ARTICLE IN PRESS

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Physical Therapy in Sport 9 (2008) 136–147

www.elsevier.com/ptsp

Literature Review

The effects of proprioceptive exercise and taping on proprioception insubjects with functional ankle instability: A review of the literature

Tom Hughesa,�, Patsy Rochesterb

aPhysiotherapy Department, Bradford Teaching Hospitals NHS Trust, St. Luke’s Hospital, Bradford, BD5 0NA, UKbDivision of Rehabilitation Studies, School of Health Studies, University of Bradford, 25 Trinity Road, Bradford, BD5 OBB, UK

Received 7 November 2007; received in revised form 29 May 2008; accepted 9 June 2008

Abstract

Objective: To investigate the effects of proprioceptive exercise rehabilitation and taping techniques on proprioceptive measures in

chronic functional ankle instability (FAI).

Design: Literature review.

Data sources: Keyword search of the AMED, CINAHL, Medline, PEDro and SPORTDiscus online databases from January 1985

to February 2007. Also reference lists of articles obtained were manually searched for relevant literature.

Results: The search yielded nine studies that investigated the effects of proprioceptive exercise training on proprioceptive measures.

Four studies investigated the effects of ankle taping on proprioceptive measures. The exercise literature was limited due to

poor methodological quality. There is some agreement that muscle reaction time, kinaesthetic deficits and postural sway may improve

with proprioceptive exercise; however, due to differences in study methodology and quality, no specific recommendations for

practice can be made. Taping literature is also limited in terms of quantity and methodological quality. The effect on muscle reaction

time, kinaesthesia, and postural sway rely on one study for each element, therefore conclusive recommendations for practice cannot

be made.

Conclusion: There is a paucity of high-quality evidence investigating the effects of proprioceptive exercise and taping. Further high-

quality clinical trials are needed to enhance the evidence base in order to help guide physiotherapists in selecting appropriate,

effective strategies when managing FAI.

r 2008 Elsevier Ltd. All rights reserved.

Keywords: Ankle injuries; Proprioception; Exercise; Taping

1. Introduction

Ankle inversion sprains are common athletic injuries(Denegar & Miller, 2002; Hertel, 2002) with morethan 40% of cases becoming recurrent following theinitial incident (Gerber, Williams, Scoville, Arciero, &Taylor, 1998). Mechanical instability and functional

ee front matter r 2008 Elsevier Ltd. All rights reserved.

sp.2008.06.003

ing author. Present address: Physiotherapy Depart-

y Primary Care Trust, Whiston Hospital, Warrington

Merseyside, L35 5DR, UK. Tel.: +44 151 4301277;

01162.

ess: tom.hughes@knowsley.nhs.uk (T. Hughes).

ankle instability (FAI) have been hypothesised asunderlying causes of recurrent sprains (Hertel, 2000).Mechanical instability is defined as laxity and excessivejoint motion of the talocrural, subtalar and/or inferiortibiofibular joints due to structural damage of thesupporting ligamentous tissues (Hertel, 2000). FAI wasoriginally proposed by Freeman, Dean, and Hanham(1965) to describe subjective ‘‘giving way’’ or sensationsof ankle instability, and has been refined to meaningjoint motion occurring beyond voluntary control, butnot necessarily exceeding the physiological range ofmotion (Tropp, Odenrick, & Gillquist, 1985). Mechan-ical instability (MI) and FAI can coexist following ankle

ARTICLE IN PRESST. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147 137

inversion sprains although may not be related (Boyle &Negus, 1998), as a high proportion of individualscomplaining of recurrent sprains do not demonstrategross mechanical instability on examination (Hertel,2000).

In normal functioning, proprioceptive informationsuch as kinaesthesia and joint position sense (JPS) areobtained from mechanoreceptors upon detection ofjoint displacements or perturbations. This elicits com-plex responsive reflex neural muscle activation, toincrease muscle stiffness and resist these displacements,to maintain postural stability (Baltaci & Kohl, 2003)and functional joint stability (Riemann & Lephart,2002). Following lateral ankle sprain, ligamentous tissueis thought to heal effectively but mechanoreceptordisruption within the lateral ligaments and talocruraljoint capsule results in reduced ability to detect changesin JPS (Hertel, 2000), a process termed deafferentiationby Freeman et al. (1965). Ankle sprains also causesubstantial deficits to kinaesthetic sense (Konradsen,2002) although it is unclear how this occurs. JPS deficitsresult in improper positioning of the foot prior to and atheel strike during gait, causing susceptibility to inversioninjury (Bernier & Perrin, 1998) whereas kinaestheticdeficits delay reflex neuromuscular response time tosudden inversion, subsequently contributing to FAI(Hertel, 2000).

Experimental studies have demonstrated a correlationbetween impaired proprioception and FAI. Deficitshave been identified in JPS (Boyle & Negus, 1998;Jerosch & Bischof, 1996; Liu, Jeng, & Lee, 2005),postural stability control (Fu & Hui-Chan, 2005;Nakagawa & Hoffman, 2004), kinaesthesia (Garn &Newton, 1988; Lentell et al., 1995; Refshauge, Kilbreath,& Raymond, 2003) and delayed peroneal reaction timeto sudden inversion stresses (Fernandes, Allison, &Hopper, 2000; Konradsen & Ravn, 1990; Lofvenberg,Karrholm, Sundelin, & Ahlgren, 1995; Vaes, VanGheluwe, & Duquet, 2001). Consequently, narrativereviews report that exercise rehabilitation aimed atretraining proprioceptive deficits associated with FAI,such as using multiaxial platforms or wobble boards, isassociated with positive outcome (Baltaci & Kohl, 2003;Mattacola & Dwyer, 2002; Wilkerson & Nitz, 1994)Additionally, therapeutic ankle taping is advocated toenhance proprioception in FAI (Wilkerson, 2002), byproviding cutaneous afferent feedback (Refshauge,Kilbreath, & Raymond, 2000). However, the internalvalidity of these reviews is questionable, as it is unclear ifevidence upon which recommendations are based hasbeen assessed for quality. Also, it is unclear whichaspects of proprioception might be affected.

There is currently only one systematic review avail-able that has investigated prevention of ankleligament injuries (Handoll, Roe, Quinn, & de Bie,2001) but this focuses on prophylactic interventions

for subjects at risk of, or following acute lateralligament sprain and their effects on re-injury occurrence,whereas trials investigating treatment effects on pro-prioceptive measures were excluded. There are currentlyno known systematic reviews exclusively investigatingthe effects of proprioceptive exercise and the use oftherapeutic taping on measures of proprioception inFAI management.

As such, there is little high-quality evidence-basedguidance available to physiotherapists to aid selectionof appropriate proprioceptive management strategies.The aim of this paper is to provide a review of primaryevidence relating to the effects of proprioceptive exerciserehabilitation and taping techniques on measures ofproprioception in subjects with chronic FAI.

2. Methodology

2.1. Search strategy

The literature search was date limited from January1985 to February 2007. The AMED, CINAHL, Med-line, PEDro and SPORTDiscus online databases weresearched using the following keywords: ankle jointAND sprains and strains; OR joint instability; ANDproprioception; OR kinaesthesia; OR joint positionsense; OR peroneal reaction time; OR postural control;OR postural sway; AND physiotherapy; OR physicaltherapy; OR exercise therapy; OR therapeutic exercise;OR rehabilitation; OR balance training; OR tape; ORstrapping. Reference lists of all articles obtained weremanually scanned to identify additional studies relevantto the search.

2.2. Study selection criteria

Titles and abstracts identified from the results of thesearch were screened by both researchers. Suitabilityconsensus was reached using the agreed inclusion/exclusion criteria. If the authors were uncertain, the fulltext of a reference was obtained and analysed toestablish suitability.

Randomised controlled trials (RCTs) or quasi-experimental clinical trials were included for assessmentif the criteria in Table 1 were met.

2.3. Assessment of methodological quality and data

collection

All relevant studies were independently assessed bythe researchers without blinding, using the ScottishIntercollegiate Guidelines Network (SIGN) criticalappraisal tool (SIGN, 2006), as this forms a systematicmethod of appraising, scoring and grading evidence interms of validity. Data collection forms were used for

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Table 1

Inclusion and exclusion criteria

Criteria

Inclusion � Trials investigating subjects of any age, classified as

suffering from FAI or chronic, recurrent lateral ankle

sprains with subjective feeling of instability/giving way

� Trials that primarily investigate the effects of

proprioceptive exercise therapy and therapeutic taping

on proprioceptive outcome measures including JPS

(joint reposition tests), kinaesthesia (detection of active/

passive movement), muscle response time (muscle

reaction time to external perturbation) and postural

control (stabilometry/postural sway tests)

� Trials published in peer-reviewed journals only, written

in the English language

Exclusion � Trials investigating healthy, uninjured subjects, subjects

that have experienced only one acute lateral ankle

sprain. Subjects classified as suffering ‘‘ankle injury’’

only

� Trials where the primary outcome measures are not

directly related to proprioceptive testing, such as

reinjury rate and athletic performance tests (i.e. agility/

vertical jump height/sprinting times)

� Trials published in language other than English, and

grey literature

T. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147138

each article reviewed to provide a visual representationof each trial’s key points and an evidence level grade wasassigned. Once completed, the researchers met tocompare the results and reach consensus regarding eachstudy’s methodological quality.

2.4. Data synthesis

It was anticipated that following data collection, datafrom each trial that carried a low risk or very low risk ofbias according to SIGN (2006) were to be included foranalysis, whereas trials considered as carrying a highrisk of bias according to SIGN (2006) were to beexcluded from the analysis. Due to the limited quantityand quality of available evidence, however, this was notpossible. Therefore, all trials that met the inclusioncriteria were included for analysis, providing no exclu-sion criteria existed.

Extracted data were summarised by tabulation,allowing descriptive analysis of methodological rigourand whether heterogeneity of methodology and resultsexisted between studies (Deeks et al., 2001).

3. Results

Fig. 1 shows the flow chart for study selection for thispaper.

3.1. Effects of proprioceptive exercise rehabilitation on

proprioception

A summary of trials investigating proprioceptiveexercise rehabilitation is provided in Table 2.

3.1.1. Methodological quality

The methodological quality of all trials investigatingthe effects of proprioceptive exercise training wasconsidered poor. A clear research aim was provided ineight studies (Bernier & Perrin, 1998; Clark & Burden,2005; Eils & Rosenbaum, 2001; Gauffin, Tropp, &Odenrick, 1988; Hess, Joyce, Arnold, & Gansneder,2001; Osborne, Chou, Laskowski, Smith, & Kaufman,2001; Powers, Buckley, Kaminiski, Hubbard, & Ortiz,2004; Rozzi, Lephart, Sterner, & Kuligowski, 1999).However, in comparison, Pintsaar, Brynhildsen, andTropp (1996) presented an unclear aim, thus it wasunknown whether the methodology addressed theresearch question.

Four studies were RCTs (Bernier & Perrin, 1998;Clark & Burden, 2005; Hess et al., 2001; Powers et al.,2004) whereas five were considered of quasi-experimentaldesign (Eils & Rosenbaum, 2001; Gauffin et al., 1988;Osborne et al., 2001; Pintsaar et al., 1996; Rozzi et al.,1999). Although randomised subject allocation was usedin all RCTs, none reported details of the actualprocedure, nor were any details regarding concealmentmethods documented. As such, it is unknown whetherthe allocation methods were robust against researcherbias, and as inadequate allocation concealment isassociated with selection bias (Schulz, Chalmers, Hayes,& Altman, 1995), the reliability and internal validity ofthese studies is questionable.

Of the quasi-experimental trials, Gauffin et al. (1988)and Eils and Rosenbaum (2001) did not report sampleselection methods used, although Rozzi et al. (1999)used a volunteer sample of FAI subjects. Pintsaar et al.(1996) also reported on selection methods implemented,but their description was ambiguous. As such, in allthese studies it is questionable whether the sampleswere truly representative of the target population, inaddition to potentially introducing selection bias asdiscussed previously. In contrast, Osborne et al. (2001)provided adequate detail of sample selection methods,where a medical records database was reviewed forsubjects with the diagnosis of ‘‘ankle sprain’’. Recordsretrieved were then randomly reviewed to establishinclusion suitability, and those applicable were invitedto participate.

Anthropometric data of subject groups were notdescribed by Gauffin et al. (1988), Pintsaar et al. (1996)and Bernier and Perrin (1998), whereas characteristicssuch as age, weight and height were reported for thesample as a whole by Hess et al. (2001) and Powers et al.(2004). Therefore, it was difficult to ascertain whether

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239 potentially relevant studies identified by title, following cross-

referencing in bibliographic software.

Abstracts screened of all 239 potentially relevant studies

retrieved for detailed analysis

214 studies excluded as inclusion criteria not met/exclusion criteria

present

25 full text articles of studies potentially appropriate for

inclusion in review obtained and analysed in detail

12 studies excluded as inclusion criteria not met/exclusion criteria

present

13 studies included in systematic review

Fig. 1. Flow chart illustrating study selection for inclusion.

T. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147 139

samples used were comparable. Conversely, Rozzi et al.(1999), Osborne et al. (2001) and Clark and Burden(2005) presented descriptive anthropometric data ac-cording to the conditions subjects were allocated,indicating comparable cohorts, although this was nottested statistically. Although Eils and Rosenbaum(2001) analysed anthropometric data in groups bothdescriptively and statistically, the statistical test usedwas not reported, therefore it was unknown whetherappropriate analyses were conducted, and subsequentlyif groups were actually comparable.

Only three trials reported subject drop out. Pintsaaret al. (1996) found that two subjects dropped out of theexercise group, whereas Osborne et al. (2001) found onlyone subject failed to complete the study. Bernier andPerrin (1998) documented that two subjects droppedout of the control group, and one dropped out of thesham electrotherapy group. In these studies, this

represents a degree of attrition bias. As all other trialsdid not report drop out, it is questionable whether thedata were afflicted with such bias, threatening internalvalidity.

Detailed procedural descriptions were provided byBernier and Perrin (1998), Rozzi et al. (1999), Eils andRosenbaum (2001), Hess et al. (2001), Powers et al.(2004) and Clark and Burden (2005). However, descrip-tion of the exercise intervention was limited by Osborneet al. (2001), whereas inadequate description of theprocedure was provided by Gauffin et al. (1988) andPintsaar et al. (1996), therefore threatening methodolo-gical reliability.

Powers et al. (2004) utilised examiner blinding in anattempt to eliminate researcher bias, but how this wasachieved was unclear. However, all other trials did notstate whether blinding was used. Surprisingly, instru-mental validity was not reported in any trial, and only

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STable 2

Summary of trials investigating proprioceptive exercise rehabilitation

Author Number of

subjects (N)

Intervention Testing and follow up

time

Outcome measurement Results

Gauffin et al.

(1988)

10 FAI subjects 1. Affected leg trained only using single leg

standing on an ankle disk, for 10min, 5

times per week for 8 weeks

Pre-test and following 8

weeks

Postural sway calculated by

measure of centre of pressure

in single leg stand on force

plate

There was a significant decrease in postural

sway following ankle disk training (po0.001)

Pintsaar et al.

(1996)

12 uninjured

subjects

1. Uninjured control subjects measured once

for reference

Control subjects tested

once for reference (not

stated when)

Postural sway measured by

calculating postural control

latency in response to

perturbation on force plate in

single leg standing

No differences observed in latencies of any

group

15 FAI subjects 2. FAI subjects underwent an 8-week

proprioceptive training session (3–5 sessions

per week) using an ankle disk

In FAI subjects, ankle strategies used less at

pre-test, and returned to ‘‘normal’’ post-test

(no p-value given)

11 MI subjects 3. MI subjects used an ankle brace for 6 weeks

and measured in barefoot, with shoe, and

with shoe and brace

FAI subjects pre-tested

and after 2 weeks

Degree of use of ankle

strategy/hip strategy in

maintaining postural

equilibrium following

perturbation calculated using

force plate data in

biomechanical equation

MI subjects used less ankle strategy in barefoot,

increasing with a shoe in situ. No further

differences observed with brace and shoe

combined (no p-value given)MI subjects only tested

after 6 weeks (no pre-

test measure taken)

Bernier and

Perrin (1998)

48 FAI subjects Subjects randomised into:

1. Control: requested not to participate in

strength/balance training for 6 weeks

2. Sham: sham electrical stimulation of

peroneal muscles for 6 weeks

3. 10min sessions per week of standardised

progressive proprioceptive exercises: single

leg balancing on stable surface, on uniaxial

tilt board (in the plantar/dorsiflexion,

inversion/eversion and combined plantar/

dorsiflexion and inversion/eversion planes),

on wobble board, and hopping activities, all

repeated with eyes open/closed

Pre-test and 6 weeks Active and passive angle

reproduction using isokinetic

dynamometer

Modified equilibrium score significantly

improved in group 3 compared to 1 and 2 at

post-test (po0.05)

Postural sway using single leg

stand on balance platform

and calculating sway index

and modified equilibrium

score

No significant differences observed for sway

index or angle reproduction measures

Rozzi et al.

(1999)

13 FAI subjects Both groups underwent:

1. 4-week balance training programme using

Biodex Stability System (three sessions per

week) consisting of: balancing on single

limb on a stable and unstable setting,

balancing on single limb, actively moving

platform anterior/posterior, medial/lateral,

and multiplane circles

Pre-test and 4 weeks Postural sway calculated by

measuring single leg balance

using Biodex Stability System

FAI group subjects had significantly greater

pre-training postural sway scores than controls

(po0.05), though no significant differences at

the stable setting

13 uninjured

control subjects

At unstable and stable settings, post-training

postural sway significantly improved compared

to pretraining scores (po0.05). There was no

significant difference in post-training scores

between either group

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SEils and

Rosenbaum

(2001)

30 FAI subjects Subjects randomised into:

1. Exercise group (N ¼ 20) completed

6-week circuit (20min sessions, once per

week) consisting of: warm up, single leg

stance on mobile platform, ankle disk, with

contralateral leg performing resisted

abduction with exercise band, trampette.

Maintaining balance during; double and

single leg stand on air cushion, tilt board,

horizontal/vertically mobile platform,

Biodex Stability system

2. Control group (N ¼ 10) only participated in

test procedures

Pre-test and following 6

weeks

JPS measured with footplate

and goniometer to measure

reproduction of passive

dorsiflexion and

plantarflexion angle

Exercise group demonstrated significant

improvements in passive angle reproduction at

all angles other than 101 dorsiflexion

(p ¼ 0.057), whereas non-significant differences

with control scores existed

Postural sway measured in

single leg stance on force plate

Postural sway significantly improved in both

groups at post-test (po0.01)

Surface electrode EMG of

tibialis anterior, peroneus

longus and peroneus brevis

muscular reaction time to

simulated inversion injury

Muscle reaction time of peroneus longus and

brevis significantly improved in the exercise

group (po0.001), but no other differences

observed

Hess et al.

(2001)

20 FAI subjects Subjects randomised into:

1. Control condition, where pre-test and post-

test measures taken, but no training

performed for the duration of the study

2. 4-week agility training programme using

agility ladder (3� 20min sessions/week)

consisting of 3–5min warm up and the

following drills: forward 2 feet in, lateral

2 feet in, forward shuffle, 1 foot in shuffle,

forward slalom jumps, forward cross steps

and 901 angle exercises

Pre-test and 4 weeks Postural sway measured by

calculating sway index during

single leg stand on Chattex

Balance System

No significant differences observed between

pre-test and post-test sway index scores for

either group

Osborne et al.

(2001)

9 subjects with

history of non

rehabilitated ankle

sprains

1. 8-week training programme using an ankle

disk for 15min per day

Pre-test and following 8

weeks

Indwelling fine wire EMG of

tibialis anterior, posterior,

peroneus longus and flexor

digitorum longus assessing

onset latency

A significant decrease (p ¼ 0.02) in tibialis

anterior onset latency was observed in ankles

following training

Powers et al.

(2004)

38 FAI subjects Subjects randomised into:

1. Progressive plantarflexion, dorsiflexion,

inversion, eversion strength training using

theraband

2. Proprioception training using theraband

kicks

3. A combination of the above

4. Control, where no exercise permitted

Pre-test and following 6

weeks

Postural sway using single leg

stand on force plate

No significant effects of any condition between

groups of pre-test and post-test measure of

postural sway or muscle fatigueEMG of tibialis anterior and

peroneus longus, to assess

muscular fatigue

Clark and

Burden, (2005)

19 FAI subjects Subjects randomised into:

1. Exercise programme completed 3-times per

week; standing on wobble board-rocking

board forward/backward, side/side, circular

Pre-test, 2 weeks and

following 4 weeks

Surface EMG of tibialis

anterior and peroneus longus

assessing onset latency

Exercise group showed significant

improvement in AJFAT score post-test

(po0.01) compared to the control

Ankle joint functional

assessment tool (AJFAT)

Significant improvements occurred between pre

and post-test scores for the exercise group,

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2(c

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Author

Number

of

subjects(N

)

Intervention

Testingandfollow

up

time

Outcomemeasurement

Results

movem

ents.Allexercisesrepeatedwith

flexed

kneesandhandsonbuttocks.Also

single

legstandingonthewobble

board

completed

2.Control—

notraining

(po0.01),withsignificantdifferencesobserved

betweenweeks0–2(po0.05)fortibialis

anterior(po0.05)andperoneuslongus

(po0.01)onsetlatency

FAI¼

Functionalankle

instability,MI¼

Mechanicalinstability,JP

S¼

Jointpositionsense.

T. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147142

Rozzi et al. (1999) provided data highlighting thereliability of the instrumentation used. The intraclasscorrelation coefficient of the Biodex Stability Systemwas reported as between 0.6 and 0.95 at varying levels ofstability (Rozzi et al., 1999), which represents fair toexcellent reliability. Therefore, data presented in alleight other trials must be interpreted with caution, as itis unknown whether the instruments used are valid andreliable measures of proprioception.

Finally, small sample sizes may affect overall statis-tical power in the trials by Gauffin et al. (1988), Hesset al. (2001) and Osborne et al. (2001).

3.1.2. Summary

The evidence investigating effects of proprioceptiveexercise therapy was limited due to poor methodologicalquality, therefore the data should be interpreted withcaution. However, there is some agreement thatperoneus longus muscle reaction time may improveafter proprioceptive retraining (Clark & Burden, 2005;Eils & Rosenbaum, 2001). Nevertheless, differences intraining activities, duration and frequency of bothrehabilitation programmes make it difficult to recom-mend specific evidence-based exercises that may influ-ence this. There is some agreement that ankle disktraining improves tibialis anterior reaction time (Clark& Burden, 2005; Osborne et al., 2001), though there isno consensus regarding specific types, duration andfrequency of training required to influence this, due tomethodological differences.

There is consensus that proprioceptive exercise mayimprove postural sway in FAI subjects (Bernier &Perrin, 1998; Eils & Rosenbaum, 2001; Gauffin et al.,1988; Rozzi et al., 1999), with agreement from twostudies that 6-week composite exercise programmesusing modalities, such as ankle disks, tilt boards andsingle-leg standing activities are effective (Bernier &Perrin, 1998; Eils & Rosenbaum, 2001). However, thereis no agreement in optimum exercise frequency due tomethodological differences.

Other exercises in isolation may improve posturalsway, such as single-leg stand ankle disk training(Gauffin et al., 1988) and Biodex Stability Systemprogrammes (Rozzi et al., 1999). Conclusive recommen-dations, however, cannot be made as each approachrelies on data from one trial in isolation, and as bothmodalities have been used in the composite programmespresented by Bernier and Perrin (1998) and Eils andRosenbaum (2001), it may be more appropriate toutilise these combined with other activities.

Training using agility ladders (Hess et al., 2001),theraband kicks, theraband strengthening and bothcombined may not improve postural sway (Powerset al., 2004). These results are based upon limitedevidence of one study for each component, therefore,further research is required before conclusive

ARTICLE IN PRESST. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147 143

recommendations could be given regarding the use ofthese modalities in rehabilitation.

There is conflicting evidence regarding the effect of6-week composite proprioceptive exercise programmeson JPS, therefore recommendations for practice cannotbe made. In light of the limited evidence relating to theeffects of proprioceptive exercise rehabilitation, there isa clear need for further high-quality research into thisarea.

3.2. Effects of ankle taping on proprioception

A summary of trials investigating the effects of tapingon proprioception are included in Table 3.

3.2.1. Methodological quality

The evidence related to the effects of taping onproprioception in subjects with FAI was consideredpoor. The research aim was adequate but lacking insome specificity in one study (Karlsson & Andreasson,1992), but was clear and detailed in the other threestudies (Leanderson, Ekstam, & Salomonsson, 1996;Matsusaka, Yokoyama, Tsurusaki, Inokuchi, & Okita,2001; Refshauge et al., 2000). Three studies were ofquasi-experimental design. Leanderson et al. (1996) andRefshauge et al. (2000) used non-equivalent pre-testpost-test designs, and Karlsson and Andreasson (1992)utilised a repeated measures design. The study byMatsusaka et al. (2001) was the only RCT included.Despite using randomised subject allocation, the meth-od implemented was not documented, nor were detailsprovided regarding allocation concealment, subse-quently creating a source of potential researcher andselection bias.

Sample selection methods were not reported byKarlsson and Andreasson (1992), and Leandersonet al. (1996), although Refshauge et al. (2000) high-lighted that a volunteer sample was obtained. Therefore,for all three trials it was unclear whether the sampleswere representative of the FAI population, in additionto being potential sources of selection bias.

Anthropometric data of subject groups were notdescribed by Karlsson and Andreasson (1992), and onlyage ranges of both groups were reported by Leandersonet al. (1996) with a mean age difference of 7 yearsbetween groups. Therefore, it is questionable whethergroups were comparable. This was addressed byRefshauge et al. (2000), who matched groups on age,height, weight and activity level factors. However,although descriptively comparable, inferential statisticswere not performed to establish significant differences.Matsusaka et al. (2001) was the only trial to address thisto ensure appropriate group comparability.

Participant drop out rate was reported by Matsusakaet al. (2001) only, where no attrition was observed. Assuch the internal validity of the other three trials is

threatened, as it is unclear whether the results wereinfluenced by attrition bias. Blinding was not addressedby Karlsson and Andreasson (1992), Leanderson et al.(1996) and Matsusaka et al. (2001), although Refshaugeet al. (2000) implemented subject blinding in an attemptto reduce detection bias. However, it was unclear howthis was achieved. Procedural descriptions lacked detailin three trials thus limiting reliability. Karlsson andAndreasson (1992) provided adequate description of theankle inversion platform used, but limited detailsregarding electrode placement, taping techniques usedand when testing procedures were completed. Leander-son et al. (1996) provided no details regarding tapingtechnique used, which undermines the external validityof the results. Also an adequate description wasprovided regarding outcome measurement, although itwas unclear whether the control group underwent thesame intervention, and whether they participated in afootball practice session. Refshauge et al. (2000)provided adequate procedural description and detaileddiagrams demonstrating the taping method used,although details were lacking regarding duration andfrequency of rest periods. In contrast Matsusaka et al.(2001) provided specific procedural details.

Reliability and validity of outcome measures used wasnot addressed in any study, therefore all data should beinterpreted with caution as it is unknown whether thetechniques and instruments used are reliable or valid inmeasuring proprioception.

3.2.2. Summary

The evidence related to effects of taping on proprio-ceptive measures is severely limited in terms of quantityand methodological quality, and interpretation ofavailable data must be completed with caution. Threestudies suggest that taping may affect some propriocep-tive measures. However, evidence relating to tapingeffects on muscle reaction time and kinaesthesia relyon 1 study each (Karlsson & Andreasson, 1992;Refshauge et al., 2000). Similarly, the effects of tapingin isolation on postural sway has been addressed byone study (Leanderson et al., 1996), and taping incombination with ankle disk training addressed in onestudy (Matsusaka et al., 2001), therefore conclu-sive recommendations for practice cannot be provided.In retrospect, there is a clear need for further high-quality clinical research addressing the areas covered,and relating to other aspects of taping such as effects onJPS.

4. Discussion

The aim of this study was to provide a review ofprimary evidence relating to the effects of proprioceptiveexercise rehabilitation and taping techniques on mea-sures of proprioception in subjects with chronic FAI. It

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Table 3

Summary of trials investigating effects of taping on proprioception

Author Number of

subjects (N)

Intervention Testing and follow-

up time

Outcome measurement Results

Karlsson and

Andreasson

(1992)

20 FAI subjects All subjects underwent:

1. Muscle reaction time to simulated

inversion sprain measured with no tape

2. Repeated procedure with application of

Gibney taping technique (minus heel

lock strips) using inelastic tape

Conditions tested

consecutively, time

between not stated

Muscle reaction time

measured of peroneus longus

and brevis using

electromyography surface

electrode

Muscle reaction time significantly shorter

(po0.05) with tape in situ than without

Leanderson et al.

(1996)

9 FAI subjects FAI group underwent:

1. Both feet tested before football practice

session

2. Tape applied to ankle and re-tested

prior to practice session

3. Taped ankle tested following 2 hr

practice session

4. Tape removed and untaped ankle

re-tested after 2 hr practice session

Conditions 1 and 2

measured before

football practice,

conditions 3 and 4

measured after

practice session

Postural sway measured by

recording maximum sway

amplitude during disk

perturbation and mean sway

during each trial; measured

with using single leg stand

on ankle disc mounted on

force plate

No significant differences between FAI and

control subjects before practice session

8 uninjured

control subjects

Maximal sway of both groups decreased

when the ankles were taped before the

practice session but unclear if this was

significant

After session no significant differences

existed in maximal or mean sway between

taped and untaped ankles

Maximal and mean sway amplitude

without taping was significantly smaller

after the practice session than beforehand

(po0.01)

Refshauge et al.

(2000)

25 subjects

suffering from

recurrent

inversion sprains

Both groups underwent:

1. Ankle taping applied consisting of heel

lock, stirrup and figure of six inelastic

strips

2. Ankles not taped

2� 1.5 hr testing

periods. Time

between not stated

Detection of angular

displacements of passive

plantarflexion and

dorsiflexion measured with

using linear servomotor

driven by ramp generator

No significant difference (p ¼ 0.27)

movement detection at any velocity tested

between experimental and control groups

18 uninjured,

matched control

subjects

No significant difference (p ¼ 0.28) in

movement detection between taped/

untaped conditions for either subject group

Matsusaka et al.

(2001)

22 FAI subjects Randomised to either

(1) Ankle disk training group completed

single limb stance on affected side,

10min per day, and 3 times per week

for 10 weeks

(2) As above, combined with two strips of

inelastic tape, one anterior and one

posterior to the lateral malleolus from

distal 1/3 of leg to sole of foot

Pre-test and at weeks

2, 3, 4, 5, 6, 8 and 10

Postural sway measured

using stabilometry with

subjects in single limb stance

with affected leg on force

plate

In group 1, postural sway significantly

improved after week 8 (po0.0001), but no

significant differences existed between

weeks 8–10 (p ¼ 0.254)

In group 2 postural sway significantly

improved between 4–6 weeks (po0.0001),

but no significant difference between weeks

6–10 (p40.892)

Postural sway was significantly less in

group 2, compared to group 1 in each test

made at the fourth (p ¼ 0.012), fifth

(p ¼ 0.006) and sixth (p ¼ 0.002) weeks

FAI ¼ Functional ankle instability.

T.

Hu

gh

es,P

.R

och

ester/

Ph

ysica

lT

hera

py

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13

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7144

ARTICLE IN PRESS

Table 4

Areas for further research

� Further trials investigating effects of specific proprioceptive

exercises/programmes and taping techniques on reaction time of

other muscles such as peroneus brevis, tibialis posterior, extensor

hallucis longus and extensor digitorum longus

� Trials investigating the optimum duration, frequency and intensity

of specific proprioceptive exercises/programmes on all

proprioceptive measures

� Trials investigating long-term follow-up of subjects who have

completed an exercise or taping rehabilitation programme on

measures of proprioception

� The effects of specific exercises/programmes, specific exercises/

programmes combined with taping techniques or taping in

isolation on measures of proprioception

� The effects of self-management proprioceptive exercise

programmes that are completed independently utilising equipment

commonly found in the home setting, on measures of

proprioception

� The effect of taping or proprioceptive exercises on self reported

measures of disability, and whether this correlates with

proprioceptive measures

� The effect of taping or proprioceptive exercise rehabilitation on

inversion injury recurrence, and whether this correlates with

proprioceptive measures

T. Hughes, P. Rochester / Physical Therapy in Sport 9 (2008) 136–147 145

was anticipated that the results would help guidephysiotherapists in selecting appropriate, evidence-based strategies in the management of FAI, thusimproving efficiency, time and cost effectiveness ofphysiotherapy management. Although the aim of thepaper had been adequately addressed, unfortunately,following completion of the literature search strategy itwas clear that there was a paucity of high-quality RCTsrelating to this subject area. However, the searchstrategy used might have imposed limits on the quantityof literature obtained, and ultimately resulted in asource of publication and selection bias. Trials were onlyconsidered for inclusion if they were published in peer-reviewed journals and written in the English language.As such other important evidence could have beenmissed if written in other languages or available withinunpublished grey literature. Nevertheless, the overallquality of the included evidence was poor, and allstudies were classed as carrying a high risk of biasaccording to the appraisal tool used. Therefore, theoverall validity of the evidence base is questionable andsubsequently, it has been difficult to formulate recom-mendations for physiotherapy practice.

Although acknowledged that statistical analysis of theobtained data by meta-analysis can increase statisticalpower and precision of conclusions of a review, meta-analyses of poor quality studies may be seriouslymisleading, as if bias is present, errors will be com-pounded leading to inappropriate conclusions (Higgins &Green, 2006). Therefore, following data extraction, it wasclear that meta-analysis was inappropriate for this review.

Despite conflicting results regarding effects of proprio-ceptive exercise on JPS, there is some agreement thatproprioceptive exercise training may improve peronealreaction time, kinaesthetic and postural sway deficitsassociated with FAI. Differences in study quality,methodology and exercise programmes implemented,however, do not allow specific recommendations regard-ing optimum duration and frequency of training sessions,and specific effective exercises to use cannot be made.Unfortunately, due to the paucity of evidence related tothe effects of taping, no recommendations for practice canbe made. As such, it could be argued that the primaryevidence available weakly supports the suggestions fromnarrative reviews published by Wilkerson and Nitz (1994),Mattacola and Dwyer (2002) and Baltaci and Kohl(2003), which suggest proprioceptive exercise rehabilita-tion is correlated with positive proprioceptive improve-ments in FAI management. The argument proposed byWilkerson (2002) that ankle taping facilitates propriocep-tion is not currently supported.

There is a clear need for further high quality andappropriately powered RCTs investigating all areascovered by this review, in order to enhance under-standing of the effects of proprioceptive exercise andtaping on proprioceptive measures. Also, other areas

that require further investigation have been identifiedand are presented in Table 4.

5. Conclusion

This review has highlighted a paucity of high-qualityclinical trials investigating the use of proprioceptiveexercise rehabilitation and taping on proprioceptivemeasures in FAI management. It is essential that furtherhigh-quality clinical trials are conducted to improveknowledge and understanding of the effects of proprio-ceptive exercise and taping on proprioception inindividuals experiencing FAI.

Acknowledgements

Conflict of Interest: No known conflict of interestoccurred during or after completion of this paper.

Ethical Approval: Prior to commencement, this studywas ethically approved by the University of BradfordEthics Panel.

Funding: This study was completely self-funded by theauthors.

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