenbaum, D. (2010). Multistation proprioceptive exercise program prevents ankle injuries in basketball. Medicine and Science in Sports and Exercise, 42(11), 2098–2105. Emery, C., Rose, M., McAllister, J., & Meeuwisse, W. (2007). A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clinical Journal of Sport Medicine, 172(6), 749–754. Emery, C. A., Cassidy, J. D., Klassen, T. P., Rosychuk, R. J., & Rowe, B. H. (2005). Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: A cluster randomized controlled trial. Canadian Medical Association Journal, 172(6), 749–754. Fong, D. T.-P., Hong, Y., Chan, L.-K., Yung, P. S.-H., & Chan, K.-M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Medicine, 37(1), 73–94. Franco, N., Martínez-López, E., Lomas-Vega, R., Contreras, F., & Amat, A. (2012). Effects of proprioceptive training program on core stability and center of gravity control in sprinters. Journal of Strength and Conditioning Research, 26, 2071–2077. Gioftsidou, A., Malliou, P., Pafis, G., Beneka, A., Godolias, G., & Maganaris, C. (2006). The effects of soccer training and timing of balance training on balance ability. European Journal of Applied Physiology, 96(6), 659–664. Glencross, D., & Thornton, E. (1981). Position sense following joint injury. Journal of Sports Medicine and Physical Fitness, 21 (1), 23–27.
839
Grigg, P., & Hoffman, A. H. (1982). Properties of Ruffini afferents revealed by stress analysis of isolated sections of cat knee capsule. Journal of Neurophysiology, 47(1), 41–54. Grigg, P., & Hoffmann, A. H. (1993). Loading and deformation of the cat posterior knee joint capsule in axial and extension rotations. Journal of Biomechanics, 26(11), 1283–1290. Hagert, E. (2010). Proprioception of the wrist joint: A review of current concepts and possible implications on the rehabilitation of the wrist. Journal of Hand Therapy, 23, 2–17. Haguenauer, M., Legreneur, P., & Monteil, K. M. (2006). Influence of figure skating skates on vertical jumping performance. Journal of Biomechanics, 39(4), 699–707. Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training, 37, 364–375. Hinman, M. (2000). Factors affecting reliability of the Biodex Balance System: A summary of four studies. Journal of Sport Rehabilitation, 9, 240–252. Hoffman, M., & Payne, V. (1995). The effects of proprioceptive ankle disk training on healthy subjects. Journal of Orthopaedic and Sports Physical Therapy, 21(2), 90–93. Horak, F. B. (1987). Clinical measurement of postural control in adults. Physical Therapy, 67(12), 1881–1885. Hupperets, M. D. W., Verhagen, E. A. L. M., & van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: Randomised controlled trial. British Journal of Sports Medicine, 339, 1–6. Jerosch, J. (1999). Propriozeption – was ist das? [Proprioception – what it is?]. Orthopädieschuhtechnik, 2, 12–22. Karlsson, J., & Andreasson, G. O. (1992). The effect of external ankle support in chronic lateral ankle joint instability: An electromyographic study. The American Journal of Sports Medicine, 20(3), 257–261. Konradsen, L., & Bohsen Ravn, J. (1991). Prolonged peroneal reaction time in ankle instability. International Journal of Sports Medicine, 12(3), 290–292. Lephart, S., Pincivero, D., Giraido, J., & Fu, F. (1997). The role of proprioception in the management and rehabilitation of athletic injuries. The American Journal of Sports Medicine, 25, 130–137. Martina, I., van Koningsveld, R., Schmitz, P., van der Meche, F., & van Doorn, P. (1998). Measuring vibration threshold with a graduated tuning fork in normal aging in patients with polyneuropathy. Journal of Neurology, Neurosurgery, and Psychiatry, 65(5), 743–747. McKeon, P. O., & Hertel, J. (2008). Systematic review of postural control and lateral ankle instability, part II: Is balance training clinically effective? Journal of Athletic Training, 43(3), 305–315. Munn, J., Sullivan, S. J., & Schneiders, A. G. (2010). Evidence of sensorimotor deficits in functional ankle instability: A systematic review with meta-analysis. Journal of Science and Medicine in Sport, 13, 2–12. Myklebust, G., Engebretsen, L., Braekken, I. H., Skjølberg, A., Olsen, O.-E., & Bahr, R. (2003). Prevention of anterior cruciate ligament injuries in female team handball players: A prospective intervention study over three seasons. Clinical Journal of Sport Medicine, 13, 71–78. Newton, R. (1982). Joint receptors contributions to reflexive and kinesthetic responses. Physical Therapy, 62(1), 22–29. Park, I. S., Yoon, J. H., Kim, N., & Rhyu, I. J. (2013). Regional cerebellar volume reflects static balance in elite female shorttrack speed skaters. International Journal of Sports Medicine, 35, 465–470. Paterno, M., Myer, G., Ford, K., & Hewett, T. (2004). Neuromuscular training improves single-limb stability in young female athletes. Journal of Orthopaedic and Sports Physical Therapy, 34, 305–316.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
840
T. Winter et al.
Perron, M., Hebert, L., McFadyen, B., Belzile, S., & Regnieare, M. (2007). The ability of the Biodex Stability System to distinguish level of function in subjects with a second degree ankle sprain. Clinical Rehabilitation, 21, 73–81. Rahnama, L., Salavati, M., Akhbari, B., & Mazaheri, M. (2010). Attentional demands and postural control in athletes with and without functional ankle instability. Journal of Orthopaedic and Sports Physical Therapy, 40(3), 180–187. Refshauge, K. M., Kilbreath, S. L., & Raymond, J. (2000). The effect of recurrent ankle inversion sprain and taping on proprioception at the ankle. Medicine and Science in Sports and Exercise, 32(1), 10–15. Rein, S., Fabian, T., Weindel, S., Schneiders, W., & Zwipp, H. (2011a). The influence of playing level on functional ankle stability in soccer players. Archives of Orthopaedic and Trauma Surgery, 131(8), 1043–1052. Rein, S., Fabian, T., Zwipp, H., Mittag-Bonsch, M., & Weindel, S. (2010). Influence of age, body mass index and leg dominance on functional ankle stability. Foot & Ankle International, 31, 423–432. Rein, S., Fabian, T., Zwipp, H., Rammelt, S., & Weindel, S. (2011b). Postural control and functional ankle stability in professional and amateur dancers. Clinical Neurophysiology, 122(8), 1602–1610. Rein, S., Hagert, E., Hanisch, U., Lwowski, S., Fieguth, A., & Zwipp, H. (2013). Immunohistochemical analysis of sensory nerve endings in ankle ligaments: A cadaver study. Cells Tissues Organs, 197, 64–76. Richie, D. H. (2001). Functional instability of the ankle and the role of neuromuscular control: A comprehensive review. The Journal of Foot and Ankle Surgery, 40(4), 240–251. Riemann, B. L., & Lephart, S. M. (2002a). The sensorimotor system, part II : The role of proprioception in motor control and functional joint stability. Journal of Athletic Training, 37(1), 80–84. Riemann, B. L., & Lephart, S. M. (2002b). The sensorimotor system, part I : The physiologic basis of functional joint stability. Journal of Athletic Training, 37(1), 71–79. Riemann, B. L., Myers, J. B., & Lephart, S. M. (2002). Sensorimotor system measurement techniques. Journal of Athletic Training, 37(1), 85–98. Rothenberger, L. A., Chang, J. I., & Cable, T. A. (1988). Prevalence and types of injuries in aerobic dancers. The American Journal of Sports Medicine, 16, 403–407.
Schmidt, R., Benesch, S., Bender, A., Claes, L., & Gerngross, H. (2005). Die Trainierbarkeit vom propriozeptiven und koordinativen Parametern bei der chronisch-funktionellen Sprunggelenkinstabilität [The potential for training of proprioceptive and coordinative parameters in patients with chronic ankle instability]. Zeitschrift Für Orthopädie Und Ihre Grenzgebiete, 143(2), 227–232. Skoglund, S. (1956). Anatomical and physiological studies of knee joint innervation in the cat. Acta Physiologica Scandinavica, 36, 1–101. Stasinopoulos, D. (2004). Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. British Journal of Sports Medicine, 38(2), 182–185. Taube, W., Gruber, M., & Gollhofer, A. (2008). Spinal and supraspinal adaptations associated with balance training and their functional relevance. Acta Physiologica, 193(2), 101–116. Testerman, C., & van der Griend, R. (1999). Evaluation of ankle instability using the Biodex Stability System. Foot & Ankle International, 20, 317–321. Tropp, H., Askling, C., & Gillquist, J. A. N. (1985). Prevention of ankle sprains. The American Journal of Sports Medicine, 13(4), 259–262. van der Wees, P. J., Lenssen, A. F., Hendriks, E. J. M., Stomp, D. J., Dekker, J., & de Bie, R. A. (2006). Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy, 52(1), 27–37. van Ingen Schenau, G. J., de Groot, G., & de Boer, R. (1985). The control of speed in elite female speed skaters. Journal of Biomechanics, 18(2), 91–96. Verhagen, E., Bobbert, M., Inklaar, M., van Kalken, M., van der Beek, A., Bouter, L., & van Mechelen, W. (2005). The effect of a balance training programme on centre of pressure excursion in one-leg stance. Clinical Biomechanics, 20(10), 1094–1100. Waterman, B. (2010). The epidemiology of ankle sprains in the United States. The Journal of Bone and Joint Surgery (American), 92, 2279–2284. Wester, J., Jespersen, S., Nielsen, K., & Neumann, L. (1996). Wobble board training after partial sprains of the lateral ligaments of the ankle: A prospective randomized study. Journal of Orthopaedic and Sports Physical Therapy, 23(5), 332–336.
Journal of Sports Sciences Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/rjsp20
Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study a
a
a
a
Tina Winter , Heidrun Beck , Achim Walther , Hans Zwipp & Susanne Rein
b
a
Center for Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Germany b
Department of Hand Surgery, Rhoen Klinikum, Germany Published online: 25 Nov 2014.
Click for updates To cite this article: Tina Winter, Heidrun Beck, Achim Walther, Hans Zwipp & Susanne Rein (2015) Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study, Journal of Sports Sciences, 33:8, 831-840, DOI: 10.1080/02640414.2014.964751 To link to this article: http://dx.doi.org/10.1080/02640414.2014.964751
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions
Journal of Sports Sciences, 2015 Vol. 33, No. 8, 831–840, http://dx.doi.org/10.1080/02640414.2014.964751
Influence of a proprioceptive training on functional ankle stability in young speed skaters – a prospective randomised study TINA WINTER1, HEIDRUN BECK1, ACHIM WALTHER1, HANS ZWIPP1 & SUSANNE REIN2 1
Center for Orthopedic and Trauma Surgery, University Hospital Carl Gustav Carus, Germany and 2Department of Hand Surgery, Rhoen Klinikum, Germany
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
(Accepted 9 September 2014)
Abstract The influence of a 12-week-proprioceptive training on functional ankle stability was investigated in young speed skaters. Twenty-eight speed skaters were randomly divided into an intervention (n = 14) and into a control group (n = 14). A 15-min circle training was performed 5 times per week over a 12-week period. Measurements were taken prior to the training, after 6 and 12 weeks of training. Kinaesthesia was evaluated with the Isomed2000 in all movements of the ankle joint. Dynamic balance was tested with the Biodex Stability System at the stable level 8 and at the unstable level 2, measuring the overall stability index, the anterior/posterior and the medial/lateral scores. Static single-leg stance was evaluated using the Kistler force platform. Kinaesthesia of the intervention group improved significantly for plantarflexion of the right foot (P = 0.001) after 12 weeks. Dynamic balance showed significant differences in the intervention group after 12 weeks in comparison with the first measurement for each foot in the overall stability index, the anterior/posterior and the medial/lateral scores (P ≤ 0.017, respectively) at the unstable level 2. Functional ankle stability improved in terms of dynamic balance after 12 weeks of proprioceptive training. Therefore, inclusion of proprioceptive exercises in the daily training programme is recommended for young speed skaters. Keywords: balance, kinaesthesia, proprioception, speed skating, training
Introduction Speed skating is a fast sport with speeds up to 50 km · h−1. So the risk of ankle injuries is high. With 14% it is the second most common injury in speed skating (Fong, Hong, Chan, Yung, & Chan, 2007). Athletes wear skates with a blade thickness of 1.3 to 1.5 mm that ends below the ankle joint, so it does not stabilise it properly. The plantarflexion is restricted to reduce friction during the push-off phase. The blade stands on the inside edge in pronation, while the outside edge of the blade is retouching the ice in a supinated position after the push-off (Haguenauer, Legreneur, & Monteil, 2006). Speed skaters need to position the blade with high precision on the ice in order to avoid ankle sprains. Particularly in the curves, there is a high risk of ankle injuries, as the right ankle is adjusted in a pronated position and the left one is supinated (van Ingen Schenau, de Groot, & de Boer, 1985). Additionally, the risk of injuries is even higher with an increasing frequency of training
sessions in the competitive sports (Rothenberger, Chang, & Cable, 1988). However, there is hardly any literature addressing the functional ankle stability in speed skaters, which is essential to protect them from ankle sprains. Proprioception implies the perception and depth sensitivity of the body, and it influences the planning and modification of intrinsic generated motor control (Jerosch, 1999; Riemann & Lephart, 2002b). Proprioception includes different qualities: the neuromuscular unconscious aspect, including balance, is important for the preparation of joint movement and to reach a functional joint stability (Hagert, 2010; Riemann & Lephart, 2002a; Riemann, Myers, & Lephart, 2002). Balance is the ability to maintain the centre of pressure on a base of support with a maximum of stability and a minor body sway (Horak, 1987). Postural control is investigated statically with force platforms analysing the centre of pressure or dynamically with the Biodex Stability System, which consists of a moving platform. The conscious somatosensory aspect incorporates
Correspondence: Tina Winter, Center for Orthopedic and Trauma Surgery, University Hospital “Carl Gustav Carus”, Fetscherstr. 74, Dresden, 01307, Germany. E-mail: [email protected] © 2014 Taylor & Francis
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
832
T. Winter et al.
kinaesthesia, joint position sense and force sense, and it is influenced by the afferent information from muscle spindles and the cutaneous receptors (Cordo, Gurfinkel, Brumagne, & Flores-Vieira, 2005; Hagert, 2010; Riemann et al., 2002). One possibility to investigate kinaesthesia is measuring the threshold to detect a passive movement. It indicates the smallest change in a joint, which is necessary to detect a conscious movement of the limb (Riemann et al., 2002). Velocities of 0.5° s−1 to 2° s−1 are used to test slow-adapting mechanoreceptors, including the Ruffini endings and the Golgi-like endings. While the Ruffini endings are responsible for registering the joint’s position and its motion due to their ability to detect direction and velocity of active and passive joint movements (Grigg & Hoffman, 1982; Rein et al., 2013; Skoglund, 1956), the Golgi-like endings react to extreme range of motion (Lephart, Pincivero, Giraido, & Fu, 1997; Newton, 1982). Recurring ankle sprains cause damage to these sensory nerve endings, resulting in a functional ankle instability due to the reduced joint position sense, the decreased postural control and the prolonged peroneal reaction time (Arnold, Linens, de la Motte, & Ross, 2009; Glencross & Thornton, 1981; Hertel, 2002; Karlsson & Andreasson, 1992; Konradsen & Bohsen Ravn, 1991; Munn, Sullivan, & Schneiders, 2010; Richie, 2001; Tropp, Askling, & Gillquist, 1985). The risk of recurrent ankle sprains is reduced by proprioceptive training (Eils & Rosenbaum, 2001; Eils, Schröter, Schröder, Gerss, & Rosenbaum, 2010). However, in literature, recommendations for training periods vary between 6 (Bernier & Perrin, 1998; Eils & Rosenbaum, 2001; McKeon & Hertel, 2008; Paterno, Myer, Ford, & Hewett, 2004; Schmidt, Benesch, Bender, Claes, & Gerngross, 2005) and 12 weeks (Gioftsidou et al., 2006). Due to this fact and the lack of knowledge about the functional ankle stability in speed skaters, the aim of this study was to investigate the influence of a 12-week-proprioceptive training programme on functional ankle stability in speed skaters.
Materials and methods Participants Twenty-eight speed skaters from a sport school centre, aged between 11 and 19 years, were recruited. The study took place during the build-up period in spring after the competition season. Participants were divided randomly into two groups by an independent study nurse during the first measurement. The intervention group (n = 14) completed a 12-week training programme 5 times per week for 15 min. The second measurement was performed after 6 weeks
and the third one after 12 weeks of proprioceptive training. The control group (n = 14) just participated in their usual training sessions. Speed skaters who had a frequency of five sport-specific training sessions equivalent to 10 h per week as well as those who participated in regional and national competitions were included in this study. Exclusion criteria were injuries of the lower limb, acute anterolateral rotation instability of the ankle joint as well as neuromuscular or neural diseases. Clinical history and investigations The local ethics committee review board approved this study. Before collecting data, informed consent was obtained from all athletes and their parents. Participants completed a questionnaire with information about weight, height, body mass index, dominant leg, regular medication, general, neurological and orthopaedic disease as well as sportspecific conditions like starting age of training, number of training sessions per week, previous ankle sprains, date and content of the last training session. On the physical examination, participants’ ankle joints were inspected and palpated for areas of tenderness and swelling at the ankle joint by a medical doctor. Vibration sensibility of the lower leg was evaluated over the head of the fibula and the lateral malleolus by a tuning fork (Rydel-Seiffer tuning fork, Model AB-125; C 64vHz frequency, Arno Barthelmes & Co. GmbH, Tuttlingen, Germany) (Martina, van Koningsveld, Schmitz, van der Meche, & van Doorn, 1998). In order to exclude sensory ataxia, Romberg’s test was performed. The active range of motion in plantarflexion, dorsiflexion, pronation and supination was measured on the non-weight-bearing ankle joints with a standard goniometer. To avoid passive load on the ankle joint, the participants laid supine. Kinaesthesia The Isomed2000 (D&R Ferstl GmbH, Hemau, Germany) with the “DualAthletic” software (D&R Ferstl GmbH, Hemau, Germany) was used to evaluate kinaesthesia in plantarflexion, dorsiflexion, pronation and supination. The device consists of a lying surface with an adjustable seat back and a swivelling dynamometer to which a foot adapter was attached. The dynamometer and the swivel arm can be moved 360° around the participant. For pronation and supination tests, the dynamometer was tilted 90°. The athletes sat with their knees flexed at 90° (Figure 1). Plantarflexion and dorsiflexion was performed in a lying position. The foot was placed barefoot and unfixed on the foot adapter in the neutral position. The foot was moved passively by the device with a velocity of 0.5° s−1 from
Influence of a proprioceptive training
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Figure 1. The testing position of pronation and supination on the Isomed2000 is shown. The participant was blindfolded and wore earphones to avoid visual and auditive cues.
the neutral position into the respective ending position, which was reached after 15° and then backwards to the neutral position. To minimise possible vibrations from the device, a relax foam matt (Polyform GmbH & Co. KG, Rinteln, Germany) with a size of 30 × 7 cm and a thickness of 0.75 cm was fixed on the adapter. Participants wore headphones and were blindfolded to avoid visual and auditory influences. They were given a button to press as soon as they realised any movement in the ankle joint. The examiner supervised the movements with a remote control. The measurement procedure was standardised with a randomised beginning of movement. One practice trial was granted prior to each new position in order to reduce learning effects and also to prevent participants to adapt to the next trial. A special developed software (University of Lausitz, Senftenberg, Germany) transformed the raw data into a graph, which showed the displacement in degrees of the movement perception. Mean scores were calculated from three single trials for every foot position and each foot.
Biodex Stability System The ability of dynamic balance was tested with the Biodex Stability System (Biodex Medical Systems, Shirley, New York, USA). This mobile balance platform has a movement range of 360° with a surface tilt of maximal 20°. Eight different levels allow an assessment of different grades of platform instability. In this study, the most stable level 8 and the more unstable level 2 were chosen, measuring three trials over a period of 20 s, which is in accordance with previous studies (Aydoğ, Bal, Aydoğ, & Çakci, 2006; Rein, Fabian, Weindel, Schneiders, & Zwipp, 2011a; Rein, Fabian, Zwipp, Mittag-Bonsch, & Weindel, 2010; Rein, Fabian, Zwipp, Rammelt, & Weindel, 2011b; Testerman & van der Griend,
833
1999). The order of testing was randomised. Participants were tested barefoot with eyes open in a quiet room to avoid auditory influences. Participants stepped on the platform with one foot, slightly flexed in the knees (15°), looking straight ahead to the screen with their arms in a neutral position. Coordinates of the foot position were marked to ensure the same conditions for all participants. Before each new position, the athletes underwent a practice trial to reduce learning effects. The overall stability index, which indicates the variance of foot-platform displacement in degrees from a level position in all motions during the test, the anterior/posterior and the medial/lateral stability scores, representing the variance of foot-platform displacement in degrees for motions in the sagittal and frontal plane, were determined (Arnold & Schmitz, 1998; Rein et al., 2011b). The variance from the neutral position over time expresses the ability of the athletes to control the angle on the tilted platform. A high score indicates poor balance ability, whereas a score of “0 degrees” implies a maximum of postural control. Mean scores of the three trials were calculated for each level and foot. Kistler force platform The Kistler force platform (Kistler Instrumente GmbH, Ostfildern, Germany) was used to assess the static balance ability through the registration of the centre of pressure (D’Hondt et al., 2011; Verhagen et al., 2005). The platform was 35 mm thick with a mass of 18 kg. The minimum body weight required to start the software analysis was 35 kg. Single-leg stance on the right and left leg was performed randomly, barefoot and with eyes open over 20 s with 10 s rest. The participant stood with the tested foot on the platform, maintaining a slight flexion of the knee. The contralateral knee was held in a relaxed 90° flexion. The head was held in a neutral position, and the hands were close to the trunk. The setting took place in a quiet room to reduce auditory influence. The software analysed the centre of pressure of the mediolateral and anteroposterior direction of the foot movement. The mean distance of movement shift was measured over 15 s. A high score indicated poor static balance control. Three trials were recorded for the right and the left foot, followed by the calculation of the mean score. Proprioceptive training The training programme of 15 min took place 5 times per week. Six exercises were done in a circle training of 45 s of practice time and a resting interval of 30 s (Eils, 2003; Eils & Rosenbaum, 2001; Wester, Jespersen,
834
T. Winter et al.
Nielsen, & Neumann, 1996). The exercise programme was done twice to train both feet equally. Strengthening exercises with 45-cm clubs (SportTec Physio & Fitness, Pirmasens, Germany) and the Airex® Balanceboard (Gaugler & Lutz oHG, AalenEbnat, Germany) were performed to secure balance in extreme positions. Kinaesthesia was promoted by using an angle board and a joint position exercise. A wobble board (Jakobs GmbH, Nörvenich, Germany) and the Pedalo® round woods (Holz-Hoerz GmbH, Münsingen, Germany) were used to improve balance by different daily exercises. Exercises varied daily or weekly because different stimuli are required to prevent ankle injuries effectively.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Statistical analysis Three different measurements were analysed separately for the intervention and the control group. The parameters of all three test measurements were compared to each other, respectively. Mean values with standard deviation were selected for descriptive statistics. The Kolmogorov–Smirnov test was used to investigate data distribution. The Kruskal–Wallis test was applied for statistical analysis, which was followed by the Mann–Whitney test with post hoc Bonferroni adjustment. The final level of significance was P = 0.017, because of the three possible tests between the three measurements. Additionally, the difference of the medians was given including their 95% confidence interval (CI).
Results Clinical history and investigations Results of the demographic and anthropometric variables of all speed skaters are reported in Table I. No participant stated a polyneuropathy in the questionnaire. One athlete stated an attention-deficit
Table I. Anthropometric data are shown for the intervention and the control group. Anthropometric data
Intervention
Participants (n) Female (n) Male (n) Age (years) Height (m) Weight (kg) BMI (kg · m−2) Age of training (years) Training sessions/week (n) Frequency distribution Dominant leg right (n) Dominant leg left (n) Ankle sprains (n) Regularly twisting (n) Twisting (frequency/week) Orthopaedic diseases (n) Neurological diseases (n) General diseases (n) Medication
14 6 8 12.6 160.9 49.6 18.9 4 5.2
± ± ± ± ± ±
1.5 13 10 1,3 2.3 1.6
8 6 1 4 0.8 ± 1.5 2 0 2 2
Control 14 5 9 12.9 160.1 46.6 18 6.9 4.6
± ± ± ± ± ±
1.7 10.7 9.2 1.9 2.9 1.2
11 3 3 3 0.6 ± 1.5 2 1 1 1
hyperactivity disorder, which was reported as a “neurological disease”. The only orthopaedic disease that appeared was a mild juvenile idiopathic scoliosis. Regular medication did not alter proprioception and only consisted of salbutamol for asthmatics. Regular twisting included participants who indicated a subjective feeling of “giving away” of the ankle joint without any swelling or tender to palpation of the ankle joint region nor positive anterior drawer test and also nor positive talar tilt test. Tuning fork tests showed no abnormality in all participants. The Romberg test was also negative in all athletes. No pathological condition was found during the foot inspection. Neither local swelling nor tenderness was palpable during the clinical investigation. The results of active range of motion are shown in Figure 2.
Figure 2. Active range of motion of the ankle sprain is shown for the intervention and the control group prior to the proprioceptive training sessions.
Influence of a proprioceptive training Kinaesthesia
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Comparing to the first measurement (mean value = 1.39, s = 0.78°), kinaesthesia improved significantly (P = 0.001, median 0.53°, CI 0.23 to 1.03°) for plantarflexion of the right foot after 12 weeks of training (mean value = 0.69, s = 0.52°) in the intervention group, but not after 6 weeks (Figure 3). Plantarflexion of the left foot as well as dorsiflexion, pronation and supination did not show any significant differences based on the first measurement among the intervention and the control group (Figure 4). Furthermore all movements, starting at the extreme position, were not influenced by proprioceptive training.
Biodex Stability System Dynamic balance control showed no significant differences for each single-leg stance at the stable level 8 among all groups, neither when comparing it with the first to the second and to the third measurement nor when comparing it with the second to the third investigation for the overall stability index, the anterior/posterior and the medial/lateral scores.
835
The intervention group achieved significantly better results for the overall stability index, the anterior/ posterior and the medial/lateral scores at the unstable level 2 after 12 weeks of proprioceptive training compared to the baseline measurement for right (overall stability index: first measurement mean value = 3.4, s = 1.7°; third measurement mean value = 1.7, s = 0.7°; P = 0.001, median 1.37°, CI 0.53 to 2.10°; medial/lateral score: first measurement mean value = 1.9, s = 0.9°; third measurement mean value = 1.2, s = 0.4°; P = 0.012; median 0.57°; CI 0.10 to 1.20°; anterior/posterior score: first measurement mean value = 2.9, s = 1.7°; third measurement mean value = 1.5, s = 0.7°; P = 0.005, median 1.00°, CI 0.33 to 1.73°) and left single-leg stance (overall stability index: first measurement mean value = 3.2, s = 1.7°; third measurement mean value = 1.8, s = 0,7°; P = 0.006, median 0.97°, CI 0.33 to 1.73°; medial/lateral score: first measurement mean value = 1.9, s = 1.5°; third measurement mean value = 1.1, s = 0.4°; P = 0.014, median 0.47°, CI 0.10 to 0.90°; anterior/posterior score: first measurement mean value = 2.5, s = 1.2°; third measurement mean value = 1.5, s = 0.6°; P = 0.006, median 0.72°; CI 0.23 to 1.03°) (Figures 5 and 6).
Figure 3. The kinaesthesia results of the right foot are shown as mean with standard deviation. Only plantarflexion improved significantly (*) in the intervention group (P = 0.001) after 12 weeks of training. Note: 1 = intervention group; 2 = control group.
Figure 4. Means with standard deviation of left-foot kinaesthesia are presented. No significant differences between all three measurements and all foot positions have been seen. Note: 1 = intervention group; 2 = control group.
836
T. Winter et al.
Figure 5. Results of the Biodex Stability System are shown as means with standard deviation for the right single-leg stance at the unstable level 2 for the OSI, ML and AP scores. The intervention group improved significantly (*) after 12 weeks of proprioceptive training for the OSI (P = 0.001), ML (P = 0.014) and AP (P = 0.006) scores.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Note: 1 = intervention group; 2 = control group; OSI = overall stability index; ML = medial/lateral score; AP = anterior/posterior score.
Figure 6. Means with standard deviation for the OSI, ML and AP scores of the Biodex Stability System for the left single-leg stance at the unstable level 2 are demonstrated. The third measurement showed significant improvement of the intervention group for the OSI (P = 0.007), ML (P = 0.015) and AP (P = 0.007) score. Note: 1 = intervention group; 2 = control group; OSI = overall stability index; ML = medial/lateral score; AP = anterior/posterior score.
Kistler force platform Four athletes had to be excluded due to low body weight. The Kistler force platform starts analysing postural control at a weight of 35 kg. Twelve participants for the intervention group and twelve
for the control group finally took part. Static balance assessment did not improve for the right and left single-leg stance after 6 or 12 weeks of training in the intervention and the control group (Figure 7).
Figure 7. Results of the Kistler force platform are shown for the right and the left foot as means with standard deviation. No significant changes were remarked either after 6 or after 12 weeks of proprioceptive training. Note: 1 = intervention group; 2 = control group.
Influence of a proprioceptive training Discussion
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Kinaesthesia The intervention group showed a significant improved kinaesthesia of their right foot’s plantarflexion after 12 weeks of proprioceptive training. No significant differences have been revealed for any other tested movement direction. Speed skaters practice to suppress the plantarflexion in order to reduce friction and to achieve a better gliding phase (de Koning, Thomas, Berger, de Groot, & van Ingen Schenau, 1995). Due to proprioceptive training, the perception of plantarflexion was trained explicitly. Moreover, the right leg performs the major work during the push-off in the curve (van Ingen Schenau et al., 1985). This pronounced role of the right leg might be an explication for improved kinaesthesia in plantarflexion. However, there were no kinaesthetic changes in the supination of the left foot as well as in the pronation of the right foot. This is probably caused by the supination position of the left foot and pronation position of the right foot during skating into the curve (van Ingen Schenau et al., 1985). The young speed skaters in this study represented a healthy study population with a high basic level of motion perception. Therefore, the capacities for improving were limited (Cox, Lephart, & Irrgang, 1993). Surprisingly, movement perception did not improve in motions starting in the extreme position neither after 6 nor after 12 weeks of training. It seems to be that Golgi-like endings, which are activated in extreme position providing information about joint position and movement direction, were not stimulated through proprioceptive training due to the insufficient maximal movement positions (Grigg & Hoffman, 1982; Grigg & Hoffmann, 1993; Newton, 1982; Skoglund, 1956). In order to achieve a standardised examination, it was decided to choose a starting position of 15° in relation to the neutral position for each direction of movement. Out of this limitation not every speed skater reached his individual ending position. There is a probability that Golgi-like endings were not involved in the perception of kinaesthesia. Refshauge, Kilbreath, and Raymond (2000) instructed their participants to signalise a movement perception just when they were sure about the direction of movement. In the present study, the athletes had to press a button when feeling a movement but they did not have to differentiate the direction of movement. Each direction of movement, which was investigated, was known in advance. The time between the three single trials was chosen randomly. However, athletes sometimes anticipated the next movement. Therefore, some of them pressed the button before perceiving a movement, which only
837
could be analysed after the measurement. This limitation has been noted by other researchers as well (Refshauge et al., 2000). Moreover, it is essential to support the awareness of young athletes, that a proprioceptive training, performed additionally to their regular trainings protocol, reduces the risk of injuries. Preventive training achieves the best results in motivated athletes (Myklebust et al., 2003). Children and young adolescents between 10 and 19 years have a high incidence of ankle sprains (Waterman, 2010). Professional athletes spend up to 20 h per week performing their sport activities and competitions (Caine, Maffulli, & Caine, 2008). The burst of growth in this age is combined with physiologically reduced ligament strength causing a higher risk for injuries. Moreover, the bone mineralisation is delayed compared to the bone growth. Hence, the bones are more porous and vulnerable to injuries (Caine et al., 2008). But also overstraining due to extensive training sessions is a possible reason for sport injuries in youth age (Caine et al., 2008). Additionally, unconscious neuromuscular activation of dynamic mechanism to regain joint stability depends on previous experiences with the disturbing stimulus. In order to have an adequate reaction to balance interferences, athletes need a wide range of prior experiences (Riemann & Lephart, 2002a; Taube, Gruber, & Gollhofer, 2008), which obviously young athletes have less of than adults.
Biodex Stability System No significant differences were observed after 6 or 12 weeks of training for each single-leg stance at the stable level 8 in both groups. A low level of difficulty is not challenging enough for athletes with a high acquirement of movements pattern (Hinman, 2000; Perron, Hebert, McFadyen, Belzile, & Regnieare, 2007; Rein et al., 2011a, 2011b). More unstable levels are necessary to achieve significant improvement results (Rahnama, Salavati, Akhbari, & Mazaheri, 2010; Rein et al., 2011a). In the present study, the intervention group showed significant improvement in all tested dynamic balance scores after 12 weeks of proprioceptive training at the unstable level 2. This is in accordance with former studies (Dohm-Acker, Spitzenpfeil, & Hartmann, 2008; Emery, Rose, McAllister, & Meeuwisse, 2007; Franco, MartínezLópez, Lomas-Vega, Contreras, & Amat, 2012; Gioftsidou et al., 2006; Rein et al., 2011a, 2011b; Stasinopoulos, 2004; Wester et al., 1996). No significant differences based on the first measurement were found after 6 weeks. A cumulative effect for balance training is shown, indicating that a longer
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
838
T. Winter et al.
training period leads to a greater preventive effect (McKeon & Hertel, 2008). On the other hand, some studies state a period of 6 weeks equally effective to improve proprioception (Bernier & Perrin, 1998; Eils & Rosenbaum, 2001; Emery, Cassidy, Klassen, Rosychuk, & Rowe, 2005; Hupperets, Verhagen, & van Mechelen, 2009; McKeon & Hertel, 2008; Paterno et al., 2004; Schmidt et al., 2005). The present study demonstrates that 12 weeks of proprioceptive training is required to improve dynamic balance control, due to changes in the neuromuscular control (Eils et al., 2010). Previous experiences influence the compensatory response. Balance training reduces the excitation of spinal reflexes through an elevation of supraspinal-induced presynaptic inhibition (Taube et al., 2008). Subcortical structures have thereby a more important role than the motor cortex to maintain and to control balance. Synaptic efficiency for direct corticospinal projection on the muscles that are surrounding the ankle is improved and is used for voluntary muscle contraction (Taube et al., 2008). Different types of exercises are challenging for the individual and are required to prevent ankle injuries efficiently. Additionally, the previous general training protocol could be used for older athletes as well as for other competitive sports. The more intense athletes are practicing their sport, the more important the role of proprioception gets in order to reduce injuries. Moreover, it was shown that a high level of stability is associated with skating speed in young ice hockey players (Behm, Wahl, Button, Power, & Anderson, 2005).
Static balance tests are easy to perform and useful for clinical integration to evaluate proprioception (Arnold et al., 2009). Nevertheless, it is not a challenge for competitive speed skaters and therefore considered as an inappropriate assessment (Hinman, 2000; McKeon & Hertel, 2008; Perron et al., 2007). Dynamic balance tests are more adequate for the finely graduated ability of postural control in athletes. One limitation is the duration of single-leg stance; 20 s might not be sufficient enough in competitive sports. Cox et al. (1993) have already noticed that an interval of 10 s is not enough for single-leg stance to record differences in a healthy population. The test duration was chosen to achieve equal measurement conditions between static and dynamic balance assessment in the present study. Conclusion Proprioceptive training performed 5 times per week for 15 min improves functional ankle stability after 12 but not after 6 weeks in speed skaters. Aspects of proprioception are influenced differently. Kinaesthesia improved only in the right feet for plantarflexion due to the technical specifics of speed skating. The intervention group achieved significant better results in all tested scores for dynamic balance, but there was no improvement in static singleleg stance. Regular proprioceptive training is recommended for speed skaters to achieve better functional ankle stability. Acknowledgement
Kistler force platform No significant improvement in static balance was achieved either after 6 or after 12 weeks. These results are in accordance with previous studies (Cox et al., 1993; van der Wees et al., 2006; Verhagen et al., 2005). In contrast, other studies have shown significant differences in postural stability after proprioceptive training (Eils et al., 2010; Hoffman & Payne, 1995). These differences might be explained by a different choice of exercises. Hoffman and Payne (1995) explicitly exercised the single-leg stance on the dominant leg with a biomechanical ankle platform system. On the other hand, in the present study, 6 different exercises were used to improve the conscious and the unconscious aspects of proprioception. Interestingly, a recent study has shown that left static balance proficiency correlated with higher cerebellar volume of the vermian lobule VI-VII in female short tracker (Park, Yoon, Kim, & Rhyu, 2013).
The authors thank the following individuals for their contributions to this article: Ursula Range for statistical support, Thomas Albrecht for photographical work as well as Diana Scheibe and Heike Reinwarth for logistic support. Disclosure statement The authors declare that they have no competing interests. The authors disclose any financial conflicts of interest that may influence interpretation of this study and/or results. References Arnold, B. L., Linens, S., de la Motte, S., & Ross, S. (2009). Concentric evertor strength differences and functional ankle instability: A meta-analysis. Journal of Athletic Training, 44(6), 653–662. Arnold, B. L., & Schmitz, R. J. (1998). Examination of balance measures produced by the Biodex Stability System. Journal of Athletic Training, 33(4), 323–327.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
Influence of a proprioceptive training Aydoğ, E., Bal, A., Aydoğ, S., & Çakci, A. (2006). Evaluation of dynamic postural balance using the Biodex Stability System in rheumatoid arthritis patients. Clinical Rheumatology, 25(4), 462–467. Behm, D. G., Wahl, M. J., Button, D. C., Power, K. E., & Anderson, K. G. (2005). Relationship between hockey skating speed and selected performance measures. Journal of Strength and Conditioning Research, 19(2), 326–331. Bernier, J., & Perrin, D. (1998). Effect of coordination training on proprioception of the functionally unstable ankle. Journal of Orthopaedic and Sports Physical Therapy, 27(4), 264–275. Caine, D., Maffulli, N., & Caine, C. (2008). Epidemiology of injury in child and adolescent sports: Injury rates, risk factors, and prevention. Clinics in Sports Medicine, 27, 19–50. Cordo, P., Gurfinkel, V., Brumagne, S., & Flores-Vieira, C. (2005). Effect of slow, small movement on the vibrationevoked kinesthetic illusion. Experimental Brain Research, 167, 324–334. Cox, E., Lephart, S., & Irrgang, J. (1993). Unilateral training of non-injured individuals and the effect on postural sway. Journal of Sport Rehabilitation, 2, 87–96. D’Hondt, E., Deforche, B., de Bourdeaudhuij, I., Gentier, I., Tanghe, A., Shultz, S., & Lenoir, M. (2011). Postural balance under normal and altered sensory conditions in normal-weight and overweight children. Clinical Biomechanics, 26(1), 84–89. de Koning, J., Thomas, R., Berger, M., de Groot, G., & van Ingen Schenau, G. (1995). The start in speed skating: From running to gliding. Medicine and Science in Sports and Exercise, 27(12), 1703–1708. Dohm-Acker, M., Spitzenpfeil, P., & Hartmann, U. (2008). Auswirkung propriozeptiver Trainingsgeräte auf beteiligte Muskulatur im Einbeinstand [Effect of proprioceptive trainings tools for the muscles in stance stability]. Sportverletzung Sportschaden, 22(1), 52–57. Eils, E. (2003). The role of proprioception in the primary prevention of ankle sprains in athletes: A review. International Journal of Sports Medicine, 4(5), 1–9. Eils, E., & Rosenbaum, D. (2001). A multi-station proprioceptive exercise program in patients with ankle instability. Medicine and Science in Sports and Exercise, 33(12), 1991–1998. Eils, E., Schröter, R., Schröder, M., Gerss, J., & Rosenbaum, D. (2010). Multistation proprioceptive exercise program prevents ankle injuries in basketball. Medicine and Science in Sports and Exercise, 42(11), 2098–2105. Emery, C., Rose, M., McAllister, J., & Meeuwisse, W. (2007). A prevention strategy to reduce the incidence of injury in high school basketball: A cluster randomized controlled trial. Clinical Journal of Sport Medicine, 172(6), 749–754. Emery, C. A., Cassidy, J. D., Klassen, T. P., Rosychuk, R. J., & Rowe, B. H. (2005). Effectiveness of a home-based balance-training program in reducing sports-related injuries among healthy adolescents: A cluster randomized controlled trial. Canadian Medical Association Journal, 172(6), 749–754. Fong, D. T.-P., Hong, Y., Chan, L.-K., Yung, P. S.-H., & Chan, K.-M. (2007). A systematic review on ankle injury and ankle sprain in sports. Sports Medicine, 37(1), 73–94. Franco, N., Martínez-López, E., Lomas-Vega, R., Contreras, F., & Amat, A. (2012). Effects of proprioceptive training program on core stability and center of gravity control in sprinters. Journal of Strength and Conditioning Research, 26, 2071–2077. Gioftsidou, A., Malliou, P., Pafis, G., Beneka, A., Godolias, G., & Maganaris, C. (2006). The effects of soccer training and timing of balance training on balance ability. European Journal of Applied Physiology, 96(6), 659–664. Glencross, D., & Thornton, E. (1981). Position sense following joint injury. Journal of Sports Medicine and Physical Fitness, 21 (1), 23–27.
839
Grigg, P., & Hoffman, A. H. (1982). Properties of Ruffini afferents revealed by stress analysis of isolated sections of cat knee capsule. Journal of Neurophysiology, 47(1), 41–54. Grigg, P., & Hoffmann, A. H. (1993). Loading and deformation of the cat posterior knee joint capsule in axial and extension rotations. Journal of Biomechanics, 26(11), 1283–1290. Hagert, E. (2010). Proprioception of the wrist joint: A review of current concepts and possible implications on the rehabilitation of the wrist. Journal of Hand Therapy, 23, 2–17. Haguenauer, M., Legreneur, P., & Monteil, K. M. (2006). Influence of figure skating skates on vertical jumping performance. Journal of Biomechanics, 39(4), 699–707. Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability. Journal of Athletic Training, 37, 364–375. Hinman, M. (2000). Factors affecting reliability of the Biodex Balance System: A summary of four studies. Journal of Sport Rehabilitation, 9, 240–252. Hoffman, M., & Payne, V. (1995). The effects of proprioceptive ankle disk training on healthy subjects. Journal of Orthopaedic and Sports Physical Therapy, 21(2), 90–93. Horak, F. B. (1987). Clinical measurement of postural control in adults. Physical Therapy, 67(12), 1881–1885. Hupperets, M. D. W., Verhagen, E. A. L. M., & van Mechelen, W. (2009). Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: Randomised controlled trial. British Journal of Sports Medicine, 339, 1–6. Jerosch, J. (1999). Propriozeption – was ist das? [Proprioception – what it is?]. Orthopädieschuhtechnik, 2, 12–22. Karlsson, J., & Andreasson, G. O. (1992). The effect of external ankle support in chronic lateral ankle joint instability: An electromyographic study. The American Journal of Sports Medicine, 20(3), 257–261. Konradsen, L., & Bohsen Ravn, J. (1991). Prolonged peroneal reaction time in ankle instability. International Journal of Sports Medicine, 12(3), 290–292. Lephart, S., Pincivero, D., Giraido, J., & Fu, F. (1997). The role of proprioception in the management and rehabilitation of athletic injuries. The American Journal of Sports Medicine, 25, 130–137. Martina, I., van Koningsveld, R., Schmitz, P., van der Meche, F., & van Doorn, P. (1998). Measuring vibration threshold with a graduated tuning fork in normal aging in patients with polyneuropathy. Journal of Neurology, Neurosurgery, and Psychiatry, 65(5), 743–747. McKeon, P. O., & Hertel, J. (2008). Systematic review of postural control and lateral ankle instability, part II: Is balance training clinically effective? Journal of Athletic Training, 43(3), 305–315. Munn, J., Sullivan, S. J., & Schneiders, A. G. (2010). Evidence of sensorimotor deficits in functional ankle instability: A systematic review with meta-analysis. Journal of Science and Medicine in Sport, 13, 2–12. Myklebust, G., Engebretsen, L., Braekken, I. H., Skjølberg, A., Olsen, O.-E., & Bahr, R. (2003). Prevention of anterior cruciate ligament injuries in female team handball players: A prospective intervention study over three seasons. Clinical Journal of Sport Medicine, 13, 71–78. Newton, R. (1982). Joint receptors contributions to reflexive and kinesthetic responses. Physical Therapy, 62(1), 22–29. Park, I. S., Yoon, J. H., Kim, N., & Rhyu, I. J. (2013). Regional cerebellar volume reflects static balance in elite female shorttrack speed skaters. International Journal of Sports Medicine, 35, 465–470. Paterno, M., Myer, G., Ford, K., & Hewett, T. (2004). Neuromuscular training improves single-limb stability in young female athletes. Journal of Orthopaedic and Sports Physical Therapy, 34, 305–316.
Downloaded by [Heriot-Watt University] at 23:17 07 March 2015
840
T. Winter et al.
Perron, M., Hebert, L., McFadyen, B., Belzile, S., & Regnieare, M. (2007). The ability of the Biodex Stability System to distinguish level of function in subjects with a second degree ankle sprain. Clinical Rehabilitation, 21, 73–81. Rahnama, L., Salavati, M., Akhbari, B., & Mazaheri, M. (2010). Attentional demands and postural control in athletes with and without functional ankle instability. Journal of Orthopaedic and Sports Physical Therapy, 40(3), 180–187. Refshauge, K. M., Kilbreath, S. L., & Raymond, J. (2000). The effect of recurrent ankle inversion sprain and taping on proprioception at the ankle. Medicine and Science in Sports and Exercise, 32(1), 10–15. Rein, S., Fabian, T., Weindel, S., Schneiders, W., & Zwipp, H. (2011a). The influence of playing level on functional ankle stability in soccer players. Archives of Orthopaedic and Trauma Surgery, 131(8), 1043–1052. Rein, S., Fabian, T., Zwipp, H., Mittag-Bonsch, M., & Weindel, S. (2010). Influence of age, body mass index and leg dominance on functional ankle stability. Foot & Ankle International, 31, 423–432. Rein, S., Fabian, T., Zwipp, H., Rammelt, S., & Weindel, S. (2011b). Postural control and functional ankle stability in professional and amateur dancers. Clinical Neurophysiology, 122(8), 1602–1610. Rein, S., Hagert, E., Hanisch, U., Lwowski, S., Fieguth, A., & Zwipp, H. (2013). Immunohistochemical analysis of sensory nerve endings in ankle ligaments: A cadaver study. Cells Tissues Organs, 197, 64–76. Richie, D. H. (2001). Functional instability of the ankle and the role of neuromuscular control: A comprehensive review. The Journal of Foot and Ankle Surgery, 40(4), 240–251. Riemann, B. L., & Lephart, S. M. (2002a). The sensorimotor system, part II : The role of proprioception in motor control and functional joint stability. Journal of Athletic Training, 37(1), 80–84. Riemann, B. L., & Lephart, S. M. (2002b). The sensorimotor system, part I : The physiologic basis of functional joint stability. Journal of Athletic Training, 37(1), 71–79. Riemann, B. L., Myers, J. B., & Lephart, S. M. (2002). Sensorimotor system measurement techniques. Journal of Athletic Training, 37(1), 85–98. Rothenberger, L. A., Chang, J. I., & Cable, T. A. (1988). Prevalence and types of injuries in aerobic dancers. The American Journal of Sports Medicine, 16, 403–407.
Schmidt, R., Benesch, S., Bender, A., Claes, L., & Gerngross, H. (2005). Die Trainierbarkeit vom propriozeptiven und koordinativen Parametern bei der chronisch-funktionellen Sprunggelenkinstabilität [The potential for training of proprioceptive and coordinative parameters in patients with chronic ankle instability]. Zeitschrift Für Orthopädie Und Ihre Grenzgebiete, 143(2), 227–232. Skoglund, S. (1956). Anatomical and physiological studies of knee joint innervation in the cat. Acta Physiologica Scandinavica, 36, 1–101. Stasinopoulos, D. (2004). Comparison of three preventive methods in order to reduce the incidence of ankle inversion sprains among female volleyball players. British Journal of Sports Medicine, 38(2), 182–185. Taube, W., Gruber, M., & Gollhofer, A. (2008). Spinal and supraspinal adaptations associated with balance training and their functional relevance. Acta Physiologica, 193(2), 101–116. Testerman, C., & van der Griend, R. (1999). Evaluation of ankle instability using the Biodex Stability System. Foot & Ankle International, 20, 317–321. Tropp, H., Askling, C., & Gillquist, J. A. N. (1985). Prevention of ankle sprains. The American Journal of Sports Medicine, 13(4), 259–262. van der Wees, P. J., Lenssen, A. F., Hendriks, E. J. M., Stomp, D. J., Dekker, J., & de Bie, R. A. (2006). Effectiveness of exercise therapy and manual mobilisation in acute ankle sprain and functional instability: A systematic review. Australian Journal of Physiotherapy, 52(1), 27–37. van Ingen Schenau, G. J., de Groot, G., & de Boer, R. (1985). The control of speed in elite female speed skaters. Journal of Biomechanics, 18(2), 91–96. Verhagen, E., Bobbert, M., Inklaar, M., van Kalken, M., van der Beek, A., Bouter, L., & van Mechelen, W. (2005). The effect of a balance training programme on centre of pressure excursion in one-leg stance. Clinical Biomechanics, 20(10), 1094–1100. Waterman, B. (2010). The epidemiology of ankle sprains in the United States. The Journal of Bone and Joint Surgery (American), 92, 2279–2284. Wester, J., Jespersen, S., Nielsen, K., & Neumann, L. (1996). Wobble board training after partial sprains of the lateral ligaments of the ankle: A prospective randomized study. Journal of Orthopaedic and Sports Physical Therapy, 23(5), 332–336.
