Original research

A 4-week wobble board exercise programme improved muscle

onset latency and perceived stability in individuals
with a functionally unstable ankle
Victoria M. Clark
*
, Adrian M. Burden
Manchester Metropolitan University, Department of Exercise and Sport Science, Hassall Road, Alsager, Cheshire ST7 2HL, UK
Received 20 January 2005; revised 29 July 2005; accepted 1 August 2005
Abstract
Objectives: To investigate the effects of wobble board training on the onset of muscle activity and perception of stability in participants with a
functionally unstable ankle.
Participants: Nineteen male participants (Mean ageZ29.7 years, SDZ4.9) who complained of a weak ankle and had sustained at least three
sprains in the past 2 years, but no injury for 3 months, a negative anterior draw, normal standing biomechanics, no movement dysfunction,
and no cardiac or neurological balance problems.
Method: Participants completed a questionnaire on functional stability. Using surface electromyography (sEMG) the onset time of the tibialis
anterior (TA) and peroneus longus (PL) were recorded in response to a sudden 208 inversion. Participants were assigned to two groups;
control (nZ9) and exercise (nZ10). The exercise group underwent a monitored 4-week wobble board programme (10 min per session, three
times per week).
Results: Post training, the exercise group showed a signicant decrease in muscle onset latency (p!0.05) and a signicant improvement in
perception of their functional stability (p!0.01).
Conclusion: The ndings indicate that, even after a short period, wobble board exercise reduces the likelihood of further sprains in
individuals with functionally unstable ankles.
q 2005 Published by Elsevier Ltd.
Keywords: Ankle sprain; Proprioception; Electromyography
1. Introduction
Ankle sprains are amongst the most common injuries
within the athletic population with an incidence rate as high
as 80% (Smith & Reischl, 1986). Injury to the most
commonly affected lateral ligament complex is a result of a
combination of excessive plantar exion and inversion
(Wester, Jespersen, Nielsen, & Neumann, 1996). Further-
more, and of signicant concern, is the reoccurrence of
ankle sprains. Yeung, Chang, So, & Yuan (1994) reported
that as many as 73% of athletes had recurrent ankle sprains
and 59% of these had signicant residual symptoms (e.g.
pain, weakness, crepitus, instability, swelling, stiffness) that
affected their performance. These symptoms may be a
consequence of residual mechanical instability, functional
instability, or a combination of both. Mechanical instability
involves muscle weakness and joint laxity; however, many
people have no mechanical decit but experience recurrent
ankle sprains because they have functionally unstable
ankles (FUAs) (Hertel, 2000).
Functional instability of the ankle was rst dened by
Freeman (1965) as a feeling of giving way in the ankle and
was later redened as a subjective complaint of weakness
often in the absence of mechanical instability (Evans,
Hardcastle, & Frenyo, 1984). The pathogenesis of FUAs is
complex but is reported to involve sensorimotor, mechan-
ical, and muscular deciences (Kaminski, Buckley, Powers,
Hubbard, & Ortiz, 2003). Loss of proprioception, resulting
Physical Therapy in Sport 6 (2005) 181187
www.elsevier.com/locate/yptsp
1466-853X/$ - see front matter q 2005 Published by Elsevier Ltd.
doi:10.1016/j.ptsp.2005.08.003
* Corresponding author. Address: The Ridgeway Studio Clinic, 20 The
Ridgeway, Nettlebed, Oxfordshire RG9 5AN, UK. Tel.: C44 1491 640
725.
E-mail address: victoria@ridgewaystudioclinic.co.uk (V.M. Clark).
in lack of balance and joint position sense, is considered to
be particularly important (Laskowski, Newcomber-Anney,
& Smith, 1997; Lentell, Baas, Lopez, McGuire, Sarrels, &
Snyder, 1995). Proprioception involves stimulus detection,
processing, and the initiation of a reactive output via the
neuromuscular system (Laskowski et al., 1997). Cutaneous,
joint and muscle mechanoreceptors provide proprioceptive
information to varying degrees depending on the situation
and environment (Waddington & Shepherd, 1996). In the
FUA mechanoreceptors may have been damaged directly
during an initial ankle sprain, or indirectly due to swelling
and inammation (Laskowski et al., 1997). Disruption to the
proprioception system may, therefore, lead to a delay in
protective muscle activity and the resultant loss of postural
awareness and stability. Some previous studies (e.g.
Karlsson, Peterson, Andreasson, & Hogfors, 1992; Konrad-
sen & Ravn, 1991) reported a delay in the onset time of the
peroneal muscles to a sudden ankle inversion in individuals
with a FUA, which may explain why sprain reoccurrence is
so frequent. Other studies (e.g. Fernandes, Allison, &
Hopper, 2000; Larsen & Lund, 1991) found no difference in
onset latency of peroneal muscles between individuals with
and without FUAs. Fernandes et al. (2000) suggested that
the lack of difference between groups could be because
those with a FUA had adapted after injury via rehabilitation.
The wobble board is commonly used in the rehabilitation
of FUAs. It is designed to assist the reeducation of the
proprioceptive system by improving mechanoreceptor
function and restoring the normal neuromuscular feedback
loop (Rozzi, Lephart, Sterner, & Kuligowski, 1999). The
effectiveness of wobble board training in the improvement of
markers of proprioception in individuals with no history of
ankle instability has been well documented (e.g. Chong,
Ambrose, Carzoli, Hardison, & Jacobson, 2001; Hoffman &
Payne, 1995; Waddington, Adams, &Jones, 1999). Previous
research has also shown that wobble board training improves
single leg stance ability (Rozzi, Lephart, Sterner, &
Kuligowski, 1999) and postural sway (Bernier & Perrin,
1998; Gaufn, Tropp, &Odenrick, 1988) in participants with
a FUA. Wester et al. (1996) showed that patients with a FUA
who underwent wobble board training experienced signi-
cantly fewer recurrent sprains during a follow-up period than
those who did not follow the training programme.
Electromyography (EMG) has been used in the assess-
ment of proprioception as it allows the timing and degree of
muscle activity to be determined during a functional task.
Soderberg, Cook, Rider, & Stephenitch, (1991) investigated
the activity of the TA, PL, and gastrocnemius in participants
with FUAs during exercise on a wobble board, although they
did not investigate the effect of any rehabilitation programme
per se. Osborne, Chou, Laskowski, Smith, & Kaufman,
(2001) previously investigated the effect of wobble board
training on the onset times of muscles (TA, tibialis posterior,
PL, exor digitorumlongus) in individuals with a FUA. Only
the TA showed a statistically signicant decrease in onset
time in response to 208 of rapid inversion caused by the
release of a hinged platform upon which participants stood.
Previous research reports improvements in indicators of
proprioception using wobble board training, but there is a
lack of research that measures this in a functional situation
involving inversion of the ankle joint. The rst aim of this
study was to investigate the effect of a 4-week wobble board
programme on participants who were classied with FUAs to
a sudden inversion perturbation using surface electromyo-
graphy (sEMG) to determine the onset times of an invertor
and evertor muscle. Secondly, a functional questionnaire was
used to determine changes in the perception of stability at the
start and end of the programme. The hypotheses were that
wobble board training will: (1) reduce the onset latency of the
TA and PL muscles to a sudden 208 inversion, and (2)
improve participants perception of functional stability.
2. Method
2.1. Participants
Nineteen male participants (Table 1 for demographic
details) were randomly assigned to two groups; control (nZ9)
and exercise (nZ10). All participants had a subjective
complaint of a weak ankle and a history of at least three
ankle sprains of the lateral complex over the past 2 years.
On examination, participants had a negative anterior draw
test, no history of cardiac or neurological balance problems,
and normal biomechanics (dened as calcaneus varus of 208
and valgus of 108, a medial tibiofemoral angle of 1801958,
genum recurvatum less than 108, and medial hip rotation of
30608 and lateral hip rotation of 45608 at 908 exion
(Norkin & Levangie, 1992). Ethical approval was obtained
through the Department of Exercise and Sport Science
Ethics Committee at the Manchester Metropolitan Univer-
sity, Cheshire. Participants signed an informed consent form
following a full explanation of the procedures.
2.2. Equipment
A customised platform was developed, similar to that
used by other researchers (e.g. Fernandes et al., 2000;
Table 1
Mean and standard deviation (SD) for age, height, mass, and number of ankle sprains in the past 2 years
Age (years) SD Height (cm) SD Mass (kg) SD Sprains in past 2 years SD
Exercise group 29.9 4.2 177.5 5.7 81.0 9.1 5.2 3.1
Control group 29.6 5.8 178.6 5.5 83.3 7.4 5.7 2.2
V.M. Clark, A.M. Burden / Physical Therapy in Sport 6 (2005) 181187 182
Osborne et al., 2001; Sheth, Bing, Laskowski, & Kai-Nan,
1997). One side of the platform had a hinged trapdoor that
inverted to 208 and the other side housed a set of weighing
scales that, unlike in Osborne et al. (2001) study, were ush
with the trapdoor and ensured even weight bearing (Fig. 1).
The platform was synchronised with an MIE MT8 Radio
Telemetry System so that the deactivation of a solenoid that
released the trapdoor was marked on electromyograms
recorded from the TA and PL.
2.3. Procedure
Participants attended a physiotherapy clinic and com-
pleted the Ankle Joint Functional Assessment Tool
questionnaire (AJFAT) (Rozzi et al., 1999), which was
used to rate each participants perception of their ankle
stability. Biomechanical alignment and mechanical
stability of participants ankles were assessed using a
goniometer, a method determined as reliable and valid by
Fess (1998).
The belly of the TA and PL were then located using
resisted ankle dorsi exion with foot inversion and
plantar exion with eversion respectively (Kendall,
McCreary, & Provance, 1993). The area of maximal
muscle bulk was then palpated, shaved, and cleaned with
an alcohol wipe to reduce skin-electrode impedance. Two
3.3 cm!2.3 cm Ag/AgCl electrodes were then placed
either side of the belly of the muscle with a distance of
5 mm between their edges, and parallel to the orientation
of the underlying muscle bres. Electrode positions were
measured in relation to anatomical landmarks and
photographed to ensure that the same positions were
used during subsequent testing sessions.
2.4. Data collection
sEMG activity was recorded at a frequency of
1000 Hz over a 3-s period that included the opening of
the trap door. Each participant performed the test three
times and returned to the clinic after 2 and 4 weeks for
repeat testing. The AJFAT was only completed again at
the week 4 test.
2.4.1. Wobble board training
This exercise programme (adapted from Wester et al.,
1996 and detailed in Table 2) was taught to the exercise
group and initially practised under the guidance of a
qualied physiotherapist. The programme was completed
over 4 weeks, as neural factors are known to affect muscle
performance before this time (Moritani & DeVries, 1979),
and was performed 3 times per week.
2.5. Data reduction
Electromyograms from both muscles were full wave
rectied and time to muscle activation (or onset latency)
was recorded for each trial as the time between the
deactivation of the solenoid that released the trap door and
the point when muscle activity exceeded two SD of the
baseline, as recommended by De Luca (1997). An
immediate rather than gradual threshold was used as the
initial muscle activity was deemed to be functionally
relevant. Methods similar to these, including the use of a
trap door to provide a sudden inversion perturbation have
been shown by Hopper, Allison, Fernandes, OSullivan, &
Wharton (1998) to provide reliable measures of muscle
latency.
Fig. 1. Trapdoor in (a) the closed position and (b) the open position, resulting in 208 of ankle inversion.
V.M. Clark, A.M. Burden / Physical Therapy in Sport 6 (2005) 181187 183
2.6. Data analysis
Preexercise AFJAT scores were analysed using a Mann
Whitney test, to determine if any signicant differences
occurred in the groups perception of their stability prior to
the programme. Pre-and postexercise scores were analysed
using a Wilcoxon test to determine if any signicant
changes occurred because of the programme. Percentage
change in scores was also calculated to determine the
magnitude of any change.
Mean preexercise muscle activation time was analysed
for each muscle using an independent t-test, to determine
any statistical differences between the two groups prior to
the programme. Time to muscle activation was further
analysed using a mixed 2!3 ANOVA, with the two factors
being group (exercise and control) and point in the exercise
period (pre/mid/post). The Huynh-Feldt adjustment was
used to account for any violations to the assumption of
sphericity. To determine any simple main effects repeated
measures one-way ANOVA was also performed on the data
from the exercise group. In the event of any signicant
difference in this group, a post-hoc Tukey test was also
performed to establish when during the exercise period the
difference occurred. Percentage changes in muscle onset
time and effect size were also calculated pre-to postexercise
for both muscles. All data were analysed using SPSS for
Windows Version 11 and an alpha level of 0.05 was used to
determine statistical signicance.
3. Results
Pre-and postexercise period ndings from the AJFAT are
shown in Fig. 2. No signicant difference existed in the
preexercise scores between the two groups. A signicant
difference did occur between the pre and post results for the
exercise group (p!0.01) but not for the control group. The
mean (SD) percentage change over the programme was
28.4% (13.8%) in the exercise group and 0.6% (11.1%) in
the control group.
No signicant difference existed in preexercise muscle
onset latency between two groups for either muscle.
Latencies throughout the training period are shown in
Figs. 3 and 4. A signicant difference was found during the
wobble board programme for both the TA, (F
1.3,22.0
Z8.74,
p!0.05) and PL (F
1.4,24.3
Z8.07, p!0.01), and a signicant
interaction also existed for both muscles (TA, F
1.3,22.0
Z
8.92, p!0.05; PL, F
1.4,24.3
Z6.20, p!0.05).
The percentage change in muscle onset latency for the
two groups is presented in Table 3. Simple main effects
showed that within the exercise group a signicant
difference existed in onset latency for both the TA
(F
2,20
Z10.07, p!0.05) and the PL (F
2,20
Z8.052, p!
0.05). Post-hoc testing revealed that signicant differences
occurred for both muscles between the pre-mid, and pre-
post periods (p!0.05), but not for the mid-post period. The
effect sizes for the pre-post period in the exercise group
Table 2
Wobble board training instructions (adapted from Wester et al., 1996)
1. Stand with feet parallel on the board, rock the board forward and back
2. Stand with feet parallel on the board rock the board from side to side
3. Stand with feet wide apart on the board rock the front of the board from side to side in a circulating movement
4. Repeat exercises 1-3 but with your knees slightly bent and your hands on your buttocks
Continue exercises 14 for 30 s, rest for 10 s and repeat
5. Stand on the previously injured leg and keep the board level for 10 s, repeat six times, rest for 10 s and repeat
If in stage 5 balance can be maintained without losing stability of the board, then complete with the eyes closed
Fig. 2. Mean (CSD) AJFAT score at the beginning (pre) and end (post) of
the training period for both the exercise and control groups.
Fig. 3. Mean (Cor KSD) onset time for the tibialis anterior in response to
208 of ankle inversion throughout the training period for both the exercise
and control groups.
V.M. Clark, A.M. Burden / Physical Therapy in Sport 6 (2005) 181187 184
were 1.29 and 1.20 for the TA and PL, respectively, which
resulted in a power of 0.94.
4. Discussion
The results of this study showed that the time to
activation (i.e. the onset latency) of the TA and PL in
response to rapid ankle inversion was signicantly reduced
by 4 weeks of wobble board exercise. Participants
perception of their ankle stability also improved over the
course of the exercise programme. Neither muscle onset
latency or perceived stability were statistically different
between the two groups at the start of the investigation,
which indicates that the changes observed were likely to be
due to wobble board training alone.
The onset latencies of the PL (mean!80 ms; Figs. 3
and 4) were shorter than those (meanO90 ms) previously
reported by Fernandes et al. (2000) for individuals with
normal and unstable ankles. This is most likely due to the
different algorithm used to calculate muscle latency. We
dened the onset of peroneus longus activity as when
activity reached 2 SDs above the mean baseline of the
electromyogram, whereas Fernandes et al. (2000) used an
algorithm including 5 SDs. Thus, if the rst peak of
electrical activity following the inversion perturbation
measured 3 SD above the baseline, it would have been
used to calculate the latency period in this investigation,
but not in the study carried out by Fernandes et al. (2000).
Muscle onset latencies calculated by Osborne et al. (2001)
(mean TA!70 ms; PL!60 ms) were lower than those
presented here, probably because they were recorded
using ne-wire rather than sEMG.
Whilst this investigation found the wobble board
programme to cause a signicant decrease in the latency
of both the TA and PL, Osborne et al. (2001) only found
this for the TA. Analysis of their data, however, reveals
that the experimental groups PL latency reduced by
9.5 ms (18%). Although this is not as high as the 31%
change recorded for the same muscle in this study, it could
be deemed to be clinically relevant (Hopper et al., 1998).
The major difference in the design of this study and that of
Osborne et al.s is that we used a separate control group
whereas they used the contralateral leg as the control.
Whereas muscle latencies in our control group were
unaffected, those from the control limb in Osborne et al.s
study mirrored the reductions seen in the experimental
limb in both the PL and TA. Their claim that similar
changes in the contralateral limb occurred as a result of
cross education is supported by Wolf, Segal, Heter, &
Catlin, (1995) who also found improvements in the reex
response on the untrained limb. Had we measured the
latency of the PL in the contralateral leg it would,
therefore, be likely to have reduced.
The exercise programme demanded that the participants
learn to react to a variety of movements on the wobble
board. The large reductions in onset latency observed in the
exercise group (TAZ29.9%, PLZ31.2%) initially suggest
that such movements resulted in an improvement in the
mechanoreceptor function, which restores the neuromus-
cular loop (Rozzi et al., 1999). However, it has been
reported that neither otolith (Waddington & Shepherd,
1996) nor proprioceptive (Konradsen, Voigt, & Hojsgaard,
1997) generated responses could protect the ankle until
130 ms or 176 ms, respectively, after stimulus detection. As
the trapdoor mechanism similar to the one used in this study
rotates through 308 in approximately 80 ms it is likely that
these responses would be too late to produce sufcient
eversion torque to prevent injury from sudden inversion
(Konradsen et al., 1997).
Konradsen & Ravn (1991) reported that the latency of
the PL was not signicantly different between the affected
and unaffected limbs of their FUA group. Based on these
ndings, both Fernandes et al. (2000) and Waddington &
Shepherd (1996) suggested that changes to either limb
following injury would be based on a central rather than a
peripheral response. Fernandes et al. (2000) further
suggested that the proprioceptive response of the PL
may serve to increase the stiffness of the ankle, as part of
a muscle activation pattern response to a sudden
perturbation. The cross education effect reported by
Osborne et al. (2001) also supports the theory that
changes in the protective mechanism may be centrally
Fig. 4. Mean (Cor -SD) onset time for the peroneus longus in response to
208 of ankle inversion throughout the training period for both the exercise
and control groups.
Table 3
Mean and standard deviation (SD) percentage change in onset latency
between the start and the end of the training period for tibialis anterior and
peroneus longus
Exercise group Control group
% Change SD % Change SD
Tibialis
Anterior
K29.9 6.3 C0.13 2.5
Peroneus
Longus
K31.2 4.8 K1.9 0.4
V.M. Clark, A.M. Burden / Physical Therapy in Sport 6 (2005) 181187 185
rather than peripherally based. Statistically signicant and
clinically relevant improvements in participants percep-
tion of ankle stability (meanZ28.4%, SD 13.8) reported
in this investigation lend further support to these
adaptations being centrally based.
Whilst Osborne et al. (2001) only assessed the effect of
their wobble board programme at the beginning and end of
an 8-week period, this investigation showed that even a
short period of 2 weeks can elicit signicant changes in
muscle onset latency. This may be pertinent when working
with athletes who have difculty with adhering to lengthy
rehabilitation programmes. Although not of statistical
signicance, the improvements in muscle onset latency
during the third and fourth weeks of the programme were
still clinically relevant for both muscles. Further research is
required to investigate when during the rehabilitation period
wobble board induced improvements in muscle latency and
perceived stability begin to plateau.
5. Conclusion
The ndings of this study advocate the use of a wobble
board exercise programme as part of the rehabilitation for
individuals with FUAs who experience recurrent ankle
sprains. Results demonstrated that the programme
decreased muscle onset latency of the TA and PL in
response to a sudden 208 ankle inversion. Whilst these
improvements may still not be enough to produce sufcient
torque to prevent injury from sudden inversion, it is likely
that they would reduce the risk of recurrent injury by
increasing joint stiffness. This is supported by improve-
ments in participants perception of their functional
stability. The largest improvements in muscle onset latency
occurred during the rst 2 weeks of training for both TA and
PL, which indicated that even a short programme may
reduce the risk of ankle sprain. Further research is needed
identify if improvements reach a plateau over a longer
training programme.
Acknowledgements
This study was supported by a grant from the Chartered
Society of Physiotherapy, Charitable Trust. The authors
would like to thank Chris Dunne for IT support.
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