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1.  Postural-Stability Tests That Identify Individuals With Chronic Ankle Instability 
Journal of Athletic Training  2014;49(1):15-23.
Context:
Chronic ankle instability (CAI) is characterized by repeated ankle sprains, which have been linked to postural instability. Therefore, it is important for clinicians to identify individuals with CAI who can benefit from rehabilitation.
Objective:
To assess the likelihood that CAI participants will exhibit impaired postural stability and that healthy control participants will exhibit better test performance values.
Design:
Case-control study.
Setting:
Laboratory.
Patients or Other Participants:
People with CAI (n = 17, age = 23 ± 4 years, height = 168 ± 9 cm, weight = 68 ± 12 kg) who reported ankle “giving-way” sensations and healthy volunteers (n = 17, age = 23 ± 3 years, height = 168 ± 8 cm, weight = 66 ± 12 kg).
Intervention(s):
Participants performed 7 balance tests: Balance Error Scoring System (BESS), time in balance, foot lift, single-legged stance on a force plate, Star Excursion Balance Test, side hop, and figure-of-8 hop.
Main Outcome Measure(s):
Balance was quantified with errors (score) for the BESS, length of time balancing (seconds) for time-in-balance test, frequency of foot lifts (score) for foot-lift test, velocity (cm/s) for all center-of-pressure velocity measures, excursion (cm) for center-of-pressure excursion measures, area (cm2) for 95% confidence ellipse center-of-pressure area and center-of-pressure rectangular area, time (seconds) for anterior-posterior and medial-lateral time-to-boundary (TTB) measures, distance reached (cm) for Star Excursion Balance Test, and time (seconds) to complete side-hop and figure-of-8 hop tests. We calculated area-under-the-curve values and cutoff scores and used the odds ratio to determine if those with and without CAI could be distinguished using cutoff scores.
Results:
We found significant area-under-the-curve values for 4 static noninstrumented measures, 3 force-plate measures, and 3 functional measures. Significant cutoff scores were noted for the time-in-balance test (≤25.89 seconds), foot-lift test (≥5), single-legged stance on the firm surface (≥3 errors) and total (≥14 errors) on the BESS, center-of-pressure resultant velocity (≥1.56 cm/s), standard deviations for medial-lateral (≤1.56 seconds) time-to-boundary and anterior-posterior (≤3.78 seconds) time-to-boundary test, posteromedial direction on the Star Excursion Balance Test (≤0.91), side-hop test (≥12.88 seconds), and figure-of-8 hop test (≥17.36 seconds).
Conclusions:
Clinicians can use any of the 10 significant measures with their associated cutoff scores to identify those who could benefit from rehabilitation that reestablishes postural stability.
doi:10.4085/1062-6050-48.6.09
PMCID: PMC3917291  PMID: 24377958
lower extremity; ankle sprains; Balance Error Scoring System; Star Excursion Balance Test
2.  Clinical Examination Results in Individuals With Functional Ankle Instability and Ankle-Sprain Copers 
Journal of Athletic Training  2013;48(5):581-589.
Context:
Why some individuals with ankle sprains develop functional ankle instability and others do not (ie, copers) is unknown. Current understanding of the clinical profile of copers is limited.
Objective:
To contrast individuals with functional ankle instability (FAI), copers, and uninjured individuals on both self-reported variables and clinical examination findings.
Design:
Cross-sectional study.
Setting:
Sports medicine research laboratory.
Patients or Other Participants:
Participants consisted of 23 individuals with a history of 1 or more ankle sprains and at least 2 episodes of giving way in the past year (FAI: Cumberland Ankle Instability Tool [CAIT] score = 20.52 ± 2.94, episodes of giving way = 5.8 ± 8.4 per month), 23 individuals with a history of a single ankle sprain and no subsequent episodes of instability (copers: CAIT score = 27.74 ± 1.69), and 23 individuals with no history of ankle sprain and no instability (uninjured: CAIT score = 28.78 ± 1.78).
Intervention(s):
Self-reported disability was recorded using the CAIT and Foot and Ankle Ability Measure for Activities of Daily Living and for Sports. On clinical examination, ligamentous laxity and tenderness, range of motion (ROM), and pain at end ROM were recorded.
Main Outcome Measure(s):
Questionnaire scores for the CAIT, Foot and Ankle Ability Measure for Activities of Daily Living and for Sports, ankle inversion and anterior drawer laxity scores, pain with palpation of the lateral ligaments, ankle ROM, and pain at end ROM.
Results:
Individuals with FAI had greater self-reported disability for all measures (P < .05). On clinical examination, individuals with FAI were more likely to have greater talar tilt laxity, pain with inversion, and limited sagittal-plane ROM than copers (P < .05).
Conclusions:
Differences in both self-reported disability and clinical examination variables distinguished individuals with FAI from copers at least 1 year after injury. Whether the deficits could be detected immediately postinjury to prospectively identify potential copers is unknown.
doi:10.4085/1062-6050-48.3.15
PMCID: PMC3784359  PMID: 23914879
laxity; chronic ankle instability; giving way; range of motion
3.  Customized Noise-Stimulation Intensity for Bipedal Stability and Unipedal Balance Deficits Associated With Functional Ankle Instability 
Journal of Athletic Training  2013;48(4):463-470.
Context:
Stochastic resonance stimulation (SRS) administered at an optimal intensity could maximize the effects of treatment on balance.
Objective:
To determine if a customized optimal SRS intensity is better than a traditional SRS protocol (applying the same percentage sensory threshold intensity for all participants) for improving double- and single-legged balance in participants with or without functional ankle instability (FAI).
Design:
Case-control study with an embedded crossover design.
Setting:
Laboratory.
Patients or Other Participants:
Twelve healthy participants (6 men, 6 women; age = 22 ± 2 years, height = 170 ± 7 cm, mass = 64 ± 10 kg) and 12 participants (6 men, 6 women; age = 23 ± 3 years, height = 174 ± 8 cm, mass = 69 ± 10 kg) with FAI.
Intervention(s):
The SRS optimal intensity level was determined by finding the intensity from 4 experimental intensities at the percentage sensory threshold (25% [SRS25], 50% [SRS50], 75% [SRS75], 90% [SRS90]) that produced the greatest improvement in resultant center-of-pressure velocity (R-COPV) over a control condition (SRS0) during double-legged balance. We examined double- and single-legged balance tests, comparing optimal SRS (SRSopt1) and SRS0 using a battery of center-of-pressure measures in the frontal and sagittal planes.
Main Outcome Measure(s):
Anterior-posterior (A-P) and medial-lateral (M-L) center-of-pressure velocity (COPV) and center-of-pressure excursion (COPE), R-COPV, and 95th percentile center-of-pressure area ellipse (COPA-95).
Results:
Data were organized into bins that represented optimal (SRSopt1), second (SRSopt2), third (SRSopt3), and fourth (SRSopt4) improvement over SRS0. The SRSopt1 enhanced R-COPV (P ≤ .05) over SRS0 and other SRS conditions (SRS0 = 0.94 ± 0.32 cm/s, SRSopt1 = 0.80 ± 0.19 cm/s, SRSopt2 = 0.88 ± 0.24 cm/s, SRSopt3 = 0.94 ± 0.25 cm/s, SRSopt4 = 1.00 ± 0.28 cm/s). However, SRS did not improve R-COPV over SRS0 when data were categorized by sensory threshold. Furthermore, SRSopt1 improved double-legged balance over SRS0 from 11% to 25% in all participants for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRSopt1 also improved single-legged balance over SRS0 from 10% to 17% in participants with FAI for the center-of-pressure frontal- and sagittal-plane assessments (P ≤ .05). The SRSopt1 did not improve single-legged balance in participants with stable ankles.
Conclusions:
The SRSopt1 improved double-legged balance and transfers to enhancing single-legged balance deficits associated with FAI.
doi:10.4085/1062-6050-48.3.12
PMCID: PMC3718348  PMID: 23724774
chronic ankle instability; noise; postural stability; therapy
4.  Functional Ankle Instability and Health-Related Quality of Life 
Journal of Athletic Training  2011;46(6):634-641.
Context:
To our knowledge, no authors have assessed health-related quality of life (HR-QOL) in participants with functional ankle instability (FAI). Furthermore, the relationships between measures of ankle functional limitation and HR-QOL are unknown.
Objective:
To use the Short Form–36v2 Health Survey (SF-36) to compare HR-QOL in participants with or without FAI and to determine whether HR-QOL was related to functional limitation.
Design:
Cross-sectional study.
Setting:
Sports medicine research laboratory.
Patients or Other Participants:
Sixty-eight participants with FAI (defined as at least 1 lateral ankle sprain and 1 episode of giveway per month) or without FAI were recruited (FAI group: n = 34, age = 25 ± 5 years, height = 1.71 ± 0.08 m, mass = 74.39 ± 12.78 kg, Cumberland Ankle Instability Tool score = 19.3 ± 4; uninjured [UI] group: n = 34, age = 23 ± 4 years, height = 1.69 ± 0.08 m, mass = 67.94 ± 11.27 kg, Cumberland Ankle Instability Tool score = 29.4 ± 1).
Main Outcome Measure(s):
All participants completed the SF-36 as a measure of HR-QOL and the Foot and Ankle Ability Measure (FAAM) and the FAAM Sport version (FAAMS) as assessments of functional limitation. To compare the FAI and UI groups, we calculated multiple analyses of variance followed by univariate tests. Additionally, we correlated the SF-36 summary component scale and domain scales with the FAAM and FAAMS scores.
Results:
Participants with FAI had lower scores on the SF-36 physical component summary (FAI = 54.4 ± 5.1, UI = 57.8 ± 3.7, P = .005), physical function domain scale (FAI = 54.5 ± 3.8, UI = 56.6 ± 1.2, P = .004), and bodily pain domain scale (FAI = 52.0 ± 6.7, UI = 58.5 ± 5.3, P < .005). Similarly, participants with FAI had lower scores on the FAAM (FAI = 93.7 ± 8.4, UI = 99.5 ± 1.4, P < .005) and FAAMS (FAI = 84.5 ± 8.4, UI = 99.8 ± 0.72, P < .005) than did the UI group. The FAAM score was correlated with the physical component summary scale (r = 0.42, P = .001) and the physical function domain scale (r = 0.61, P < .005). The FAAMS score was correlated with the physical function domain scale (r = 0.47, P < .005) and the vitality domain scale (r = 0.36, P = .002).
Conclusions:
Compared with UI participants, those with FAI had less HR-QOL and more functional limitations. Furthermore, positive correlations were found between HR-QOL and functional limitation measures. This suggests that ankle impairment may reduce overall HR-QOL.
PMCID: PMC3418941  PMID: 22488189
functional limitations; Short Form–36; Foot and Ankle Ability Measure; disability
5.  A prospective cluster-randomized trial to implement the Canadian CT Head Rule in emergency departments 
Background
The Canadian CT Head Rule was developed to allow physicians to be more selective when ordering computed tomography (CT) imaging for patients with minor head injury. We sought to evaluate the effectiveness of implementing this validated decision rule at multiple emergency departments.
Methods
We conducted a matched-pair cluster-randomized trial that compared the outcomes of 4531 patients with minor head injury during two 12-month periods (before and after) at hospital emergency departments in Canada, six of which were randomly allocated as intervention sites and six as control sites. At the intervention sites, active strategies, including education, changes to policy and real-time reminders on radiologic requisitions were used to implement the Canadian CT Head Rule. The main outcome measure was referral for CT scan of the head.
Results
Baseline characteristics of patients were similar when comparing control to intervention sites. At the intervention sites, the proportion of patients referred for CT imaging increased from the “before” period (62.8%) to the “after” period (76.2%) (difference +13.3%, 95% CI 9.7%–17.0%). At the control sites, the proportion of CT imaging usage also increased, from 67.5% to 74.1% (difference +6.7%, 95% CI 2.6%–10.8%). The change in mean imaging rates from the “before” period to the “after” period for intervention versus control hospitals was not significant (p = 0.16). There were no missed brain injuries or adverse outcomes.
Interpretation
Our knowledge–translation-based trial of the Canadian CT Head Rule did not reduce rates of CT imaging in Canadian emergency departments. Future studies should identify strategies to deal with barriers to implementation of this decision rule and explore more effective approaches to knowledge translation. (ClinicalTrials.gov trial register no. NCT00993252)
doi:10.1503/cmaj.091974
PMCID: PMC2950184  PMID: 20732978
6.  Noise‐enhanced postural stability in subjects with functional ankle instability 
British Journal of Sports Medicine  2007;41(10):656-659.
Objective
To examine the effects of stochastic resonance (SR) stimulation on the postural stability of subjects with functional ankle instability (FAI).
Design
Experimental research design.
Setting
Sports medicine research laboratory.
Participants
12 subjects with FAI who reported a history of recurrent ankle sprains and “giving way” sensations at the ankle.
Interventions
Subjects performed 20 s single‐leg balance tests under SR stimulation at 0.05 mA and 0.01 mA and under control conditions. Testing order was randomised. Stimulators that delivered subsensory stimulation to ankle muscles and ligaments were worn. Subjects were blinded to the test conditions, as SR stimulation was subsensory and stimulators were turned off during the control condition.
Main outcome measures
Anterior/posterior and medial/lateral centre‐of‐pressure velocities (COPVs) were combined to form a resultant vector (COPV‐R). The COPV‐R differences between the optimal SR stimulation and control conditions were analysed. Optimal SR stimulation was defined as the SR stimulation input intensity level (0.05 mA or 0.01 mA) that produced the greatest percentage improvement in postural stability compared with the control condition. Slower velocities indicated enhanced postural stability.
Results
The optimal input intensity was 0.05 mA for nine subjects and 0.01 mA for the other three. The optimal SR stimulation significantly (p<0.05) improved COPV‐R compared with the control condition (6.60 (1.06) vs 7.20 (1.03) cm/s; mean (SD)).
Conclusion
SR stimulation may enhance signal detection of sensorimotor signals associated with postural stability. This result has clinical relevance as improvements in postural instability associated with FAI may decrease ankle sprain injury.
doi:10.1136/bjsm.2006.032912
PMCID: PMC2465155  PMID: 17550917
ankle; balance; postural stability; sprain; stochastic resonance
7.  BULLY PREVENTION IN POSITIVE BEHAVIOR SUPPORT 
Bullying behaviors are a growing concern in U.S. schools. We present here a behavioral approach to bully prevention utilizing a schoolwide intervention. Bully prevention in positive behavior support (BP-PBS) teaches students to withhold the social rewards hypothesized to maintain bullying. A single-subject multiple baseline design across 6 students and three elementary schools was implemented in an empirical evaluation of the intervention's effectiveness. Results indicated that implementation was functionally related to decreased incidents of bullying for all 6 students observed. In addition, we observed a decrease in the social responses from victims and bystanders. Finally, school staff implemented the program with a high degree of fidelity and rated the program as effective and efficient. Limitations and implications of these results are discussed.
doi:10.1901/jaba.2009.42-747
PMCID: PMC2791686  PMID: 20514181
bullying; positive behavior support; prevention; secondary intervention
8.  Concentric Evertor Strength Differences and Functional Ankle Instability: A Meta-Analysis 
Journal of Athletic Training  2009;44(6):653-662.
Abstract
Objective:
To determine whether concentric evertor muscle weakness was associated with functional ankle instability (FAI).
Data Sources:
We conducted an electronic search through November 2007, limited to English, and using PubMed, Pre-CINAHL, CINAHL, and SPORTDiscus. A forward search was conducted using the Science Citation Index on studies from the electronic search. Finally, we conducted a hand search of all selected studies and contacted the respective authors to identify additional studies. We included peer-reviewed manuscripts, dissertations, and theses.
Study Selection:
We evaluated the titles and abstracts of studies identified by the electronic searches. Studies were selected by consensus and reviewed only if they included participants with FAI or chronic ankle instability and strength outcomes. Studies were included in the analysis if means and SDs (or other relevant statistical information, such as P values or t values and group n's) were reported for FAI and stable groups (or ankles).
Data Extraction:
Data were extracted by the authors independently, cross-checked for accuracy, and limited to outcomes of concentric eversion strength. We rated each study for quality. Outcomes were coded as either fast or slow velocity (ie, equal to or greater than 110°/s or less than 110°/s, respectively).
Data Synthesis:
Data included the means, SDs, and group sample sizes (or other appropriate statistical information) for the FAI and uninjured groups (or ankles). The standard difference in the means (SDM) for each outcome was calculated using the pooled SD. We tested individual and overall SDMs using the Z statistic and comparisons between fast and slow velocities using the Q statistic. Our analysis revealed that ankles with FAI were weaker than stable ankles (SDM  =  0.224, Z  =  4.0, P < .001, 95% confidence interval  =  0.115, 0.333). We found no difference between the fast- and slow-velocity SDMs (SDMFast  =  0.189, SDMSlow  =  0.244, Q  =  29.9, df  =  24, P  =  .187). Because of the small SDM, this method of measuring ankle strength in the clinical setting may need to be reevaluated.
doi:10.4085/1062-6050-44.6.653
PMCID: PMC2775368  PMID: 19911093
ankle sprains; chronic ankle instability; ankle weakness; isokinetic assessment; ankle torque; ankle force
9.  Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial 
Objective To evaluate the effectiveness of an active strategy to implement the validated Canadian C-Spine Rule into multiple emergency departments.
Design Matched pair cluster randomised trial.
Setting University and community emergency departments in Canada.
Participants 11 824 alert and stable adults presenting with blunt trauma to the head or neck at one of 12 hospitals.
Interventions Six hospitals were randomly allocated to the intervention and six to the control. At the intervention sites, active strategies were used to implement the Canadian C-Spine Rule, including education, policy, and real time reminders on radiology requisitions. No specific intervention was introduced to alter the behaviour of doctors requesting cervical spine imaging at the control sites.
Main outcome measure Diagnostic imaging rate of the cervical spine during two 12 month before and after periods.
Results Patients were balanced between control and intervention sites. From the before to the after periods, the intervention group showed a relative reduction in cervical spine imaging of 12.8% (95% confidence interval 9% to 16%; 61.7% v 53.3%; P=0.01) and the control group a relative increase of 12.5% (7% to 18%; 52.8% v 58.9%; P=0.03). These changes were significant when both groups were compared (P<0.001). No fractures were missed and no adverse outcomes occurred.
Conclusions Implementation of the Canadian C-Spine Rule led to a significant decrease in imaging without injuries being missed or patient morbidity. Final imaging rates were much lower at intervention sites than at most US hospitals. Widespread implementation of this rule could lead to reduced healthcare costs and more efficient patient flow in busy emergency departments worldwide.
Trial registration Clinical trials NCT00290875.
doi:10.1136/bmj.b4146
PMCID: PMC2770593  PMID: 19875425
10.  Thigh Muscle Activity, Knee Motion, and Impact Force During Side-Step Pivoting in Agility-Trained Female Basketball Players 
Journal of Athletic Training  2009;44(1):14-25.
Context:
Improving neuromuscular control of hamstrings muscles might have implications for decreasing anterior cruciate ligament injuries in females.
Objective:
To examine the effects of a 6-week agility training program on quadriceps and hamstrings muscle activation, knee flexion angles, and peak vertical ground reaction force.
Design:
Prospective, randomized clinical research trial.
Setting:
Sports medicine research laboratory.
Patients or Other Participants:
Thirty female intramural basketball players with no history of knee injury (age  =  21.07 ± 2.82 years, height  =  171.27 ± 4.66 cm, mass  =  66.36 ± 7.41 kg).
Intervention(s):
Participants were assigned to an agility training group or a control group that did not participate in agility training. Participants in the agility training group trained 4 times per week for 6 weeks.
Main Outcome Measure(s):
We used surface electromyography to assess muscle activation for the rectus femoris, vastus medialis oblique, medial hamstrings, and lateral hamstrings for 50 milliseconds before initial ground contact and while the foot was in contact with the ground during a side-step pivot maneuver. Knee flexion angles (at initial ground contact, maximum knee flexion, knee flexion displacement) and peak vertical ground reaction force also were assessed during this maneuver.
Results:
Participants in the training group increased medial hamstrings activation during ground contact after the 6-week agility training program. Both groups decreased their vastus medialis oblique muscle activation during ground contact. Knee flexion angles and peak vertical ground reaction force did not change for either group.
Conclusions:
Agility training improved medial hamstrings activity in female intramural basketball players during a side-step pivot maneuver. Agility training that improves hamstrings activity might have implications for reducing anterior cruciate ligament sprain injury associated with side-step pivots.
PMCID: PMC2629035  PMID: 19180214
anterior cruciate ligament; injury prevention; knee sprains
11.  Assessment Tools for Identifying Functional Limitations Associated With Functional Ankle Instability 
Journal of Athletic Training  2008;43(1):44-50.
Context:
Assessment tools should identify functional limitations associated with functional ankle instability (FAI) by discriminating unstable from stable ankles.
Objective:
To identify assessment tools that discriminated FAI from stable ankles and determine the most accurate assessment tool for discriminating between FAI and stable ankles.
Design:
Case-control study.
Setting:
Research laboratory.
Patients or Other Participants:
Fifteen individuals with FAI and 15 healthy individuals; participants with unilateral FAI reported “giving-way” sensations and ankle sprains, whereas healthy participants did not.
Intervention(s):
Participants answered 12 questions on the Ankle Joint Functional Assessment Tool (AJFAT). They also performed a single-leg jump landing, which required them to jump to half their maximum jump height, land on a single leg, and stabilize quickly on a force plate.
Main Outcome Measure(s):
Receiver operating characteristic curves determined cutoff scores for discriminating between ankle groups for AJFAT total score and resultant vector (RV) time to stabilization. Accuracy values for discriminating between groups were determined by calculating the area under the receiver operating characteristic curves.
Results:
The cutoff score for discriminating between FAI and stable ankles was ≥26 (sensitivity  =  1, specificity  =  1) and ≥1.58 seconds (sensitivity  =  0.67, specificity  =  0.73) for the AJFAT total score and RV time to stabilization, respectively. The area under the curve for the AJFAT was 1.0 (asymptotic significance <.05), whereas the RV time to stabilization had an area under the curve of 0.72 (asymptotic significance <.05).
Conclusions:
The AJFAT was an excellent assessment tool for discriminating between ankle groups, whereas RV time to stabilization was a fair assessment tool. Although both assessments discriminated between ankle groups, the AJFAT more accurately discriminated between groups than the RV time to stabilization did. Future researchers should confirm these findings using a prospective research design.
PMCID: PMC2231396  PMID: 18335012
balance; ankle sprains; time to stabilization; Ankle Joint Functional Assessment Tool
12.  Enhanced balance associated with coordination training with stochastic resonance stimulation in subjects with functional ankle instability: an experimental trial 
Background
Ankle sprains are common injuries that often lead to functional ankle instability (FAI), which is a pathology defined by sensations of instability at the ankle and recurrent ankle sprain injury. Poor postural stability has been associated with FAI, and sports medicine clinicians rehabilitate balance deficits to prevent ankle sprains. Subsensory electrical noise known as stochastic resonance (SR) stimulation has been used in conjunction with coordination training to improve dynamic postural instabilities associated with FAI. However, unlike static postural deficits, dynamic impairments have not been indicative of ankle sprain injury. Therefore, the purpose of this study was to examine the effects of coordination training with or without SR stimulation on static postural stability. Improving postural instabilities associated with FAI has implications for increasing ankle joint stability and decreasing recurrent ankle sprains.
Methods
This study was conducted in a research laboratory. Thirty subjects with FAI were randomly assigned to either a: 1) conventional coordination training group (CCT); 2) SR stimulation coordination training group (SCT); or 3) control group. Training groups performed coordination exercises for six weeks. The SCT group received SR stimulation during training, while the CCT group only performed coordination training. Single leg postural stability was measured after the completion of balance training. Static postural stability was quantified on a force plate using anterior/posterior (A/P) and medial/lateral (M/L) center-of-pressure velocity (COPvel), M/L COP standard deviation (COPsd), M/L COP maximum excursion (COPmax), and COP area (COParea).
Results
Treatment effects comparing posttest to pretest COP measures were highest for the SCT group. At posttest, the SCT group had reduced A/P COPvel (2.3 ± 0.4 cm/s vs. 2.7 ± 0.6 cm/s), M/L COPvel (2.6 ± 0.5 cm/s vs. 2.9 ± 0.5 cm/s), M/L COPsd (0.63 ± 0.12 cm vs. 0.73 ± 0.11 cm), M/L COPmax (1.76 ± 0.25 cm vs. 1.98 ± 0.25 cm), and COParea (0.13 ± 0.03 cm2 vs. 0.16 ± 0.04 cm2) than the pooled means of the CCT and control groups (P < 0.05).
Conclusion
Reduced values in COP measures indicated postural stability improvements. Thus, six weeks of coordination training with SR stimulation enhanced postural stability. Future research should examine the use of SR stimulation for decreasing recurrent ankle sprain injury in physically active individuals with FAI.
doi:10.1186/1743-0003-4-47
PMCID: PMC2254419  PMID: 18086314
13.  Functional Balance Training, With or Without Exercise Sandals, for Subjects With Stable or Unstable Ankles 
Journal of Athletic Training  2006;41(4):393-398.
Context: Improving postural stability through balance training may prevent ankle sprains. Exercise Sandals may increase the demands placed on ankle muscles during rehabilitation, which could improve postural stability.
Objective: To examine the effects of functional balance training, with and without the use of Exercise Sandals, on postural stability in subjects with stable or unstable ankles.
Design: Prospective, nonrandomized clinical trial.
Setting: Sports medicine research laboratory.
Patients or Other Participants: Sixteen subjects with functional ankle instability and 16 subjects with no history of ankle sprains.
Intervention(s): Subjects were assigned to an Exercise Sandal functional balance training group or a shoe functional balance training group. Subjects trained 3 times per week for 8 weeks and then performed a single-limb stance posttest.
Main Outcome Measure(s): Subjects were required to remain as motionless as possible during a single-limb stance pretest. Anterior-posterior and medial-lateral center-of-pressure excursions were measured.
Results: Exercise Sandal balance training improved anterior-posterior postural stability in both ankle groups ( P < .05). Both training interventions improved medial-lateral postural stability in stable and unstable ankles ( P < .05).
Conclusions: Postural stability improved after subjects performed functional balance training programs, both with and without Exercise Sandals. Training with Exercise Sandals might not be any more effective in improving postural stability than performing functional balance training without Exercise Sandals. However, Exercise Sandals did not impair postural stability and, consequently, might serve as an alternative therapy to improve postural stability.
PMCID: PMC1748421  PMID: 17273464
balance shoes; chronic ankle instability; functional ankle instability
14.  Single-Leg Jump-Landing Stabilization Times in Subjects With Functionally Unstable Ankles 
Journal of Athletic Training  2005;40(4):298-304.
Context: Factors contributing to functional ankle instability may cause individuals with the condition to land from a jump differently than those with stable ankles.
Objective: To determine stabilization time differences during single-leg jump landings between stable and unstable ankle groups and to report the reliability and precision of time-to-stabilization measures.
Design: A mixed design with 1 between factor (ankle group) and 1 within factor (direction) was used to analyze the comparison between our 10 subjects with functional ankle instability and 10 subjects with stable ankles. Time to stabilization (seconds) was the dependent measure. Reliability for time-to-stabilization measures of our 12 additional subjects with stable ankles were assessed using intraclass correlation coefficients (ICC 2,7). Standard errors of measurements were also calculated for time-to-stabilization measures.
Setting: Sports medicine research laboratory.
Patients or Other Participant(s): Ten subjects with functional ankle instability who reported at least 2 sprains and ``giving way'' sensations at their ankles constituted the functional ankle instability group. Ten subjects without a history of ankle sprain injury served as healthy subjects. Twelve additional healthy subjects participated in the reliability study.
Intervention(s): Subjects performed a jump-landing test, which required them to jump 50% to 55% of their maximum vertical jump height and then land on a single leg on a force plate. After landing, they stabilized quickly and remained as motionless as possible in a single-leg stance for 20 s.
Main Outcome Measure(s): Anterior-posterior and medial/ lateral vibration magnitude curve fit time-to-stabilization.
Results: Time to stabilization was longer for the functional ankle instability group (1.98 ± 0.81 s) than for the stable ankle group (1.45 ± 0.30 s) (P < .05). Reliability (standard error of the measurement) values for anterior/posterior and medial/lateral time-to-stabilization were 0.79 (0.15 s) and 0.65 (0.26 s), respectively.
Conclusions: Time to stabilization was longer for subjects with functional ankle instability than subjects with stable ankles. The ankle instability may have impaired the subjects' ability to stabilize after a single-leg jump landing. Reliabilities and standard errors of the measurements of time-to-stabilization measures were moderate and low, respectively.
PMCID: PMC1323291  PMID: 16404451
chronic ankle instability; dynamic balance; postural control
15.  Postural Stability and Neuropsychological Deficits After Concussion in Collegiate Athletes 
Journal of Athletic Training  2001;36(3):263-273.
Objective:
Postural stability and neuropsychological testing are gradually becoming integral parts of postconcussion assessment in athletes. Clinicians, however, sometimes question the viability of instituting preseason baseline testing and the value of these results in making return-to-play decisions. Our purpose was to examine the course of recovery on various postural stability and neuropsychological measures after sport-related concussion. A secondary goal was to determine if loss of consciousness and amnesia, both of which are heavily weighted in most of the concussion classification systems, affect the rate of recovery.
Design and Setting:
All subjects underwent a battery of baseline postural stability and neuropsychological tests before the start of their respective seasons. Any athletes subsequently injured were followed up at postinjury days 1, 3, and 5. Matched control subjects were assessed using the same test battery at the same time intervals.
Subjects:
We studied 36 Division I collegiate athletes who sustained a concussion and 36 matched control subjects.
Measurements:
We assessed postural stability using the Sensory Organization Test on the NeuroCom Smart Balance Master System and the Balance Error Scoring System. Neurocognitive functioning was measured with several neuropsychological tests: Trail-Making Test, Wechsler Digit Span Test, Stroop Color Word Test, and Hopkins Verbal Learning Test.
Results:
Injured subjects demonstrated postural stability deficits, as measured on both the Sensory Organization Test and Balance Error Scoring System. These deficits were significantly worse than both preseason scores and matched control subjects' scores on postinjury day 1. Only the results on the Trail-Making Test B and Wechsler Digit Span Test Backward resulted in a logical recovery curve that could explain lowered neuropsychological performance due to concussive injury. Significant differences were revealed between the control and injured groups at day 1 postinjury, but a significant decline between baseline and postinjury scores was not demonstrated. Loss of consciousness and amnesia were not associated with increased deficits or slowed recovery on measures of postural stability or neurocognitive functioning.
Conclusions:
Athletes with cerebral concussion demonstrated acute balance deficits, which are likely the result of not using information from the vestibular and visual systems effectively. Neurocognitive deficits are more difficult to identify in the acute stages of concussion, although concentration, working memory, immediate memory recall, and rapid visual processing appear to be mildly affected. More research is necessary to determine the best neuropsychological test battery for assessing sport-related concussion.
PMCID: PMC155417  PMID: 12937495
mild head injury; balance; neurocognitive function

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