Effects of a Neuromuscular Reeducation Program on the Postural

Control in Gymnasts with Chronic Ankle Instability

Marc Reis

, Raúl Oliveira

and Filipe Melo

Health School of Alcoitão, Portuguese Gymnastics Federation, Lisbon, Portugal

Technical University of Lisbon, Human Motricity Faculty, Lisbon, Portugal

Key Words: Chronic Ankle Instability, Gymnastics, Neuromuscular Reeducation, Postural Sway, Postural Control, Time

to Stabilization.

Abstract: Chronic ankle instability (CAI) is associated to the mechanical and/or functional instability of the ankle,

being described as often residual change after sprain. Objective: To analyze the effects of a neuromuscular

reeducation program for six weeks, in postural sway (PS) and time to stabilization (TS), in functional tests,

in asymptomatic gymnasts and in gymnasts with CAI. Methods: The postural variation was evaluated –

within sample of 24 gymnasts - 9 with CAI (experimental group) and 15 healthy ones (control group)

through a pressure platform, before and after applying the exercise program. Results and Discussion: In the

instability group it was observed an improvement in PS and TS in a single limb static stance with open and

closed eyes, and after a landing of an anterior jump, medial and lateral side. In the control group a decrease

of the PS in a single-limb static stance with eyes open and after the landing of a medial side jump was

verified; improvement of the time to stabilization in the landing of lateral and medial side jump, after

applying the exercise program. Conclusion: A neuromuscular reeducation program had a positive effect in

the improvement of the postural control in gymnasts with or without CAI.

1 INTRODUCTION

Chronic ankle instability (CAI) has been described

as the most common residual change of the ankle

joint after injury (Caulfield et al., 2006). The ankle

sprain is the most common injury in professional

gymnasts (Kolt and Kirkby, 1999). According to

Yeung et al., (1994) 40% to 70% of the individuals

that suffered a ligament injury developed CAI.

CAI is one of the major residual dysfunction

after an ankle sprain, being characterized as having a

mechanic and/or functional component. Symptoms

such as experiencing joint instability (giving away),

pain and deficit in functional activities associated

with recurrent injuries, establish a CAI scenario

(Delahunt et al., 2010). This presents a multifactorial

aetiology, where factors as joint laxity, muscular

weakness and diminishing of sensibility of the

proprioceptive mechanisms are related, originating a

structural and biomechanical change in the joint,

with a consequent deficit of the postural control

when compared with healthy individuals (Denegar

and Miller, 2002; Hubbard et al., 2006; Kavanagh,

1999; Willems et al., 2002).

According to Delahunt et al. (2010) CAI is a

term used to describe individuals that portray

mechanic and functional instability of the ankle,

experience joint instability for at least one year after

the injury and that have suffered from at least two

sprains of average/mild severity in the last two to

three years.

About 45% of all ankle injuries occur in landing

after a jump (McKay et al., 2001). Individuals with

functional instability (FI) of the ankle present

changes in the standard movement before impact

with the soil in the reception of a single-limb jump

when compared with healthy individuals (Caulfield

and Garrett, 2002). These differences can occur

because of changes in the control of the standard

movement due to earlier injury (Caulfield and

Garrett, 2004) or resulting dysfunctions. Single Leg

Jump Landing (SLJL) testing has been frequently

used to assess the CAI effects in postural sway

stability (Brown et al., 2004; Wikstrom et al., 2005).

CAI has been related with an increase in the

stabilization time (ST) in the frontal and sagital

plans and several studies support this as the

responsible factor for the changes and deficits that

Reis M., Oliveira R. and Melo F..

Effects of a Neuromuscular Reeducation Program on the Postural Control in Gymnasts with Chronic Ankle Instability.

DOI: 10.5220/0004618000560063

In Proceedings of the International Congress on Sports Science Research and Technology Support (icSPORTS-2013), pages 56-63

ISBN: 978-989-8565-79-2

 2013 SCITEPRESS (Science and Technology Publications, Lda.)

occur in the jump landing (Brown et al., 2004; Ross

et al., 2005). Brown and Mynark (2007) show that

individuals with CAI take more time stabilizing after

a dynamic activity than the non-injured control

group.

Postural control is usually calculated by postural

sway, through the measure of the distance and

amplitude of the CoP´s displacement (Mattacola and

Dwyer, 2002). A decrease of the length and area of

the CoP´s displacement and a reduction of its

velocity of excursion indicate an improvement of the

efficiency of the postural control (Sefton et al.,

2009).

Several studies refer neuromuscular reeducation,

namely through platforms or unstable surface,

presenting positive results in the reintegration of the

postural control mechanisms (Mattalcola and

Dwyer, 2002; Baltaci and Kohl, 2003; Wilkerson

and Nitz, 1994).

The main goal of the present study is to analyze

the effects of a neuromuscular reeducation program

adapted to gymnastics, in postural sway and the time

to stabilization, in some dynamics or physical tests

in asymptomatic gymnasts and in gymnasts with

CAI.

2 METHODS

This is a quasi-experimental study, with a

framework of research of the pre-testing – post-

testing type with non-equivalent work group: there

was no random element distribution that belonged to

the two groups – the group of unstable subjects and

the group of healthy subjects.

The study sample is composed by 24 subjects, 9

(37,5%) males and 15 (62,5%) females; aged

between 15 and 24 years old (Average = 17,67 ±

2,85 years). It was selected by convenience out of a

population of gymnasts from Portugal’s Gymnastics

Federation and according to the following inclusion

criteria:

Experimental Group (EG): Inclusion Criteria

 History of occurrence of, at least two ankle sprain

injury (grade II), from which resulted ligament

injuries with an edema/ecchymosis, pain,

temporary loss of function and that have occurred

in the last three years but more than three months

ago.

 CAI history with symptoms of lack of confidence

in the joint and/or residual pain, diminished

function and momentary loss of control, even if in

minor episodes.

Experimental Group (EG): Exclusion Criteria

 Ankle joint’s average gravity sprain in study in the

last three months (excludes acute and sub-acute

situations).

 History of other injuries in the lower limbs (except

the ankle joint) in the six months before the data

collection and/or not totally recovered.

 Neurologic symptoms or troubles.

 Vestibular and visual disorders that affect the

balance.

 Previous surgery history and/or lower limb

fractures.

Control Group (CG) – Inclusion Criteria

With no changes or previous injuries from the

musculoskeletal and neurologic nature in any of the

lower limbs. Asymptomatic gymnasts with no

functional or sportive limitations and in full

gymnastics activity.

The subjects were properly informed about the

study’s objectives, about all the procedures and were

only included in the sample after their formal

consent. Each subject also fulfilled an informed

permission form. In the cases when gymnasts were

underage, the form needed to be fulfilled by a tutor.

Two groups were created, the Experimental

Group (EG) – subjects with chronic ankle instability

(n=9) and the Control Group (CG) – healthy subjects

(n=15). The healthy group was randomly divided in

two sub-groups, a group of healthy individuals that

did an exercise program (n=7) – Control Group with

Exercises (CG1); and a group of healthy individuals

that was not subjected to the exercise program (n=8)

– Control Group without Exercises (CG2). All the

EG gymnasts were subjected to an exercise program.

The length and displacement area of the CoP

were measured – dependable variables, during six

seconds in the maintenance of the single limb static

stance (open and closed eyes) and after a jump’s

landing (anterior, lateral, medial). Moreover, the

first six seconds measured for each of these motor

tasks were analyzed in three distinct timeframes – in

the first two seconds (T1), from the second to the

forth seconds (T2); and from the forth to the sixth

seconds (T3). Having the concept of stabilization

time used by Ross e al. (2005) as basis and because

there is no consensus on the existing studies, about

its definition, we have approached the stabilization

time through the changes and postural oscillation

parameters’ evolution – area and length, in a

determined timeframe in comparison to other (ex.

T1_T2, which corresponds to the different values

obtained in the Cop in the timeframe T2 in

comparison to T1).

EffectsofaNeuromuscularReeducationProgramonthePosturalControlinGymnastswithChronicAnkleInstability

A multi-station exercise plan was developed (see

Appendix). This frames a set of seven functional

strengthening and neuromuscular re-education

exercises, to control the dynamic balance, in a series

of motor tasks and functional activities related with

gymnastic tasks, mainly the single limb standing

stance on unstable surfaces and a jump’s landing, in

order to improve the feedback and feedforward

mechanisms. Research suggests (Konradsen et al.,

1997; Holmes and Delahunt, 2009) are important

and essential in the task’s motor control and injury

prevention. The created exercise plan was performed

with a total duration of six weeks, in a frequency of

three times per week and an average duration of

15/20 minutes per session.

3 MEASUREMENT TOOLS

In this study, the postural oscillation was measured

through a 0,5m Footscan

pressure platform to

measure the length (mm

) and area (cm

) covered by

the CoP´s displacement to the different study tasks.

The individuals studied were also subjected to a

characterization and evaluation in the Foot and

Ankle Outcome Score (FAOS), aimed at identifying

the existing differences about pain, other symptoms,

daily life functions, sports and leisure functions and

quality of life between the subjects.

4 PROCEDURES

All the subjects were informed not to take coffee,

alcoholic drinks and medication 24 hours prior to the

evaluation, as well as trying to sleep eight hours the

night before.

According to the design of this study’s research,

there were performed two moments of evaluation,

one before the application of the multi-station

exercise program – Baseline (O1), and another, six

weeks after its application (O2). The several tasks

were evaluated on the same day, choice of the order

of tasks done randomly, and for each of them there

were made three measurements. The average of the

three results was used throughout the treatment and

interpretation of the results. In case the subject

doesn’t complete one of the measurements with

success in time, by unbalance and loss of test

position, the test will be repeated as many times as

necessary until three valid measures are obtained for

each test. In the evaluated dynamic activities, each

subject had the opportunity to perform the required

test once, before its effective measure.

To measure the postural oscillation of a jump it

was determined a priori the value of the maximum

vertical impulsion for each gymnast. After

determining this value, the jump tasks were

performed at least at 50% of the maximum vertical

impulsion, this value being marked in the space with

a rubber band and serving as a reference for the

gymnast during the jump from the floor to the

platform.

5 DATA ANALYSIS

After data collection and process was performed, the

statistical treatment was of them was given through

a SPSS for Window V.19.0 statistic treatment

software. A statistic inference was used for the data

treatment. Due to the small number of the sample,

the collected data was subjected to a statistic

treatment using non parametrical tests. For

intragroup evaluation tests were used for grouped

samples and for intergroup evaluation, tests for

independent samples - Kruskal-Wallis, to a level of

significance of p ≤ 0,05.

6 RESULTS

In Tables 1 and 2 are presented the results of the

comparison between the intragroup and the

intergroup concerning the values obtained in O1 and

O2 in CoP´s length and displacement area in the

three timeframes analyzed – from zero to two

seconds; from two to four seconds and from four to

six seconds, in maintaining the balance and after the

jump’s landing. The results presented will be just the

ones with statistical significance (p≤0,05).

In the experimental group we saw statistical

significant improvements in all the tasks being

studied concerning the CoP´s displacement and its

stabilization time. The control group that did the

neuromuscular reeducation program (GC1) showed

significant statistic results in the displacement of the

single limb static stance with the eyes open and in

the length and area of the CoP's displacement after

the landing of a medial jump. When it comes to the

stabilization time, GC1 showed more improvement

in the medial and lateral jumps' landing. For the

control group that didn't performed the

neuromuscular reeducation program (GC2), we saw

significant statistical changes in the CoP's single

limb static stance with eyes closed and after an

icSPORTS2013-InternationalCongressonSportsScienceResearchandTechnologySupport

Table 1: Results obtained from comparasion of the O1´s

comparison with O2 CoP´s displacement length and area,

in the different tasks analyzed, in the three groups.

TASKS EG CG 1 CG 2

SLSS_YO

A T3

(p=0,020)

A T2

(p=0,055)

----

SLSS_YC

L T3

(p=0,037)

----

L + A T1

(p=0,02;

p=0,008)

A T1

(p=0,037)

----

L + A T1

(p=0,027;

p=0,055)

L T1

(p=0,065)

L + A T3

(p=0,008;

p=0,002)

---- ----

L + A T1

(p=0,037;

p=0,027)

L + A T3

(p=0,04;

p=0,20)

L + A T1

(p=0,08;

p=0,08)

A T3

(p=0,023)

----

SLSS_YO – single limb static stance with eyes open; SLSS_YC –

single limb static stance with eyes closed; AJ – anterior jump; LJ

– lateral jump; MJ – medial jump; EG – experimental group; CG1

– control group with exercises; CG2 – control group without

exercises; A - the area of the CoP´s displacement; L – the length

of the CoP´s displacement; T1 – 0 to 2 sec; T2 – from 2 to 4 sec;

T3 – from 4 to 6 sec.

significant statistical changes in the CoP's single

limb static stance with eyes closed and after an

anterior jump's landing. Still in this group, we

verified improvement in the stabilization time after

an anterior jump.

By analyzing chart 1 we may verify that there

was a slight improvement in the score obtained by

the FAOS scale, in the EG Experimental Group,

after the exercise plan finished, at the level of the

other symptoms, sports and leisure functions and

quality of life connect to the foot and ankle. We

didn´t verify any differences by the FAOS scale,

when comparing observation 2 to 1, to the control

group with exercises (GC1).

7 DISCUSSION

SLJL tests have often been used to evaluate the

effects of FAI on the dynamic postural stability of

the ankle (Brown et al., 2004; Wikstrom et al.,

2005), and its improvement through exercise

programs in patients with CAI (Ross et al., 2005).

Several studies (Powers et al., 2004; Sefton et al.,

2011) report that statistically significant results in

improving postural sway on single leg standing,

Table 2: Results obtained from comparison of the O1´s

comparison with O2 time of stabilization, in the different

tasks analyzed, in the three groups.

TASKS EG CG 1 CG 2

SLSS_YO

L + A T2_T3

(p=0,037;

p=027)

---- ----

SLSS_YC

L T1_T3

(p=0,025)

---- ----

A T1_T2

(p=0,037)

A T1_T3

(p=0,037)

----

L T1_T2

(p=0,008)

A T2_T3

(p=0,006)

A T1_T2

(p=0,055)

----

A T2_T3

(p=0,027)

A T1_T3

(p=0,020)

A T1_T2

(p=0,055)

----

SLSS_YO – single limb static stance with eyes open; SLSS_YC –

single limb static stance with eyes closed; AJ – anterior jump; LJ

– lateral jump; MJ – medial jump; EG – experimental group; CG1

– control group 1; CG2 – control group 2; A - the area of the

CoP´s displacement; L – the length of the CoP´s displacement; T1

– 0 to 2 sec; T2 – from 2 to 4 sec; T3 – from 4 to 6 sec; T1_T2

difference of CoP´s values obtained in the interval T1 in

comparison to T2; T2_T3 difference of COP´s values obtained in

the interval T2 in comparison to T13; T1_T2 difference of CoP´s

values obtained in the interval T1 in comparison to T3.

through the assessment of static balance, following

the application of an exercise program were not

found. However, changes were found through

dynamic assessment (Sefton et al., 2011). Based on

these data and considering the fact that at the gym,

most ankle injuries occur on landings, it seemed

useful to assess the postural sway and stabilization

time dynamically on landings.

Graphic 1: Values obtained through the FAOS to the EG

in O1 and O2.

A study by Fellander-Tsai and Wredmark (1995)

found that most injuries in competitive gymnasts

occurred on landings. The gymnast’s ability to land

a jump or technical element skill, often on different

surfaces, and prepare for immediate take-off for

another skill, requires a high motor and postural

control of the gymnast. In case of CAI, deficits in

the neuromuscular mechanisms, inherent to postural

EffectsofaNeuromuscularReeducationProgramonthePosturalControlinGymnastswithChronicAnkleInstability

control, can lead to an increased risk of recurrent

injury. The specificity of the sport, with the more

emphasis on feedforward mechanisms, rather than

feedback mechanisms in postural control

(Konradsen et al., 1997; Holmes and Delahunt,

2009), led to the creation of an exercise program

with special focus on skills development for motor

pre-programming where the landing of jumps was

given special emphasis. According Delahunt (2007),

training exercises performed on unstable surfaces for

the training correct technique of landing, especially

on single leg, will emphasize the synergistic muscle

activity pre-programmed by feedforward

mechanisms in subjects with FAI. Thus, the study

also included in the program exercises that promote

specific mechanisms of postural control feedback

like single leg balance, with the need of constant

posture adjustments and where the reflex activity

plays a key role. Mynark and Brown (2007)

demonstrated in their study that individuals with

CAI take longer to stabilize after a dynamic activity

than the control group of subjects with no previous

injuries. This increase in stabilizing time can lead to

an increased recurrence of ankle injuries due to the

inability to properly execute the landing after a jump

(Ross et al., 2005). It at least it suggests that the

posture control mechanisms are less efficient. Based

on these studies, our program also included

exercises that develop balance and motor control in

plyometric tasks (different types of jumps in

different conditions and landing directions). The

program had six weeks duration with a weekly

frequency of three times a week. The determination

of the time set for its use is in line with previous

studies. Hale et al., (2007) in their study

demonstrated positive results in improving posture

control with an exercise program for four weeks five

times per week. Bernier and Perrin (1998);

Rosenbaum and Elis (2001); Burden and Clark

(2005), Powers et al., (2004); Docherty et al.,

(1998); Sefton et al., (2011) found positive results

with an experimental six weeks protocol, three times

a week.

Within the group of gymnasts with CAI -

experimental group - there was a significant

improvement in all the tasks in study, which

reinforces the effectiveness of the exercise program

in improving postural control and joint stability.

These results are in line with other studies, where

the application of an exercise program with

proprioceptive exercises, particularly balance

training on unstable surfaces, showed positive

results in the reprogramming of postural control

mechanisms in subjects with CAI (Mattacola and

Dwyer, 2002; Baltaci and Kohl, 2003; Wilkerson

and Nitz, 1994). Bernier and Perin (1998) had

statistically significant results with CoP´s

displacement on single leg balance with eyes closed,

in the CAI group, after application of an exercise

program for six weeks.

Gymnastics skills with postures in single leg

support are frequent (eg. static balance skills like

scales, stability posture after a jump for a relatively

long period). The results achieved in improving

single leg postural sway demonstrate the positive

effect of training, with the exercise program

performed. This aspect determines improved

stability, and thereby improving the performance of

the gymnasts.

For more dynamic activities, there were

improvements in postural sway and stabilization

time on landing, to the front and to the medial and

lateral sides, in subjects with CAI. These data reveal

an improvement of dynamic joint stability, both

anteroposterior and mediolateral stability after

completion of the exercise program. According

Sefton et al. (2009), a decrease in CoP´s length and

area displacement and a reduction of its velocity

indicate an improvement in postural control. In their

study, these authors reported an improvement in the

dynamic balance in the anteroposterior, medial and

posteromedial directions, after the application of a

proprioceptive exercise training program for six

weeks in subjects with CAI.

In the control group of healthy subjects, who also

performed the exercise program (GC1), there were

statistically significant improvements in single leg

balance with eyes open, and on the landing of an

medial lateral jump. These results demonstrate a

positive effect of the exercise plan, improving the

dynamic stability in healthy subjects. The

improvement in postural sway and stabilization time

in healthy subjects reported in this study, suggests a

possible implementation of this type of training for

injury prevention of the ankle and performance

improvement in gymnasts.

In a study of this nature, the kinematics and

EMG analysis could give more information. This

could be considered one of the limitations to this

study. Another methodological limitation of this

study relates to the size of the sample. However, the

value of the sample under study (n = 24), while

somewhat lower than in other studies appear to be

similar to the average sample used in some similar

studies carried out previously.

However, we consider our options are in line

with the goal set for the scope of this research. The

options seem appropriate, taking into account the

icSPORTS2013-InternationalCongressonSportsScienceResearchandTechnologySupport

specific context of the sample under study and

specificity of the sport.

Despite these limitations, the objectives set for

this study were achieved: to assess the effects of a

neuromuscular program in competitive gymnasts

with CAI, thus making a contribution to practice

evidence-based physiotherapy.

8 CONCLUSIONS

The application of a six weeks neuromuscular

program seems to have positive effects in improving

postural control in gymnasts with and without CAI.

Results suggest an improvement of postural control

on the sample subjects, stressing the relevance of the

use of rehabilitation programs to improve dynamic

and functional stability, in order to reduce the risk of

recurrence of injury and further improvement of

athletic performance.

Although many studies have been developed in

this area, we emphasize the importance of assessing

dynamic postural control, where the feedforward

mechanisms are especially important, as well as the

intervention with exercise programs that improve the

development of these neuromotor mechanisms.

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icSPORTS2013-InternationalCongressonSportsScienceResearchandTechnologySupport

APPENDIX

Multi-Station Exercise Program Sets x Repetitions / Time between Sets

Exercise 1 – Rotation of the body in a single limb stance

1. 2.

1x 1 min – on the floor

1x1min – on the mat (medium density)

1x1min – on the Trampoline

Time between Sets - from 20 to 60s

week – with eyes closed

Exercise 2 – Sequence in a single limb stance

1. 2. 3.

2x 4 sequences

week – on the floor

week - on the mat (medium density)

From 3

to 6

week – on the trampoline

Time between Sets - from 20 to 60s

Exercise 3 - ¼ jump, stabilizing the landing

1. 2. 3.

2 x 12 jumps

and 2

week – on the floor

and 4

week - on the mat (medium

density)

and 6

week - on the trampoline

Time between Sets - from 20 to 60s

Exercise 4 – Lateral jumps

1. 2. 3.

2x 10 jumps

Time between Sets - from 30 to 60s

Exercise 5 – Antero-posterior jumps

1. 2. 3.

2x 10 jumps

Time between Sets - from 30 to 60s

Exercise 6 - Plyometric trainning with multidireccional jumps

1. 2. 3.

1x 2 sequences around

1x 2 sequences in 8

Time between Sets - from 30 to 60s

Exercise 7 – Running with direction changing

1. 2.

1x 1 min

EffectsofaNeuromuscularReeducationProgramonthePosturalControlinGymnastswithChronicAnkleInstability