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Journal of Back and Musculoskeletal Rehabilitation -1 (2017) 1–10 1

DOI 10.3233/BMR-170836
IOS Press

Effects of two proprioceptive training

programs on ankle range of motion, pain,
functional and balance performance in
individuals with ankle sprain
Lazaros Lazarou∗ , Nikolaos Kofotolis, Georgios Pafis and Eleftherios Kellis
Laboratory of Neuromechanics, Department of Physical Education and Sport Sciences at Serres, Aristotle

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University of Thessaloniki, Thessaloniki, Greece

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Abstract.
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BACKGROUND: Following ankle sprain, residual symptoms are often apparent, and proprioceptive training is a treatment
approach. Evidence, however, is limited and the optimal program has to be identified.
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OBJECTIVE: To investigate the effects of two post-acute supervised proprioceptive training programs in individuals with ankle
sprain.
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METHODS: Participants were recruited from a physiotherapy center for ankle sprain rehabilitation. In a pre-post treatment,
blinded-assessor design, 22 individuals were randomly allocated to a balance or a proprioceptive neuromuscular facilitation
(PNF) group. Both groups received 10 rehabilitation sessions, within a six-week period. Dorsiflexion range of motion (ROM),
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pain, functional and balance performance were assessed at baseline, at the end of training and eight weeks after training.
RESULTS: Follow-up data were provided for 20 individuals. Eight weeks after training, statistically significant (p < 0.017)
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improvements were found in dorsiflexion ROM and most functional performance measures for both balance and PNF groups.
Eight weeks after training, significant (p < 0.017) improvements in the frontal plane balance test and pain were observed for the
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balance group.
CONCLUSIONS: Balance and PNF programs are recommended in clinical practice for improving ankle ROM and functional
performance in individuals with sprain. Balance programs are also recommended for pain relief.
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Keywords: Ankle sprain, proprioceptive training, range of motion, function, dynamic balance, pain
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1 1. Introduction support (bandage, brace or tape). Prognosis is typically 8

a decrease in disablement within two weeks [2]. Never- 9

2 Lateral ankle sprains are among the most common theless, a considerable number of these individuals re- 10

3 musculoskeletal injuries and account for 80% of total port residual symptoms and experience an insufficient 11

4 ankle injuries [1]. For most individuals, conventional recovery up to three years after the sprain, irrespective 12

5 treatment is the initial preferable strategy, comprising of the injury severity [2]. 13

6 early mobilization and weight-bearing of the ankle, Among residual symptoms, deficits in the functional 14

performance of daily activities are common up to 15

7 unsupervised exercises and sometimes use of external
18 months post-injury in generic clinic populations [3]. 16

For athletic populations, functional deficits have been 17

∗ Corresponding author: Lazaros Lazarou, 1, D. Ipatrou Street,

found up to two years after the sprain [4]. Furthermore, 18

Postal Code: 54634, Thessaloniki, Greece. Tel.: +30 6947560795; findings from a systematic review in 18 studies show 19

E-mail: lazaroslazarou@phed-sr.auth.gr. that 5% to 33% of conventionally treated sprains pro- 20

ISSN 1053-8127/17/$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 on ankle ROM, pain, functional and balance performance

21 duce pain one to three years post-injury [2]. One rea- ing participation in balance training and running activ- 72

22 son for the persistence of functional deficits and pain ities [15]. In addition, wobble board and strength ex- 73

23 may be limited ankle ROM. Limited dorsiflexion ROM ercises, mobilization techniques and cryotherapy were 74

24 is often apparent to individuals with conventionally able to reduce pain, but similar reduction in pain has 75

25 treated sprains [5,6], and without proper rehabilitation been reported following bandage support and immobi- 76

26 this may result in recurrent episodes of giving way and lization [16,17]. The effects of proprioceptive training 77

27 chronic ankle instability [7]. The risk for chronic an- on ankle ROM have not been investigated until now. 78

28 kle instability is also increased in individuals who ex- Proprioceptive neuromuscular facilitation (PNF) is 79

29 hibit poor balance performance [8], indicating the im- another proprioceptive training technique, which is de- 80

30 portance of proprioceptive training after the sprain. signed to stimulate proprioceptors and promote re- 81

31 For individuals with sprain, the high incidence of sponse of neuromuscular mechanisms [18]. The pat- 82

32 residual symptoms and the risk for developing chronic terns of PNF techniques emphasize multi-planar move- 83

33 ankle instability require identification of the optimal ment, and they have diagonal direction with goal to 84

34 approaches for rehabilitation. Systematic reviews re- stimulate functional movements through strengthen- 85

35 veal the benefits of supervised training for sprains [9, ing (facilitation) and relaxation (inhibition) of mus- 86

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36 10], and until now the effects of various programs cle groups [18]. Despite that PNF techniques are com- 87

37 have been investigated. Published clinical guidelines monly used in clinical practice, there is still limited re- 88

search evidence investigating effectiveness in ligament

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38 for sprains recommend participation in proprioceptive
training, which consists of balance activities and ex- injuries [19], whereas there is lack of studies concern- 90

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40 ercises promoting functional movements [11]. Propri- ing the rehabilitation of ankle sprains. Taking into con- 91

sideration that the application of PNF patterns is com- 92

41 oceptive training is thought to promote afferent sig-
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42 nals and sensory feedback from the ankle propriocep- parable to the performance of functional movement 93

tors to the central nervous system in order to improve patterns [18], it is suggested that PNF training may im- 94
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44 sensorimotor function and maintain orientation during prove functional and balance performance in individ- 95

45 activities [12]. Guideline recommendations, however, uals with sprain. Moreover, as PNF techniques have 96
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already been used in musculoskeletal rehabilitation in 97

46 are based on weak evidence, as relevant studies ex-
order to improve articular ROM and pain [20,21], they 98
47 hibit methodological limitations, including assessment
may also be capable of improving dorsiflexion ROM
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48 bias, poor description of sample characteristics and in-
and pain after the ankle sprain. 100
49 appropriate handling of missing data [11]. Moreover,
Although multi-component protocols are commonly 101
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50 the conclusions from a recent systematic review and

used for the rehabilitation of sprains, investigating one 102
51 meta-analysis in individuals with ankle ligament in-
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specific component, such as proprioceptive training, in 103

52 juries, such as sprain and chronic instability, underline
a controlled research setting will enable us to reveal 104
53 that proprioceptive exercises may improve functional
effectiveness of a single approach. Since propriocep- 105
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54 outcomes, but there is no consensus on using proprio-

tive training alone has the potential to improve multiple 106
55 ceptive exercises to improve balance performance [12]. deficits after the sprain, this could save time for both 107
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56 The reviewers mention that until now there are no stud- therapists and sprained individuals. Balance training 108
57 ies investigating effectiveness of proprioceptive exer- has already been established in literature as the most 109
58 cises on ankle ROM, and point out the need for fur- commonly used protocol of proprioceptive training for 110
59 ther research into the effects of different proprioceptive sprains [13–17]. In this context, it would be beneficial 111
60 training programs in individuals with ankle sprain and to compare the effectiveness of balance and PNF train- 112
61 chronic instability [12]. ing for the first time. Hence, the objectives of this study 113
62 For individuals with ankle sprain, there is limited ev- were to investigate the effects of two supervised bal- 114
63 idence for effectiveness of proprioceptive training pro- ance and PNF training programs on dorsiflexion ROM, 115
64 grams, and in relevant studies investigators have uti- pain, functional and balance performance in individu- 116
65 lized multi-component rehabilitation protocols, includ- als with ankle sprain. 117
66 ing balance training. In particular, a rehabilitation pro-
67 tocol that consisted of balance and strength training,
68 stretching and running activities was capable of im- 2. Methods 118

69 proving functional performance [13]. Balance perfor-

70 mance has also been improved following participation The present study was undertaken in accordance 119

71 in balance and strength training [14], but not follow- with the principles outlined in the Declaration of 120
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L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance 3

121 Helsinki and it was prospectively registered at a clini- sent form. Anthropometric and demographic data and 170

122 cal trial registry (ID: NCT01853462). The design was sports activity level were also collected for each partic- 171

123 randomized group, pre-post treatment, with a blinded ipant. 172

124 assessor. Two intervention groups, balance and PNF, were 173

included. Group allocation was random and it was 174

125 2.1. Participants performed by an independent statistician, blinded to 175

the study’s objectives, with a computer program (R 176

126 A total of 34 individuals who were referred to a software 3.1.2, blockrand package). Stratified random- 177

127 physiotherapy center for ankle sprain rehabilitation ization was utilized, ensuring that balance and PNF 178

128 were initially invited to participate. They had sus- groups were balanced for gender, history of sprain to 179

129 tained a post-acute sprain to the ankle and experienced the injured ankle and sports activity level. High level 180

130 pain in the performance of functional or sports ac- was considered as participation in sports for more than 181

131 tivities. To be included, it was required that the in- 3 hours per week [22]. After commencement of the 182

132 dividuals were 18 to 40 years, with a clinical diag- study, two participants discontinued training, and 20 183

133 nosis of ankle sprain by an orthopedic specialist, and participants completed the intervention. An articula- 184

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134 their sprain had been conventionally treated. Individ- tion of participant flow is shown in Fig. 1. 185

135 uals with grade III sprains were excluded. Individu-

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136 als who had sustained a sprain to the medial ligaments 2.2. Testing procedures 186

or the interosseous (syndesmotic) ankle ligament were

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138 not included. Additional exclusion criteria were: con- Assessment was performed in a private research lab-
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139 current fracture, chronic ankle instability, history of an- oratory by a blinded investigator, who is physical ther- 188

140 kle surgery, lower limb nerve injuries and further an- apist with more than 10 years experience in the assess- 189

kle injuries after the sprain. Individuals with any in- ment and treatment of ankle sprains. The blinded in-
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141 190

142 juries that hindered participation in training were not vestigator was unaware to participants’ group alloca- 191

included. tion. In order to decrease the effects of fatigue on test- 192

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143

144 The eligibility criteria of the study were initially ing procedures, functional performance was assessed 193

145 screened by the principal investigator, via an interview. last. Each session lasted approximately one hour. Mea- 194
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146 In addition, all prospective participants were instructed sures were recorded at baseline, at the end of training 195

147 to show for consideration any relevant documentation (follow-up 1) and eight weeks after training (follow-up 196
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148 to the clinical diagnosis of the sprain and the results 2). 197

149 of diagnostic testing, such as radiographs, ultrasonog-

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150 raphy or magnetic resonance imaging, in order to con- 2.2.1. Pain 198

151 firm the grade and the ankle ligaments affected. An The Greek version of the short form of the McGill 199
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152 orthopedic specialist confirmed suitability for partici- Pain Questionnaire (GR-SFMPQ) was used to assess 200

153 pation and obtained a thorough medical history of the pain experience. Specifically, participants rated: i) pain 201
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154 ankle sprain, including information concerning the ae- sensation, on a 4-point scale, for 15 descriptive adjec- 202

155 tiology and mechanism of injury, conventional treat- tives – the Pain Rating Index (PRI), ii) average pain in- 203

156 ment of choice and symptoms. The principal investi- tensity during the week before testing, on a visual ana- 204

157 gator also performed a physical examination, includ- logue scale (VAS) and iii) present pain, on a 5-point 205

158 ing palpation of bony and ligamentous structures of verbal scale, the Present Pain Index (PPI). The GR- 206

159 the ankle and assessment for the presence of ligament SFMPQ fulfills the criteria of reliability and sensitivity 207

160 laxity, swelling, hemorrhaging and tenderness. Ankle to pain fluctuations [23]. 208

161 ROM and strength were also checked manually, in

162 comparison to the uninjured ankle. During screening 2.2.2. Dorsiflexion range of motion 209

163 procedure, the investigators were unaware of the group Measurements were taken at the sprained ankle, 210

164 the next participant would be allocated to and hence, with a goniometer (Baseline; Irvington, NY). During 211

165 concealed allocation was achieved. Of the 34 initially testing, participants were in long sitting, on examina- 212

166 invited individuals with ankle sprains, 12 individuals tion table, with the ankle and foot suspended over the 213

167 were not eligible to participate. The rest 22 participants end of the table and the subtalar joint in neutral po- 214

168 received written information sheets and verbal expla- sition. Participants were instructed to actively dorsi- 215

169 nations for the study. Afterwards, they signed a con- flex the ankle, as far as comfortable, without pain. The 216
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4 L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance

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Fig. 1. Study flowchart.

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axis of the goniometer was placed just distal to the lat- lowed, with open eyes, at medium (4 out of 8) stabil-
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217 237

218 eral malleolus, the stationary arm was aligned with the ity level, without footwear [25], and the mean score 238

219 head of fibula and the movable arm was aligned par- was used for the analysis. During testing, the oppo- 239
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220 allel to the plantar aspect of the calcaneus and fifth site leg was flexed off the platform, and the arms were 240

221 metatarsal [11]. Measurements were recorded in de- at the side (Fig. 2). Between trials, 2 min resting was 241
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222 grees, and the mean score of three measurements was included [17]. For BSS balance measurements, intrat- 242

223 computed. This testing method has shown intra-rater ester reliability has demonstrated intra-class correla- 243

224 reliability measures greater than 0.90 [24]. tion coefficients (ICCs) between 0.82 and 0.43 for the 244

SI [26]. 245

225 2.2.3. Balance performance

226 A moveable tilting platform, the Biodex Stability 2.2.4. Functional performance 246

227 System (BSS; Shirley, NY), was used to record in Two tests, rising on heel and rising on toes were used 247

228 degrees the Stability Index (SI), which was the de- to assess endurance of the ankle dorsiflexor and plantar 248

229 pendent variable and corresponded to the variance of flexor muscles, respectively. For the rising on heel test, 249

230 the foot platform displacement. The SI was measured participants were instructed to rise, as many times as 250

231 in single-leg stance, for the sprained ankle, for mo- possible, on the heel of the sprained leg. A pace of 60 251

232 tions: in the saggital plane (anterior-posterior SI), the beats per min was maintained by a metronome. Dur- 252

233 frontal plane (medial-lateral SI), and overall (overall ing testing, which was performed without footwear, the 253

234 SI). Low SI scores indicated increased stability and opposite knee was approximately at 90◦ flexion. A rise 254

235 high SI scores decreased stability. An adaptation 15 sec was registered since toes had attained 1 cm movement. 255

236 trial was initially performed. Three trials of 20 sec fol- In cases of lost balance, balance was regained and the 256
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L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance 5

Fig. 4. Single-leg hop for distance test.

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Fig. 2. Balance performance testing.

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Fig. 5. Single-leg hops for time test.

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pants covered as fast as possible a six-meter distance, 271

with the sprained leg, using single-leg hops, and the 272
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trial was timed (Fig. 5). For the distance and time tests, 273

all participants performed three maximal attempts with

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274

complete stabilization after landing, and no faults trials 275

were recorded. For each test, the mean score of three 276
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trials was calculated. Participants rested for 30 sec be- 277

tween trials and 45 sec between tests. For the distance 278
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Fig. 3. Rising on heel and rising on toes tests. test, intra-class correlation coefficients range from 0.84 279

to 0.99, and or the time test they are between 0.66 and 280

257 performance continued. Rising on toes was also tested 0.77 [28]. Prior to functional performance testing, par- 281

258 for the sprained leg, analogically (Fig. 3). For each ticipants warmed up for 5 min. 282

259 test, participants scored 10 points for over 40 rises, five

260 points for 30–39 rises and zero points for less than 30 2.3. Training procedures 283

261 rises. These tests are valid, and exhibit excellent re-
262 producibility (Pearson correlation coefficients: 0.84– All participants received 10 training sessions, super- 284

263 0.99) [27]. vised by the same physical therapist, at a private re- 285

264 Ankle functional stability was assessed with two habilitation center, within a six-week period. The du- 286

265 tests: single-leg hop for distance and single-leg hops ration of each session was 50 to 60 min. Participants 287

266 for time, with footwear on. For the distance test, par- were instructed to discontinue a session in cases of sig- 288

267 ticipants were instructed to hop, using the sprained leg, nificant pain or fatigue. For the balance group, the de- 289

268 as far forward as possible, with free arms, and remain signed protocol reflects clinical guidelines for the re- 290

269 in the landing position for 2 sec (Fig. 4). The hopping habilitation of sprains [29]. The balance training pro- 291

270 distance was then measured. For the time test, partici- tocol is presented in Table 1. Balance activities were 292
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6 L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance

Table 1
Balance training protocol
Training Exercise Details
Balance on wobble board Move back to front, both legs Duration: 2 min, no rest
Move right to left, both legs Duration: 2 min, no rest
Move in circle, both legs Duration: 3 min, no rest
Sprained-leg stance Duration: 15 sec/trial,16 trials, 30 sec rest after 4 trials
Balance on firm surface Sprained-leg squat, squat depth as tolerated Duration: 6 sec/trial, 40 trials, 30 sec rest after 8 trials
Sprained-leg distance hop series, in front, right, left, 6 hops/trial, pause to balance after each hop: 5 sec, 8
diagonal right and left patterns trials, 30 sec rest after each trial, with footwear on
Balance on soft surface Sprained-leg stance, resistance-band exercises with Duration: 15 sec/trial, 16 trials, 30 sec rest after 4 tri-
the opposite leg als

Table 2
293 performed without footwear, apart from the hopping Characteristics of participants in the balance and PNF groups
294 activities. Rest periods of 60 sec and 2 min were pro-
Balance PNF
295 vided after each exercise and between different train- (n = 10) (n = 10)
296 ing types, respectively. Gender, females/males 7/3 7/3

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297 For the PNF group, two different techniques, rhyth- Sprain history to the injured ankle 5 5
298 mic stabilization (RS) and combination of isotonics Sports activity level 5 High 5 High

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Ankle injured, right/left 9/1 8/2
299 (COI) [20] were applied to the sprained leg of partic- Time since sprain∗ (months) 2.6 (1.2) 3.0 (0.9)
ipants, who were positioned in supine, on a physical

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300 Age∗ (years) 22 (1.8) 22 (3.8)
301 therapy table, facing the therapist. Each PNF technique Height∗ (cm) 174 (13) 172 (8)
Body mass∗ (kg) 76 (14) 68 (9)
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302 was applied for both lower extremity diagonals, at the
∗ Means (SD).
303 end of the upper and lower diagonal’s range, with the
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304 knee in extension. During application, timing for em-

305 phasis was implemented for the ankle and foot, and 2.4. Statistical analysis 332
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306 the therapist resisted against the occurrence of hip and

The non-parametric Friedman test was used to de- 333
307 knee motions. The therapist’s hands were placed ac-
termine the within-group differences for all outcome 334
cording to PNF principles, depending on the technique
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308
variables across time points, with a two-tailed signifi- 335
309 and diagonal pattern under application. Maximal resis-
cance level of α = 0.05. For the significant results, post 336
310 tance was provided, in conformity with each individ-
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hoc Wilcoxon signed-rank tests were performed for all 337

311 ual’s needs.
time combinations (baseline to follow-up 1, baseline 338
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312 The RS protocol comprised alternating isometric

to follow-up 2, follow-up 1 to follow-up 2), and the 339
313 contractions for 10 sec, with no intended motion [20].
α level was set at 0.017, following Bonferroni adjust- 340
314 The COI protocol included combined concentric, sta-
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ment. The between-group differences were examined 341

315 bilizing and eccentric contractions of the agonistic with the Mann Whitney U test, at α = 0.05, two-tailed, 342
316 muscles, without relaxation, for 15 sec; the duration of
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after standardization of data against time. Standardiza- 343

317 each contraction was 5 sec [20]. Training consisted of 5 tion of data was performed via the calculation of dif- 344
318 to 15 repetitions per set, depending on the exercise tol- ference scores: follow-up 1 – baseline, follow-up 2 – 345
319 erance of each individual [29]. Between the sets, 30 sec baseline, follow-up 2 – follow-up 1, for each group and 346
320 rest was included [20]. The RS protocol was performed all outcome variables. Post hoc effect sizes were com- 347
321 first and the COI protocol followed, after 2 min rest. puted for all within- and between-group differences. 348
322 Each protocol lasted approximately 20 min, including The SPSS 21.0 and G∗ Power programs was used for 349

323 rest intervals. Prior to the application of each proto- the analyses. 350

324 col, instructions were provided regarding the correct

325 performance of the pattern and maximal effort was re-
326 quired for all repetitions. At the end of each session, 3. Results 351

327 for both groups, training included forward and back-

328 ward walking on toes and heels for 4 min, with 60 sec Participants’ characteristics are displayed in Table 2; 352

329 of in-between rest. During the study, participants were these were similar for the balance and PNF groups. At 353

330 instructed to refrain from any form of additional super- baseline, no significant (p > 0.05) differences were 354

331 vised training. found between the two groups for all study outcomes. 355
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L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance 7

Table 3
Balance group scores and Friedman test’s results for each outcome measure
Baseline Follow-up 1 Follow-up 2 X2 value (df)
PRI (0–45) 6 (3) 1 (1) 1 (1) 18.8 (2)∗
VAS (0–10) 2.8 (2.1) 1.1 (1.3) 0.5 (0.7) 10.1 (2)∗
PPI (0–5) 1 (0,2) 0 (0,1) 0 (0,1) 13.0 (2)∗
DF ROM (degrees) 8 (2) 15 (2) 15 (1) 15.2 (2)∗
Ant-post SI (degrees) 3.1 (0.6) 3.0 (0.7) 3.1 (0.7) 0.5 (2)
Med-lat SI (degrees) 1.9 (0.4) 2.0 (0.5) 1.5 (0.3) 10.4 (2)∗
Overall SI (degrees) 3.6 (0.8) 3.4 (0.5) 3.4 (0.6) 3.1 (2)
Rising on heel 5 (0,10) 10 (5,10) 10 (5,10) 13.5 (2)∗
Rising on toes 0 (0,0) 7.5 (0,10) 7.5 (0,10) 13.2 (2)∗
Total rises 5 (0,10) 15 (5,20) 15 (5,20) 14.7 (2)∗
Distance hop (cm) 82.8 (19.5) 101.4 (29.8) 110.0 (30.5) 18.2 (2)∗
Time hops (sec) 3.3 (0.4) 2.7 (0.4) 2.2 (0.4) 14.6 (2)∗
At baseline, follow-up 1 and follow-up 2, means (SD) are reported, except to the PPI, rising on heel, rising on toes and total rises ordinal
data for which median scores (minimum, maximum) are reported; ∗ significant difference (p < 0.05); PRI: Pain Rating Index, VAS: Visual
Analogue Scale, PPI: Present Pain Index, DF ROM: Dorsiflexion Range of Motion, Ant-post SI: Anterior-posterior Stability Index, Med-lat SI:

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Medial-lateral Stability Index.

Table 4

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PNF group scores and Friedman test’s results for each outcome measure

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Baseline Follow-up 1 Follow-up 2 X2 value (df)
PRI (0–45) 7 (4) 1 (1) 4 (3) 16.6 (2)∗
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VAS (0–10) 2.0 (1.6) 0.4 (0.4) 1.3 (1.0) 12.4 (2)∗
PPI (0–5)∗ 1 (0,2) 0 (0,1) 1 (0,2) 9.9 (2)∗
DF ROM (degrees) 7 (3) 13 (3) 15 (2) 12.4 (2)∗
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Ant-post SI (degrees) 2.6 (0.6) 2.6 (0.3) 2.5 (0.4) 0.4 (2)
Med-lat SI (degrees) 1.9 (0.5) 1.7 (0.5) 1.6 (0.4) 1.1 (2)
Overall SI (degrees) 3.1 (0.7) 3.0 (0.6) 2.9 (0.6) 2.3 (2)
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Rising on heel 0 (0,10) 10 (5,10) 7.5 (0,10) 11.4 (2)∗

Rising on toes 0 (0,0) 5 (0,10) 7.5 (0,10) 12.9 (2)∗
12.4 (2)∗
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Total rises 0 (0,10) 15 (5,20) 15 (0,20)

Distance hop (cm) 65.6 (17.0) 100.3 (17.0) 77.0 (17.6) 12.6 (2)∗
Time hops (sec) 2.9 (0.6) 2.1 (0.2) 2.1 (0.3) 15.2 (2)∗
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At baseline, follow-up 1 and follow-up 2, means (SD) are reported, except to the PPI, rising on heel, rising on toes and total rises ordinal
data for which median scores (minimum, maximum) are reported; ∗ significant difference (p < 0.05); PRI: Pain Rating Index, VAS: Visual
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Analogue Scale, PPI: Present Pain Index, DF ROM: Dorsiflexion Range of Motion, Ant-post SI: Anterior-posterior Stability Index, Med-lat SI:
Medial-lateral Stability Index.
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356 For each outcome, baseline, follow-up 1, follow-up 2 changed across time (p = 0.83, p = 0.57 and p = 374

357 scores, and results of Friedman test across assessment 0.32); the effect sizes were r < 0.30. For pain mea- 375
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358 time points, for the balance and PNF groups, are pro- sures, results of post-hoc tests showed that baseline 376

359 vided in Tables 3 and 4. PRI and VAS scores of the PNF group were signifi- 377

360 Table 3 shows significant (p < 0.05) improve- cantly improved at follow-up 1 assessment (PRI: p = 378

361 ment for the balance group in most outcome measures, 0.005, r = 0.63; VAS: p = 0.008, r = 0.60), but 379

362 across time. Post-hoc data analysis confirmed that sig- not at follow-up 2 assessment (PRI: p = 0.020, r = 380

363 nificant (p < 0.017) improvement was observed at 0.52; VAS: p = 0.515, r = 0.15). For the PPI scores, 381

364 most follow-up 1 and follow-up 2 assessments, against despite that results of the Friedman test were signif- 382

365 baseline. The effect sizes ranged from r = 0.54 to 0.63. icant (p < 0.05), post-hoc changes against baseline 383

366 For the balance group, solely the baseline anterior- lacked significance for both follow-up 1 (p = 0.020, 384

367 posterior and overall SI scores were not significantly r = 0.52) and follow-up 2 assessments (p = 1.000, 385

368 changed across time (p = 0.79 and p = 0.21); the ef- r = 0.00). For dorsiflexion ROM, significant improve- 386

369 fect sizes ranged from r = 0.05 to r = 0.29. ment against baseline was found for the PNF group 387

370 For the PNF group, Table 4 shows significant (p < at follow-up 1 assessment (p = 0.009, r = 0.58) and 388

371 0.05) improvement in most outcome measures, across follow-up 2 assessment (p = 0.007, r = 0.60). 389

372 time. However, baseline anterior-posterior, medial- For the functional performance measures of the PNF 390

373 lateral and overall SI scores were not significantly group, post-hoc analysis showed that significant (p < 391
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8 L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance

392 0.017) improvement against baseline scores was found body’s inhibitory reflexes to induce relaxation of mus- 440

393 for rising on toes, total rises and time hops tests at cles [18]. Muscle relaxation has probably promoted in- 441

394 both follow-up 1 and follow-up 2 assessments. The ef- creased stretch magnitudes during application in our 442

395 fect sizes were between r = 0.55 and r = 0.64. For study, resulting in the ROM gains observed. To our 443

396 the rising on heel test, baseline scores were signifi- knowledge, this is the first study investigating the ef- 444

397 cantly improved at follow-up 1 assessment (p = 0.006, fects of proprioceptive training on ROM following an- 445

398 r = 0.61), but not at follow-up 2 assessment (p = kle sprain. 446

399 0.114, r = 0.35). For the distance hop test, significant In our findings, most functional performance mea- 447

400 (p < 0.017) improvement against baseline was shown sures significantly improved eight weeks after training 448

401 at follow-up 1 assessment (p = 0.005, r = 0.63), but for both balance and PNF groups (Tables 3 and 4). For 449

402 not at follow-up 2 assessment (p = 0.203 r = 0.29). individuals with ankle sprain, significant functional 450

403 In terms of the between-group differences, most improvement has also been found following participa- 451

404 comparisons against baseline lacked significance (p > tion in 10 sessions of balance and strength training, 452

405 0.05). The effect sizes were r < 0.41, with observed stretching and running activities [13]. These findings 453

406 power 6 68%. For the PPI scores, however, the dif- support our results; in opposition to our study however, 454

on
407 ference shown at follow-up 2, compared to baseline, balance training was solely one component of the re- 455

408 was significantly better for the balance group (p = habilitation protocol [13]. The effects of PNF training 456

si
409 0.02, r = 0.54). For the distance hop test, the improve- have been investigated in individuals with chronic an- 457

ment found for both groups at follow-up 1, compared kle instability, and no significant functional gains were

er
410 458

411 to baseline, was significantly better for the PNF group demonstrated, compared to no exercise [19]. In our
fv 459

412 (p = 0.049, r = 0.44). study, we found functional gains, which could be at- 460

tributed to the fact that the applied PNF program fo- 461

cused on entire lower extremity, and not just the an-

oo
462

413 4. Discussion kle, as occurred in the chronic instability study [19]. 463

It seems that PNF training incorporating knee and hip 464

pr

414 The main finding of this study is that for individuals neuromuscular control strategies is required in order 465

415 with ankle sprain both balance and PNF groups signifi- to achieve significant functional improvement. In our 466
ed

416 cantly improved dorsiflexion ROM and most measures study, measures in heel rises and distance hop tests 467

417 of functional performance eight weeks after training. were significantly improved eight weeks after training 468
ct

418 Eight weeks after training, solely the balance group solely for the balance group. This may be justified by 469

419 significantly improved performance in frontal plane the specificity of the balance protocol, which included 470
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420 balance test and reported significant reduction in pain. heel rising activities on wobble board and firm surfaces 471

421 For all significant improvements, the effect sizes were and distance hop tasks in various directions (Table 1). 472
co

422 large, indicating clinical significance. In our study, ten 50–60 min sessions of propriocep- 473

423 In our study, participants exhibited limited dorsiflex- tive training produced no significant changes in most 474
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424 ion ROM at baseline. As shown in Tables 3 and 4, measures of balance performance, for both groups (Ta- 475

425 dorsiflexion means for the balance and PNF groups bles 3 and 4). For the balance group, nevertheless, 476

426 were 8 and 7 degrees. After training, normal dorsiflex- significant improvement was observed in the frontal 477

427 ion ROM means were recorded, for both groups (Bal- plane balance test, eight weeks after training. In rela- 478

428 ance: 15 degrees; PNF: 13 to 15 degrees). The signifi- tion to these results, negative findings on balance per- 479

429 cant ROM gains, observed in our results, could be at- formance have been demonstrated in individuals with 480

430 tributed to the specific proprioceptive training proto- acute sprain, four months post-injury, following partic- 481

431 cols utilized. In particular, the balance program in- ipation in balance training and running activities [15]. 482

432 cluded wobble board activities. As the deflection angle In opposition to our protocol, however, the effects of 483

433 of the board utilized is 22 degrees (Thera-Band; Akron, training were assessed in comparison to the uninjured 484

434 Ohio), backward board’s tilts should have produced side, and baseline measurements were not performed 485

435 dynamic stretching of the ankle plantar flexor mus- owing to the acute phase of the sprain [15]. Further- 486

436 cles, and hence dorsiflexion ROM was improved for more, 18 sessions of strength and balance training (du- 487

437 the balance group. Moreover, PNF techniques were ap- ration: 10 min per session) caused significant gains on 488

438 plied against resistance at maximal, non-painful ROM. dynamic balance measures in three individuals under 489

439 It is suggested that PNF techniques are able to activate 18 years of age, with post-acute ankle sprain [14]. Di- 490
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L. Lazarou et al. / Effects of two proprioceptive training programs on ankle ROM, pain, functional and balance performance 9

491 rect comparisons with our findings may be attempted PNF groups against baseline were not significant and 542

492 with caution, due to differences in the type and dura- the observed power was 6 68%. The power values ob- 543

493 tion training and participants’ age. served in our study are less than the convention of 80% 544

494 Balance performance in our study was assessed in power, which is proposed for general use [30], suggest- 545

495 single-leg stance on a tilting platform of medium sta- ing that a type II error might have occurred. Between- 546

496 bility. The applied proprioceptive training programs, group differences would have more precisely been es- 547

497 however, included a small number of weight-bearing timated with a larger sample. However, in our study the 548

498 exercises using solely the injured leg, and this was the effect sizes of all significant within-group differences 549

499 case for the balance program. This is a possible reason were large, indicating significance of findings in clin- 550

500 for the significant recordings in the frontal plane bal- ical practice. Generalization of these findings in ath- 551

501 ance test, found eight weeks after training for the bal- letic populations may be attempted with caution, as our 552

502 ance group. On the contrary, application of PNF exer- sample comprised participants with both high (n = 10) 553

503 cises in non-weight bearing positions under static con- and low (n = 10) level of sports activity. 554

504 ditions may have resulted in the non significant find-

505 ings observed for the PNF group. Our findings suggest

on
506 that balance protocols may be beneficial after sprains 5. Conclusion 555

507 for improving measures of balance performance on

si
508 unstable surfaces; however, these balance protocols This study shows that both balance and PNF pro- 556

should contain a considerable number of dynamic ex- grams resulted in clinically significant improvements 557

er
509

510 ercises in sprained-leg stance. The PNF protocols are in dorsiflexion ROM and most functional performance 558

measures in individuals with ankle sprain, eight weeks

511 not recommended for improving balance performance
fv 559

512 in ankle sprains. after training. The balance program also caused clin- 560

In our study, solely the balance group reported sig- ically significant improvements in frontal plane bal- 561
oo
513

514 nificant reduction in pain eight weeks after training ance test and pain, eight weeks after training. The PNF 562

515 for all GR-SFMPQ components (Tables 3 and 4). For program was not capable of improving balance perfor- 563
pr

516 ankle sprains, effectiveness on pain has been investi- mance and pain, eight weeks after training. For future 564

517 gated for rehabilitation programs that comprised wob- studies, long-term effectiveness of balance and PNF 565
ed

518 ble board training, mobilization techniques, cryother- training programs in ankle sprains is worth investigat- 566

519 apy [16,17] and strengthening exercises [17]. Findings ing. 567
ct

520 showed significant reduction in pain following rehabil-

521 itation; nevertheless, similar pain reduction was also
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522 found following bandage support [16,17] and immobi- Conflict of interest 568

523 lization [16], indicating that pain relief may have re-
None to report.
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569
524 sulted from natural sprain’s recovery. In opposition to
525 these multi-component rehabilitation programs, which
un

526 were initiated at the acute phase of the injury, we ap-

527 plied post-acute (2.6 to 3.0 months after sprain; Ta- References 570

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