493461

research-article2013
FASXXX10.1177/1938640013493461Foot & Ankle SpecialistMONTH MONTH XXXXvol. X no. XFoot & Ankle Specialist

346 Foot & Ankle Specialist October 2013

Clinical Research
Aquatic Training for Ankle Gioftsidou Asimenia, PhD, Malliou

Instability
Paraskevi, PhD, Sofokleous Polina, MsC,
Beneka Anastasia, PhD, Tsapralis Kyriakos,
PhD, and Godolias Georgios, PhD

Abstract: The aim of the present study The present study indicates that the after an ankle sprain in approximately
was to evaluate balance deficits after performance of balance exercises in or 40% of injured persons.5
an ankle sprain in collegiate students out of water by collegiate students with It is believed that ankle proprioception
and to examine the effectiveness of functional ankle instability improves is critical to the balance of the human
2 different balance rehabilitation their balance ability. body during functional activities such as
programs on balance ability. Thirty standing, walking, and running.6,7
Level of Evidence: Therapeutic, Level 1
collegiate students with functional Subjects with FAI showed impaired
ankle instability were randomly Keywords: aquatic training; ankle; postural stability, decreased
divided into 2 groups. Both groups balance; ankle instability; ankle proprioception, and altered peripheral
followed an intervention balance rehabilitation control of ankle muscle function when
program for 6 weeks, 3 times per compared with nonimpaired subjects.8-10
week, 20 minutes per session, using In particular, damage to the
balance boards. One of the 2 training Introduction proprioception system is thought to be

groups performed the exercises on The human ankle joint
the groundthe Land group (n = is one of the most
15), and the other in a swimming frequently injured joints
poolthe Aquatic group (n = 15). in the human body, with . . . ankle proprioception is critical to
Balance ability was assessed before lateral ligament sprains
and after the 6-week intervention being the most common
the balance of the human body during
program. Balance assessments type of ankle injury.1,2 functional activities such as standing,
included static (stability indices: total, Following initial sprain,
anteriorposterior, mediallateral) the development of walking, and running.
and dynamic (dynamic moving the residual symptoms are
cursor) stability tests on the Biodex common.3 Two of the
Stability System (Biodex, Inc, Shirley, most frequently
NY). The results showed that in both encountered residual symptoms include the major cause of functional instability
training groups balance ability of the reported episodes of giving way and after ankle injuries. Many studies
injured leg was significantly improved feelings of ankle joint instability. Persons concluded that exercise rehabilitation
after the training period. In the who describe the presence of both these programs resulted in retraining
final measurements, no statistically symptoms are considered to have proprioceptive deficits associated with
significant differences between the functional instability.4 It is reported that FAI, such as using multiaxial platforms or
injured and healthy limb were found. functional ankle instability (FAI) occurs wobble boards.11-13

DOI: 10.1177/1938640013493461. From the Department of Physical Education and Sports Science, Democritus University of Thrace, Komotini, Greece (GA, MP,
SP, BA, GG) and Isokinetic Medical Center, Bologna, Italy (TK). Address correspondence to Asimenia Gioftsidou, Department of Physical Education and Sports Sciences,
Democritus University of Thrace, Campus, 69100 Komotini, Greece; e-mail: agioftsi@phyed.duth.gr.

For reprints and permissions queries, please visit SAGEs Web site at http://www.sagepub.com/journalsPermissions.nav.
Copyright 2013 The Author(s)
vol. 6 / no. 5
The wobble board has been commonly
used by athletic trainers and physicians
in rehabilitation after ankle injuries. It is
designed to aid in reeducating the
proprioceptive system by improving
mechanoreceptor function and restoring
normal neuromuscular coordination.8,14,15
Traditionally, balance training has
involved single-limb stance activities on
stable and unstable surfaces.16-18
On the other hand, aquatic training has
been adequately studied in healthy
people and people with knee or hip
osteoarthritis with mostly positive results
on mobility,19-21 muscle strength,19-22 or
muscle mass.22 Although it has been
recognized that the pool can be a safe
environment used not only at the first
stage of musculoskeletal injuries
rehabilitation (anterior cruciate ligament,
medial collateral ligament) but also for
the rehabilitation of chronic
musculoskeletal disease, such as knee
osteoarthritis,21 its use for functional
ankle instability is limited.
When using the pool environment for
lower limb training, subjects try to stand
in the water and maintain a stable
upright stance over the base of support,
while water movement and turbulence
play an important role by overloading
the postural control systems especially
during one-leg stance.23 Although
water-based training is a non-weight-
bearing condition for the joints, keeping
balance is a difficult task because of the
turbulence produced in the water.
The purpose of this study was to (a)
detect functional deficits after an ankle
sprain in collegiate students and (b)
examine the effectiveness of 2 different
rehabilitation programs (the first
performed on land and the second in a
pool environment) on balance ability in
collegiate students.
Methods
Subjects
The participants in this study were 30
physically active collegiate students who
volunteered to participate in this study.
Their age ranged from 20 to 22 years
(M = 20.58 years, SD = 0.64); 16 of them
were male and 14 were female.
Physically active meant participating in
exercise (ie, walking, swimming, weight
training, jogging, or participating in
sports at the recreational or varsity level)
at least twice each week.
All participants had one functionally
unstable ankle. To be characterized as
functionally unstable, the participants
satisfied the following criteria: (a) at least
one repeated injury or perception of
ankle instability or giving away in the
unstable ankle; (b) no evidence of
mechanical instability as assessed by an
orthopaedic doctor using anterior drawer
test; and (c) pain-free, full weight
bearing, and normal gait at the time of
study. The average time period since the
last episode of instability and injury was
2 months.
Exclusion criteria for the participants
included a history of lower extremity
surgery or fracture, joint swelling, or any
systemic disease that might interfere with
sensory input. The experimental
procedures were in accordance with
ethical standards of the Committee on
Human Experimentation at the institution
where the work was conducted and with
the Helsinki Declaration of 1975.
Participants were randomized using
computer-generated numbers into 2
different training groups: 1Land
Training, Land and 2Aquatic Training,
Aquatic.
Prior to any testing informed consent
was obtained from all participants.
Equipment and Instruments
The balance ability assessment was
performed with the Biodex Stability
System (Biodex, Inc, Shirley, NY),24
which comprises a multiaxial foot
platform connected to a computer and a
screen located in front of the subject.
The magnitude and direction of the
displacements of the tilting platform can
be monitored with the help of a cursor
moving on the screen. The multiaxial
platform is free to move about the
anteriorposterior and mediallateral
axes simultaneously. The Biodex Stability
System offers several levels of difficulty
from L1 (most difficult) to L8 (least
Foot & Ankle Specialist 347
difficult), which determines the rate of
deflection of the platform. Springs apply
this force to the underside of the
platform and can be adjusted to preset
resistances established by the
manufacturer. Rather than measuring the
deviation of the center of pressure
during static conditions, this device
measures the degree of tilt about each
axis during dynamic conditions. Thus,
the Biodex Stability System appears to
provide more specific information on
ankle joint movements.25
Procedure for Completing the
Balance Ability Assessment
Participants Preparation.The subjects
stood on the Biodex Stability system on
one leg. They were allowed to flex the
support knee to no more than 10 but
were required to maintain an upright
posture with the supporting leg. Addi-
tionally, participants were instructed to
keep their hands at their sides and to
maintain a comfortable knee angle with
the unsupported leg during testing. Once
in this position, the stability platform was
unlocked to allow motion. The partici-
pants were then instructed to adjust the
supporting foot position until they found
a position at which they could maintain
platform stability. This was done to estab-
lish the participants ideal foot position-
ing for testing. The platform was then
locked, and participants were told to
maintain the foot position. This position
was used for testing. During the tests,
subjects were instructed to avoid touch-
ing the ground.
Testing Protocols
1. Static balance test. The testing
protocol consisted of a single 20-second
test, while the platform (Figure 1) was
set to freely move with the minimal
resistance available (level 1).
Participants focus on the visual
feedback screen (Figure 2) directly in
front of them and attempt to maintain
the cursor depicting the position of
the body center of mass at the center
of the bulls-eye on the screen as long
as 20 seconds. From the magnitude
and duration of these deviations, total
348 Foot & Ankle Specialist
Figure. 1.
The platform of the Biodex Stability
System.
Figure 2.
Biodex system screen, where
participants attempt to keep the
cursor at the center of the bulls-eye.
stability index, an anteriorposterior
index, and a mediallateral index were
computed by the system. The subjects
performed three 20-second practice
trials and three 20-second test trials out
of which only the best score was further
processed.
2. Dynamic balance test. The testing
protocol consisted of moving the cursor
(platform) back and forth from a central
box to 5 peripheral boxes appearing
successively in a random order on the
screen (Figure 3). In the present study,
subjects were tested at the difficulty level
4. After the auditory countdown, the
subject was instructed to start moving
the cursor toward the flashing target. The
cursor had to stay within the target box
for a minimum of 0.5 seconds before it
disappeared and showed the next target
on the screen.26 Each trial ended when
the fifth target boxes had been reached
and the cursor repositioned in the central
Figure 3.
Biodex system screen, where
participants attempt to move the
cursor to the flashing target.
box, and the time recorded. The subjects
performed 3 practice trials and 3 test
trials out of which only the best score
the best timewas further processed.
Balance ability was assessed before and
after the 6-week intervention program.
Procedures for the Balance
Training Program
Subjects were randomly assigned to 1 of
the 2 training groupsLand and
Aquaticand performed the same type
of balance exercises for 6 weeks, 3 times
per week. Both training groups performed
a 20-minute training program (45 seconds
exercise and 15 seconds rest), with 5 dif-
ferent exercises performed (a) on a hard
balance board and (b) on air disk, with
2 repetitions for each exercise (5 exercise
2 boards 2 repetitions). The first exper-
imental group, the Land group (n = 15),
performed the rehabilitation program on
land and the second experimental group
the Aquatic group (n = 15), performed
the same rehabilitation program in a swim-
ming pool (detailed in Table 1).
Statistical Analysis
Analysis of variance (both one-way and
repeated-measures) was used to
determine possible statistically significant
differences among measurements, among
the experimental groups, and among the
injured and noninjured lower limbs.
October 2013
Results
According to the results, analysis of
variance (one-way) initial measurements
revealed differences in all balance
performance indicators between the
healthy and injured leg (P < .05);
however, without differences between
groups (P > .05). After the completion of
the training programs, repeated-measures
analysis of variance revealed that the
6-week balance training programs
improved (P < .05) all balance
performance indicators in both training
groups. However, the rate of the
improvement (P > .05) did not vary
between the 2 groups. Finally, no
statistically significant differences were
found between the injured and healthy
limbs in the testing after the completion
of the training program (Table 2).
Discussion and Conclusions
The main objectives of this study were
to investigate (a) whether a previous
ankle sprain influences balance ability
and (b) whether the effectiveness of
balance training program is affected by
the environment in which it is
performednamely, on land or in a
swimming pool. It was found that (a) a
previous ankle sprain caused functional
deficits, and influenced the balance
ability of the college-aged individuals
and (b) the balance training program
effectiveness was not affected by the
exercise environment.
In previous studies, impaired postural
control is frequently evident in subjects
with both acute and repetitive ankle
sprains. Similarly, functional deficits in
postural control are consistently
recognized in subjects with chronic ankle
instability. These postural deficits are
most likely secondary to a combination
of impaired neuromuscular control and
proprioception.27-29 As far as postural
deficits are concerned, the present study
found higher instability scores at the
initial measurement, which is in
accordance with the results of previous
studies researching subjects with FAI.27,28
In particular, a static and a dynamic
balance test have been used in the
vol. 6 / no. 5 Foot & Ankle Specialist 349

Table 1.
Balance Training Program.

Exercises performed on (a) hard balance board and (b) on air disk
1. Attempt to maintain single-limb stance
2. Attempt to maintain single-limb stance and try to bend and extend the knee
3. Attempt to maintain single-limb stance and try to move the unsupporting leg in front and back
4. Attempt to maintain single-limb stance and try to catch and return the ball to the trainer
5. Attempt to maintain single-limb stance while the trainer from the back passes the exerciser

Table 2.
Balance Assessments.

Pretraining Posttraining

Land Group Aquatic Group Land Group Aquatic Group

Healthy Injured Healthy Injured Healthy Injured Healthy Injured

Total stability 4.18 1.9 8.41 2.8 4.20 1.7 8.30 2.9 4.19 1.6 4.41 1.7** 4.32 1.5 4.36 1.4**
index ()

Anteriorposterior 3.41 1.8 7.42 2.7 3.39 1.5 7.66 2.8 3.71 1.2 3.76 1.4** 3.26 1.3 3.23 1.3**
index ()

Mediallateral 3.21 1.6 7.35 2.2 3.22 1.2 7.32 2.4 3.23 1.0 3.41 0.9** 3.21 1.1 3.12 1.1**
index ()

Targets (seconds) 109 14 224 29 108 13 232 26 104 13 111 17** 106 12 112 16***

Indicates P < .01 between injured and healthy limb.

*In any given group in postbalance training indicates P < .05 compared with prebalance training.
**In any given group in postbalance training indicates P < .01 compared with prebalance training.
***In any given group in postbalance training indicates P < .001 compared with prebalance training.

present study. The dynamic balance test
was designed to measure the ability of
subjects to actively control their ankle
(and proximal joints) to the limits of its
functional range of motion while
keeping balance on a multidirectionally
unstable surface and using the dynamic
limit-of-stability mode.26 We used the
dynamic balance test because testing in
the dynamic limit-of-stability mode
appears more demanding. The reason
for that is that subjects have to maintain
balance while actively controlling joint
movements within the functional limits
of their range of motion. Such a
protocol is probably more appropriate
for people who need to control the
movements at the extremes of their
range of motion.26 In addition, it is
stated that testing dynamic control on
an unstable surface also assesses
indirectly other factors possibly
contributing to impaired dynamic
balance such as strength deficits, pain,
mechanical instability, and inadequate
control at the proximal joints.26
Assessing dynamic control may provide
a better functional picture than solely
testing proprioception since altered
mechanoreceptors do not appear to be
the only contributors to ankle functional
instability.26,30
Concerning the second objective of our
study, it was found that both balance
training programs decreased the postural
instability of the subjects, result that is in
agreement with those of previous
reports.15,16,29,31,32 Previous research has
also shown that wobble board training
improves single-leg stance ability15 and
postural sway16,31,32 in participants with
FAI. Wester et al33 showed that patients
with FAI who underwent wobble board
training experienced significantly fewer
recurrent sprains during a follow-up
period than those who did not follow a
training program. As far as the exercise
equipment is concerned, it is identical to
350 Foot & Ankle Specialist
that use in the studies by Bernier and
Perrin31 and Eils and Rosenbaum,16
involving modalities such as ankle disks,
tilt boards, and single-leg standing
activities.
The duration of the present studys
balance training programs was 6 weeks,
3 times per week. Similar period for
balance training on individuals with
functionally unstable ankles was applied
by Kidgell et al34 who compared the
effect of a 6-week balance training on
either a mini-trampoline or a dura disk
on postural sway, and their results
indicated that the mini-trampoline was
equally effective as the dura disk for
improving balance after lateral ankle
sprain. Similarly, the results of the study
by ODriscoll et al35 showed that a
6-week dynamic neuromuscular training
program improved parameters of ankle
joint sensorimotor control and subjective
function in an athlete with chronic ankle
instability.
Regarding the water-based balance
training program, our focus was on
adapting the land-based balance
exercises to water environment, adding
hand movement to create water
turbulence, which would contribute to
the progressiveness of exercise difficulty
with the aim to improve balance ability.
The water turbulence during balance
exercises challenges balance control in
multiple directions, and, in addition,
when turbulences are applied by
instructors in predictable and
unpredictable manners they allow
subjects to exercise safely and progress
when needed.23 Apart from the research
by Melzer et al,23 no study has proposed
a water-based training program that
includes turbulence to improve stability.
Conclusion
The findings of this study advocate the
use of balance exercise program for
rehabilitation of college-aged individuals
with functional ankle instability. The
results demonstrated that individuals
with a previous ankle sprain experienced
balance deficits. A balance training
program performed on balance boards
increased the balance ability of the
participants. The performance of balance
exercises can take place in either a pool
or land environment, with the same
positive effect.
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