Next Article in Journal
Muscle Oxygen Extraction during Vascular Occlusion Test in Physically Very Active versus Inactive Healthy Men: A Comparative Study
Next Article in Special Issue
Locomotion and Postural Control in Young Adults with Autism Spectrum Disorders: A Novel Kinesiological Assessment
Previous Article in Journal
Disc Degeneration and Cervical Spine Intervertebral Motion: A Cross-Sectional Study in Patients with Neck Pain and Matched Healthy Controls
 
 
Search for Articles:
Title / Keyword
Author / Affiliation / Email
Journal
Article Type
 
 
Advanced Search
 
Section
Special Issue
Volume
Issue
Number
Page
 
Journals
JFMK
Volume 9
Issue 1
10.3390/jfmk9010056
jfmk-logo
Submit to this Journal Review for this Journal Propose a Special Issue
► Article Menu

Article Menu

share Share announcement Help format_quote Cite question_answer Discuss in SciProfiles thumb_up
...
Endorse textsms
...
Comment
first_page
settings
Order Article Reprints
Font Type:
Arial Georgia Verdana
Font Size:
Aa Aa Aa
Line Spacing:
Column Width:
Background:
Article

The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability

by
Konstantinos Parlakidis
1,
Lazaros Alexandors Kontopoulos
1,
Dimitris Mandalidis
2,
Eleftherios Paraskevopoulos
3,4,
Maria Papandreou
3,
Eleni Kapreli
5 and
Anna Christakou
4,*
1
Department of Physiotherapy, University of Peloponnese, 23100 Sparta, Greece
2
Department of Physical Education and Sports Science, University of Athens, 11527 Athens, Greece
3
Laboratory of Advanced Physiotherapy, Department of Physiotherapy, University of West Attica, 23100 Sparta, Greece
4
Laboratory of Biomechanics, Department of Physiotherapy, University of Peloponnese, 23100 Sparta, Greece
5
Department of Physiotherapy, Clinical Exercise Physiology and Rehabilitation Research Laboratory, University of Thessaly, 41500 Larissa, Greece
*
Author to whom correspondence should be addressed.
J. Funct. Morphol. Kinesiol. 2024, 9(1), 56; https://doi.org/10.3390/jfmk9010056
Submission received: 14 February 2024 / Revised: 18 March 2024 / Accepted: 19 March 2024 / Published: 21 March 2024
(This article belongs to the Special Issue Gait Analysis in Athletes)
Browse Figures
Versions Notes

Abstract

:
Chronic ankle instability (CAI) is characterized by muscle weakness and impaired neuromuscular control. This study aimed (a) to assess the impact of external verbal feedback on the dynamic balance of athletes with CAI and (b) to examine the maintenance of dynamic balance ability after the end of the completion of the intervention balance program. Thirty athletes (mean age 21.63 ± 1.53) were randomly divided into three groups: an experimental group with external verbal feedback, 1st control group without external verbal feedback and the 2nd control group without balance training and without feedback. Assessments using a balance board and the ‘Y-balance’ test were conducted before and after the balance training period. Additionally, participants completed the Cumberland Ankle Joint Instability Tool. A retention test of balance ability was administered after the 4-week intervention period. Statistical analysis revealed a significant overall improvement in balance (F(2,36) =5.96, p = 0.006, partial η2 =0.249), including those with no balance training, but no significant differences between the groups. Thus, the external verbal feedback did not show a positive impact on the balance ability between the three different groups. Also, the experimental group with the external verbal feedback demonstrated maintenance of dynamic balance learning ability. Although it appears that balance training has a positive effect on the dynamic balance of individuals with CAI, a non-positive impact of external verbal feedback was found. Also, it appears that external verbal feedback significantly led to sustained retention of balance learning ability. Further research is recommended to validate these findings.

1. Introduction

Ankle sprains represent a prevalent musculoskeletal injury in sports, affecting athletes across various disciplines such as basketball (41.1%), rugby (9.3%), and football (7.9%) [1]. Individuals who sustain ankle sprains often exhibit a range of impairments including decreased proprioception, delayed neuromuscular control, pain, and susceptibility to re-injury, which can lead to the development of chronic ankle instability (CAI) [2,3]. CAI patients commonly experience recurrent or excessive sprains, affecting approximately 15.7% of individuals with ankle injuries [4,5]. Symptoms associated with CAI include pain, swelling, muscle weakness, instability, reduced proprioception, limited range of motion, and delayed neuromuscular control [6,7,8,9]. These symptoms can significantly impact an athlete’s performance and increase the risk of further injury, highlighting the importance of effective management and rehabilitation strategies for individuals with CAI.
Balance plays a crucial role in the rehabilitation of CAI, as it is recognized as a key factor influencing the risk of recurrent sprains [10]. Numerous studies have demonstrated significant improvements in both static [11,12,13] and dynamic balance [11,12,14] among individuals with CAI following participation in physiotherapy rehabilitation programs. Specifically, balance retraining has been shown to activate the somatosensory system [15] and enhance participants’ strength and functional ability [9,16]. These findings underscore the importance of incorporating balance training into CAI rehabilitation protocols to address deficits in proprioception, stability, and neuromuscular control, thereby reducing the risk of future ankle injuries.
Motor learning refers to an individual’s ability to acquire motor skills [17], which has broad applications in enhancing sports performance [18,19], preventing injuries [20,21], and facilitating rehabilitation [22,23]. Within the domain of motor learning, attentional focus, observational learning, and feedback are key components that are widely utilized in sports [24,25]. Feedback, in particular, plays a critical role in providing information to individuals about the outcome or process of their actions [26]. Feedback can be categorized as internal (intrinsic) or external (extrinsic), with external feedback further divided into verbal, motor, and feedback delivered via taped videos [27]. Research has shown that feedback is effective in improving performance in both healthy populations [28,29,30,31,32] and clinical populations undergoing rehabilitation [22,33,34]. By providing individuals with information about their performance, feedback allows for adjustments and improvements in motor skills, contributing to enhanced athletic performance and rehabilitation outcomes.
The existing research on the impact of feedback on the balance of musculoskeletal injured athletes is limited, with only one previous study focusing on the effects of verbal feedback on individuals with chronic ankle instability (CAI) [33]. Furthermore, there is a gap in the literature regarding the maintenance of dynamic balance ability following the completion of a balance program and external verbal feedback intervention. Additionally, there is a lack of experimental research investigating the psychophysiological processes involved in applying external verbal feedback in sports injury rehabilitation.
Understanding the psychophysiological processes underlying sports injury rehabilitation is not only theoretically important but also holds clinical significance. Such knowledge could lead to the development of more effective rehabilitation programs aimed at improving sports performance. Therefore, the primary objective of this study was to investigate the impact of external verbal feedback on the dynamic balance of athletes with CAI. It was hypothesized that external verbal feedback would lead to improvements in dynamic balance among patients with CAI and that these improvements would be sustained even after the completion of the feedback intervention.

2. Materials and Methods

The present study is a randomized single blind study.

2.1. Participants

All participants were provided with detailed information regarding the study procedures and were required to sign a written consent form before participating. They were informed of their right to withdraw from the study at any point, and assured that any publication of the results would maintain their anonymity. The sample comprised 30 athletes, consisting of 18 men and 12 women, with ages ranging from 18 to 30 years old (mean age = 21.63 years, standard deviation = 1.53 years). All participants had a minimum of two years of experience participating in sports competitions. They were diagnosed with chronic ankle instability (CAI) affecting either the left or right ankle joint (see Table 1).
The participants were randomly assigned to one of three groups using a drawing lots method: (a) an experimental group that received balance training along with external verbal feedback, (b) the 1st control group that underwent balance training without external verbal feedback, and (c) the 2nd control group that did not receive any balance training or external verbal feedback. Each group comprised 10 participants. In the experimental group, there were 3 men (30%) and 7 women (70%), in the 1st control group there were 6 men (60%) and 4 women (40%), and in the 2nd control group, there were 9 men (90%) and 1 woman (10%).
To be eligible for inclusion in the study, participants had to meet the following criteria: (i) diagnosis of CAI, (ii) aged between 18 and 40 years old, (iii) undergone conservative medical care in either a public hospital or private clinic, and (iv) engaged in sports activities at least three times weekly over the past two years. Exclusion criteria included: (i) visual disorders, (ii) vestibular or neurological disorders, (iii) history of surgery on the ankle joint or adjacent joints (e.g., knee), (iv) no fractures, (v) no severe traumas on the lower limbs, and (vi) no ankle sprains in the last 3 months or participation in physiotherapy programs in the last 3 months. The study was approved by the Ethics Committee of the University of Peloponnese (6 April 2023, No 206).

2.2. Measures

The balance assessment instruments and tests utilized in our study were validated, reliable, and widely employed [35,36,37,38,39,40,41,42,43,44,45]. Specifically, we employed:
(a)
Y-Balance test on a plantar pressure recording platform:
The Y-Balance test [35] was utilized to evaluate dynamic balance in individuals with chronic ankle instability [36]. The plantar pressure recording platform comprised 1792 capacitive force sensors arranged in a 32 cm × 56 cm matrix, synchronized with a personal computer. Foot pressure signals were recorded at a sampling rate of 120 Hz and analyzed using dedicated computer software (WinFDMS v.1.18.40, Zebris Medical GmbH Standort Seltmans, Weitnau, Germany) [37]. The recorded images displayed the footprint of each participant’s foot, with hot colors (red, orange, yellow) indicating higher pressures and cold colors (blue, green) indicating lower pressures [38] (Figure 1). This pressure distribution platform has been previously used by Cobos-Moreno et al. [39] in a study involving 52 subjects to identify physiological lower limb pressures, demonstrating a high reliability index (r = 0.95) [39]. Additionally, Mandalidis and Karagiannakis [40] employed it to assess postural control during a dynamic balance test, showing high reliability (ICC = 0.87). Center of Pressure (CoP) path length and CoP path velocity are indices derived from the platform, with the former reflecting values related to the oscillation of the center during the test and the latter indicating the speed at which the person moves during the test [40]. Therefore, we examined both the center of pressure distribution length and the center of pressure distribution velocity.
(b)
Balance tray
The balance tray is a circular platform equipped with various-sized domes that protrude from the bottom of the tray, allowing for adjustments to the difficulty level of balance tasks [11]. This equipment, known as a balance disc, is widely recognized as a valid and reliable instrument for balance retraining and has been utilized in interventions for individuals with chronic ankle instability [41,42,43].
(c)
Cumberland Ankle Joint Instability Tool (CAIT)
The Cumberland Ankle Instability Tool (CAIT) is a widely used assessment tool for selecting individuals with ankle instability. It consists of 9 items designed to evaluate ankle joint instability during various functional activities. The score of the tool ranges from 30-0, where a score of ≤24 indicates chronic ankle instability in individuals who have experienced sprains. The CAIT has demonstrated high validity and reliability, with a Cronbach’s alpha coefficient of 0.83 [44,45].

2.3. Procedure

The participants were recruited by the authors through personal or telephone contact, or through their coach. During the first meeting, they completed the Cumberland Ankle Instability Tool (CAIT) to be assessed for eligibility by the last author. Thirty-six athletes met the inclusion criteria, but only 30 agreed to participate and completed the demographic data sheet. In the second meeting, the participants were randomly assigned into three groups using the method of drawing lots, conducted by the fourth author.
All participants’ balance ability was evaluated by the second author, who was unaware of each participant’s randomization group. The first assessment of dynamic balance was performed using the Y-Balance test on a pressure distribution platform, specifically in the forward direction only. This direction was chosen as it has a larger area and requires less speed compared to the rearward directions [46]. The length and velocity of the center of pressure distribution were measured during the Y-balance test using a plantar pressure recording platform.
During the Y-Balance test on the pressure distribution platform, participants performed reaches as far as possible with one lower limb anteriorly, while standing at the other end with their hands on the iliac spines. Each participant completed three trial attempts and three normal attempts on the Y-balance test, with a one-minute rest between repetitions to prevent fatigue. The mean values of the three normal attempts were used to calculate the score. The score for each direction was calculated by dividing the average distance reached by the length of the participant’s lower limb, then multiplying by 100 to obtain the percentage of lower limb length. The length of the lower limb was measured from the anterior superior iliac spine to the medial malleolus. To calculate the score, the sum of the attempts was divided by three times the limb length (Figure 2).
All participants completed the CAIT prior to (a) the 1st assessment of dynamic balance, (b) the 2nd assessment of dynamic balance (4th week), and (c) the retention of the learning phase of dynamic ability (the 3rd assessment) (8th week). In the experimental group, participants engaged in a balance training program with both lower limbs on a balance tray, receiving specific verbal feedback from the first author. The training frequency was three sessions per week for duration of four weeks [47]. Each training session consisted of seven trials, each lasting 90 s, with breaks between each trial to avoid fatigue [48]. Participants wore their preferred training shoes during the sessions. Verbal feedback instructions given to the experimental group included: “Try to keep the tray steady” or “Try to keep the tray in a straight line”, “Straighten the back”, “Lower the center of gravity”, “Bend (the) knees”, “Head forward and eyes looking straight ahead”, “Don’t hold your breath”, “Stretch your arms out to the side” as appropriate for each participant. Participants were instructed to step onto the balance board using their left foot first and then put their right one on while keeping their weight on the left, ensuring that the platform touched the ground on the left side. They waited for the examiner’s signal to start balancing by distributing weight on both legs. At the end of each trial, participants were instructed to stop balancing on the board by putting all their weight on the left side and stepping off the board using their right foot first.
The 1st control group followed the same balance program without external verbal feedback, receiving only internal feedback. The 2nd control group did not follow any balance program or receive external verbal feedback. At the end of the intervention program, a 2nd assessment of dynamic balance was conducted for the entire sample by the second author. After four weeks, a 3rd assessment of dynamic balance was conducted for the entire sample, serving as a retention evaluation assessment of balance ability.

2.4. Statistical Analyses

Descriptive statistics were used to examine the demographic data of the sample.. Homogeneity of sample demographics was assessed using independent samples t-tests with a significance level of α = 0.05. A normality test of the distribution of all variables was conducted using the Shapiro-Wilk normality test. Repeated measures ANOVA (Mixed ANOVA) was performed on the variable of balance ability, including (a) Y-balance test, (b) center length and center velocity pressure distribution, and (c) CAI test. Greenhouse-Geisser correction was applied when necessary. Kruskal-Wallis non-parametric H test comparisons were used between the three groups to compare the 1st and the 3rd measurement and the 2nd and the 3rd measurement on center length and center velocity pressure distribution during the Y-balance test. Separate paired t-test comparisons of repeated measures in each group on the three tests were also conducted to investigate the retention of balance learning ability. Data were analyzed using the IBM Statistical Package for the Social Sciences (SPSS) 23.00 with a significance level α = 0.05.

3. Results

In the experimental group, 1 participant did not perform the measurement to maintain learning in the retention phase. In the 1st control group, 1 participant performed only the 1st measurement at the beginning of the study. In the 2nd control group, 2 participants performed only the 1st measurement, and 1 participant performed the 1st and the 2nd measurements due to injury.
No statistically significant differences were found between the three groups in age, height, weight, BMI, and number of sprains. Descriptive statistics of the (a) Y-Balance test, (b) center of pressure distribution length, (c) center of pressure distribution velocity, and (d) CAIT at the beginning, end, and retention phase between the three groups are presented in Table 2.

3.1. Examining the Comparisons and Retention of Balance Learning with Y-Balance Test

The Repeated Measures ANOVA (mixed ANOVA) examined the differences between the three different groups (between-subjects effect) and between the three repeated measurements (within-subjects effect). The results revealed only a significant main effect for intervention between the three repeated measurements (within-subjects effect) (F(2,36) =5.96, p = 0.006, partial η2 = 0.249), with no significant interaction effect between the three different groups. Additionally, the between-subjects effects (i.e., between-subject factor) were not statistically significant to perform post hoc analyses.
In order to further examine the within-subjects effects and assess the retention of balance learning ability, three paired samples t-tests with a Bonferroni adjustment were conducted (significance level for multiple comparisons p = 0.017), comparing the three measurements in each group (1st and 2nd measurement, 1st and 3rd measurement, 2nd with 3rd measurement). The results of the paired samples t-tests showed that the intervention group with external verbal feedback demonstrated a statistically significant difference between the 1st and the 2nd measurement (t = −3.44, p = 0.040), between the 1st and the 3rd measurement (t = −2.93, p = 0.010), but not between the 2nd and 3rd measurement (t = −0.31, p = 0.380).
The paired samples t-test for the 1st control group without feedback showed a tendency towards statistical significance between the 1st and 2nd measurement (t = −2.36, p = 0.020), between the 1st and 3rd measurement (t = −2.58, p = 0.021), but not between the 2nd and the 3rd measurement (t = −1.68, p = 0.071). In contrast, the paired samples t-test for the 2nd control group without balance training and without feedback showed no statistically significant difference between the three measurements.
These results indicate that only the experimental group with external verbal feedback demonstrated maintenance of dynamic balance learning ability during the retention phase of the dynamic ability learning process.

3.2. Examining the Comparisons and Retention of Balance on Center Length and Center Velocity Pressure Distribution during the Y-Balance Test

The Repeated Measures ANOVA (mixed ANOVA) examined the differences between the three different groups (between-subjects effect) and between the three repeated measurements (within-subjects effect). However, the results showed no statistically significant effects, neither between the three groups nor between the three repeated measurements.
Regarding the retention of balance learning ability on center length and center velocity pressure distribution, the test of normal distribution of variables using the Shapiro-Wilk index indicated the need for using non-parametric analysis. Therefore, the Kruskal-Wallis non-parametric H test comparisons were conducted. However, the results showed non-statistically significant differences for the balance ability and the learning retention test for the 2nd and 3rd measurements of the center length and the velocity pressure distribution among the three groups.

3.3. Examining the Comparisons and Retention of Learning of Balance on the CAIT

The Repeated Measures ANOVA (mixed ANOVA) examined differences between the three different groups (between-subjects effect) and between the three repeated measures (within-subjects effect). The results revealed a statistically significant main effect between the three repeated measures (within-subjects effect) with Greenhouse-Geisser correction (F (2,36) = 9.33, p = 0.005, partial η2 = 0.342) and a significant interaction effect between the three measurements and the group with a Greenhouse-Geisser (F(4,36) = 3.18, p = 0.058, partial η2 = 0.261). Consequently, all three groups, including those with no balance training, demonstrated significant overall improvement in their balance on the CAI. However, the between-subjects effects (i.e., between-subject factor) were not statistically significant to perform post hoc analyses. Therefore, external verbal feedback did not show a positive impact on the balance ability among the three different groups.
To further examine the within-subjects effects and the retention of balance learning ability, three paired samples tests with a Bonferroni adjustment were conducted (significance level for the multiple comparisons p = 0.017), comparing the three measurements in each group (1st and 2nd measurement, 1st and 3rd measurement, 2nd and 3rd measurement). The results of the paired t-tests showed that the intervention group with external verbal feedback demonstrated a statistically significant difference between the 1st and the 2nd measurement (t = −3.12, p = 0.006), between the 1st and 3rd measurement (t = −3.32, p = 0.005), but not between the 2nd and 3rd measurement (t = −1.00, p = 0.173), indicating maintenance of dynamic balance learning ability in the experimental group with external verbal feedback. The paired t-tests for the 1st control group without feedback and the 2nd control group without balance training and without feedback showed no statistically significant differences between the three measurements.

4. Discussion

The results indicate that balance training positively affects the dynamic balance of individuals with CAI. Additionally, external verbal feedback significantly contributes to the sustained retention of balance learning ability in individuals with CAI. However, there was no observed positive impact of external verbal feedback on the balance ability of individuals with CAI compared to those who did not receive feedback during the balance training. Therefore, larger sample sizes are necessary to confirm these findings.
Only one other study has investigated the effectiveness of feedback on the balance ability of participants with CAI. Jaffri and Saliba [33] utilized the Star Excursion Balance Test with and without verbal feedback, reporting improved balance ability after feedback. However, their study did not show any improvements in the length and velocity of the center of pressure distribution, which are crucial indicators of instability. These parameters are important because participants may exhibit good performance in the Star Excursion Balance Test but still have greater oscillation of the pressure center and velocity, indicating instability. Furthermore, Jaffri and Saliba did not administer the Cumberland Ankle Instability Tool (CAIT), thus they did not assess whether there was an improvement in instability symptoms before and after feedback. In contrast, our study demonstrated an improvement in ankle joint instability symptoms at the end of the intervention program compared to the beginning. Additionally, real-time external feedback using a crossline laser device did not result in changes in neuromechanical characteristics in the entire lower extremity (i.e., ankle, knee, and hip joints) during static postural control between feedback and no feedback conditions in 18 individuals with CAI [49].
In the cognitive phase of motor skill acquisition, where participants follow instructions during the initial learning stage of a skill, verbal feedback emerges as a highly effective technique. During this phase, participants require more feedback than in other stages of motor skill learning. Consequently, participants demonstrated improvement in their motor skills, especially in balance, following these feedback instructions [50].
The improvements observed following the balance program, facilitated by feedback, may be attributed to a reduction in fear, leading to increased confidence in participants’ performance. It seems that a psychological mechanism could be influencing the relationship between feedback and balance ability. While the reduced performance in the dynamic balance test in CAI is attributed to a reduced trajectory range, balance deficits may also be associated with psychological limitations stemming from the chronic pathology. Ohno et al. [51] found a positive correlation between stress levels and the center of balance in participants with CAI. Feedback may increase motivation, focus on motor function, enhance activity in the athlete’s higher brain centers, and familiarize the cerebral cortex by reducing psychological barriers [33]. Further research is warranted to elucidate the relationship between feedback, psychological factors, and balance improvement, particularly in the context of CAI. If a relationship is identified, further investigation is needed to discern the specific mechanisms accountable for the observed enhancement in balance ability.
Rendos et al. [34] investigated the maintenance of gait learning in patients with post-stroke hemiparesis using functional electrical stimulation and feedback after 24 h. The combination of these techniques improved gait ability. Their study had a smaller sample size than the present study, which included an intervention group but lacked a control group. Additionally, while Rendos et al. assessed retention 24 h after the intervention, our study had a longer learning retention interval. We extended the abstinence period to 4 weeks to minimize the impact of performance variables. This approach aimed to ensure that participants’ performance on each test primarily reflected the effectiveness of the taught and trained balance training, as previously demonstrated [27].
The sex of participants may influence the outcomes of the current study. Previous research suggests that female athletes in basketball and soccer often demonstrate superior single-legged balance abilities compared to their male counterparts. However, female basketball athletes may exhibit increased ankle range of eversion and inversion, indicating potential greater functional instability in the ankle joint [52]. Ottaviani et al. [53] observed that, on average, young women have 39% less eversion muscle strength than young men. These findings underscore the importance of considering sex-specific factors when interpreting and generalizing the results of the present study.
Moreover, male basketball athletes often exhibit higher vertical jump and sprint run performance compared to their female counterparts, indicating better functional performance measures. However, this sex difference becomes non-significant when ankle strengths are normalized by body size. In contrast, Greene et al. [54] found no significant differences between male and female basketball athletes in a single-limb balance time test. Additionally, no significant sex differences were reported for ankle range of motion in plantar flexion and dorsiflexion. These insights underscore the importance of considering sex-specific factors when interpreting and generalizing the results of the present study.
The current study has several notable strengths. Firstly, the inclusion of two control groups enhances the validity of the results, providing a more robust basis for drawing conclusions. Secondly, the utilization of electronic equipment for assessing improvements in instability and center of pressure distribution length and velocity adds precision to the measurements. A third strength lies in the investigation of balance maintenance post-intervention, shedding light on the endurance of balance improvements over time. Moreover, the study holds significance as the first to explore the impact of external verbal feedback on the shift of the center of pressure and velocity within a balance program. This novel aspect contributes valuable insights to the existing body of knowledge. Additionally, the study breaks new ground by examining the effects of feedback in conjunction with the Y balance test, further expanding the understanding of feedback in balance assessments. Lastly, the examination of balance learning maintenance after a 4-week abstinence period sets this study apart, filling a gap in the existing literature.

Limitations and Future Recommendations

The present study is subject to several limitations. The primary constraint lies in the small and diverse sample size, comprising both male and female participants engaged in various sports. While it was challenging to find athletes with identical demographic characteristics and injury types, this heterogeneity may affect the generalizability of the results. Increasing the sample size could potentially unveil additional positive effects of feedback on balance. Another limitation is the incomplete assessment of learning retention due to injuries during the study, reducing the sample size for this analysis to n = 30. Additionally, the study’s findings may not be generalized beyond athletes or those with a similar chronic musculoskeletal injury. Future research should aim for larger, homogeneous samples in terms of gender and sport to overcome these limitations and enhance the generalizability of the results.
To address these limitations, future studies should explore the effects of different balance programs with feedback on athletes sharing similar musculoskeletal injuries. Combining strength training with balance programs and incorporating additional motor learning techniques, such as attention, could offer a more comprehensive approach to rehabilitation and performance enhancement. Subjective evaluations should extend beyond balance to include neuromuscular coordination and proprioception, providing a more holistic understanding of athletes’ motor abilities. New experimental designs, considering the complementary application of various motor learning and control methods, are proposed to mitigate limitations and provide more robust evidence.
Additionally, there is a crucial need for investigations into the psychophysiological processes of motor learning techniques that unfold during sports injury rehabilitation. Understanding these processes could inform the development of more effective rehabilitation protocols tailored to individual athlete needs.
Moreover, future studies should examine the balance variable not only on the leg with CAI but also on the contralateral “healthy” leg. This approach is essential due to the “bilateral consequences of unilateral injury” hypothesis, which suggests that unilateral injury could lead to bilateral consequences, resulting in altered postural control on the “healthy” limb due to a general reorganization of the sensorimotor system [55]. By considering both limbs, researchers can gain a more comprehensive understanding of the effects of injury on balance and motor control.
Furthermore, future research should investigate the impact of feedback on other joints, such as the knee or shoulder, with different sports injuries (e.g., shoulder impingement syndrome, patellofemoral pain syndrome). This comprehensive approach would contribute to a more nuanced understanding of the effects of feedback across various musculoskeletal conditions.

5. Conclusions

Balance training has a positive effect on the dynamic balance of the CAI. Although external verbal feedback did not have any observed positive impact on the balance ability of individuals with CAI compared to those who did not receive feedback during the balance training, it contributes to the sustained retention of balance learning ability even after the completion of the balance and feedback intervention. Replicating the present study with a larger and more homogeneous sample is imperative to validate the reliability of these results. By expanding our understanding of the role of feedback in improving balance among individuals with CAI, we can potentially advance rehabilitation strategies and optimize the recovery process for sports-related injuries.

Author Contributions

Conceptualization, A.C., L.A.K. and K.P.; methodology, A.C. and D.M.; software, D.M.; validation, E.P., E.K., M.P. and A.C.; formal analysis, A.C. and E.K.; investigation, A.C., L.A.K. and K.P.; resources, D.M.; data curation, A.C., L.A.K. and K.P.; writing—original draft preparation, A.C., L.A.K.and K.P.; writing—review and editing, E.P., E.K. and M.P.; visualization, E.P., E.K. and M.P.; supervision, E.P., E.K., M.P. and A.C.; project administration, A.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Ethics Committee of the University of Peloponnese (6 April 2023, No. 206).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data available upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

References

  1. Waterman, B.R.; Owens, B.D.; Davey, S.; Zacchilli, M.A.; Belmont, P.J., Jr. The epidemiology of ankle sprains in the United States. J. Bone Jt. Surg. Am. Vol. 2010, 92, 2279–2284. [Google Scholar] [CrossRef]
  2. Chen, E.T.; Borg-Stein, J.; McInnis, K.C. Ankle Sprains: Evaluation, Rehabilitation, and Prevention. Curr. Sports Med. Rep. 2019, 18, 217–223. [Google Scholar] [CrossRef]
  3. Safran, M.R.; Benedetti, R.S.; Bartolozzi, A.R., 3rd; Mandelbaum, B.R. Lateral ankle sprains: A comprehensive review: Part 1: Etiology, pathoanatomy, histopathogenesis, and diagnosis. Med. Sci. Sports Exerc. 1999, 31, S429–S437. [Google Scholar] [CrossRef]
  4. Delahunt, E.; Coughlan, G.F.; Caulfield, B.; Nightingale, E.J.; Lin, C.W.; Hiller, C.E. Inclusion criteria when investigating insufficiencies in chronic ankle instability. Med. Sci. Sports Exerc. 2010, 42, 2106–2121. [Google Scholar] [CrossRef] [PubMed]
  5. Swenson, D.M.; Collins, C.L.; Fields, S.K.; Comstock, R.D. Epidemiology of U.S. high school sports-related ligamentous ankle injuries, 2005/06–2010/11. Clin. J. Sport Med. Off. J. Can. Acad. Sport Med. 2013, 23, 190–196. [Google Scholar] [CrossRef] [PubMed]
  6. Gribble, P.A.; Delahunt, E.; Bleakley, C.M.; Caulfield, B.; Docherty, C.L.; Fong, D.T.; Fourchet, F.; Hertel, J.; Hiller, C.E.; Kaminski, T.W.; et al. Selection criteria for patients with chronic ankle instability in controlled research: A position statement of the International Ankle Consortium. J. Athl. Train. 2014, 49, 121–127. [Google Scholar] [CrossRef] [PubMed]
  7. Willems, T.; Witvrouw, E.; Verstuyft, J.; Vaes, P.; De Clercq, D. Proprioception and Muscle Strength in Subjects With a History of Ankle Sprains and Chronic Instability. J. Athl. Train. 2002, 37, 487–493. [Google Scholar] [PubMed]
  8. Drewes, L.K.; McKeon, P.O.; Paolini, G.; Riley, P.; Kerrigan, D.C.; Ingersoll, C.D.; Hertel, J. Altered ankle kinematics and shank-rear-foot coupling in those with chronic ankle instability. J. Sport Rehabil. 2009, 18, 375–388. [Google Scholar] [CrossRef] [PubMed]
  9. McKeon, P.O.; Ingersoll, C.D.; Kerrigan, D.C.; Saliba, E.; Bennett, B.C.; Hertel, J. Balance training improves function and postural control in those with chronic ankle instability. Med. Sci. Sports Exerc. 2008, 40, 1810–1819. [Google Scholar] [CrossRef] [PubMed]
  10. McGuine, T.A.; Greene, J.J.; Best, T.; Leverson, G. Balance as a predictor of ankle injuries in high school basketball players. Clin. J. Sport Med. Off. J. Can. Acad. Sport Med. 2000, 10, 239–244. [Google Scholar] [CrossRef]
  11. Linens, S.W.; Ross, S.E.; Arnold, B.L. Wobble Board Rehabilitation for Improving Balance in Ankles With Chronic Instability. Clin. J. Sport Med. Off. J. Can. Acad. Sport Med. 2016, 26, 76–82. [Google Scholar] [CrossRef]
  12. Mettler, A.; Chinn, L.; Saliba, S.A.; McKeon, P.O.; Hertel, J. Balance training and center-of-pressure location in participants with chronic ankle instability. J. Athl. Train. 2015, 50, 343–349. [Google Scholar] [CrossRef] [PubMed]
  13. Sierra-Guzmán, R.; Jiménez, F.; Abián-Vicén, J. Predictors of chronic ankle instability: Analysis of peroneal reaction time, dynamic balance and isokinetic strength. Clin. Biomech. 2018, 54, 28–33. [Google Scholar] [CrossRef] [PubMed]
  14. Anguish, B.; Sandrey, M.A. Two 4-Week Balance-Training Programs for Chronic Ankle Instability. J. Athl. Train. 2018, 53, 662–671. [Google Scholar] [CrossRef] [PubMed]
  15. Li, Z.; Han, X.G.; Sheng, J.; Ma, S.J. Virtual reality for improving balance in patients after stroke: A systematic review and meta-analysis. Clin. Rehabil. 2016, 30, 432–440. [Google Scholar] [CrossRef] [PubMed]
  16. Hall, E.A.; Chomistek, A.K.; Kingma, J.J.; Docherty, C.L. Balance- and Strength-Training Protocols to Improve Chronic Ankle Instability Deficits, Part I: Assessing Clinical Outcome Measures. J. Athl. Train. 2018, 53, 568–577. [Google Scholar] [CrossRef]
  17. Schmidt, R.A.; Wrisberg, C.A. Motor Learning and Performance: A Situation-Based Learning Approach; Human Kinetics: Champaign, IL, USA, 2008. [Google Scholar]
  18. Gokeler, A.; Benjaminse, A.; Welling, W.; Alferink, M.; Eppinga, P.; Otten, B. The effects of attentional focus on jump performance and knee joint kinematics in patients after ACL reconstruction. Phys. Ther. Sport Off. J. Assoc. Chart. Physiother. Sports Med. 2015, 16, 114–120. [Google Scholar] [CrossRef] [PubMed]
  19. Gredin, V.; Williams, A.M. The Relative Effectiveness of Various Instructional Approaches During the Performance and Learning of Motor Skills. J. Mot. Behav. 2016, 48, 86–97. [Google Scholar] [CrossRef] [PubMed]
  20. Orangi, B.M.; Yaali, R.; Bahram, A.; Aghdasi, M.T.; van der Kamp, J.; Vanrenterghem, J.; Jones, P.A. Motor learning methods that induce high practice variability reduce kinematic and kinetic risk factors of non-contact ACL injury. Hum. Mov. Sci. 2021, 78, 102805. [Google Scholar] [CrossRef]
  21. Benjaminse, A.; Otten, B.; Gokeler, A.; Diercks, R.L.; Lemmink, K.A. Motor learning strategies in basketball players and its implications for ACL injury prevention: A randomized controlled trial. Knee Surg. Sports Traumatol. Arthrosc. 2017, 25, 2365–2376. [Google Scholar] [CrossRef]
  22. Forsyth, L.; Bonacci, J.; Childs, C. A pilot randomised control trial of the efficacy of stability-based training with visualisation for people with chronic ankle instability. Med. Biol. Eng. Comput. 2022, 60, 1199–1209. [Google Scholar] [CrossRef]
  23. Johnson, L.; Burridge, J.H.; Demain, S.H. Internal and external focus of attention during gait re-education: An observational study of physical therapist practice in stroke rehabilitation. Phys. Ther. 2013, 93, 957–966. [Google Scholar] [CrossRef]
  24. Wulf, G.; Shea, C.; Lewthwaite, R. Motor skill learning and performance: A review of influential factors. Med. Educ. 2010, 44, 75–84. [Google Scholar] [CrossRef]
  25. Christakou, A.; Gkikopoulou, A.; Iosif, E.; Gioftsos, G. The effectiveness of focus of attention in static balance and functional ability of chronic ankle instability. A pilot study. Iran. Rehabil. J. 2024, accepted. [Google Scholar]
  26. Winstein, C.J. Knowledge of results and motor learning--Implications for physical therapy. Phys. Ther. 1991, 71, 140–149. [Google Scholar] [CrossRef] [PubMed]
  27. Anderson, D.I.; Magill, R.A.; Mayo, A.M.; Steel, K.A. Enhancing motor skill acquisition with augmented feedback. In Skill Acquisition in Sport; Routledge: London, UK, 2019; pp. 3–19. [Google Scholar]
  28. Paraskevopoulos, E.; Simeonidis, T.; Tsolakis, C.; Koulouvaris, P.; Papandreou, M. Mirror cross-exercise on a kinetic chain approach improves throwing performance in professional volleyball athletes with scapular dyskinesis. J. Sport Rehabil. 2021, 31, 131–139. [Google Scholar] [CrossRef]
  29. Paraskevopoulos, E.; Simeonidis, T.; Tsolakis, C.; Koulouvaris, P.; Papandreou, M. The adjunctive benefits of mirror cross education on kinetic chain exercise approach in volleyball athletes with scapular dyskinesis. J. Sports Med. Phys. Fit. 2021, 62, 98–109. [Google Scholar] [CrossRef]
  30. RL, E.S.; Maia, D.F.M.; de Oliveira, R.R.; Scattone Silva, R. Simple verbal instructions are able to improve quality of movement during the lateral step-down test in healthy females. J. Bodyw. Mov. Ther. 2021, 27, 207–215. [Google Scholar] [CrossRef]
  31. Halperin, I.; Chapman, D.W.; Thompson, K.G.; Abbiss, C. False-performance feedback does not affect punching forces and pacing of elite boxers. J. Sports Sci. 2019, 37, 59–66. [Google Scholar] [CrossRef] [PubMed]
  32. Puce, L.; Trompetto, C.; Currà, A.; Marinelli, L.; Mori, L.; Panascì, M.; Cotellessa, F.; Biz, C.; Bragazzi, N.L.; Ruggieri, P. The Effect of Verbal Encouragement on Performance and Muscle Fatigue in Swimming. Medicina 2022, 58, 1709. [Google Scholar] [CrossRef] [PubMed]
  33. Jaffri, A.H.; Saliba, S. Does verbal encouragement change dynamic balance? The effect of verbal encouragement on Star Excursion Balance Test performance in chronic ankle Instability. Braz. J. Phys. Ther. 2021, 25, 617–622. [Google Scholar] [CrossRef] [PubMed]
  34. Rendos, N.K.; Zajac-Cox, L.; Thomas, R.; Sato, S.; Eicholtz, S.; Kesar, T.M. Verbal feedback enhances motor learning during post-stroke gait retraining. Top. Stroke Rehabil. 2021, 28, 362–377. [Google Scholar] [CrossRef] [PubMed]
  35. Plisky, P.J.; Rauh, M.J.; Kaminski, T.W.; Underwood, F.B. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J. Orthop. Sports Phys. Ther. 2006, 36, 911–919. [Google Scholar] [CrossRef]
  36. Zhang, R.; Qi, Q.; Song, W.; Chen, Y. Predicting the success of multimodal rehabilitation in chronic ankle instability based on patient-reported outcomes. BMC Musculoskelet. Disord. 2022, 23, 706. [Google Scholar] [CrossRef]
  37. Karagiannakis, D.N.; Iatridou, K.I.; Mandalidis, D.G. Ankle muscles activation and postural stability with Star Excursion Balance Test in healthy individuals. Hum. Mov. Sci. 2020, 69, 102563. [Google Scholar] [CrossRef] [PubMed]
  38. Cobos-Moreno, P.; Astasio-Picado, Á.; Martínez-Nova, A.; Sánchez-Rodríguez, R.; Escamilla-Martínez, E.; Gómez-Martín, B. The Podoprint® plantar pressure platform: Evaluation of reliability and repeatability, and determination of the normality parameters. J. Tissue Viability 2022, 31, 619–624. [Google Scholar] [CrossRef]
  39. Sipe, C.L.; Ramey, K.D.; Plisky, P.P.; Taylor, J.D. Y-Balance Test: A Valid and Reliable Assessment in Older Adults. J. Aging Phys. Act. 2019, 27, 663–669. [Google Scholar] [CrossRef]
  40. Mandalidis, D.G.; Karagiannakis, D.N. A comprehensive method for assessing postural control during dynamic balance testing. MethodsX 2020, 7, 100964. [Google Scholar] [CrossRef]
  41. Bizovska, L.; Janura, M.; Svoboda, Z.; Cerny, M.; Krohova, J.; Smondrk, M. Intra- and inter-session reliability of traditional and entropy-based variables describing stance on a wobble board. Med. Eng. Phys. 2017, 50, 29–34. [Google Scholar] [CrossRef]
  42. Hou, Z.C.; Huang, H.S.; Ao, Y.F.; Hu, Y.L.; Jiao, C.; Guo, Q.W.; Miao, X.; Li, N.; Jiang, Y.F.; Jiang, D. The effectiveness and sustainability of supervised balance training in chronic ankle instability with grade III ligament injury: A one-year prospective study. J. Foot Ankle Res. 2022, 15, 9. [Google Scholar] [CrossRef]
  43. Taghavi Asl, A.; Shojaedin, S.S.; Hadadnezhad, M. Comparison of effect of wobble board training with and without cognitive intervention on balance, ankle proprioception and jump landing kinetic parameters of men with chronic ankle instability: A randomized control trial. BMC Musculoskelet. Disord. 2022, 23, 888. [Google Scholar] [CrossRef] [PubMed]
  44. Tsekoura, M.; Billis, E.; Fousekis, K.; Christakou, A.; Tsepis, E. Cross cultural adaptation, reliability, and validity of the Greek version of the Cumberland Ankle Instability Tool. Physiother. Theory Pract. 2021, 37, 954–962. [Google Scholar] [CrossRef] [PubMed]
  45. Hiller, C.E.; Refshauge, K.M.; Bundy, A.C.; Herbert, R.D.; Kilbreath, S.L. The Cumberland ankle instability tool: A report of validity and reliability testing. Arch. Phys. Med. Rehabil. 2006, 87, 1235–1241. [Google Scholar] [CrossRef]
  46. Keith, T.R.; Condon, T.A.; Phillips, A.; McKeon, P.O.; King, D.L. Postural control strategies are dependent on reach direction in the star excursion balance test. Int. J. Athl. Ther. Train. 2016, 21, 33–39. [Google Scholar] [CrossRef]
  47. Webster, K.A.; Gribble, P.A. Functional rehabilitation interventions for chronic ankle instability: A systematic review. J. Sport Rehabil. 2010, 19, 98–114. [Google Scholar] [CrossRef]
  48. Shea, C.H.; Wulf, G. Enhancing motor learning through external-focus instructions and feedback. Hum. Mov. Sci. 1999, 18, 553–571. [Google Scholar] [CrossRef]
  49. Han, S.; Lee, H.; Hopkins, J.T. Acute effects of external visual feedback using cross-line laser on landing neuromechanics and postural control in chronic ankle instability. Sports Biomech. 2022, 1, 1–16. [Google Scholar] [CrossRef]
  50. Schmidt, R.A.; Lee, T.D. Motor Control and Learning: A Behavioral Emphasis, 4th ed.; Human Kinetics: Champaign, IL, USA, 2005. [Google Scholar]
  51. Ohno, H.; Wada, M.; Saitoh, J.; Sunaga, N.; Nagai, M. The effect of anxiety on postural control in humans depends on visual information processing. Neurosci. Lett. 2004, 364, 37–39. [Google Scholar] [CrossRef]
  52. Rozzi, S.L.; Lephart, S.M.; Sterner, R.; Kuligowski, L. Balance training for persons with functionally unstable ankles. J. Orthop. Sports Phys. Ther. 1999, 29, 478–486. [Google Scholar] [CrossRef]
  53. Ottaviani, R.A.; Ashton-Miller, J.A.; Wojtys, E.M. Inversion and eversion strengths in the weightbearing ankle of young women: Effects of plantar flexion and basketball shoe height. Am. J. Sports Med. 2001, 29, 219–225. [Google Scholar] [CrossRef]
  54. Greene, J.J.; McGuine, T.A.; Leverson, G.; Best, T.M. Anthropometric and performance measures for high school basketball players. J. Athl. Train. 1998, 33, 229. [Google Scholar] [PubMed]
  55. Deodato, M.; Coan, L.; Buoite Stella, A.; Ajčević, M.; Martini, M.; Di Lenarda, L.; Ratti, C.; Accardo, A.; Murena, L. Inertial sensors-based assessment to detect hallmarks of chronic ankle instability during single-leg standing: Is the healthy limb “healthy”? Clin. Biomech. 2023, 107, 106036. [Google Scholar] [CrossRef] [PubMed]
Jfmk 09 00056 g001
Figure 1. Footprint with the distribution of pressures.
Figure 1. Footprint with the distribution of pressures.
Jfmk 09 00056 g001
Jfmk 09 00056 g002
Figure 2. Y-Balance test on a plantar pressure recording platform.
Figure 2. Y-Balance test on a plantar pressure recording platform.
Jfmk 09 00056 g002
Table 1. Demographic data (mean ± SD).
Table 1. Demographic data (mean ± SD).
Age (Years)
(Μ ± SD)		Height (cm)
(Μ ± SD)		Weight (Kilogram) (Μ ± SD)BMI
(kg/m2)
(M ± SD)		Time since the Last Sprain (Months)
(Μ ± SD)		History of Sprains (Number)
(Μ ± SD)
Experimental group with feedback19.8 ± 1.03172.3 ± 9.3169.10 ± 11.7823.35± 10.2412.6 ± 7.562.4 ± 1.28
1st Control group without feedback21.4 ± 1.95172.9 ± 10.1670.80± 10.5923.93 ± 10.236.2 ±4.022.9 ± 1.13
2nd Control group without balance training-without feedback23.7 ± 1.63181.8 ± 4.9680.10 ± 7.7824.58 ± 6.3411.5 ± 7.892.6 ± 1.35
Table 2. Descriptive statistics of the Y-Balance Test, of the center of pressure distribution length and velocity, CAIT (mean ± SD).
Table 2. Descriptive statistics of the Y-Balance Test, of the center of pressure distribution length and velocity, CAIT (mean ± SD).
Experimental Group with Feedback1st Control Group without Feedback2nd Control Group without Balance Training—without Feedback
Variables1st measurement2nd
measurement		3nd measurement1st measurement2nd measurement3nd measurement1st measurement2nd measurement3nd measurement
Y-Balance96.13 ± 9.3299.97 ± 7.38100.19 ± 6.1896.13 ± 9.3299.97 ± 7.38100.19 ± 6.1894.32 ± 5.9993.71 ± 7.4995.18 ± 5.68
Centre length pressure distribution567.61 ± 168.7514.51 ± 176.26524.44 ± 167.1659.64 ± 205.8671.99 ± 167.3588.46 ± 119.7656.47 ± 211.7624.22 ± 159.7609.7± `186.7
Pressure distribution centre velocity56.75 ± 16.8751.44 ± 17.6252.44 ± 16.4256.75 ± 16.8751.44 ± 17.6252.44 ± 16.4256.75 ± 16.8751.44 ± 17.6252.44 ± 16.42
CAIT17.40 ± 4.8821.90 ± 1.8522 ± 1.7319.80 ± 3.1222.67 ± 1.522.11 ± 1.7620.60 ± 3.0220.88 ± 2.5820.86 ± 2.79
Abbreviation: CAIT, Cumberland Ankle Instability Tool.
Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

Share and Cite

MDPI and ACS Style

Parlakidis, K.; Kontopoulos, L.A.; Mandalidis, D.; Paraskevopoulos, E.; Papandreou, M.; Kapreli, E.; Christakou, A. The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability. J. Funct. Morphol. Kinesiol. 2024, 9, 56. https://doi.org/10.3390/jfmk9010056

AMA Style

Parlakidis K, Kontopoulos LA, Mandalidis D, Paraskevopoulos E, Papandreou M, Kapreli E, Christakou A. The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability. Journal of Functional Morphology and Kinesiology. 2024; 9(1):56. https://doi.org/10.3390/jfmk9010056

Chicago/Turabian Style

Parlakidis, Konstantinos, Lazaros Alexandors Kontopoulos, Dimitris Mandalidis, Eleftherios Paraskevopoulos, Maria Papandreou, Eleni Kapreli, and Anna Christakou. 2024. "The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability" Journal of Functional Morphology and Kinesiology 9, no. 1: 56. https://doi.org/10.3390/jfmk9010056

APA Style

Parlakidis, K., Kontopoulos, L. A., Mandalidis, D., Paraskevopoulos, E., Papandreou, M., Kapreli, E., & Christakou, A. (2024). The Effectiveness of External Verbal Feedback on Balance in Athletes with Chronic Ankle Instability. Journal of Functional Morphology and Kinesiology, 9(1), 56. https://doi.org/10.3390/jfmk9010056

Article Metrics

Back to TopTop