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Effects of two proprioceptive training programs on joint position sense,

strength, activation and recurrent injuries after ankle sprains

Article  in  Isokinetics and exercise science · December 2017

DOI: 10.3233/IES-171146

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Galley Proof 13/10/2017; 10:02 File: ies–1-ies171146.tex; BOKCTP/xjm p. 1

Isokinetics and Exercise Science -1 (2017) 1–12 1

DOI 10.3233/IES-171146
IOS Press

Effects of two proprioceptive training

programs on joint position sense, strength,
activation and recurrent injuries after ankle
sprains
Lazaros Lazaroua,∗ , Nikolaos Kofotolisa , Paraskevi Mallioub and Eleftherios Kellisa
a
Laboratory of Neuromechanics, Department of Physical Education and Sport Sciences at Serres, Aristotle
University of Thessaloniki, Greece
b
Laboratory of Therapeutic Exercise and Rehabilitation, Department of Physical Education and Sport Sciences,
Democritus University of Thrace, Komotini, Greece

Received 15 May 2017

Accepted 18 September 2017

Abstract.
BACKGROUND: After ankle sprains, therapists may use proprioceptive training programs to manage residual symptoms and
reduce the risk for recurrent injuries. However, evidence on program effectiveness is limited.
OBJECTIVE: To investigate effectiveness of balance and proprioceptive neuromuscular facilitation (PNF) programs in individ-
uals with sprain.
METHODS: Participants were recruited from a rehabilitation center and were randomly allocated to a balance or PNF group.
Both groups received 10 training sessions, within a six-week period. Ankle position sense, isokinetic strength and EMG activity
were assessed by a blinded investigator at baseline, at the end of training and eight weeks after training. Recurrent injuries were
recorded 12 months after training.
RESULTS: Twenty participants provided follow-up data. Eight weeks after training, significant (p < 0.017) gains were found
in most strength measures for both groups, apart from dorsiflexion strength (p > 0.05). For the balance group, there were no
recurrent injuries and for the PNF group the recurrent injury rate was 20%. Eight weeks after training, the balance group sig-
nificantly (p < 0.017) improved plantar flexion position sense and EMG activity of peroneus longus muscle and the PNF group
significantly (p < 0.017) improved EMG activity of tibialis anterior muscle.
CONCLUSIONS: For individuals with sprain, balance and PNF programs are recommended for ankle strengthening. They may
also be effective in reducing the risk for recurrent injuries.

Keywords: Ankle sprain, balance training, PNF training, joint position sense, isokinetic strength, electromyography, recurrent
injury

1. Introduction 1

Ankle sprains are very common musculoskeletal in- 2

∗ Corresponding author: Lazaros Lazarou, Laboratory of Neu- juries, and approximately 85% of these injuries are 3
romechanics, Department of Physical Education and Sport Sciences
at Serres, Aristotle University of Thessaloniki, 62110, Greece. Tel.: related to the weaker lateral ligaments [1]. After the 4

+30 6947 560795; E-mail: lazaroslazarou@phed-sr.auth.gr. sprain, most individuals prefer to use a conventional 5

ISSN 0959-3020/17/$35.00
c 2017 – IOS Press and the authors. All rights reserved
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2 L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains

6 treatment approach [2], comprising early ankle mo- bias [3]. Clinical guidelines also highlight the need for 57

7 bilization and weight-bearing, often combined with further research into the effects of different propriocep- 58

8 use of external support, such as tape, brace or ban- tive training programs in individuals with sprain [3]. 59

9 dage. With the exception of complete ligament tears For individuals with sprain, research findings indi- 60
10 (grade 3), typical prognosis of the conventional treat- cate that participation in balance and running activi- 61
11 ment is a rapid decrease in disablement within two ties, twice a week, was not able to improve joint inver- 62
12 weeks [2]. However, residual symptoms are often ap- sion sense and strength of the injured ankle [9]. It is of 63
13 parent and a high percentage of individuals with con-
note that, for ankle strengthening after the sprain most 64
14 ventionally treated sprain still experience pain in the
investigators have applied protocols of strength and 65
15 performance of functional and sports activities one
functional training, which included eccentric and resis- 66
16 year post-injury [2]. It has also been reported that these
17 individuals are predisposed to an increased risk for re- tive exercises [10,11] and sport-related activities [12], 67

18 current injuries and chronic ankle instability [3]. rather than protocols of proprioceptive training [9]. For 68

19 Recurrent injuries and chronic ankle instability are sprains, eight weeks of ankle disk training also im- 69

20 likely to originate from a significant loss of proprio- proved the reaction time of the tibialis anterior muscle 70

21 ceptive input from mechanoreceptors [4]. Propriocep- during sudden simulated inversion perturbations [13]. 71

22 tion is a neuromuscular process, including afferent and In addition, most research evidence confirms that bal- 72

23 efferent signals in order to maintain proper position- ance training, with the use of activities on ankle disk 73

24 ing of the foot during gait and provide orientation for or wobble board, may be effective in reducing future 74

25 performance of functional activities [5]. Investigators ankle injuries [14–16]. 75

26 commonly assess proprioception with the use of joint In clinical practice, therapists use proprioceptive 76
27 position sense, and individuals with sprain often ex- neuromuscular facilitation (PNF) training programs in 77
28 hibit deficits in the position sense of the injured an- order to enhance proprioceptors and promote response 78
29 kle [6]. Moreover, strength of the muscles around the of neuromuscular mechanisms [17]. The PNF pat- 79
30 ankle, especially the ankle evertors, is often decreased
terns usually have diagonal direction and aim to stim- 80
31 after the sprain [6]. Therapists should assess and ad-
ulate the performance of functional movements, us- 81
32 dress ankle strength in clinical practice, as potential
33 deficits are related to increased risk for recurrent in- ing strengthening (facilitation) and relaxation (inhibi- 82

34 juries and chronic ankle instability [4]. In addition, for tion) of muscle groups [17]. In PNF literature, pro- 83

35 individuals with sprain, electromyographic (EMG) ac- grams of PNF training are often used for the rehabili- 84

36 tivities of peroneus longus and tibialis anterior mus- tation of a number of chronic musculoskeletal injuries, 85

37 cles are important for maintaining dynamic stability of including ankle instability [18], low back pain [19] 86

38 the foot [7] and after the sprain they need to sustain and patellofemoral pain syndrome [20], with goals to 87

39 within normal range. There are suggestions, and thera- improve strength [18,19] and EMG activity of mus- 88

40 pists also need to consider that individuals with chronic cles [20]. To our knowledge, there are no studies in- 89

41 ankle instability often exhibit deficits in EMG activity vestigating the effectiveness of PNF training on ankle 90

42 of these two muscles [8]. sprains. Taking into consideration that PNF techniques 91
43 For sprains, it seems that the individuals who exhibit have also been used to improve joint position sense 92
44 significant deficits in joint position sense, strength and in healthy individuals [21], we hypothesized that PNF 93
45 EMG activity of the injured ankle are in increased risk training may improve ankle position sense, strength 94
46 for sustaining recurrent injuries or developing chronic
and EMG activity in ankle sprains. For individuals with 95
47 ankle instability [4,8]. In this context, clinical guide-
sprain, balance training can be used prophylactically 96
48 lines recommend participation in proprioceptive train-
in an effort to reduce future ankle injuries [14–16]. It 97
49 ing programs after the sprain, which include balance
50 activities and techniques promoting functional move- would be beneficial to elucidate for the first time com- 98

51 ments, to improve ankle strength and coordination [3]. parative effectiveness of PNF training on recurrent in- 99

52 Nevertheless, these recommendations are supported jury rate. The aims of this study were to investigate 100

53 by weak evidence, as the relevant studies are limited the effects of two supervised proprioceptive training 101

54 and they are characterized by methodological flaws, programs, balance and PNF, on ankle position sense, 102

55 such as poor description of cohort characteristics, in- strength, EMG activity and recurrent injury rate in in- 103

56 appropriate managing of missing data and assessment dividuals with post-acute ankle sprain. 104
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L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains 3

105 2. Methods participation. Prior to participation, verbal explana- 153

tions and written information sheets concerning the 154

106 Our study was undertaken in conformity with the study protocol were provided to all individuals, who 155

107 Code of Ethics of the World Medical Association then signed a consent form, approved by the university 156

108 (Declaration of Helsinki), printed in the British Medi- ethics committee. The principal investigator collected 157

109 cal Journal (18 July 1964). This was a randomized two- demographic and anthropometric data for each partic- 158

110 group, pre-post treatment design, with a blinded asses- ipant, and information concerning the sprain and level 159

111 sor. The study was prospectively registered at a clinical of sports activity were also recorded. 160

112 trial registry (ID: NCT01853462). Participants were allocated to one of the two groups 161

by a statistician, who was blinded to the aims of the 162

113 2.1. Participants study, using computer generated number lists. Strat- 163

ified randomization was implemented, ensuring that 164

114 Participants for the study were recruited from a re- the balance and PNF groups were balanced for gen- 165

115 habilitation centre, and a total of 34 individuals were der, sprain history to the injured ankle and sports ac- 166

116 initially invited to participate. These individuals exhib- tivity level. For sports activity, high level was defined 167

117 ited a post-acute ankle sprain (mean: 11 weeks since as participation in sports for more than 3 hours per 168

118 sprain) and they experienced pain in the performance week [22]. After initiation of the study, two female 169

119 of functional or sport activities. For inclusion, it was participants discontinued training, due to increased 170

120 required that the individuals had a clinical diagnosis of professional commitments (balance group) and non- 171

121 ankle sprain by an orthopedic specialist and they had related lower back injury (PNF group), and 20 partici- 172

122 not participated in any form of supervised training after pants completed the intervention. 173

123 the injury. The following exclusion criteria were also

124 defined: chronic ankle instability, grade 3 ankle sprain, 2.2. Testing procedures 174

125 medial or interosseous (syndesmotic) ligament ankle

126 sprain, concurrent fracture, history of nerve injury or An independent investigator, blinded to the group al- 175

127 ankle surgery to the lower limbs and further ankle in- location of participants, was responsible for the assess- 176

128 jury after the sprain. Individuals with any injuries that ment of outcomes. For ankle position sense, strength 177

129 impeded participation in the training sessions of the and EMG activity, each assessment session lasted be- 178

130 study were also excluded. tween 60 and 70 minutes. In order to minimize the ef- 179

131 The principal investigator initially screened the el- fects of fatigue on testing procedures, joint position 180

132 igibility criteria of our study, via an interview. All sense was assessed first and strength and EMG mea- 181

133 prospective participants were instructed to show for surements followed. A second day, the same investiga- 182

134 consideration all clinical documentation and diagnos- tor collected data concerning pain, ankle range of mo- 183

135 tic testing findings related to the ankle sprain in order tion (ROM), functional and balance performance, as 184

136 to confirm the grade and ligaments affected. Suitabil- part of an additional study performed by our research 185

137 ity for participation was confirmed by an orthopedic team [23]. Data were collected at baseline, at the end 186

138 specialist, who also obtained a medical history of the of training (follow-up 1) and eight weeks after training 187

139 sprain. Information concerning aetiology and mecha- (follow-up 2). For potential recurrent ankle injuries, 188

140 nism of injury, symptoms and conventional treatment data were collected 12 months after training. 189

141 of choice were recorded. In addition, the principal in-

142 vestigator performed a clinical examination of the in- 2.2.1. Joint position sense 190

143 jured ankle including palpation and assessment for the A Biodex System II Pro isokinetic dynamometer 191

144 presence of swelling, hemorrhaging, tenderness and (Biodex Medical; Shirley, NY) was used to assess ac- 192

145 ligament laxity. Range of motion and strength were tive joint position sense at the sprained ankle, for three 193

146 also assessed manually, compared to the uninjured an- test positions: 10◦ of dorsiflexion, 15◦ of plantar flex- 194

147 kle. During the screening procedure, the investigators ion and 30◦ of plantar flexion [24]. Measurements were 195

148 were blinded to the group allocation of participants recorded in degrees by the internal goniometer of the 196

149 and concealed allocation was attained. According to Biodex, and the investigator calculated degrees of er- 197

150 the inclusion and exclusion criteria of the study, 12 ror, representing foot’s deviation from the test position. 198

151 out of the 34 initially invited individuals with sprains For each test position, participants performed three 199

152 were excluded, and 22 individuals were eligible for measurements in random order, and the mean score 200
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4 L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains

201 was used for the analysis. During testing, participants plantar flexion to complete dorsiflexion and back to 251

202 were in sitting position blindfolded [24,25], so as to complete plantar flexion, and from complete inversion 252

203 prevent potential assessment bias. For the tested limb, to complete eversion and back to complete inversion. 253

204 a support pad was placed under the distal femur and Prior to testing, ROM limits were set for each partic- 254

205 the knee was at 30◦ of flexion, secured with a strap. ipant including all movements of the ankle. Gravity 255

206 The tested foot was in alignment with the axis of the torque was also recorded with ankle in neutral posi- 256

207 dynamometer, with the subtalar joint in neutral posi- tion and it was used to correct isokinetic ankle plan- 257

208 tion, and it was stabilized to the footplate with strap tarflexion/dorsiflexion torque. In addition, each partic- 258

209 to reduce cutaneous receptor input. Constraining straps ipant performed five submaximal cycles of practice at 259

210 were used for stabilization of trunk. During testing, test speed in order to familiarize with the procedure, 260

211 the arms and the non-tested limb of participants were and a 2 min rest period followed until the initiation of 261

212 placed in rest positions. testing [26]. For lateral ankle sprains, the test-retest re- 262

213 Initially, the instigator moved the foot through the liability of isokinetic testing has demonstrated intra- 263

214 complete non-painful plantar flexion and dorsiflexion class correlation coefficients between 0.89 and 0.92 for 264

215 ROM for each participant, and then to the test posi- eversion at 120◦ /s, and between 0.71 and 0.90 for in- 265

216 tion, where it was held for 15 sec [25]. Each partici- version at 30◦ /s [26]. 266

217 pant received instructions to concentrate to that posi-

218 tion and reproduce it in the assessment. The investiga- 2.2.3. Electromyographic activity 267

219 tor then moved the foot to the extreme opposite non- Surface EMG data were recorded for peroneus 268

220 painful ROM (i.e. to plantar flexion for the dorsiflexion longus and tibialis anterior muscles of the sprained an- 269

221 test position, and to dorsiflexion for plantar flexion test kle, during isokinetic testing at 30◦ /s and 120◦ /s ve- 270

222 positions). Participants were then requested to actively locities. Prior to testing, two pre-gelled Ag-agCL sur- 271

223 move the foot in order to reproduce the test position, face circular electrodes, with 10 mm in diameter, were 272

224 and push a stop button immediately when they thought placed 20 mm apart, parallel to the fibers of the tested 273

225 that the test position was matched. Prior to testing, par- muscles, in conformity with European recommenda- 274

226 ticipants were informed concerning the applied proto- tions for the surface EMG assessment of muscles [27]. 275

227 col and a practice session was performed, followed by For the peroneus longus muscle, the location was at 1/4 276

228 30 sec of rest [25]. on the line between the tips of the fibular head and lat- 277

eral malleolus and EMG recordings were analyzed for 278

229 2.2.2. Muscle strength eversion and plantar flexion testing. For the tibialis an- 279

230 The Biodex dynamometer was used for the isoki- terior muscle, the location was at 1/3 between the tip of 280

231 netic testing of the sprained ankle, and peak torque fibula and the tip of medial malleolus and EMGs were 281

232 scores were recorded in Nm. Initially, testing was analyzed for dorsiflexion and inversion testing. Ref- 282

233 performed for dorsiflexion-plantar flexion, and after- erence electrodes were placed around the ankle [27]. 283

234 wards for eversion-inversion, at controlled 30◦ /s and Skin preparation included shaving of application area 284

235 120◦ /s test velocities. Testing at 30◦ /s proceeded test- and cleaning with isopropyl alcohol. 285

236 ing at 120◦ /s, and 1 min of in-between rest was in- A Shimmer3 EMG Unit (Dublin), which acquired 286

237 cluded [26]. During dorsiflexion-plantar flexion test- signals at 1024 Hz, was used for collection of EMG 287

238 ing, the position of participants was the same with joint recordings. The input impedance of the differential 288

239 position sense testing. During eversion-inversion test- amplifier was 22 megaohms, with 110 dB common 289

240 ing, all Biodex equipment and the tested foot of par- mode rejection ratio and a signal-to-noise ratio of 290

241 ticipants were placed according to manufacturer’s in- 0.75 dB. The investigator stabilized two EMG units 291

242 structions. Testing was performed with the eyes open, to the tested limb with straps and connected each unit 292

243 and maximal effort was encouraged for all muscle con- with the electrodes of a muscle. The third EMG unit 293

244 tractions [26]. was attached to the arm of the dynamometer and it was 294

245 One isokinetic test comprised five cycles of max- used as an accelerometer to define precisely the ini- 295

246 imal concentric muscle contractions, at test veloc- tiation of movement. For the normalization of EMG 296

247 ity. For each test velocity, peak scores were used for signals, EMG activity of the specified muscle dur- 297

248 the analysis. During a cycle, each participant moved ing maximal voluntary isometric contraction (MVIC) 298

249 his/her sprained ankle through the complete, non- was used as a reference value. Prior to isokinetic test- 299

250 painful ROM of the tested movement: from complete ing, each participant performed three 5 sec MVICs for 300
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L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains 5

301 each muscle, and there was a 30 sec rest between two to abstain from any form of additional training during 349

302 MVICs. For the peroneus longus muscle, EMGs were the study. 350

303 recorded during MVICs of the evertor muscles. For

304 the tibialis anterior muscle, EMGs were recorded dur- 2.3.1. Balance protocol 351

305 ing MVICs of the dorsiflexor muscles. During perfor- The balance protocol was designed according to the 352

306 mance of MVICs, the position of participants was the rehabilitation guidelines of ankle sprains in clinical 353

307 same with strength isokinetic testing, and ankle and practice [3]. The protocol consisted of wobble board, 354

308 subtalar joints were in neutral position. For the MVICs, firm surface and soft surface activities, with the eyes 355

309 the resistance was provided by the Biodex ankle appa- open. Initially, participants performed wobble board 356

310 ratus, in relation to the tested muscle. For each mus- exercises on both legs, for 7 min, with no rest intervals. 357

311 cle, prior to performance of MVICs the investigator During training, feet were parallel and participants 358

312 emphasized that maximal effort was required for each were instructed to balance, while moving board’s edge 359

313 muscle contraction, and all participants performed one at saggital plane (back to front), frontal plane (left to 360

314 practice trial so as to familiarize with the procedure. right) and circulating directions. Moreover, each par- 361

315 During testing, verbal reinforcement was provided to ticipant tried to stand on the wobble board for 15 sec, 362

316 all participants. Prior to isokinetic testing, a 3 min rest using only the sprained leg. The sprained-leg stance 363

317 was included. exercise included 16 repetitions, and there was a 30 sec 364

318 The MyoResearch XP software package (Noraxon rest after 4 repetitions. 365

319 Inc., Scottsdale) was used for analysis of EMG data. The activities on firm surface (floor) involved per- 366

320 Analog to digital converters provided digital represen- formance of 40 squats on the sprained leg, with 6 sec 367

321 tation of the EMG input analogue signals into the com- duration per squat. The depth of squats was dependent 368

322 puter by a 24-bit signed integer value to each sample, on the exercise tolerance of each individual. Follow- 369

323 using Bluetooth. A Butterworth band-pass filter was ing eight squats, 30 sec rest was provided. In addi- 370

324 applied at 8 Hz and 500 Hz, using a full-wave rectifi- tion, participants performed a distance hop series ex- 371

325 cation. Smoothing was performed using the root mean ercise, using the sprained leg. This exercise consisted 372

326 square of the rectified signal. During strength test- of 6 hops in primary and diagonal patterns, and bal- 373

327 ing, the three contraction cycles producing the great- ance was maintained for 5 sec after each hop. The dis- 374

328 est amount of EMG activity at test velocity were iden- tance hop series exercise comprised 8 repetitions, with 375

329 tified, and the mean score (in mVolts) was computed 30 sec rest after each repetition. For activities on soft 376

330 for the normalization of EMG data. For data normal- surface, a foam pad was utilized, and participants tried 377

331 ization, the mean score of the MVICs of the per- to balance using the sprained leg, while performing re- 378

332 oneus longus and tibialis anterior muscles producing sistance band exercises with the opposite leg. The du- 379

333 the greatest amount of EMG activity was also used. ration of the soft surface exercise was 15 sec, and 16 380

334 The normalized data were used for further analyses. repetitions were performed, with a 30 sec rest after 4 381

repetitions. Moreover, 60 sec and 2 min rest intervals 382

335 2.2.4. Recurrent injury rate were included after each exercise and between differ- 383

336 The independent assessor contacted all participants ent training activities, respectively. Apart from the hop 384

337 by telephone, 12 months after training, and recorded series exercises, balance training was performed with- 385

338 potential recurrent injuries to the ankle. out footwear. The wobble board and foam pad used 386

in our study were of Thera-Band equipment (Akron, 387

339 2.3. Training procedures Ohio). 388

340 Within a six-week period, the same physiothera- 2.3.2. PNF protocol 389

341 pist provided 10 supervised training sessions to all The PNF protocol comprised two different tech- 390

342 study participants, at a rehabilitation research labora- niques: rhythmic stabilization (RS) and combination 391

343 tory. Each session lasted 50 to 60 min, and partici- of isotonics (COI) [19]. During application, partici- 392

344 pants received clear instructions to discontinue a ses- pants were in supine position, on a treatment table, fac- 393

345 sion since they experienced significant pain or fatigue. ing the therapist. The PNF protocol was applied to the 394

346 For both groups, training ended with 4 min of walking sprained leg, with the knee in extension, for both di- 395

347 on toes and heels, in forward and backward directions, agonals of the lower extremity, at the end of the upper 396

348 with 60 sec in-between rest. Participants were directed and lower range of each diagonal. The therapist pro- 397
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6 L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains

Table 1
398 vided maximal resistance, according to the needs of Characteristics of participants in each group
399 each individual. In order to emphasize training of the
Balance PNF
400 foot and ankle, timing for emphasis was implemented
(n = 10) (n = 10)
401 and the therapist prevented all hip and knee motions of Gender, females/males 7/3 7/3
402 the performed PNF pattern. The position of the thera- Sprain history to the injured ankle 5 5
403 pist’s hands was contingent on the technique and diag- Level of sports activity 5 High 5 High
404 onal under application and conformed to the PNF prin- Ankle injured (Right/Left) 9/1 8/2
Active DF ROM∗ (degrees) 8 (2) 7 (3)
405 ciples. Time since sprain∗ (weeks) 11 (5) 13 (4)
406 The RS technique was applied first and comprised Age∗ (years) 22 (2) 22 (4)
407 alternating isometric muscle contractions of agonis- Body mass index∗ (kg/m2 ) 25 (3) 23 (2)
408 tic and antagonistic muscles, against resistance, with ∗ Means (SD). DF ROM = dorsiflexion range of motion.
409 10 sec total duration and no intended motion [19].
410 The COI technique was applied after 2 min and it in- Table 2
411 cluded combined concentric, stabilizing and eccentric Mean (SD) balance group scores and Friedman test results across
time points for joint position sense (degrees of error)
412 contractions of agonistic muscles, with no rest between
413 contractions [19]: resisted active concentric contrac- Baseline Follow- Follow- X 2 value
up 1 up 2 (df)
414 tion for 5 sec, resisted isometric contraction for 5 sec
Dorsiflexion 10◦ 6 (4) 3 (3) 4 (2) 3.7 (2)
415 and resisted eccentric contraction for 5 sec. For both Plantar flexion 15◦ 9 (4) 5 (1) 5 (1) 10.5 (2)∗
416 RS and COI techniques, each set included 5 to 15 rep- Plantar flexion 30◦ 4 (3) 3 (1) 3 (2) 0.2 (2)
417 etitions, according to the endurance of each individ- ∗ Significant difference (p < 0.05).
418 ual [3]. Maximal effort was requested for all repeti-
419 tions. Rest intervals of 30 sec were included between Table 3
420 sets. The duration of each technique was 20 min, in- Mean (SD) PNF group scores and Friedman test results across time
421 cluding rest intervals. Prior to application, the therapist points for joint position sense (degrees of error)
422 provided clear instructions concerning the correct per- Baseline Follow- Follow- X 2 value
423 formance of each PNF technique to the specified diag- up 1 up 2 (df)
424 onal. Dorsiflexion 10◦ 4 (2) 1 (1) 5 (3) 10.1 (2)∗
Plantar flexion 15◦ 10 (4) 7 (3) 8 (3) 2.1 (2)
Plantar flexion 30◦ 7 (6) 4 (2) 5 (2) 5.2 (2)
425 2.4. Statistical analysis ∗ Significant difference (p < 0.05).

426 For joint position sense, muscle strength and EMG

427 normalized data, the non-parametric Friedman test was 3. Results 448

428 used to determine the within-group differences of each

429 outcome measure across the assessment time points. Table 1 shows the characteristics of the 20 partici- 449

430 The significance level was α = 0.05, two-tailed. For pants who completed the intervention; these were sim- 450

431 the significant results, post hoc Wilcoxon signed-rank ilar between the balance and PNF groups. At base- 451

432 tests were performed at α = 0.017, following Bonfer- line, no significant (p > 0.05) between-group differ- 452

433 roni adjustment, for all time combinations: baseline to ences were found for all study outcome measures. For 453

434 follow-up 1, baseline to follow-up 2 and follow-up 1 joint position sense, Tables 2 and 3 display the base- 454

435 to follow-up 2. For each group, data were standardized line, follow-up 1, follow-up 2 recordings and results of 455

436 against time by calculating difference scores (follow- Friedman test, for the balance and PNF groups, across 456

437 up 1 – baseline, follow-up 2 – baseline, follow-up 2 – the assessment time points. For peak torque, Tables 4 457

438 follow-up 1) for all outcome measures. After data stan- and 5 display these data. 458

439 dardization, the Mann Whitney U test was used to de- For joint position sense, post hoc tests indicated that 459

440 termine the between-group differences, using a two- the balance group significantly improved against base- 460

441 tailed α = 0.05. Post hoc effect sizes were calculated line for 15◦ of plantar flexion, at follow-up 1 assess- 461

442 for all within- and between-group differences. The Fis- ment (p = 0.016; r = 0.54) and follow-up 2 assess- 462

443 cher’s exact test was used to detect any significant rela- ment (p = 0.015; r = 0.55). For the PNF group, signif- 463

444 tionship between recurrent injury rate and group, and a icant baseline improvement was found for 10◦ of dor- 464

445 contingency table 2 × 2 was constructed. Significance siflexion at follow-up 1 assessment (p = 0.012; r = 465

446 level was α = 0.05, two-sided. All data were analysed 0.39), but not at follow-up 2 assessment (p = 0.307; 466

447 with the SPSS 21.0 and G∗ Power programs. r = 0.25). All between-group differences against base- 467
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L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains 7

Table 4
Mean (SD) balance group scores and Friedman test results across
time points for peak torque (Nm)
BaselineFollow- Follow- X 2 value
up 1 up 2 (df)
Dorsiflexion 30◦ /s 31.7 (6.8) 32.3 (8.6) 30.3 (7.3) 2.6 (2)
Dorsiflexion 22.7 (5.9) 21.4 (5.5) 22.1 (5.5) 2.6 (2)
120◦ /s
Plantar flexion 47.8 (23.6) 80.6 (31.4) 65.5 (25.5) 9.6 (2)∗
30◦ /s
Plantar flexion 26.0 (15.5) 40.2 (12.1) 38.1 (12.4) 7.8 (2)∗
120◦ /s
Eversion 30◦ /s 13.6 (2.5) 14.5 (2.0) 18.8 (2.3) 15.8 (2)∗
Eversion 120◦ /s 9.1 (1.5) 8.6 (2.2) 13.0 (3.0) 6.2 (2)∗
Inversion 30◦ /s 12.2 (3.8) 18.6 (3.7) 29.6 (9.9) 17.6 (2)∗
Inversion 120◦ /s 9.3 (3.5) 12.0 (3.7) 27.7 (8.9) 16.8 (2)∗
∗ Significant difference (p < 0.05).

Table 5
Mean (SD) PNF group scores and Friedman test results across time
points for peak torque (Nm)
BaselineFollow- Follow- X 2 value
up 1 up 2 (df)
Fig. 1. Mean (SD) normalized peroneus longus EMG activity across
Dorsiflexion 30◦ /s 35.8 (8.2) 30.7 (7.3) 30.8 (5.8) 5.6 (2)
assessment time points for balance and PNF groups, during ankle
Dorsiflexion 20.3 (4.2) 19.0 (5.4) 19.4 (4.1) 0.2 (2)
plantar flexion testing at 120◦ /s. ∗ significant difference (p < 0.017)
120◦ /s
against baseline.
Plantar flexion 31.5 (13.8) 46.1 (11.3) 53.5 (14.7) 18.2 (2)∗
◦
30 /s
Plantar flexion 17.4 (4.6) 25.0 (13.4) 25.0 (8.6) 6.2 (2)∗ scores were found at 30◦ /s testing, at follow-up 1 as- 489

120◦ /s sessment (p = 0.407; r = 0.19) and follow-up 2 as- 490

Eversion 30◦ /s 11.9 (1.8) 13.0 (3.8) 13.9 (4.0) 0.7 (2) sessment (p = 0.185; r = 0.30). For the PNF group, 491
Eversion 120◦ /s 8.0 (1.4) 10.5 (2.3) 10.5 (3.1) 9.0 (2)∗
Inversion 30◦ /s 10.1 (3.2) 12.6 (5.6) 26.2 (6.5) 15.0 (2)∗ baseline eversion peak torque scores at 120◦ /s signifi- 492

Inversion 120◦ /s 6.7 (2.3) 9.5 (3.2) 21.6 (5.7) 20.0 (2)∗ cantly improved at follow-up 1 assessment (p = 0.012; 493

∗ Significant difference (p < 0.05). r = 0.56), but not at follow-up 2 assessment (p = 494

0.021, r = 0.52). 495

468 line lacked significance (p > 0.05) and the effect sizes No significant (p > 0.05) differences between the 496

469 were r < 0.35. two groups were found in most muscle strength mea- 497

470 Both groups significantly (p < 0.05) improved af- sures, against baseline. The effect sizes were r < 0.34. 498

471 ter training in most measures of muscle strength (Ta- For eversion strength testing at 30◦ /s, however, the 499

472 bles 4 and 5). The main exception was dorsiflexion balance group was significantly better than the PNF 500

473 strength, as there were no significant (p > 0.05) dif- group for the difference recorded at follow-up 2 assess- 501

474 ferences in baseline peak torque across time, at 30◦ /s ment (p = 0.019; r = 0.52). In addition, for eversion 502

475 and 120◦ /s, for both groups; the effect sizes were r = strength testing at 120◦ /s, the PNF group was signifi- 503

476 0.05 to r = 0.45. For the balance group, baseline ev- cantly better than the balance group for the difference 504

477 ersion and inversion peak torque scores, at 30◦ /s and recorded at follow-up 1 assessment (p = 0.014; r = 505

478 120◦ /s, significantly (p < 0.017) improved at follow- 0.55). 506

479 up 2 assessment, and the effect sizes were r = 0.56 to For the peroneus longus muscle, the balance group 507

480 r = 0.63. For the balance group, significant improve- exhibited no significant (p > 0.05) difference in base- 508

481 ment in baseline plantar flexion peak torque scores was line EMG activity across time during eversion testing 509

482 found at 120◦ /s (p = 0.013; r = 0.63), but not at at 30◦ /s and 120◦ /s (r < 0.26). For plantar flexion test- 510

483 30◦ /s testing (p = 0.093; r = 0.38). In addition, the ing, baseline EMG activity of the balance group sig- 511

484 PNF group significantly (p < 0.017) improved base- nificantly improved only for 120◦ /s, at follow-up 2 as- 512

485 line plantar flexion and inversion peak torque scores at sessment (p = 0.012; r = 0.56). This is displayed in 513

486 follow-up 2 assessment, at 30◦ /s and 120◦ /s; the effect Fig. 1. For the PNF group, no significant (p > 0.05) 514

487 sizes were r = 0.60 to r = 0.63. For the PNF group, no differences in baseline EMG activity across time were 515

488 significant differences in baseline eversion peak torque found during eversion and plantar flexion testing, at 516
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8 L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains

and sprain history to the injured ankle) sustained a 546

recurrent sprain to the lateral ankle ligaments within 547

12 months after the intervention. Although the recur- 548

rent injury rate differed between balance and PNF 549

groups, this difference was not significant (p = 0.474). 550

4. Discussion 551

The main finding of this study is that both balance 552

and PNF training programs are effective in strength- 553

ening the ankle muscles. In addition, they may be ef- 554

fective in reducing recurrent ankle injuries. In addi- 555

tion, eight weeks after training the balance program 556

improved ankle plantar flexion sense and EMG activity 557

of the peroneus longus muscle during plantar flexion 558

strength testing. Eight weeks after training, the PNF 559

program improved EMG activity of the tibialis anterior 560

Fig. 2. Mean (SD) normalized tibialis anterior EMG activity across

muscle during inversion strength testing, but there was 561

assessment time points for balance and PNF groups, during ankle no improvement for ankle position sense. For all sig- 562

inversion testing at 30◦ /s. ∗ significant difference (p < 0.017) against nificant improvements, the effect sizes were large indi- 563
baseline. cating clinical significance. 564

◦ ◦ In our study, there were no significant changes after 565

517 30 /s and 120 /s (r < 0.47). For the tibialis anterior
training in most measures of joint position sense, for 566
518 muscle, the balance group showed significant improve-
both balance and PNF groups (Tables 2 and 3). How- 567
519 ment in baseline EMG activity during dorsiflexion test-
520 ing at 30◦ /s, at follow-up 1 assessment (p = 0.008, r = ever, for the balance group we found significant im- 568

521 0.59); however, there were no significant (p > 0.05) provement for 15◦ ankle plantar flexion sense at both 569

522 differences in baseline EMG activity across time dur- follow-up 1 and follow-up 2 assessments. In addition, 570

523 ing inversion testing at 30◦ /s and 120◦ /s (r < 0.49). the PNF group significantly improved at follow-up 1 571

524 For the PNF group, baseline EMG activity significantly assessment for 10◦ ankle dorsiflexion sense. Research 572

525 improved during inversion testing at 30◦ /s, at follow- evidence concerning the effects of proprioceptive train- 573

526 up 2 assessment (p = 0.013; r = 0.56). This is shown ing on ankle sprains is limited. To our knowledge, 574

527 in Fig. 2. There were no significant (p > 0.05) differ- there is one relevant study. This study showed that par- 575

528 ences in baseline EMG activity across time for the PNF ticipation in balance and running activities, twice a 576

529 group during dorsiflexion testing at 30◦ /s and 120◦ /s week, was not effective in improving ankle inversion 577

530 (r < 0.40). sense [9]. For joint position sense, the tested positions 578

531 For EMG activity, most between-group differences utilized in our study (10◦ of dorsiflexion, 15◦ and 30◦ 579

532 against baseline were not significant (p > 0.05), and of plantar flexion) have also been investigated in indi- 580

533 the effect sizes were r < 0.36. However, the bal- viduals with chronic ankle instability [28]. For these 581

534 ance group was significantly better than the PNF group individuals, six sessions of a multi-station propriocep- 582

535 during dorsiflexion testing at 30◦ /s, for the difference tive training program improved ankle plantar flexion 583

536 recorded at follow-up 1 assessment (p = 0.003; r = sense at the end of training, but there was no improve- 584

537 0.67), and during plantar flexion testing at 120◦ /s, for ment for ankle dorsiflexion sense, in comparison to a 585

538 the difference recorded at follow-up 2 assessment (p = non-exercise control group [28]. 586

539 0.023; r = 0.51). The PNF group was significantly bet- Joint position sense is the ability to replicate posi- 587

540 ter than the balance group during inversion testing at tions of a joint using active or passive movement cues. 588

541 30◦ /s, for the difference recorded at follow-up 2 assess- The active replication of joint positions is thought to 589

542 ment (p = 0.002; r = 0.68). measure activity in the muscle spindle receptors [5]. 590

543 No recurrent ankle injuries were observed for the Hence, increments in the activity of the muscle spindle 591

544 balance group. For the PNF group, 20% of the par- receptors may explain the improvements in active joint 592

545 ticipants (two females with high sports activity level position sense observed in our study. In our study, we 593
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L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains 9

594 assessed joint position sense in a not weight-bearing ing to absence of pre- and post-intervention effects, 645

595 position. As the magnitude of mechanical stress that comparisons with our study should be made with cau- 646

596 is imposed on a joint is significantly different between tion. Concerning the application of PNF protocols, 647

597 weight-bearing and non-weight-bearing activity [5], Hall et al. [18] have recently investigated the effects 648

598 the non-significant findings for the balance group in of the slow reversal PNF technique, which consists of 649

599 our study might be justified by the specificity of the a concentric contraction of antagonistic muscles fol- 650

600 applied protocol, which included solely performance lowed by a concentric contraction of agonistic mus- 651

601 of weight-bearing exercises. This, however, was not cles [17], on isometric ankle strength in individuals 652

602 the case with PNF protocol, as participants in the PNF with chronic ankle instability. After PNF training for 653

603 group performed exercises in non-weight-bearing posi- six weeks, strength improved for inversion and ever- 654

604 tions and similarly there were no significant changes in sion, but there were no improvements for dorsiflexion 655

605 most joint position sense measures after training. Fur- and plantar flexion [18]. In our findings, the PNF group 656

606 ther studies investigating the effectiveness of balance showed no significant improvement in dorsiflexion and 657

607 and PNF programs on ankle position sense in individ- eversion strength measures, eight weeks after training. 658

608 uals with ankle sprain should be conducted. We hypothesize that during the application of PNF pat- 659

609 In our study, eight weeks after training both groups terns in our study, the investigator failed to provide an 660

610 improved ankle inversion and plantar flexion strength, adequate amount of manual resistance in dorsiflexion 661

611 but there was no improvement in dorsiflexion strength and eversion directions in order to induce a significant 662

612 (Tables 4 and 5). Eight weeks after training, solely change. In clinical practice, PNF therapists should con- 663

613 the balance group improved ankle eversion strength. In sider the utilization of additional open and closed ki- 664

614 concordance with our findings, evidence in individuals netic chain exercises to improve strength for ankle dor- 665

615 with sprain confirms improvement in eversion strength siflexion and eversion. 666

616 after participation in strength and functional train- In our study, we recorded EMG activities of the per- 667

617 ing, including eccentric exercises [10,11] and soccer- oneus longus and tibialis anterior muscles during isoki- 668

618 specific activities [12]. In addition, participation in pro- netic testing of the ankle. Eight weeks after training, 669

619 grams including eccentric and resistive strength exer- EMG activity of the balance group significantly im- 670

620 cises for a six-week period improved ankle inversion proved during plantar flexion at 120◦ /s. This was a 671

621 strength in individuals with sprain [11]. A two-week 27% increase in mean EMG normalized scores, against 672

622 functional training program of soccer-specific activi- baseline (from 0.61 to 0.83; Fig. 1). For the PNF group, 673

623 ties also improved plantar flexion strength of an athlete eight weeks after training EMG activity significantly 674

624 with ankle sprain [12]. Although these findings con- improved during inversion at 30◦ /s. This was a 26% 675

625 firm conclusions in our study, it should be mentioned increase in mean baseline EMG normalized scores 676

626 that investigators in most of these studies applied pro- (from 0.40 to 0.54; Fig. 2). Eight weeks after train- 677

627 tocols of strength training. In our study, we applied two ing, no other significant changes in baseline EMF ac- 678

628 protocols of proprioceptive training, balance and PNF, tivity were found for both groups. In relevant literature, 679

629 and most measures of ankle strength also improved af- investigators have assessed EMGs of the ankle mus- 680

630 ter training for both protocols. These findings confirm cles during sudden simulated inversion perturbations, 681

631 the strengthening ability of balance and PNF protocols and comparisons with our findings could be attempted 682

632 in sprains and recommend their use in clinical practice in this perspective. In particular, for individuals with 683

633 for ankle strengthening, as an additional approach to sprain, the reaction time of the tibialis anterior mus- 684

634 strength protocols to obtain optimal results. cle improved after participation in eight weeks of an- 685

635 For ankle sprains, Holme et al. [9] assessed the ef- kle disk training [13]. In addition, for individuals with 686

636 fects of proprioceptive training on muscle strength of chronic ankle instability, six balance training sessions 687

637 the injured ankle. In opposition to our conclusions, the improved reaction times of peroneus longus and brevis 688

638 investigators found no gains in isometric ankle strength muscles, which were between 60 and 70 msec at the 689

639 four months post-injury for the individuals who par- end of intervention [28]. Such reactions times, how- 690

640 ticipated in balance and running activities, against a ever, may be too long to sort an effect on the degree of 691

641 control group of conventional treatment [9]. However, a sudden sprain, which lasts 40 to 45 msec [29]. 692

642 Holme et al. [9] assessed effectiveness in relation to Ankle sprains to the lateral ligaments are inversion 693

643 the uninjured ankle and there were no baseline mea- injuries that occur in the plantar-flexed position. It has 694

644 surements due to the acute phase of the sprain. Ow- been reported that peroneus longus and tibialis ante- 695
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10 L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains

696 rior are the first muscles to contract in response to ous physiological processes, such as the sensory appre- 747

697 such injurious perturbations [13]. In this context, it ciation of specific peripheral mechanoreceptors, nerve 748

698 could be suggested that EMG activities of peroneus conduction velocity, pool excitability of alpha mo- 749

699 longus muscle-during eversion isokinetic testing- and toneurons and gamma-efferent motor activity in mus- 750

700 tibialis anterior muscle-during dorsiflexion testing- are cle spindles [5,31]. Possible adaptations in morphol- 751

701 important for the prevention of recurrent lateral liga- ogy are changes in the cross-sectional area of muscles, 752

702 ment sprains. In our study, eight weeks after training size of myofibrils and/or structure of ligaments [31]. 753

703 we recorded no significant changes in EMG activity It could be suggested that proprioceptive training in 754

704 of these muscles during eversion and dorsiflexion test- our study increased the motor control and coordination 755

705 ing. Nevertheless, our findings reveal the roles of the of participants during the performance of functional or 756

706 peroneus longus and tibialis anterior muscles as an- sport activities and as a consequence, recurrent injuries 757

707 kle plantar flexor and invertor muscles, eight weeks af- were effectively prevented. The mechanisms through 758

708 ter balance and PNF training, respectively. For ankle which proprioceptive training programs may prevent 759

709 sprains, research concerning effectiveness of various recurrent ankle injuries are still unclear [31]. Imple- 760

710 proprioceptive training programs on EMG activity of mentation of enhanced assessment techniques seems 761

711 the ankle is necessary. beneficial for investigating these mechanisms. 762

712 The recurrent rate of ankle sprains is noteworthy and This study is not without limitations. We used a 763

713 most patients with a history of ankle sprain will sustain relatively small number of participants in each group 764

714 at least one additional sprain in the future [30]. These (n = 10). Consequently, power of between-group anal- 765

715 recurrences increase disability and lead to chronic an- yses was decreased, indicating that a type II error 766

716 kle instability and pain in 20% to 50% of cases [31]. might have occurred. For joint position sense, mus- 767

717 For sprains, the high rate of recurrent injuries and the cle strength and EMG activity between-group compar- 768

718 associated risk for chronic instability and pain high- isons, in order to detect a large 0.5 effect size with 769

719 light the importance of using effective training pro- 80% power, at a two-tailed significance level α = 0.05, 770

720 grams in clinical practice. In our study, 12 months after would require 67 participants in each group. Similarly, 771

721 sprain, there were no recurrent injuries for the balance for recurrent injury rate between-group comparisons, 772

722 training group, whereas for the PNF training group the 39 participants in each group would be necessary so as 773

723 recurrent injury rate was 20%. Although relevant evi- to achieve a two-tailed α = 0.05, with 80% power. For 774

724 dence is not unanimous [31], most systematic reviews between-group comparisons, more precise estimates 775

725 and randomized clinical trials in individuals with an- could have been detected with the use of a larger sam- 776

726 kle sprain confirm our findings, indicating that the bal- ple. For all significant within-group comparisons, how- 777

727 ance training programs, with the use of an ankle disk ever, the observed power values were > 83%. The ef- 778

728 or wobble board, can be used prophylactically in order fect sizes were also large, indicating the significance of 779

729 to reduce recurrent injuries [14–16]. It has also been our findings in clinical practice. For the balance group, 780

730 reported that the six-week balance protocols may be eight weeks after training the effect sizes for all signifi- 781

731 effective in reducing recurrent injuries for up to one cant within-group comparisons against baseline ranged 782

732 year [14]. This is in agreement with our study. To our from r = 0.55 to r = 0.63. For the PNF group, these 783

733 knowledge, this is the first study investigating the ef- values were between r = 0.56 to r = 0.63. In addition, 784

734 fects of PNF training on recurrent injuries after the the mean age of participants in our study was 22 years. 785

735 sprain. Our findings indicate that the rhythmic stabi- Since age can be a prognostic indicator of propriocep- 786

736 lization and combination of isotonics techniques, when tive training effectiveness [32], generalization of our 787

737 applied in combination, could be effective in reducing findings in individuals with different age characteris- 788

738 the risk for recurrent ankle injuries. For this purpose, tics could be attempted with caution. 789

739 we recommend their use in clinical practice as alterna-

740 tive approach to balance training.
741 In our study, we hypothesize that the applied bal- 5. Conclusion 790

742 ance and PNF protocols induced adaptations in ankle

743 neurophysiology and morphology, as demonstrated by This study shows clinically significant improve- 791

744 the improvements observed for plantar flexion position ments in ankle strength after ten 50–60 min sessions of 792

745 sense, strength and EMG activity of the ankle. Poten- supervised balance or PNF training programs in indi- 793

746 tial neurophysiological adaptations are changes in vari- viduals with sprain. In addition, 12 months after train- 794
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L. Lazarou et al. / Effects of two proprioceptive training programs after ankle sprains 11

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