Is ankle proprioception targeted by exercises on an unstable surface?

Everyone who has ever experienced an ankle sprain knows the exercises done on unstable surfaces, such as wobble boards. This is aiming to improve proprioception.

Proprioception is defined according to Physiopedia  as:

Proprioception is the sense of the relative position of body segments in relation to other body segments. Unlike the six exteroceptive senses (sight, taste, smell, touch, hearing and Balance) by which we perceive the outside world, and interoceptive senses, by which we perceive the pain and the stretching of internal organs, proprioception is a third distinct sensory modality that provides feedback solely on the status of the body internally. It is the sense that indicates whether the body is moving with the appropriate effort and  where the various segments of the body are located in relation to each other.

However, a study done by Kiers et al. (2011) concluded that these exercises do not target ankle proprioception as thought by most people. It was even found that on foam, the effect of triceps surae vibration on mean center of pressure (CoP) velocity was significantly smaller than on a solid surface, while for paraspinal musculature vibration the effect was bigger on foam than on solid surface. Similar effects were seen for mean CoP displacement as outcome. They rather challenge the capacity of the central nervous system to shift the weighting of sources of proprioceptive signals on balance. The study does however not mention what exercises can be done instead to target ankle proprioception. Hence, further research needs to be done in this field.

Therefore, in the daily practice, the therapist should take in mind that improvement may result from improvement of paraspinal musculature and the capacity of the central nervous system rather than the ankle proprioception. This does not mean that proprioception exercises do not benefit ankle sprains but that the benefit might have a different cause for balance improvements.

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Swiss ball enhances lumbar multifidus activity in chronic low back pain

This study investigated the effects of sitting surfaces on the cross-sectional area of lumbar multifidus (LM) in patients with Chronic Low Back Pain (CLBP) and healthy controls (HC). 40 age and sex matched, sporting participants aged 18-45 years, recruited from private physiotherapy practice patients (n=20 CLBP, 16 male, 4 female, and n=20 healthy controls, 16 males and 4 females) took part in the study. Swiss Ball (SB) was more effective at stimulating LM than a Stable Surface (SS) in both groups: CLBP:SB:12.3(cm(2)) (SD:3.6), SS:10.15 (SD:2.6), p<0.0001; HC:SB:12.5 (SD:2.7), SS:11.3 (SD:2.9), p<0.0001). There weren’t any significant differences between groups to note. No differences between left and right side cross-sectional areas between or within groups were noted.

Cross-sectional area of LM increased as the lability of the surface increased, showing that SB was more effective at stimulating LM activity than a non-labile surface. This confirms current clinical practice and supports the use of a labile surface in spinal rehabilitation. The lack of LM asymmetry within and between groups is discussed.

Swiss ball enhances lumbar multifidus activity in chronic low back pain.

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Fall Prevention and measures


  • About one third of the elder population over the age of 65 falls each year, and the risk of falls increases proportionately with age. At 80 years, over half of seniors fall annually.
  • Those who fall are two to three times more likely to fall again.
  • About half (53%) of the older adults who are discharged for fall-related hip fractures will experience another fall within six months.
  • 20% to 30% of seniors fear falling.
  • 90% percent of falls that do not result in injury can still have a detrimental impact on health and well-being. 30-50% of elders report that fear of another fall results in loss of confidence and self-imposed restriction of activities, thereby increasing the risk of falls.

Learn more here

  • In older adults, the incidence of falls increases steadily with advancing age.
  • Chronic medical conditions associated with falls: cognitive impairment and arthritis (more common in older adults)
  • Physiologic changes of normal aging might also increase the risk of falls.
  • Influencing factors whether a fracture occurs; the fall descent, fall impact, and bone strength.

Berry et al. 2008 

Factors & prevention


  • consume sufficient calcium – broccoli, soybeans, almonds
  • Get sufficient Vitamin D – sunlight, supplements
  • Weight-bearing exercises on a regular basis

Lack of physical activity

  • Stay active at least every other day for 15 minutes – walking, swimming etc.
    • If you need help with that contact you physiotherapist to ensure you have a safe and adjusted exercise routine!
  • Wear good footwear
  • Move safely – take your time, position yourself

Impaired Vision

  • Get your eyes checked regularly
  • Highlight your aids (handrails etc.) and stairs at home
  • Keep your glasses clean!


  • Know all common side-effects
  • Ask physician/pharmacist about risk of falls
  • Avoid consuming alcohol with medication


  • Repair cracks and abrupt edges
  • Install handrails on stairs and steps and grab bars in bathrooms
  • Keep the floor clear of clutter, rocks and tools
  • Use highlighting for changes in surface or level
  • Sufficient lighting – bedlights, nightlights, motion-sensitive lighting
  • Anti-slip mats – bathtubs, shower rooms, tile floors
  • Bath-shower seats
  • Keep commonly used items within easy reach
  • Use a stable step stool
  • Make sure bed, chairs and couches are easy to get in and out (not too low)

Always have a phone nearby, install electronic emergency response systems (emergency watch, etc.)

For healthcare professionals

Falls efficacy scale – to measure Fear of falling

Berg Balance Scale – to assess balance

Timed up and go test - Assesses mobility, balance, walking ability, and fall risk in older adults

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Low back Pain Prevention

Low back pain is a very common symptom in the general population and among athletes. At some point in their lives up to 85% of the population suffer from Back pain and leads to annual cost of over 40 billion US $ in the United States (Brukner et al. 2012). Most people who experience activity-limiting low back pain have recurrent episodes. Approximately once a year a recurrence occurs in 24% to 80%. Environmental and personal factors influence the onset and course of low back pain. Other risk factors might be low educational status, stress, anxiety, depression, job dissatisfaction, low levels of social support in the workplace and whole-body vibration. It has been found that the incidence of LBP is highest in the third decade, and overall prevalence increases with age until the 60-65 year age group (Hoy et al. 2010).

There are 3 different types of low back pain, acute, recurrent, and chronic. Acute LBP comes on suddenly and typically lasts less than 3 months. Recurrent low back pain occurs with frequent episodes of acute LBP. Chronic LBP typically lasts longer than 3 months.

Possible causes of Low Back pain are overuse, strain, or injury. However, it is mostly caused by the inability of your back’s muscles, ligaments, and joints to work as they should. More often than not, the cause of LBP just isn’t clear. Much less frequently, LBP may be the result of a specific health condition, such as degenerative disk disease (a flattening and stiffening of the disks between the vertebrae), lumbar spinal stenosis (a narrowing within the vertebrae of the spinal column, resulting in too much pressure on the spinal cord), or osteoporosis (a thinning of bone tissue and loss of bone density over time). Rare, but serious LBP symptoms include incontinence or difficulty urinating, poor balance, numbness, or weakness in the legs. See a physician immediately if you experience any of these symptoms. It is worth repeating, however, that most LBP is not serious and may be resolved or managed effectively by using a conservative approach, such as physical therapy (American Physical Therapy Association 2012).

These precautions can help prevent LBP in your daily life (read more here American Physical Therapy Association 2012) .


  • Position your body directly in front of the object.
  • Bend your knees rather than your back.
  • When carrying do not twist your back to turn, move your feet.




Wearing Backpacks

  • For children it is suggested that backpack contents should be limited to 10 to 15% of the child’s body weight.
  • Wear both straps to keep weight distributed properly.
  • The backpack should rest evenly in the middle of the back—it should not extend below the lower back.
  • Support your back by bending at the knees to avoid straining.
  • Keep one foot on the ground while kneeling.
  • Use knee pads when kneeling to absorb some of the pressure.
  • Use a wheelbarrow to move heavy items.
  • Change positions frequently to reduce stiffness.


At the Office
  • Use an upright chair that has good back or lumbar support.
  • Postion the monitor for your head and shoulders to be able to relaxed and you don’t have to crane your neck.
  • Keep your mouse close to your body.
  • Do easy exercises at your desk (backward shoulder rolls, and get up frequently to stand straight and/or walk).


  • During long drives, stop every hour or so to stand up and move around.
  • You can also place a rolled up towel behind your back at approximately waist level to provide lumbar support while driving.


In the long-term you should consider physical exercise, which is recommended and proven to prevent low back pain. High intensity programmes, which comprise both an educational/skills programme and exercises, can be recommended for patients with recurrent and persistent back pain. Against general belief, lumbar supports or back belts are not recommended (Eurpopean Guidelines for prevention in Low Back Pain 2004).

American Physical Therapy Association: Low Back Pain: Management and Prevention Guideline
Bruckner P, Kahn K. Brukner & Khan’s Clinical Sports Medicine. 4th ed. Australia: McGraw-Hill Australia; 2012. p. 463-492
Eurpopean Guidelines for prevention in Low Back Pain
Hoy D, Brooks P, Blyth F, Buchbinder R. The Epidemiology of low back pain. Best Pract Res Clin Rheumatol. 2010 Dec;24(6):769-81.

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The Tibion Bionic Leg

Up to 40 to 50% of individuals who survive stroke experience physical disability. The ability to stand up from sitting is an important functional activity, a prerequisite for upright mobility and an important factor for independent mobility. However, sit-to-stand (STS) is biomechanically demanding and requires higher lower extremity joint torques than walking or stair climbing. Recently, robotic devices have been used in neurorehabilitation to facilitate treatment efficacy. The Tibion Bionic leg is a mobile, intention-based robotic device designed to allow individuals post-stroke to perform activities more normally. Results to date have shown improvements in balance, gait and functional performance in individuals post-stroke following therapeutic intervention using the Tibion Bionic Leg (TBL). Here we studied the effects of actuated limb assistance on hemiparetic limb asymmetry during STS using unilateral and bilateral vertical ground reaction forces (vGRF). We hypothesized that
thumbnailThe Tibion Bionic Leg is a mobile, wearable, intentionbased robotic limb orthosis (Tibion Pk-100 Bionic Leg, Tibion Corporation, Sunnyvale, CA) developed as a therapeutic device. The device is actuated to supply force to assist or resist leg extension and flexion providing limb assistance against gravity during extension (as in sit-to-stand or free standing) and controlled flexion (as in stand-to-sit). Force sensors placed under the foot detect a threshold force and trigger the actuation. In its primary mode (AUTO) the device clearly activates to assist the motion of the wearer. Three settings can be adjusted to individualize participant assistance or therapeutic challenge: threshold (force criterion required to activate the device), assistance (amount of assistance provided as percentage of body weight) and resistance (resistance provided during controlled flexion as in stand-to-sit or stair descent)the actuated limb assistance provided to the paretic side by the TBL would promote more symmetrical movement and force production by individuals post-stroke.

The study suggests that the Tibion allows the user to involve their weaker leg more than would otherwise be possible, enabling greater weight bearing through the involved lower extremity. When used during therapy, it  may enhance the capability of the wearer to perform activities with more appropriate biomechanics. Repetition of appropriate movement patterns with greater engagement of the paretic limb may ensure functional improvements.


Read more here!

Byl (2012) concuded in here case series that  additive clinical-functional benefits may be achieved by incorporating mobile, intention-based robotic technology into therapist-supervised mobility training for patients in the late-phase post stroke. 

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Effects of spiral taping applied to the neck and ankle on balance

In clinical practice patients with balance impairments are often seen. This can have several causes, e.g. after trauma, vestibular or neurological. However there is no clear definition of human balance. Postural control is defined as the act of maintaining, achieving or restoring a state of balance during any posture or activity. Postural control strategies may be either predictive or reactive, and may involve either a fixed-support or a change-in-support response. Clinical tests of balance assess different components of balance ability (Pollock et al. 2000).
Lee et al. (2015)  have shown that neck taping can have an influence on balance similar to ankle tapes.

Maintaining balance and posture is influenced not only by the muscles around the ankle, but also by input from the visual senses, and vestibular system, and sensory information from the somatic senses in the neck 23. Burl et al. 24 reported that balance improves when stability was provided to the neck in a study that investigated the effect of taping the cervical spine on standing balance. Yoo 25 also reported that taping the neck positively affected posture, a result which is in agreement with our present study’s findings. Cervical spiral taping improved the stability and balance of the head and neck muscles, which improved proprioception and balance. The balance indices improved after taping interventions for the two areas. Taping fixed the joints and stimulated the proprioceptiors, eliciting the fusimotor reflex, which increased contractibility of the surrounding muscles, which improved postural balance.

Reade more here

These results can be taken into consideration as an addition to balance exercises. However, the sample size of this trial consisted only of 20 subjects. Furthermore, they were healthy university students, therefore this might not fit the clinical patient population and the results of this trial might not be generalizable.



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Imoove® is a device with a broad spectrum of functional rehabilitation applications. It represents a major evolution in the rehabilitation field. Associated with your experience, Imoove® enables you to treat a large number of osteo-muscular pathologies.

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The observation of the movement of the vertebrae ones on others, the elispheric® movement of the plate reproduces the natural spiral movements of muscles and joints patterns of the body.
The Elispheric® Movement stimulates a deep proprioception and restores the musculopostural balance of the body: functional exercises proposed by IMOOVE® take advantage of the instability of the plate and through the sollicitation of all functions of proprioceptive and biomechanics adaptation, train control motor and postural of the body as well as joint flexibility. 

The control of instability, in a context of fully controlled disbalance, combined with the attentional mobilization tasks, restores and develops proprioceptive skills and generates musculoskeletal health of the body.

-Read more here






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The effect of Xbox Kinect intervention on balance ability for previously injured young competitive male athletes: A preliminary study

Objectives: To explore the outcomes of an Xbox Kinect intervention on balance ability, enjoyment and compliance for previously injured young competitive male athletes.
Design: Experimental pre-/post-test design with random assignment.
Participants: Sixty-three previously injured young competitive male athletes, aged 16  1 years.
Interventions: Participants were divided into three groups: one group received Xbox Kinect (XbK) training, one group received Traditional physiotherapy (TP) training, and one group did not receive any balance training (Control). Intervention involved a 24 min session, twice weekly for 10 weeks.
Main outcome measures: Overall stability index (OSI) and limits of stability (LOS) scores using the Biodex Stability System. Enjoyment using the Physical Activity Enjoyment Scale. Self-reported compliance.
Results: Both experimental groups demonstrated an improvement in OSI and LOS mean scores for the right and the left limb after the intervention. In addition, the results revealed important differences between the experimental groups and the control group on balance test indices. Group enjoyment rating was greater for XbK compared with TP, while the compliance rating was not. Conclusions: These findings suggest that the use of XbK intervention is a valuable, feasible and pleasant approach in order to improve balance ability of previously injured young competitive male athletes (Vernadakis et al. 2013).


Read more hereThe effect of Xbox Kinect intervention on balance ability for previously injured young competitive male athletes: A preliminary studyl












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Bioness L300 Footdrop system

Now there is a way to regain your freedom and independence by helping you walk with greater speed, stability and confidence.1 The award-winning L300 Foot Drop System is designed to help people with certain neurological conditions walk more naturally, with increased speed and improved balance. The L300’s advanced technology delivers programmed, low-level electrical stimulation to activate nerves and muscles that lift the foot, giving you the mobility to step back into life.







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Mehlhaff explained that Foot Drop System stimulates the muscles in a patient’s foot with mild functional electrical stimulation, which prompts him or her to lift toes when the foot is off of the ground.

Once the patient’s heel hits the ground, she said a switch in the patient’s shoe senses that and turns off the electricity so the foot can come down.

“It’s superior to a brace in many ways because the electricity helps strengthen the muscle,” she said. “And it allows a lot more freedom in the ankle motion so that your walking can be much more symmetrical.”

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Alter G – Anti gravity treadmill

Thanks to its precise unweighting technology, the AlterG® Anti-Gravity Treadmill® allows you to push your training and physical therapy rehabilitation further than ever before.

You can:

  • Reduce gravity’s impact by selecting any weight between 20% and 100% of your body weight by 1% increments

  • Rehabilitate lower extremity injuries with less pain and less impact

  • Improve mobility, strength and safety for those with neurological conditions

  • Provide a safe way to lose weight and exercise more intensively while unweighted

  • Train without pain and reduce the stress to joints and muscles

  • Recover effectively and with less pain after training or competition

The innovative AlterG Anti-Gravity Treadmill is a game changer in physical therapy rehabilitation. Whether you’re a patient or an athlete dealing with lower body injuries, chronic pain or neurological conditions that inhibit mobility, you can benefit from the unweighting capabilities. The Anti-Gravity Treadmill helps a broad spectrum of people – top level athletes, orthopedic and neurologic patients,pediatric, geriatric and those looking to lose weight – to achieve their personal health, wellness or performance goals.

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Recent studies in patients with muscular dystrophies suggest positive effects of aerobic and strength training. These studies focused training on using bicycle ergometers and conventional strength training, which precludes more severely affected patients from participating, because of their weakness. We investigated the functional effects of combined aerobic and strength training in patients with Becker and limb-girdle muscular dystrophies with knee muscle strength levels as low as 3% of normal strength.

Eight patients performed 10 weeks of aerobic and strength training on an anti-gravity treadmill, which offered weight support up to 80% of their body weight. Six minute walking distance, dynamic postural balance, and plasma creatine kinase were assessed 10 weeks prior to training, immediately before training and after 10 weeks of training. Training elicited an improvement of walking distance by 8 ± 2% and dynamic postural balance by 13 ± 4%, indicating an improved physical function. Plasma creatine kinase remained unchanged. These results provide evidence that a combination of aerobic and strength training during anti-gravity has the potential to safely improve functional ability in severely affected patients with Becker and limb-girdle muscular dystrophies.

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