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Liu N, Yang C, Song Q, Yang F, Chen Y. Patients with chronic ankle instability exhibit increased sensorimotor cortex activation and correlation with poorer lateral balance control ability during single-leg stance: a FNIRS study. Front Hum Neurosci 2024; 18:1366443. [PMID: 38736530 PMCID: PMC11082417 DOI: 10.3389/fnhum.2024.1366443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 04/12/2024] [Indexed: 05/14/2024] Open
Abstract
Introduction Chronic Ankle Instability (CAI) is a musculoskeletal condition that evolves from acute ankle sprains, and its underlying mechanisms have yet to reach a consensus. Mounting evidence suggests that neuroplastic changes in the brain following ankle injuries play a pivotal role in the development of CAI. Balance deficits are a significant risk factor associated with CAI, yet there is a scarcity of evidence regarding the sensorimotor cortical plasticity related to balance control in affected individuals. This study aims to evaluate the differences in cortical activity and balance abilities between patients with CAI and uninjured individuals during a single-leg stance, as well as the correlation between these factors, in order to elucidate the neurophysiological alterations in balance control among patients with CAI. Methods The study enrolled 24 patients with CAI and 24 uninjured participants. During single-leg stance, cortical activity was measured using a functional near-infrared spectroscopy (fNIRS) system, which included assessments of the pre-motor cortex (PMC), supplementary motor area (SMA), primary motor cortex (M1), and primary somatosensory cortex (S1). Concurrently, balance parameters were tested utilizing a three-dimensional force platform. Results Independent sample t-tests revealed that, compared with the uninjured individuals, the patients with CAI exhibited a significant increase in the changes of oxyhemoglobin concentration (ΔHbO) during single-leg stance within the left S1 at Channel 5 (t = 2.101, p = 0.041, Cohen's d = 0.607), left M1 at Channel 6 (t = 2.363, p = 0.022, Cohen's d = 0.682), right M1 at Channel 15 (t = 2.273, p = 0.029, Cohen's d = 0.656), and right PMC/SMA at Channel 11 (t = 2.467, p = 0.018, Cohen's d = 0.712). Additionally, the center of pressure root mean square (COP-RMS) in the mediolateral (ML) direction was significantly greater (t = 2.630, p = 0.012, Cohen's d = 0.759) in the patients with CAI. Furthermore, a moderate positive correlation was found between ML direction COP-RMS and ΔHbO2 in the M1 (r = 0.436; p = 0.033) and PMC/SMA (r = 0.488, p = 0.016), as well as between anteroposterior (AP) direction COP-RMS and ΔHbO in the M1 (r = 0.483, p = 0.017). Conclusion Patients with CAI demonstrate increased cortical activation in the bilateral M1, ipsilateral PMC/SMA, and contralateral S1. This suggests that patients with CAI may require additional brain resources to maintain balance during single-leg stance, representing a compensatory mechanism to uphold task performance amidst diminished lateral balance ability in the ankle joint.
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Affiliation(s)
| | | | | | | | - Yan Chen
- College of Sport and Health, Shandong Sport University, Jinan, Shandong, China
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Liu Y, Wang Y. Study on the effect of blood flow restriction training combined with IASTAM on ankle strength and function intervention in athletes with chronic ankle instability in sport dance events. BMC Sports Sci Med Rehabil 2024; 16:81. [PMID: 38605396 PMCID: PMC11007892 DOI: 10.1186/s13102-024-00873-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Accepted: 04/01/2024] [Indexed: 04/13/2024]
Abstract
BACKGROUND Athletes engaged in sports dance frequently encounter the potential for ankle injuries and instability, factors that may contribute to diminished training efficacy, compromised athletic performance, prolonged recuperation, and heightened susceptibility to recurring injuries. OBJECTIVE The objective of this study was to investigate the impact of an exercise intervention (comprising blood flow restriction training combined with low-load ankle muscle strength training and balance training) as well as instrument-assisted soft tissue mobilization (IASTM) on the foot and ankle function, strength, and range of motion in sports dance athletes exhibiting ankle instability (CAI). METHODS Thirty participants exhibiting ankle instability, restriction, or discomfort were recruited and randomly assigned to two groups: the Test group (comprising blood flow restriction training combined with IASTM, n = 15) and the traditional ankle strength training group (n = 15). The intervention spanned 4 weeks, with one session per week. Assessment of the Cumberland Ankle Instability Tool (CAIT), Foot and Ankle Ability Measure (FAAM), and ankle range of motion occurred at three time points: pre-intervention, immediately following the initial intervention, and after 4 weeks of intervention. Ankle strength testing was conducted solely before and after the intervention for comparative analysis. RESULTS There were no significant variances in baseline characteristics between the two intervention groups. In terms of CAIT scores, both groups exhibited notably higher scores following the initial intervention and after 4 weeks of intervention compared to pre-intervention (P < 0.05). The Test group displayed higher CAIT scores than the control group, signifying a more pronounced enhancement in ankle stability among patients in the Test group. Concerning FAAM scores, both groups significantly enhanced ankle function in CAI patients (P < 0.05), with the Test group demonstrating notably higher FAAM-SPORT scores than the control group (P < 0.05), indicating superior restoration of athletic capability in the Test group. As for improvements in ankle range of motion, both groups demonstrated significant enhancements compared to pre-intervention (P < 0.05). The Test group exhibited significantly superior improvements in dorsiflexion, eversion, and inversion range of motion compared to the control group (P < 0.05), while the control group did not exhibit significant enhancements in plantarflexion and eversion range of motion (P > 0.05). Both groups displayed enhanced ankle strength in CAI patients following the intervention (P < 0.05), with the Test group manifesting notably higher dorsiflexion and inversion strength than the control group (P < 0.05). CONCLUSION Both blood flow restriction training combined with IASTM and traditional ankle strength and stability training have shown significant improvements in stability, function, strength, and range of motion in CAI patients. Furthermore, the Test group exhibits superior efficacy in ankle stability, daily functional movement, dorsiflexion, and eversion range of motion compared to the control group. CLINICAL TRIAL REGISTRATION 9 February 2024, ClinicalTrials.gov, ID; NCT06251414.
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Affiliation(s)
- Yang Liu
- Graduate School, School of Arts, Wuhan Sports University, 430079, Wuhan, China
| | - Ying Wang
- Graduate School, School of Arts, Wuhan Sports University, 430079, Wuhan, China.
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Alshahrani MS, Reddy RS, Alshahrani A, Gautam AP, Alsubaie SF. Exploring the interplay between ankle muscle strength, postural control, and pain intensity in chronic ankle instability: A comprehensive analysis. Heliyon 2024; 10:e27374. [PMID: 38486775 PMCID: PMC10937675 DOI: 10.1016/j.heliyon.2024.e27374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/27/2024] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
Background Chronic Ankle Instability (CAI) is a common musculoskeletal condition characterized by recurring ankle sprains and impaired postural control (PC). Understanding the relationship between ankle muscle strength, PC, and the role of pain is essential for effective management. Objectives This prospective cross sectional study aimed to 1. Compare ankle isometric muscle strength (IMS) and PC between CAI and asymptomatic sides. 2. Assess the correlations between ankle IMS and PC and explore the potential mediating effect of pain in individuals with CAI. Methods A total of 44 individuals with CAI, were enrolled in the study. Ankle IMS (dorsiflexors, plantar flexors, invertors, and evertors) was measured using a dynamometer, while PC was evaluated using sway parameters (anterior-posterior and medial-lateral sway, ellipse area). Pain levels were reported using a Visual Analog Scale. Results The CAI ankles exhibited significantly lower ankle IMS in all muscle groups compared to the asymptomatic ankles (p < 0.001). Additionally, the CAI side showed increased postural sway and a larger ellipse area (p < 0.001), indicating reduced PC. Negative correlations were observed between ankle IMS and PC parameters on the CAI side, with dorsiflexor strength showing correlations ranging from -0.423 to -0.387, plantar flexor strength ranging from -0.423 to -0.371, invertor strength ranging from -0.412 to -0.238, and evertor strength ranging from -0.451 to -0.365 (p < 0.001). Mediation analysis revealed that pain played a significant mediating role in connecting ankle IMS and PC parameters among individuals with CAI, with statistical significance (p < 0.05). Conclusions Individuals with CAI exhibit weaker ankle IMS and diminished PC in comparison to their healthy side. Moreover, pain was identified as a mediator in the relationship between ankle IMS and PC in CAI. These findings underscore the importance of addressing both ankle IMS and pain in the rehabilitation and management of CAI.
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Affiliation(s)
- Mastour Saeed Alshahrani
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, 61421, Saudi Arabia
| | - Ravi Shankar Reddy
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, 61421, Saudi Arabia
| | - Adel Alshahrani
- Department of Medical Rehabilitation Sciences-Physiotherapy Program, College of Applied Medical Sciences, Najran University, Najran, 55461, Saudi Arabia
| | - Ajay Prashad Gautam
- Department of Medical Rehabilitation Sciences, College of Applied Medical Sciences, King Khalid University, Abha, 61421, Saudi Arabia
| | - Saud F. Alsubaie
- Department of Health and Rehabilitation Sciences, College of Applied Medical Sciences, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia
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Maricot A, Corlùy H, De Pauw K, Lathouwers E, Meeusen R, Roelands B, Verschueren J, Tassignon B. Deficits in neurocognitive performance in patients with chronic ankle instability during a neurocognitive balance task - A retrospective case-control study. Phys Ther Sport 2024; 66:1-8. [PMID: 38219693 DOI: 10.1016/j.ptsp.2023.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 12/23/2023] [Accepted: 12/27/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES To assess the neurocognitive performance while maintaining balance of patients experiencing CAI compared to healthy controls. In patients with CAI, the affected limb was also compared to the contralateral limb. DESIGN A retrospective case-control study. SETTING Laboratory study. PARTICIPANTS We included 27 patients with CAI and 21 healthy controls. METHODS The study consisted of two sessions, namely familiarisation and experimentation, which were scheduled with a gap of at least one week between them. During the experimental trial, both groups performed the Y-Balance Test and Reactive Balance Test once on each limb. MAIN OUTCOME MEASURES The main outcome measures are accuracy and visuomotor response time (VMRT) calculated via video-analysis and with the Fitlight™-hardware and software respectively during the Reactive Balance Test (RBT). RESULTS No data was excluded from the final analysis. Patients with CAI exhibited significantly lower accuracy than healthy controls, with a mean difference of 8.7% (±3.0)%. There were no differences for VMRT between groups. Additionally, no significant differences were observed between the affected and contralateral limb of the patient group for both accuracy and VMRT. CONCLUSIONS Patients with CAI showed lower accuracy, but similar VMRT compared to healthy controls during a neurocognitive balance task, indicating impaired neurocognitive function. Patients exhibit comparable speed to healthy individuals when completing neurocognitive balance tasks, yet they display a higher frequency of accuracy errors in accurately perceiving their environment and making decisions under time constraints. Future research should gain more insights in which other cognitive domains are affected in patients with CAI for a better grasp of this condition's underlying mechanism.
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Affiliation(s)
- Alexandre Maricot
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.
| | - Hortense Corlùy
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.
| | - Kevin De Pauw
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium; Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, 1050, Brussels, Belgium.
| | - Elke Lathouwers
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium; Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, 1050, Brussels, Belgium.
| | - Romain Meeusen
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.
| | - Bart Roelands
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium; Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, 1050, Brussels, Belgium.
| | - Jo Verschueren
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.
| | - Bruno Tassignon
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Pleinlaan 2, 1050, Brussels, Belgium.
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Maricot A, Lathouwers E, Verschueren J, De Pauw K, Meeusen R, Roelands B, Tassignon B. Test-retest, intra- and inter-rater reliability of the reactive balance test in patients with chronic ankle instability. Front Neurol 2024; 15:1320043. [PMID: 38434204 PMCID: PMC10906270 DOI: 10.3389/fneur.2024.1320043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 01/23/2024] [Indexed: 03/05/2024] Open
Abstract
Introduction The Reactive Balance Test (RBT) could be a valuable addition to research on chronic ankle instability (CAI) and clinical practice, but before it can be used in clinical practice it needs to be reliable. It has already been proven reliable in healthy recreational athletes, but not yet in patients with CAI who have shown persistent deficits in dynamic balance. The study aimed to determine the test-retest, intra-, and inter-rater reliability of the RBT in patients with CAI, and the test-retest and inter-rater reliability of the newly developed RBT score sheet. Methods We used a repeated-measures, single-group design to administer the RBT to CAI patients on three occasions, scored by multiple raters. We included 27 participants with CAI. The study used multiple reliability measures, including Pearson r, intra-class correlations (ICC), standard error of measurement (SEM), standard error of prediction (SEP), minimal detectable change (MDC), and Bland-Altman plots, to evaluate the reliability of the RBT's outcome measures (visuomotor response time and accuracy). It also assessed the test-retest and inter-rater reliability of the RBT score sheet using the same measures. Results The ICC measures for test-retest reliability were similar for accuracy (0.609) and VMRT (0.594). Intra-rater reliability had high correlations and ICCs for accuracy (r = 0.816, ICC = 0.815) and VMRT (r = 0.802, ICC = 0.800). Inter-rater reliability had a higher ICC for VMRT (0.868) than for accuracy (0.690). Conclusion Test-retest reliability was moderate, intra-rater reliability was good, and inter-rater reliability showed moderate reliability for accuracy and good reliability for VMRT. Additionally, the RBT shows robust SEM and mean difference measures. The score sheet method also demonstrated moderate test-retest reliability, while inter-rater reliability was good to excellent. This suggests that the RBT can be a valuable tool in assessing and monitoring balance in patients with CAI.
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Affiliation(s)
- Alexandre Maricot
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Elke Lathouwers
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Jo Verschueren
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
| | - Kevin De Pauw
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, Brussels, Belgium
| | - Romain Meeusen
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Sports, Recreation, Exercise and Sciences (SRES), Faculty of Community and Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Bart Roelands
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
- Brussels Human Robotics Research Center (BruBotics), Vrije Universiteit Brussel, Brussels, Belgium
| | - Bruno Tassignon
- Human Physiology and Sports Physiotherapy Research Group, Faculty of Physical Education and Physiotherapy, Vrije Universiteit Brussel, Brussels, Belgium
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Xue X, Wang Y, Xu X, Li H, Li Q, Na Y, Tao W, Yu L, Jin Z, Li H, Wang R, Hua Y. Postural Control Deficits During Static Single-leg Stance in Chronic Ankle Instability: A Systematic Review and Meta-Analysis. Sports Health 2024; 16:29-37. [PMID: 36872589 PMCID: PMC10732110 DOI: 10.1177/19417381231152490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023] Open
Abstract
CONTEXT Postural control deficits arising from injured ankles are central to chronic ankle instability (CAI) and its persistent symptoms. This is usually measured by recording the center of pressure (CoP) trajectory during static single-leg stance using a stable force plate. However, existing studies have produced conflicting results on whether this mode of measurement adequately reveals the postural deficits in CAI. OBJECTIVE To determine whether postural control during static single-leg stance is impaired in CAI patients when compared with uninjured healthy controls. DATA SOURCES Literature databases, PubMed, Embase, Web of Science, Cochrane Library, Scopus, CINAHL, and SPORTDiscus, were searched from inception to April 1, 2022, using ankle-, injury-, and posture-related terms. STUDY SELECTION Two authors independently performed the step-by-step screening of article titles, abstracts, and full texts to select peer-reviewed studies investigating CoP trajectory during static single-leg stance using a stable force plate in CAI patients and healthy controls. A total of 13,637 studies were reviewed, and 38 studies (0.003%) met the selection criteria. STUDY DESIGN Meta-analyses of descriptive epidemiological study. LEVEL OF EVIDENCE Level 4. DATA EXTRACTION CoP parameters, sway directions, visual condition, and numerical data (means and standard deviations) were extracted. RESULTS The injured ankles of CAI patients had higher standard deviations of sway amplitude in both anterior-posterior and medial-lateral directions (standardized mean difference [SMD] = 0.36 and 0.31, respectively) under conditions of open eyes than controls. Higher mean sway velocity in anterior-posterior, medial-lateral, and total directions (SMD = 0.41, 0.37, and 0.45, respectively) with closed eyes was also found. CONCLUSION CAI patients had deficits of postural control during static single-leg stance, and these deficits were identified by the CoP trajectory. Further methodological explorations of CoP parameters and corresponding test conditions are required to enhance the sensitivity and reliability of postural deficit assessments in CAI using force plates.
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Affiliation(s)
- Xiao’ao Xue
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiran Wang
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiaoyun Xu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Hong Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Qianru Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuyan Na
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Weichu Tao
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Le Yu
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Zhengbiao Jin
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongyun Li
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Ru Wang
- School of Exercise and Health, Shanghai University of Sport, Shanghai, China
| | - Yinghui Hua
- Department of Sports Medicine, Huashan Hospital, Fudan University, Shanghai, China; Yiwu Research Institute, Fudan University, Yiwu, China
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Jamshidi AH, Mofateh R, Orakifar N, Seyedtabib M, Najarzadeh Z, Behdarvandan A. Immediate effects of local muscle vibration on static and dynamic balance control in individuals with chronic ankle instability. Phys Ther Sport 2024; 65:113-121. [PMID: 38128288 DOI: 10.1016/j.ptsp.2023.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/28/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVES To investigate the immediate effects of local muscle vibration (LMV) on static and dynamic balance control in individuals with and without chronic ankle instability (CAI). DESIGN Quasi-experimental study. SETTING Research laboratory. PARTICIPANTS Twenty-six individuals with CAI and 26 healthy controls. MAIN OUTCOME MEASURES Center of pressure variables (mean total velocity and displacement in anteroposterior (AP) and mediolateral (ML) directions) during single-leg standing with eyes open and eyes closed and also reach distances in anterior (ANT), posteromedial (PM), and posterolateral (PL) directions of the modified star excursion balance test (MSEBT) were assessed before and after LMV. RESULTS Statistical analyses showed a significant decrease in mean total velocity and displacement in AP direction from before to after LMV in eyes open condition for both individuals with CAI (p = 0.025, p = 0.041, respectively) and healthy controls (p = 0.001, p = 0.003, respectively). Similar results were observed in eyes closed condition for both individuals with CAI (p < 0.001, p < 0.001, respectively) and healthy controls (p = 0.040, p = 0.014, respectively). The results also showed increased reach distances in ANT (p < 0.001), PM (p < 0.001), and PL directions (p < 0.001) in all participants after LMV. CONCLUSION Our results suggest that LMV may be a useful tool in rehabilitation of static and dynamic balance deficits in individuals with CAI.
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Affiliation(s)
- Amir Hossein Jamshidi
- Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Student Research Committee, School of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Razieh Mofateh
- Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Physiotherapy, School of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Neda Orakifar
- Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Physiotherapy, School of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Maryam Seyedtabib
- Department of Biostatistics and Epidemiology, School of Public Health, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Zahra Najarzadeh
- Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
| | - Amin Behdarvandan
- Rehabilitation Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran; Department of Physiotherapy, School of Rehabilitation Sciences, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
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Yousefi M, Zivari S, Yiou E, Caderby T. Effect of Chronic Ankle Instability on the Biomechanical Organization of Gait Initiation: A Systematic Review. Brain Sci 2023; 13:1596. [PMID: 38002555 PMCID: PMC10669647 DOI: 10.3390/brainsci13111596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 11/13/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
This systematic review was conducted to provide an overview of the effects of chronic ankle instability (CAI) on the biomechanical organization of gait initiation. Gait initiation is a classical model used in the literature to investigate postural control in healthy and pathological individuals. PubMed, ScienceDirect, Scopus, Web of Science, and Google Scholar were searched for relevant articles. Eligible studies were screened and data extracted by two independent reviewers. An evaluation of the quality of the studies was performed using the Downs and Black checklist. A total of 878 articles were found in the initial search, but only six studies met the inclusion criteria. The findings from the literature suggest that CAI affects the characteristics of gait initiation. Specifically, individuals with CAI exhibit notable differences in reaction time, the spatiotemporal parameters of anticipatory postural adjustments (APAs) and step execution, ankle-foot kinematics, and muscle activation compared to healthy controls. In particular, the observed differences in APA patterns associated with gait initiation suggest the presence of supraspinal motor control alterations in individuals with CAI. These findings may provide valuable information for the rehabilitation of these patients. However, the limited evidence available calls for caution in interpreting the results and underscores the need for further research.
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Affiliation(s)
- Mohammad Yousefi
- Faculty of Sport Sciences, University of Birjand, Birjand 9717434765, Iran; (M.Y.); (S.Z.)
| | - Shaghayegh Zivari
- Faculty of Sport Sciences, University of Birjand, Birjand 9717434765, Iran; (M.Y.); (S.Z.)
| | - Eric Yiou
- Complexité, Innovation, Activités Motrices et Sportives (CIAMS), Université Paris-Saclay, 91400 Orsay, France
- Complexité, Innovation, Activités Motrices et Sportives (CIAMS), Université d’Orléans, 45067 Orléans, France
| | - Teddy Caderby
- Laboratoire IRISSE—EA 4075, UFR des Sciences de l’Homme et de l’Environnement, Université de La Réunion, 97430 Le Tampon, La Réunion, France;
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Endo Y, Miura M. Differences in the center of pressure movement during standing with running shoes of different constructions: A cross-sectional study. J Orthop 2023; 45:43-47. [PMID: 37841906 PMCID: PMC10570558 DOI: 10.1016/j.jor.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 09/14/2023] [Accepted: 09/29/2023] [Indexed: 10/17/2023] Open
Abstract
Purpose This study examined the differences in the center of pressure movement in a one-leg standing position with bare feet, thin-soled shoes, and thick-soled shoes. Methods In total, 21 male university students participated in this study. The task involved standing on one leg with the dominant foot for 30 s, and the center of pressure movement was measured using a grab coder (G-620; ANIMA, Tokyo, Japan). Three shoe-wearing states, including bare feet, thin-soled shoes, and thick-soled shoes, with the eyes closed and open in each condition. Statistical analysis was performed, with the significance level set as 5%. Results In the multiple comparison results, the anteroposterior (AP) locus length, AP locus length per second, and maximum amplitude in the AP direction were significantly larger with thick-soled shoes than with bare feet in the closed eyes state. The locus length per unit area was significantly smaller with the thick-soled shoes than with the barefoot condition. Other items did not differ significantly between the shoe-wearing states. Conclusion Thick-soled shoes caused a greater center of pressure movement in the AP direction in the static one-leg standing position than did the barefoot state. Our findings suggest that the condition with thick-soled shoes was more unstable in static environments.
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Affiliation(s)
- Yasuhiro Endo
- Department of Physical Therapy, Fukushima Medical University School of Health Sciences, Japan
| | - Masashi Miura
- Tokyo Rehabilitation Service Co., Ltd., Michinoku Rehabilitation Home-Visit Nursing Station, Aoba, Japan
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Wang L, Yu G, Chen Y. Effects of dual-task training on chronic ankle instability: a systematic review and meta-analysis. BMC Musculoskelet Disord 2023; 24:814. [PMID: 37833685 PMCID: PMC10571247 DOI: 10.1186/s12891-023-06944-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Dual-task training has been a popular intervention for individuals with balance impairments. However, the effects of dual-task training on chronic ankle instability (CAI) have not been comprehensively analyzed and reliable clinical evidence is scarce. The purpose of this systematic review and meta-analysis is to evaluate the effectiveness of dual-task training on postural stability and functional ability in individuals with CAI. METHODS PubMed, Web of Science, EBSCO, Cochrane Library, Physiotherapy Evidence Database (PEDro), and China National Knowledge Infrastructure (CNKI) were researched from inception to November 2022. This study was conducted by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two reviewers assessed the studies for inclusion and extracted data. The Cochrane Risk of Bias list was used to assess the risk of bias in included studies. Mean differences (MD) with a 95% confidence interval (CI) were calculated with the RevMan 5.3 software. RESULTS A total of 7 randomized controlled trials with 192 CAI met the inclusion criteria. The meta-analysis results showed that compared with the control group, dual-task training significantly improved the Y-balance test (MD = 1.60, 95% CI: -0.00 to 3.21, P = 0.050) and reduced COP-area (MD = - 0.94, 95% CI: -1.62 to - 0.26, P = 0.007) in individuals with CAI. However, there is no significant difference between dual-task training and the control group on COP-velocity (MD = - 0.26, 95% CI: -0.70 to 0.17, P = 0.240), hop test (MD = - 0.20, 95% CI: -0.66 to 0.26, P = 0.386) and BESS (MD = - 1.24, 95% CI: -2.95 to 0.48, P = 0.157) in individuals with CAI. CONCLUSION This meta-analysis showed that dual-task training may be effective in improving static and dynamic postural stability. However, more high-quality randomized controlled trials are needed to verify the short and long-term effectiveness of dual-task training on CAI.
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Affiliation(s)
- Lu Wang
- Department of Rehabilitation, Beijing Tongren Hospital, Capital Medical University, 1 Dongjiaominxiang, Beijing, 100730, China
| | - Ge Yu
- Department of Rehabilitation, Beijing Tongren Hospital, Capital Medical University, 1 Dongjiaominxiang, Beijing, 100730, China
| | - Yaping Chen
- Department of Rehabilitation, Beijing Tongren Hospital, Capital Medical University, 1 Dongjiaominxiang, Beijing, 100730, China.
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Choi JY, Yoo T, Burcal CJ, Rosen AB. Dual-task differences in individuals with chronic ankle instability: A systematic review with meta-analysis. Gait Posture 2023; 106:28-33. [PMID: 37639962 DOI: 10.1016/j.gaitpost.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/28/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Individuals with Chronic Ankle Instability (CAI) demonstrate altered gait mechanics, impaired proprioception, and decreased postural control. In addition, individuals with CAI have been found to have complex neurophysiological changes, including during dual-task perturbations. However, the results of studies on whether cognitive tasks affect postural control are inconclusive. RESEARCH QUESTION Do individuals with CAI have worse dual-task performance compared to healthy controls? METHODS We searched 4 electronic databases (PubMed, MEDLINE, Cumulative Index of Nursing and Allied Health Literature, and SPORTDiscus) from inception to October 2022. Search terms consisted of: ("dual-task*" OR "dual task*" OR dual-task OR Multitask* OR Multi-task* OR attention OR cognit*) AND (balance OR "postural control" OR "postural sway" OR kinetics OR kinematics OR gait) NOT (concussion OR "traumatic brain injury") combined using the operator "AND" ("ankle sprain" OR "ankle instability" OR CAI). Studies were included if the physical task was postural control or gait, and if they compared control and CAI groups. RESULTS A total of 9 studies were included in the systematic-review portion, 5 of which were included in the meta-analysis. Due to assessing multiple types of dual-tasks, 10 effects were assessed for meta-analysis across postural control studies. A random-effects model for the control group in the mediolateral direction indicated a significant overall Fisher's Z mean effect size (Δ = 0.732, p = 0.029) with high heterogeneity between studies (Q=76.61; I2 = 88.25% P < 0.001). There were no significant differences between dual-tasking in the CAI group individually or when comparing control to CAI groups. SIGNIFICANCE The results of our study indicate that cognitive loading did not affect the postural control except for the control group in the mediolateral direction. Variations in dual-task results may be due to the difficulty of the task as well as the heterogeneity of CAI groups.
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Koshino Y, Akimoto M, Kawahara D, Watanabe K, Ishida T, Samukawa M, Kasahara S, Tohyama H. Inertial Sensor-Based Assessment of Static Balance in Athletes with Chronic Ankle Instability. J Sports Sci Med 2023; 22:36-43. [PMID: 36876176 PMCID: PMC9982532 DOI: 10.52082/jssm.2023.36] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 12/29/2022] [Indexed: 01/09/2023]
Abstract
The Balance Error Scoring System (BESS), a subjective examiner-based assessment, is often employed to assess postural balance in individuals with chronic ankle instability (CAI); however, inertial sensors may enhance the detection of balance deficits. This study aimed to compare the BESS results between the CAI and healthy groups using conventional BESS scores and inertial sensor data. The BESS test (six conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces, respectively) was performed for the CAI (n = 16) and healthy control (n = 16) groups with inertial sensors mounted on the sacrum and anterior shank. The BESS score was calculated visually by the examiner by counting postural sway as an error based on the recorded video. The root mean square for resultant acceleration (RMSacc) in the anteroposterior, mediolateral, and vertical directions was calculated from each inertial sensor affixed to the sacral and shank surfaces during the BESS test. The mixed-effects analysis of variance and unpaired t-test were used to assess the effects of group and condition on the BESS scores and RMSacc. No significant between-group differences were found in the RMSacc of the sacral and shank surfaces, and the BESS scores (P > 0.05), except for the total BESS score in the foam condition (CAI: 14.4 ± 3.7, control: 11.7 ± 3.4; P = 0.039). Significant main effects of the conditions were found with respect to the BESS scores and RMSacc for the sacral and anterior shank (P < 0.05). The BESS test with inertial sensors can detect differences in the BESS conditions for athletes with CAI. However, our method could not detect any differences between the CAI and healthy groups.
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Affiliation(s)
- Yuta Koshino
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Moeko Akimoto
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Daiki Kawahara
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | | | - Tomoya Ishida
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
| | - Mina Samukawa
- Faculty of Health Sciences, Hokkaido University, Sapporo, Japan
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13
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Rosen AB, Choi JY, Anderson K, Remski LE, Knarr BA. Development, validity, and test-retest reliability of a new neurocognitive functional performance test: The choice-reaction hop test. Phys Ther Sport 2023; 59:80-84. [PMID: 36525740 DOI: 10.1016/j.ptsp.2022.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/01/2022] [Accepted: 12/02/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To validate a choice-reaction hop test (CRHT) by assessing differences in timing versus the side-hop test (SHT), and to determine the CRHT's test-retest reliability. DESIGN Test-retest reliability. SETTING Laboratory. PARTICIPANTS Forty-nine healthy adults participated (16 female; age = 22.7 ± 3.4 years; height = 174.9 ± 9.1 cm; mass = 75.4 ± 14.8 kg). MAIN OUTCOME MEASURES Participants completed three trials each of the SHT and the CRHT in a counterbalanced order. Participants returned one-week later to repeat the CRHT. The fastest and the mean of the three trials were compared. RESULTS Participants took significantly longer to complete the CRHT (Mean across 3 trials = 21.4 ± 3.4s, Fastest trial = 19.7 ± 3.0s) compared to the traditional SHT (10.4 ± 2.0s, p < 0.001). The CRHT demonstrated good-excellent test-retest reliability across testing days for both the mean across 3 trials (r = 0.890, p < 0.001, SEM = 1.13) and the fastest trial (r = 0.828, p < 0.001, SEM = 1.24). CONCLUSION Compared to the SHT, the CRHT took longer to complete indicating its ability to stress neurocognitive function during an FPT. The CRHT demonstrated good-excellent test-retest reliability, which may allow it to be a useful measure in serial evaluations such as during rehabilitation benchmarking. The CRHT may be an effective FPT to assess combined physical and neurocognitive function to assist clinicians in evidence-based decision-making.
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Affiliation(s)
- Adam B Rosen
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA.
| | - Ji Yeon Choi
- School of Health and Kinesiology, University of Nebraska at Omaha, Omaha, NE, USA
| | - Katie Anderson
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
| | - Lindsey E Remski
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
| | - Brian A Knarr
- Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE, USA
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Watabe T, Takabayashi T, Tokunaga Y, Watanabe T, Kubo M. Copers exhibit altered ankle and trunk kinematics compared to the individuals with chronic ankle instability during single-leg landing. Sports Biomech 2022:1-13. [PMID: 35435154 DOI: 10.1080/14763141.2022.2058989] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Accepted: 03/23/2022] [Indexed: 10/18/2022]
Abstract
Copers are individuals who have had a lateral ankle sprain but have no history of recurrent lateral ankle sprain, residual symptoms, or functional disability. Copers have shown no significant difference in lower limb kinematics in landing for proactive conditions compared with a control (CTR) group. However, the copers (CPR) group has shown differences compared to CTR and chronic ankle instability (CAI) groups for dynamic balance conditions, suggesting that the trunk may compensate for foot instability during shock absorption. This study aimed to examine the differences in the kinematics and kinetics among CPR, CAI and CTR groups in reactive and proactive single-leg landing tasks. Participants were physically active adults with CAI (n = 14), CPR (n = 14), and CTR (n = 14), who performed proactive and reactive single-leg landings. The lower limb, trunk kinematics, vertical ground reaction force (vGRF) peak value, and the time to minimum peak vGRF were analysed. It might be conceivable that the CPR group could absorb vGRF efficiently by increasing the trunk flexion angle and increasing the time to reach the minimum peak vGRF regardless of landing condition. The results suggest that evaluating the movements of the entire body, including the ankle and trunk, is essential.
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Affiliation(s)
- Takaya Watabe
- Section of Rehabilitation, Kanazawa University Hospital, 13-1 Takaramachi, Kanazawa 920-8641, Japan
| | - Tomoya Takabayashi
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan
| | - Yuta Tokunaga
- Terrabyte Corporation, 3-10-7 Yushima, Bunkyo-ku, Tokyo 113-0034, Japan
| | - Takahiro Watanabe
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan
| | - Masayoshi Kubo
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan
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15
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Watabe T, Takabayashi T, Tokunaga Y, Kubo M. Copers adopt an altered dynamic postural control compared to individuals with chronic ankle instability and controls in unanticipated single-leg landing. Gait Posture 2022; 92:378-382. [PMID: 34923258 DOI: 10.1016/j.gaitpost.2021.12.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 11/02/2021] [Accepted: 12/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Several prior studies involving "expected" single-leg landings have not succeeded in establishing a difference between copers and a control group. RESEARCH QUESTION Does expected and unanticipated single-leg landing affect dynamic postural stability in lateral ankle sprain individuals with chronic ankle instability (CAI), copers, and controls? METHODS In this prospective cross-sectional study, physically active adults with CAI (n = 12), copers (n = 12), and controls (n = 12) were included. Participants performed expected single-leg landing by stepping off a 30-cm box. They also performed unanticipated landings including side-step cutting, side-step cutting at 60°, single-leg landing, and forward stepping. The expected and unanticipated conditions of each groups were compared in terms of time to stabilization (TTS) and center of pressure (COP) for the anterior-posterior (AP) and medial-lateral (ML) conditions. To analyze the data, a mixed-model one-way analysis of variance and a Tukey-Kramer post hoc test were performed. RESULTS A significant condition × group interaction was observed in only TTS ML, with the CAI group demonstrating a significantly longer TTS ML than the coper (p < 0.001) and control (p < 0.001) groups during unanticipated trials. In addition, group interaction effects were observed for COP AP and TTS AP. The coper group demonstrated significantly longer COP AP and TTS AP than the control group (p < 0.001). SIGNIFICANCE The CAI group demonstrated a significantly longer TTS ML than the coper and control groups during the unanticipated condition, and the coper group demonstrated significantly longer TTS AP and COP AP than the control group. Thus, longer COP AP and TTS AP sway time in the coper group may be a protection mechanism, allowing greater freedom in the AP plane while quickly controlling ML sway and preventing lateral ankle sprains. These findings can help in the prevention of lateral ankle sprains and assessment of dynamic postural control.
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Affiliation(s)
- Takaya Watabe
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan.
| | - Tomoya Takabayashi
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan.
| | - Yuta Tokunaga
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan.
| | - Masayoshi Kubo
- Niigata University of Health and Welfare, Institute for Human Movement and Medical Sciences, 1398 Shimami-cho, Kita-Ku, Niigata City, Niigata 950-3198, Japan.
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16
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Bamber ZA, Sun W, Menon RS, Wheeler PC, Swain ID, Fong DTP. Functional Electrical Stimulation of Peroneal Muscles on Balance in Healthy Females. CYBORG AND BIONIC SYSTEMS 2021; 2021:9801097. [PMID: 36285134 PMCID: PMC9494702 DOI: 10.34133/2021/9801097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 04/11/2021] [Indexed: 12/26/2022] Open
Abstract
Balance improvement could contribute to ankle stability for the prevention of ankle sprains. Functional electrical stimulation (FES) is an effective way of augmenting muscle activity and improving balance. This study investigated the effect of FES of peroneal muscles on single-and double-leg balance. Fifteen healthy females (age = 23.1 ± 1.6 years, height = 1.63 ± 0.07 m, and weight = 63.7 ± 9.9 kg) performed single- and double-leg standing balance tests with eyes open and closed before and after 15-minute FES intervention during treadmill running at a comfortable, self-selected pace. FES of peroneal muscles was provided bilaterally, using an Odstock Dropped Foot Stimulator. The total excursion of the centre of pressure (COP) was calculated to assess the standing balance control ability. The total excursion of COP in single- and double-leg stance with eyes open reduced significantly after FES intervention by 14.7% (p < 0.001) and 5.9% (p = 0.031), respectively. The eyes-closed condition exhibited a 12.7% (p = 0.002) reduction in single-leg stance but did not significantly change in double-leg stance (p > 0.05). Limb preference did not account for balance postintervention. No significant difference in total excursion of COP was found between preferred and less preferred limbs with both visual conditions (p > 0.05). FES of peroneal muscles improved standing balance control with eyes open in double-leg and single-leg stance and with eyes closed in double-leg stance. The improvements in balance control with FES treatment did not vary concerning limb preference.
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Affiliation(s)
- Zoe A. Bamber
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Division of Orthopaedics, Trauma and Sports Medicine, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Wei Sun
- Shandong Sport University, Jinan, Shandong, China
| | - Rhea S. Menon
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
| | - Patrick C. Wheeler
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
- Department of Sport and Exercise Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Ian D. Swain
- The Faculty of Science and Technology, Bournemouth University, Poole, Dorset, UK
| | - Daniel T. P. Fong
- National Centre for Sport and Exercise Medicine, School of Sport, Exercise and Health Sciences, Loughborough University, Loughborough, UK
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