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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 10  |  Issue : 3  |  Page : 317-322

Influence of strength and proprioception training on functional ankle stability among young skaters


Department of Pediatric Physiotherapy, KLE University Institute of Physiotherapy, Belagavi, Karnataka, India

Date of Web Publication5-Sep-2017

Correspondence Address:
Priyanka Mudaliar
Department of Pediatric Physiotherapy, KLE University Institute of Physiotherapy, Belagavi, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_42_17

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  Abstract 


Background: Stability of the ankle joint during functional activities depends on the presence of intact neural input from proprioceptors in the joint capsules, ligaments, muscles, tendons, and skin. Roller skaters are prone for more ankle injuries due to the nature of the sport. Repetitive falls and sprains lead to deficits that account for decreased performance and increased risk of falls.
Purpose: The purpose of this study is to determine the effect of strength and proprioceptive training on functional ankle stability among young skaters.
Design: This was a single arm pre- and post-experimental study.
Settings: The study was conducted at two skating academies of Belagavi, Karnataka, India.
Materials and Methods: Forty-five skaters in the age group of 10–18 years were recruited in the study.
Intervention: The strength and proprioception training protocol was given for 3 sessions per week for 6 weeks with each session lasting for 45 min.
Measurements: The participants were assessed for three-time points that are week 1, week 3, and week 6. The functional ankle stability was measured using Cumberland Ankle Instability Tool (CAIT), strength of the dorsiflexors, plantar flexors, invertors, and evertors were checked using Push-Pull Dynamometer, and balance was assessed using Star Excursion Balance Test (SEBT).
Results: The mean age of participants was 12.91 ± 2.26 years with more male participants than females. There was a significant finding in CAIT at all three-time points with maximum changes at the end of week 6. Both sides showed significant changes with more pronounced readings on the left side. There was statistically significant increase in the strength of all four groups of muscles, but the dorsiflexors strength remained more than the other muscle groups with more percentage change on the left side. The subjects significantly improved on SEBT scores in all the components which were statistically significant. Five components of SEBT showed more percentage of change on the left as compared to the right side.
Conclusion: The study concluded that the strength and proprioceptive training protocol has shown statistically significant improvement in the functional stability scores, strength, and balance.

Keywords: Cumberland ankle instability questionnaire, functional ankle stability, proprioception, skaters, star excursion balance test, strength


How to cite this article:
Mudaliar P, Dharmayat S. Influence of strength and proprioception training on functional ankle stability among young skaters. Indian J Health Sci Biomed Res 2017;10:317-22

How to cite this URL:
Mudaliar P, Dharmayat S. Influence of strength and proprioception training on functional ankle stability among young skaters. Indian J Health Sci Biomed Res [serial online] 2017 [cited 2019 Aug 24];10:317-22. Available from: http://www.ijournalhs.org/text.asp?2017/10/3/317/214001




  Introduction Top


The ankle joint is a complex structure of the foot that participates in all weight-bearing activities. Any abnormalities or altered movements can lead to excessive stresses on the tissues of the foot causing injuries. Thus, it is of immense importance to understand the structures that comprise this complex joint.[1] The foot is designed to perform all activities in weight-bearing positions, it is also subjected to wear and tear, leading to overuse syndromes, stress fractures, ligamentous injuries, and instability. These factors sum up to contribute improper postural alignment as a compensatory mechanism of the body. The recurrent stresses and strains encountered by the ankle/foot complex give rise to permanent damages. One such damage is the proprioceptive deficits contributing to the cause of ankle instability.

In 1906, the English neurophysiologist Sir Charles Sherrington coined “proprioception,” from a combination of the Latin “proprius” (one's own) and “perception,” to give a term for the sensory information derived from (neural) receptors embedded in joints, muscles, and tendons that enable a person to know where parts of the body are located at any time.[2]

Proprioception is necessary to establish an accurate, efficient, and coordinated response of efferent system to the demands of environment.[2],[3] The ability to maintain balance during standing on a single leg or both legs requires integrity of the visual, vestibular, and nervous systems. In the presence of an intact vestibular system, standing with eyes closed depends mostly on the normal function of the various proprioceptive receptors.[3],[4] Stability of the ankle joint is paramount when considering the regulation of balance.[3],[4]

Balance ability and ankle proprioception are both related to competition level in a range of sports. Roller skaters and ice dance skaters have a higher risk of acute injury than overuse syndrome because of falls from lifts and throw jumps.[5],[6],[7] Ankle proprioception may be one of the more important components contributing to balance control in sports, because during most sports activities, the ankle-foot complex is the only part of the body contacting the ground. Ankle proprioception provides essential information to enable adjustment of ankle positions and movements of the upper body, to successfully perform the complex motor tasks required in elite sports.[6]

Proprioception is a vital aspect of motor control and when degraded or lost can have a profound impact on function in diverse athletic population. Many children who roller skate sustain injuries. This is most likely because maturation of lower and upper extremity speed, strength, agility, coordination, balance, and reaction time and morphologically stronger bones combine to afford relative protection to the older child.[8]

Furthermore, certain components of ankle rehabilitation, such as proprioceptive exercises, have been found to protect the joint from reinjury. Multifaceted ankle sprain prevention programs that incorporate a variety of strategies for injury reduction are also effective in sprain prevention although the relative importance of each component of such programs warrants further investigation.[9]

As with the high-speed sports, traumatic injury is an associated hazard. Ankle injuries account the most common injuries among young skaters constituting in the mean age of 10–17 years of age.[7] Recurrent injuries account for symptoms varying from ankle sprain, stress fracture, articular cartilage damage, chronic synovitis, pain and eventually leading to arthritic changes. This leads to functional instability and proprioceptive issues among young skaters leading to poor athletic performance.[6],[7]

There has been literature supporting the fact that athletes involved in high-speed sports require tailor-made training to minimize the risk of falls and to enhance better performance. Contrary to the various athletic population being studied for strength training and its effects, the proprioceptive component among the younger age group has not been reported frequently. Thus, measurement of proprioception needs to be addressed to easily assess the rehabilitative progression level among this population. However, there has been a dearth of literature relating to the effect of combined training program on ankle functions in skaters. Hence, the need arises to study the influence of proprioceptive and strength training program in these population.


  Materials and Methods Top


The primary data were collected from two different skating academies, Belagavi, Karnataka, India. The participants for this single-arm pre- post-experimental study were recruited based on the inclusion and exclusion criteria using a nonprobability sampling design (sample of convenience). Inclusion criteria were male and female noncompetitive skaters (n = 45) in the age group of 10–18 years. Exclusion criteria were participants with recept ankle injuries, neurological impairments, Cumberland Ankle Instability Tool (CAIT) score of more than 27.5. strength of the dorsiflexors, plantar flexors, invertors, and evertors, Star Excursion Balance Test (SEBT) and CAIT were the outcome measures used in the study [Figure 1].
Figure 1: Flowchart of the study

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Procedure

Ethical clearance was obtained from the Institutional Ethical Committee. A permission letter along with the explanation of study was sent to the academy from which the data were to be collected. Inform assents were taken from the trainer/parent of the eligible participants. All the procedures were explained before performing the assessment in the language preferred by the participant. The participants were given an opportunity to practice skating and a 5 min warm-up which will include jogging and stretching.

Intervention

Ankle protocol was administered for a period of 6 weeks with three sessions per week in an alternate fashion for a period of 40 min. The session started with a warm up of 5 min, which included jogging, soleus and gastrocnemius stretching, and ankle movements (plantar flexion, dorsiflexion, inversion, and eversion) for a hold time of 30 s with 10 s rest time for 10 repetitions per se t and two sets per se ssion. The intervention constituted of 2–4 exercises for a hold period of 30 s and 10 s rest time with 10 repetitions and 2 set. Each session was progressed with eyes open on a firm surface to eyes closed. This was progressed to dynamic exercises where the therapist challenged the subject's center of mass with functional tasks such as catching medicine ball. The firm base was further progressed to wobble board followed by plyometrics [Table 1].
Table 1: Progression for strength and proprioception training protocol

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Training protocol

Static balance phase:

  • Dynamic standing-tandem standing with one foot in front for 5 breathing cycles
  • Single leg balance standing on one leg and maintaining balance for 5 breathing cycles
  • Body balance standing on one leg and extending the free leg forward, backward, and maintaining body alignment for 5 breathing cycles.


Dynamic phase:

  • Double leg heel raises with foot apart, push heel off the ground and bearing weight on the forefoot while maintaining foot alignment
  • Double leg jumps–while maintaining equal weight on both ankles, jump with both feet forward, backward, side-to-side, and crossing the square. You must land on whole foot rather that forefoot
  • Single-leg squats–the subject tries to sit on a low chair, perform the activity with one leg off the ground
  • Single-leg heel raises with one leg off the ground, push off the heel with maintaining the hip and shoulder alignment.


Plyometric phase:

  • Double-leg plyometric – stand on the box and jump down, stand behind the box and jump over it feeling like a spring immediately bouncing off the box, same procedure in sideways
  • Single-leg plyometric – stand on one leg on the box and hop down, hop with a single leg on the box using it like a spring and bouncing down, same procedure in side ways.



  Results Top


Statistical analysis of the data collected was done by SPSS version software 21 (IBM ®). For this purpose, the data were entered into the Microsoft Excel Sheet, tabulated, and subjected to statistical analysis. Various statistical measures such as mean, standard deviation, and test of significance such as independent and applied dependent t-test were used. Comparison of the right and left sides with each outcome measures within the group was done using independent t-test, which was utilized to measure the changes from week 1-3, week 3-6, and week 1-6 in terms of Cumberland Ankle Instability Questionnaire, strength of dorsiflexors, plantar flexors, invertors, and evertors and SEBT. Level of significance for the study was taken with P < 0.05.

The participants in the study were in the age group of 10–18 years. The mean age of the subjects was 12.91 ± 2.26 years, with 22.2% of the participants aged 10 years, 6.6% of age 11, 15.5% participants aged 12–15 years each, and 4.4% aged 17 and 18 years each. The total number of male participants in the group was 28 and that of females was 17 (n = 45).

Cumberland ankle instability score

The mean score at three different time points, i.e., at week 1, week 3, and week 6 were 27.2 ± 1.7, 28.04 ± 1.3, and 29.22 ± 0.9 for the right side whereas 27.09 ± 1.7, 27.82 ± 1.5 and 29.18 ± 1.1 on the left side. The percentage of change at three intervals was statistically significant with more changes from week 1-6. The right side showed 7.26% change while the left side showed 7.71% (P< 0.05).

Strength of dorsiflexors, plantarflexors, invertors, and evertors

All four groups of muscles showed statistically significant improvement. The percentage of change was observed to be more on the left side as compared to the right side for all muscles with dorsiflexors showing most increase in change (31.43%) (P < 0.001).

Star excursion balance test

The percentage of changes in 5 components out of 8 in the SEBT had more readings on the left side as compared to the right. The right side readings were more for anterior (5.62%), anteromedial (5.33%), and medial (5.89%) indicating the dominant side of the limb to be stronger in medial side activities.


  Discussion Top


The present study was conducted to evaluate the effectiveness of strength and proprioception training on functional ankle instability among young skaters. The study recruited participants in the age group of 10–18 years. The rationale behind recruiting this age group was to study the changes in both, the preadolescent and adolescent ages. It has served two findings, i.e., the pretraining readings of strength and balance were on the higher side among the adolescent population. This could be due to the physiological changes brought about by the growth spurt seen in this period.

Various longitudinal studies have been conducted to study various effects of growth spurt on nutritional status, physiological changes, physical activity, sports performance etc., One such study conducted by Mameletzi and Siatras (2003) concludes that physical training during the period of growth spurt has no effect on the velocity of physiological growth, stature, or sexual maturity.[10] Second, the current study also showed that the incidence of ankle instability was more among the older ages than the preadolescents. This may be attributed to more training sessions of the older participants than their younger counterparts. The participants involved in the study were pursuing skating for at least more than a year. This could have led to early biomechanical changes occurring in the developing ankle joint which might have influenced the CAIT scores.

A study conducted by Michelson and Hutchins describes that the repeated stresses and strains leading to ankle injuries leads to loss of mechanoreceptors due to damage in the type II and III fibers. It is already well established that children undergo various changes during their growing period owing to the differentiation of the muscle fibre type.[11] These findings bridge the gap as to reason of FAI scores in the older population.

The percentage of male participants (62.2%) was found to be more than female participants (37.7%) in the current study. This could be attributed to the existing cultural differences in the developing countries that provide limited opportunities to the female athletes due to overprotective environment and the impending risk of serious injuries due to the nature of the sport. Various epidemiological studies have been quoted as stating that high-speed sports on unstable terrain and reduced base of support lead to serious risk of injuries with equal casualties reported every year. Since in Indian settings, skating is still undergoing a developing phase, the awareness of this sport and the willingness to participate in spite of other famous sports is still quite a few in number. The Indian scenario of epidemiology regarding the incidence of injuries and gender difference has still not been studied widely.

The present study used three outcome measures to measure the functional ankle instability, strength, and balance of the foot and ankle complex. The CAIT is an established tool used to assess ankle instability scores by a series of questions asked regarding each ankle separately to evaluate unilateral ankle sprains. In a study conducted by Haji-Maghsoudi et al. in 2016 on the reliability of CAIT, it was concluded that CAIT was a reliable and valid tool to assess lateral ankle sprains with the variance cover of 72%, test-retest correlation coefficient for total score of CAIT being 0.95 indicating excellent reproducibility with confidence of 95% with SEM as 1.[12]

The strength was assessed using a push-pull dynamometer which is a simple and most widely used tool to assess various muscle groups. In a study conducted by Hébert et al., the inter- and intra-rater intraclass correlation coefficient (ICC) varied from 0.75 to 0.98 except dorsiflexor interrater reliability which was 0.67, and the standard measurement varied from 0.5 to 4.9 Nm. The mean concurrent validity (ICC) varied from 0.78 to 0.93 thus making the instrument valid and reliable.[13]

Gribble et al. studied the anterior, posteromedial, and posterolateral reaching directions of SEBT in participants aged 18–50 years and concluded that there was an excellent interrater reliability for all the measures of SEBT. The interclass correlation coefficients after normalizing the maximum excursion distances were 0.86–0.92 and that of nonnormalized measure was stronger ranging from 0.89 to 0.94.[14]

Moreover, the outcome measures were easy to use, portable, cost-effective and could be used in the participants settings, for example, on their training fields. The purpose of the study could be fulfilled with the help of these outcomes and could be used by the trainer to assess the rehabilitative progression of the athletes. Studies involving electromyography findings and force plates to evaluate muscle strength and proprioception shows accurate readings but are cumbersome, expensive, and time-consuming. These could be used as a pretreatment or postinjury evaluative methods to determine the severity and extent of rehabilitation required and to determine the prognosis of the athletes. The present study involved noncompetitive skaters who were practising on an everyday basis in their respective academies. It is known that aerobic capacity, trunk position, power, and balance are the main contributors of performance in skaters. The technical aspect of the training involves biomechanically minimizing the frontal area thus air frictional losses. This results in abnormal forces acting on the foot and ankle complex resulting in repetitive trauma. The present study aimed to minimize the risk of injury and fall using proprioceptive training protocol using the theory that children continue to develop the sense of proprioception as the specialization and differentiation of type II and III nerves continue up to 18 years of age. It concluded that the subjects trained, showed improvement in the questionnaire score at all the three-time points as the protocol progressed. It indicated statistically significant changes on bilateral ankle joint.

A study conducted by Ben Moussa Zouita et al. stated that the strength of the lower extremeties was associated with the gait and balance of the individual. It describes that strength is inversely proportional to the occurrences of falls.[15] Our study worked with a rationale that an increase in the muscle strength of the dorsiflexors, plantar flexors, evertors, and invertors during the developing phase of the foot-ankle complex will lead to reduced micro trauma and aid better functional stability among younger age group of athletic population engaged in high-speed sports.

Strength was one of the outcome measures to evaluate the changes occurring in dorsiflexors, plantarflexors, invertors, and evertors. A similar study conducted by Naomi and Wolfson concluded that strength of the dorsiflexors has a negative correlation with the incidence of fall and aids for better balance. The present study also had similar findings with statistically significant results with respect to the strength of dorsiflexors, which has undergone maximum percentage of change in week 6 with better ankle stability scores.

The current study has compared the strength of right and left foot with a view to determine the differences in the effect of changes seen on each foot. It was observed that the dorsiflexion power improved maximally with respect to other muscle groups that were statistically significant. These findings may be due to the biomechanical stresses occurring on foot during the push-off phase of the sport during which the athlete must resist plantar flexion to avoid the tip of the skate to scratch the ground thus minimizing ground resistance. This owes to maximum dorsiflexion activation throughout the activity of sport.

The present study used the SEBT to evaluate the changes in the 3 time points during the protocol. Our study findings indicate that all the 8 components of SEBT showed statistically significant improvement with more changes seen at the end of week 6. A similar study supports the present finding showing significant improvement irrespective of the direction among healthy children in the mean age of 11.2 ± 0.4 years to study the effect of inline skating on balance and strength of bilateral lower limbs.

There have been various protocols specified to increase strength of specific muscle groups to improve strength and balance in ankle joint, but the present study is specifically focused on the proprioceptive aspect of the foot as it is the causative factor for making the ankle joint more prone for injuries during and after the sport. As for children, it is of immense importance that the ankle and foot complex is strengthened and given intervention for proprioceptive feedbacks to avoid injuries in the developing ankle. Skating as mentioned earlier is a high-speed unstable sport which needs training under the supervision and such protocol followed in the present study has shown to improve the functional ankle stability thus minimizing the risk of falls and injury.


  Conclusion Top


  • A strength and proprioceptive training protocol for 6 weeks improves functional ankle stability in skaters
  • Second, an improvement in strength of the dorsiflexors, plantar flexors, invertors, and evertors was noted with improvement in balance performance on the SEBT.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chaurasia BD. Human Anatomy. 4th ed., Ch. 8. New Delhi: CBS Publishers and Distributors; 2009.  Back to cited text no. 1
    
2.
Winter T, Beck H, Walther A, Zwipp H, Rein S. Influence of a proprioceptive training on functional ankle stability in young speed skaters – A prospective randomised study. J Sports Sci 2015;33:831-40.  Back to cited text no. 2
    
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Debnath U, Narkeesh A, Raghumahanti R. Formulation of integrated proprioceptive screening scale and testing of its sensitivity, reliability and validity. J Exerc Sci Physiother 2010;6:78-87.  Back to cited text no. 3
    
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Dubravcic-Simunjak S, Pecina M, Kuipers H, Moran J, Haspl M. The incidence of injuries in elite junior figure skaters. Am J Sports Med 2003;31:511-7.  Back to cited text no. 4
    
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Inkelis SH, Stroberg AJ, Keller EL, Christenson PD. Roller skating injuries in children. Pediatr Emerg Care 1988;4:127-32.  Back to cited text no. 5
    
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Malanga GA, Stuart MJ. In-Line skating injuries. J Sports 2015;4:234-7.  Back to cited text no. 6
    
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Mitts KG, Hennrikus WL. In-line skating fractures in children. J Pediatr Orthop 1996;16:640-3.  Back to cited text no. 7
    
8.
Maurer C, Finley A, Martel J, Ulewicz C, Larson CA. Ankle plantarflexor strength and endurance in 7-9 year old children as measured by the standing single leg heel-rise test. Phys Occup Ther Pediatr 2007;27:37-54.  Back to cited text no. 8
    
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Hillier S, Immink M, Thewlis D. Assessing proprioception: A systematic review of possibilities. Neurorehabil Neural Repair 2015;29:933-49.  Back to cited text no. 9
    
10.
Mameletzi D, Siatras T. Sex differences in isokinetic strength and power of knee muscles in 10–12 year old swimmers. Isokinet Exerc Sci 2003;11:231-7.  Back to cited text no. 10
    
11.
Michelson JD, Hutchins C. Mechanoreceptors in human ankle ligaments. J Bone Joint Surg Br 1995;77:219-24.  Back to cited text no. 11
    
12.
Haji-Maghsoudi M, Naseri N, Nouri-Zadeh S, Jalayi S. Evidence of reliability for persian version of the “Cumberland Ankle Instability Tool (CAIT)” in Iranian Athletes with lateral Ankle Sprain. J Rehabil 2016;16:304-11.  Back to cited text no. 12
    
13.
Hébert LJ, Maltais DB, Lepage C, Saulnier J, Crête M, Perron M. Isometric muscle strength in youth assessed by hand-held dynamometry: A feasibility, reliability, and validity study. Pediatr Phys Ther 2011;23:289-99.  Back to cited text no. 13
    
14.
Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability of the star excursion balance test. J Athl Train 2013;48:621-6.  Back to cited text no. 14
    
15.
Ben Moussa Zouita A, Majdoub O, Ferchichi H, Grandy K, Dziri C, Ben Salah FZ. The effect of 8-weeks proprioceptive exercise program in postural sway and isokinetic strength of ankle sprains of Tunisian athletes. Ann Phys Rehabil Med 2013;56:634-43.  Back to cited text no. 15
    


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