ARTICLE IN PRESS

Physical Therapy in Sport 8 (2007) 177184

www.elsevier.com/locate/yptsp

Original research

The impact of single-leg dynamic balance training on

dynamic stability
Jaffar Rasoola, Keith Georgeb,
a

Department of Physiotherapy, Qatif Central Hospital, Qatif, Saudi Arabia

Research Institute for Sport and Exercise Science, Liverpool John Moores University, 1521 Webster Street, Liverpool L3 2ET, UK

Received 26 May 2006; received in revised form 22 May 2007; accepted 27 June 2007

Abstract
Objective: The aim of the study was to determine the effect of progressive one-leg dynamic balance training programme on dynamic
stability in healthy male athletes.
Design: Mixed design with repeated measures at baseline and after 2 and 4 weeks of progressive single-leg balance training.
Setting: Clinic and gymnasium.
Participants: Thirty healthy male athletes volunteered to participate in this study and were randomly assigned to a training or
control (CON) group.
Main outcome measures: Dynamic stability was assessed using the Star Excursion Balance Test (SEBT) in the trained (TRD) and
untrained (UTD) legs in the training group as well as in one leg of the CON group.
Results: SEBT scores did not change in the CON leg but signicantly increased at 2 and 4 weeks in the TRD leg for total combined
score and in all individual directions by ca. 1136%. For example, in the posterior direction reach increased from 9776 cm at
baseline to 11279 cm and 12177 cm (Po0.01) after 2 and 4 weeks, respectively. Performance in the UTD leg increased signicantly
in 4 out of 8 reach directions to a smaller extent than the TRD leg.
Conclusion: A progressive single-leg dynamic balance exercise programme can improve dynamic stability very rapidly. This has
practical implications for sporting scenarios such as pre-season training.
r 2007 Elsevier Ltd. All rights reserved.
Keywords: Proprioception; Functional reach; Postural stability; Injury prevention

1. Introduction
Inversion injuries of the lateral ligaments of the ankle
joint complex are among the most frequent injuries in
young physically active individuals (Bernier & Perrin,
1998; Holmer, Sondergaard, Konradsen, Nielsen, &
Jorgensen, 1994) and are believed to result from, and/or
lead to, diminished stability or balance ability (Cornwall
& Murrell, 1991; Lofvenberg, Karrholm, Sudelin, &
AhIgren, 1995). Balance training may be valuable in the
Corresponding author. Tel.: +44 151234088;
fax: +44 1512314353.
E-mail address: k.george@ljmu.ac.uk (K. George).

1466-853X/$ - see front matter r 2007 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ptsp.2007.06.001

prevention of, or rehabilitation from, ligamentous

injuries in the ankle joint (Freeman, 1965). The exact
mechanism(s) through which balance training could
exert such positive effects is not clearly understood but
may include central and peripheral neural adaptations,
increased strength and exibility.
Despite the employment of a wide variety of assessment and training protocols, empirical evidence of the
positive impact of balance training has been reported in
both injured (Rozzi, Lephart, Sterner, & Kuligowski,
1999) and non-injured subjects (Emery, Cassidy,
Klassen, Rosychuk, & Rowe, 2005). For example,
a 6-month home-based wobble board training programme improved measures of both static and dynamic

ARTICLE IN PRESS
178

J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

balance in healthy adolescent children (Emery et al.,

2005) and may have contributed to a reduction in the
relative risk of ankle injury. Further support for a
training effect in uninjured subjects was reported in
older women performing 12 months of balance training
(Lord, Ward, & Williams, 1996) and young healthy
subjects who trained for 10 weeks but whose balance
ability was assessed statically on a force plate (Hoffman
& Payne, 1995).
For sportspeople, the ideal intervention maybe something that is of shorter duration, and thus applicable to
specic short training cycles like pre-season preparation,
as well as containing predominantly dynamic balance
exercises to better simulate the challenges they face
during participation. Somewhat surprisingly, studies of
the impact of short programmes of dynamic training
upon simple yet valid measures of dynamic balance in
non-injured sportspeople are not available. This is
despite evidence that as little as 4 weeks of static and
dynamic balance training signicantly improved static
balance performance in subjects with functionally
unstable ankles (Rozzi et al., 1999).
On the basis of this gap in our knowledge, we
designed a short-term training intervention of progressive, dynamic single-leg balance training and applied it
to young, non-injured sportspeople. This has direct
application to a number of sporting and clinical
scenarios when working with athletes, for example, in
pre-season training which maybe only 24 weeks in
duration. Further, we employed the Star Excursion
Balance Test (SEBT; Hertel, Miller, & Denegar, 2000)
as a validated measure of dynamic balance ability
which, unlike force plates or electronically controlled
balance platforms, is a simple and highly portable test
that could be employed in a range of clinical environments. We dened dynamic balance in the context of
this study as training or testing manoeuvres that
required dynamic limb segment or whole body movements whilst maintaining balance on a single foot. We
hypothesise that 4 weeks of progressive single-leg
balance training will increase dynamic lower limb
stability in the leg of uninjured sportspeople in
comparison to their non-trained leg as well as a control
limb from a separate subject group.

2. Method
2.1. Subjects
Thirty healthy male athletes were recruited via posters
and word of mouth from the general athletic population
in Saudi Sport Clubs located in the Qatif and Dammam
area of the Eastern Province of Saudi Arabia. The
subjects were selected based on the following criteria:
Inclusion criteria: The subjects were young healthy male

athletes presently training with their respective sports

clubs. Exclusion criteria: Subjects were excluded if they
presented with a current or recent history of soft tissue
or orthopaedic injury in the ankle, knee or hip joint,
prior balance training, a history of neuromuscular
disorders, arthritis or rheumatologic disorders, systemic
disease that might interfere with sensory input and/or
disorders of vision not correctable by glasses. Ethical
approval was obtained through Manchester Metropolitan University, Cheshire, Department of Exercise and
Sport Science. Participants signed an informed consent
form following a full explanation of the trial. Volunteers
were randomly assigned, using a computer random
number generator, to a training and control (CON)
group. Mean7S.D. age (Training group [n 16]:
21.575.1 years, CON [n 14]: 21.074.2 years), height
(Training group: 179.074.1 cm, CON: 176.477.4 cm)
and body mass (Training group: 73.779.6 kg, CON:
75.577.8 kg) were not signicantly different between
groups.
2.2. Research design
Participants attended a Physical Therapy facility for
all assessments and training. Initially, they were
evaluated in terms of history and physical examination
to satisfy the inclusion and exclusion criteria. Dynamic
balance performance was assessed at baseline and then
after 2 and 4 weeks of progressive single-leg balance
training. Within the training group both the trained
(TRD) and the untrained (UTD) leg were assessed at all
time points. Furthermore, within the CON group a
single leg was assessed at all time points. The TRD leg
was chosen at random and in the CON group the leg
assessed was also chosen at random.
2.3. Protocols
The SEBT represented the primary outcome measure
for this study and offers a simple, reliable, low-cost
alternative to more sophisticated instrumented methods
that are currently available to assess balance (Cohen,
Blatchly, & Gombash, 1993; Hertel et al., 2000; Olmsted,
Carcia, Hertel, & Shultz, 2002). The SEBT is a functional
test that incorporates a single-leg stance on one leg with
maximum reach of the opposite leg (see Fig. 1). The
SEBT was performed with the subject standing at the
centre of a grid placed on the oor, with eight lines
extending at 451 increments from the centre of the grid.
The eight lines positioned on the grid were labelled
according to the direction of excursion relative to the
stance leg: anterolateral, anterior, anteromedial, medial,
posteromedial, posterior, posterolateral and lateral.
A verbal and visual demonstration of the testing
procedure was given to each subject by the examiner.
Subjects then rode a stationary bike for 5 min at a

ARTICLE IN PRESS
J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

179

Fig. 1. Subject performing the posterior reach component of the Star Excursion Balance Test (SEBT).

self-selected pace and then stretched the quadriceps,

hamstrings and triceps surae muscle groups before
testing. After the warm up, each subject performed six
practice trials in each of the eight directions (see Fig. 1)
for each leg to become familiar with the task, as
recommended by Hertel et al. (2000). A pilot study
demonstrated that a minimum of three familiarisation
trials was required to offset any learning, practice or
warm-up effect. In the testing phase, the subject
maintained a single-leg stance while reaching with the
contra-lateral leg (reach leg) from an initial position
next to the balance leg and then as far as possible along
the appropriate vector. The subject was instructed to
touch the farthest point on the line with the reach foot
(toe only) as lightly as possible in order to ensure that
stability was maintained through adequate neuromuscular control of the stance leg. The subject then returned
to a bilateral stance. The examiner manually measured
the distance from the centre of the grid to the touch
point with a tape measure in centimetre. Three reaches
in each direction were recorded. Subjects were given 15 s
of rest between reaches. The best of the three reaches for
each leg in each of the eight directions was recorded.
The leg tested (TRD or UTD), order of excursions

performed (clockwise, counter clockwise) and the

directions of the rst excursion (anterior, medial, lateral
and posterior) were counterbalanced to control for any
learning effect. Trials were discarded and repeated if the
subject did not touch the line with the reach foot while
maintaining weight bearing on the stance leg, lifted the
stance foot from the centre grid, lost balance at any
point or did not maintain start and return positions for
one full second. A single experienced physiotherapist
performed all assessments to negate any inter-observer
variability and was not aware of the designation of the
TRD and UTD leg within the training group.
2.4. Training intervention
The training group performed a range of manoeuvres
that progressed from simple static balance exercises to
more complex and challenging dynamic balance exercises (see Table 1). Progression and difculty was
developed by performing balance exercises with eyes
open and closed, on solid (gym oor) and soft surfaces
(thick gym mat) and with a range of contra-lateral limb
and trunk movements performed whilst in a single-leg
balance position.

ARTICLE IN PRESS
180

J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

Table 1
Exemplar progression details for the dynamic single-leg balance training
Floor

Eyes

Exercise

Gymnasium oor

Open

Gymnasium oor
Soft gymnasium mat
Soft gymnasium mat
Gymnasium oor

Closed
Open
Closed
Open

Gymnasium oor
Soft gymnasium mat
Soft gymnasium mat
Gymnasium oor

Closed
Open
Closed
Open

Gymnasium oor
Soft gymnasium mat
Soft gymnasium mat

Closed
Open
Closed

60 s exercise trial in single-leg balance position. The contra-lateral leg was held in a
relaxed position with minor knee and hip exion by the side of the test leg. Five
trials with 30 s rest in between trials.
Same
Same
Same
60 s exercise trial in single-leg balance position. The contra-lateral leg held in a
comfortable relaxed position with minor knee and hip exion. The trunk was then
rotated smoothly to the end of range in both directions. Five trials with 30 s rest in
between trials.
Same
Same
Same
60 s exercise trial in single-leg balance position. The contra-lateral leg held in 901
hip and knee exion. The trunk is then rotated smoothly to the end of range in both
directions. Five trials with 30 s rest in between trials.
Same
Same
Same

The training group performed the exercises 5 days a

week for 4 weeks and commenced each workout with a
5 min general cardiovasuclar warm-up. All training was
organised in group sessions, as might occur in sports
clubs and training scenarios, and held in a gymnasium
attached to the Physical Therapy clinic where the SEBT
was performed. Compliance with sessions was 495% in
the training group. All sessions were led by a single
experienced physiotherapist (different to the physiotherapist who performed the SEBT tests) and all
subjects had balance performance assessments three
times a week in order to promote progression. Progression was based on the physiotherapists opinion of
successful completion of the all movements with no loss
of balance during each 60 s trial.
2.5. Data analysis
Descriptive analyses derived mean and S.D. scores for
the total combined (all eight directions added together)
and individual direction scores in each leg. Two sets of
inferential analyses were then performed. Initially mixed
design two-way ANOVAs compared the SEBT scores,
for the total combined score as well as for each
individual direction, between the TRD leg and the
CON leg. Secondly, repeated measures two-way ANOVAs were applied to compare the TRD to the UTD leg
for a total combined score and then in all individual
directions of the SEBT. Where signicant F-ratios arose
from the ANOVA, post-hoc Tukey tests were applied to
determine where the signicant differences occurred.
The alpha level was set at Po0.01 for all analysis. This
critical alpha was selected as a sensible balance between
the chance of a type 1 and type 2 errors when making

multiple comparisons using the same subjects. Data

analysis was performed using Statistica software
(Statsoft Ltd., Tulsa, USA).

3. Results
At baseline there were no differences in reach
distance, in any direction or for the total combined
score, between the TRD and CON legs as well as
between the TRD and UTD legs (P40.01; see Table 2).
Differences in SEBT scores were noted between directions due to the nature of the test.
Signicant interaction terms (Po0.01) were recorded
for all two-way ANOVAs comparing the TRD and
CON leg reach scores before and after 2 and 4 weeks of
training. The clear indication for total combined score
as well as all individual directions was that reach
distance increased signicantly in the TRD leg at 2
weeks and then either remained greater than pre-scores
(anterior, medial) or continued to signicantly increase
from 2 to 4 weeks of training (total combined,
anteromedial, posteromedial, posterior, posterolateral,
lateral, anterolateral). For total combined and all
individual directions, TRD leg reach scores were
signicantly greater than CON leg reach scores at both
2 and 4 weeks. The percentage change from baseline to 4
weeks of training ranged from 10.7% to 35.5% in the
anterior and anterolateral directions, respectively (see
Table 2) in the TRD leg but changes in the CON leg
over the same time period were always o4% and
sometimes negative.
The consistency of ANOVA interaction term outcomes was reduced for comparisons between the TRD

ARTICLE IN PRESS
J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

181

Table 2
Reach performance data (cm; mean7S.D.) for all directions of the SEBT test in the CON, TRD and UTD legs
Direction

Leg

Total combined

CON
TRD
UTD

Anterior

Pre

2 week

4 week

% change

8674
8874
8974

8774
10077a,b,d
9679a

8774
10676a,b,c,d
9876a

+1.1
+20.4
+10.1

CON
TRD
UTD

8174
8476
8576

8275
9175a,b
8775

8376
9374a,b,d
8674

+2.5
+10.7
+1.1

Anteromedial

CON
TRD
UTD

8876
9076
9277

8975
9976a,b
9777

9075
10377a,b,c,d
9576

+2.3
+14.4
+3.2

Medial

CON
TRD
UTD

9477
9778
9877

9476
11378a,b
10678

9576
11575a,b
10876

+1.1
+18.6
+10.2

Posteromedial

CON
TRD
UTD

9577
102710
101710

9776
11778a,b
111711

9975
12276a,b,c
11478

+4.2
+19.6
+12.9

Posterior

CON
TRD
UTD

9478
9776
9979

9577
11279a,b
10778a

9776
12177a,b,c,d
10476a

+3.2
+25.8
+5.1

Posterolateral

CON
TRD
UTD

9174
9177
92710

8776
10179a,b
9878a

9074
11076a,b,c,d
10176a

1.1
+20.9
+9.8

Lateral

CON
TRD
UTD

8174
8079
79710

8074
9277a,b
86711a

7973
9976a,b,c,d
8776a

2.5
+23.8
+10.1

Anterolateral

CON
TRD
UTD

6778
62713
65711

6677
7678a,b,d
68713a

6279
8477a,b,c,d
7279a,d

7.5
+35.5
+10.8

SEBT, Star Excursion Balance Test; CON, control group leg; TRD, trained leg; and UTD, untrained leg.
a
Signicantly different from corresponding pre-score.
b
Signicantly different from corresponding CON score.
c
Signicantly different from corresponding 2 week score.
d
Signicantly different from corresponding UTD score.

and UTD leg. For the medial and posteromedial

directions the interaction term was non-signicant
(P40.01) although signicant main effect terms for
both leg and time suggested higher reach scores in the
TRD leg and higher reach scores after 2 and 4 weeks (see
Table 2). All other two-way ANOVAs reported
signicant interaction terms and consistently post-hoc
analysis determined that after 4 weeks the TRD leg
could reach signicantly further than the UTD leg
(Po0.01).
Only for total combined and the anterolateral
direction was the 2 week reach score in the TRD leg
signicantly greater than the UTD leg (Po0.01). This is
because small, but sometimes signicant, improvements
were observed in the UTD leg after 2 and 4 weeks of
training. Specically for total combined, posterior,
posterolateral, lateral and anterolateral directions the
reach score in the UTD leg at 2 and 4 weeks was

signicantly greater than the pre-UTD score (Po0.01).

In one case, the anterolateral direction, the 4 week UTD
score was signicantly increased compared to the 2 week
UTD reach score (Po0.01). The increase in reach score
in the UTD leg was never as great as in the TRD leg but
in some directions (total combined, medial, posteromedial, lateral, anterolateral) the percentage increase
was greater than 10% (see Table 2).

4. Discussion
In summary, this study has demonstrated that
following as little as 2 and 4 weeks of progressive
single-leg dynamic balance training (TRD) signicant
improvements in dynamic balance performance occurred in all directions of the SEBT. In the UTD leg,
some small but signicant improvements in reach were

ARTICLE IN PRESS
182

J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

recorded that was suggestive of a crossover training

effect. In the CON group, SEBT performance did not
change over the 4 weeks of the intervention.
The performance of both groups pre-intervention
were similar to data published in past research (Olmsted
et al., 2002) and any small differences were likely due to
tness and health status differences between cohorts.
The improvements seen in the trained limb of the
subjects following 2 and 4 weeks of balance-training
programme appear to be broadly consistent with other
studies involving a range of different balance-training/
assessment programmes for individuals with a functionally stable ankle, over longer periods of time (Emery
et al., 2005; Hoffman & Payne, 1995; Lord et al.,
1996).
Whilst there were signicant improvements in total
combined as well as all individual direction reach scores
it is pertinent to note some disparity in the percent
change from pre- to post-training. Interestingly, the
smallest improvement of ca.11% was observed in the
anterior direction and the largest improvement of
ca.36% was witnessed in the anterolateral direction.
The explanation for such differences is not immediately
apparent. Whether these changes reect a specicity
bias in the training movements employed is not clear
but requires further study. It is, indeed, unclear whether
there is a requirement to balance train in all directions,
or even assess balance ability via the SEBT in all
directions (Hertel, Braham, Hale, & Olmstead-Kramer,
2006).
There are a number of possible mechanisms that
could account for the improved balance performance in
the current study, although direct empirical support for
these cannot be found in the current data. One example
may be an improved control over centre of gravity shifts
although without data from a forceplate we can only
speculate about this factor. Another potential mechanism reects improved automatic postural response
patterns. This mechanism is supported by the work of
Sveistrup and Woollacott (1997) who demonstrated
improved automatic postural response patterns including increases in the probability of activating functionally
appropriate muscles following a 5-day perturbation
training programme. Wiley and Damiano (1998) also
suggested that balance training may serve to improve
neural output in response to postural disturbances. This
may represent an important area for future work.
Another possible explanation may involve attention,
which is dened as the process by which the central
nervous system acts upon proprioceptive information
perceived as being relevant. It is possible that balance
exercises increase the attention paid to proprioceptive
cues by the brain, rst at the conscious level early in
training, then later, after perhaps more training, at the
autonomous level (Tononi & Edelman, 1998). If this
represents a central processing adaptation rather than

just a peripheral cue sensitisation then this may have

some applicability to the current data. Interestingly, the
improvements observed in the UTD leg in the current
study could provide some indirect support for a central
processing role that could improve both TRD and UTD
legs performance in the reach trials.
An increase in muscle strength may contribute to the
increased reach scores attained after training. Indeed,
muscle strength may be positively related to balance
ability in older women (Lord & Castell, 1994) although
Chandler, Wilson, and Stone (1989) demonstrated no
signicant relationship between strength gains and
balance measures in their training study of college
students whose age is closer to the subjects recruited for
the current study. Understanding the role of strength
changes in balance training requires further study.
It is clinically and practically relevant to note that the
study demonstrated signicant improvements in balance
ability after a training period of only 2 weeks that was
further improved after 4 weeks in 6 of the 8 directions.
These ndings appear to indicate that 2 weeks is
sufcient time to promote signicant improvements in
dynamic balance ability that may be important for the
maintenance of posture and balance (Rozzi et al., 1999),
although the precise clinical impact in terms of injury
prevention and/or motor function is impossible to
determine. If more time is available to perform specic
balance training then improvements may continue to
accrue but likely at a reduced rate. It is not clear from
this study or the extant literature how the gain in
balance ability slows after an initial 4 weeks of training.
The rapid improvement in balance ability inside 2 weeks
has practical implications and is important in timelimited training and sports-related scenarios such as preseason training. The methods used in this study are also
easily transferable into the eld such that the practical
application of the current data in a clinical setting
should be quite straightforward. Future research in this
eld may also measure the effectiveness of such short
intervention programmes in decreasing injury and
improving motor skill and function.
The improvements observed in the UTD in some
directions of the SEBT test provide new data to support
that a cross-over effect in balance ability is accruing
from the TRD leg during the training sessions. The
cross-over effect has been previously described in a
number of strength training studies (Munn, Herbert, &
Gandevia, 2004) and the percent change in balance
ability in the current study is very similar to that
reported for strength development (Munn et al., 2004).
The importance of neural mechanisms to explain this
cross-over effect has recently been eloquently reviewed
(Carroll, Herbert, Munn, Lee, & Gandevia, 2006;
Gabriel, Kamen, & Frost, 2006). The clinical relevance
of the cross-over effect in the UTD leg is worthy of
further study. Conceptually, the cross-over effect may

ARTICLE IN PRESS
J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

have some implications for rehabilitation from athletic

injury. Balance training a non-injured leg could,
theoretically, lead to a small improvement in the injured
leg even if it was too early or inappropriate to balance
train the injured leg directly. An example of this has
been demonstrated in shoulder injuries (Stromber,
1986). Interestingly, the magnitude of the cross-over
effect may be direction dependent with greater effects
occurring in transfer from the dominant to the nondominant limb (Lee & Carroll, 2007) which also has
potential implications for the success of any cross-over
intervention in a clinical environment.
The study was designed to be simple and transportable, for practical application, but this resulted in some
limitations. As already discussed strength changes in the
subject were not measured in the current study for
logistical reasons and thus the impact of this cannot be
elucidated. We did not control sporting activity of any
subject during the time of the trial but simply asked
them to maintain normal training. There is always a
possibility that exposure to the training altered the
subjects approach to other aspects of the sports
preparation. We did not assess any aspect of functional
movement and the impact the training could have on
these parameters. Finally, we did not follow up these
subjects and assess any residual training effects or the
impact on injury occurrence.
In conclusion, as a result of only 2 weeks of
progressive single-leg dynamic balance training the
reach performance of the TRD leg improved signicantly across all directions of the SEBT test. Improvements continued to 4 weeks of training in 6 out of the 8
directions employed in the SEBT protocol. Small but
signicant improvements in the UTD leg in 4 out of the
8 directions of the SEBT test suggests some cross-over
training effect. The uniqueness of the current study also
lay in the ease by which the current training programme
and test protocols could be transferred into the clinical
environment to assess balance training and its impact
upon function, injury and rehabilitation.

Acknowledgements
This work was completed in partial fullment of an
M.Sc. in Science of Sports Injury at Manchester
Metropolitan University. The authors would like to
thank the physiotherapists in Saudi Arabia who
supported this study.
Conflict of interest statement: All authors have no
conicts of interest with respect to the data collected and
procedures used within this study.
Ethical statement: The authors conrm this study
meets the guidelines of the Declaration of Helsinki and
after local ethical approval all subjects provided written
informed consent.

183

References
Bernier, J. N., & Perrin, D. H. (1998). Effect of coordination training
on proprioception of the functionally unstable ankle. Journal of
Orthopaedic and Sports Physical Therapy, 27, 264275.
Carroll, T. J., Herbert, R. D., Munn, J., Lee, M., & Gandevia, S. C.
(2006). Contralateral effects of unilateral strength training:
Evidence and possible mechanisms. Journal of Applied Physiology,
101, 15141522.
Chandler, T. J., Wilson, G. D., & Stone, M. H. (1989). The effect of
the squat exercise on knee stability. Medicine and Science in Sports
and Exercise, 21(3), 299303.
Cohen, H., Blatchly, C. A., & Gombash, L. L. (1993). A study of the
clinical test of sensory interaction and balance. Physical Therapy,
73, 346354.
Cornwall, M. W., & Murrell, P. (1991). Postural sway following
inversion sprain of the ankle. American Journal on Podiatric
Medical Association, 81, 243247.
Emery, C. A., Cassidy, J. D., Klassen, T. P., Rosychuk, R. J., & Rowe,
B. H. (2005). Effectiveness of a home-based balance-training
program in reducing sports-related injuries among healthy
adolescents: A cluster randomised controlled trail. Canadian
Medical Association Journal, 172, 749754.
Freeman, M. (1965). Instability of the foot after injuries to the lateral
ligament of the ankle. Journal of Bone and Joint Surgery, 47,
669677.
Gabriel, D. A., Kamen, G., & Frost, G. (2006). Neural adaptations to
resistive exercise: Mechanisms and recommendations for practices.
Sports Medicine, 36, 133149.
Hertel, J., Braham, R. A., Hale, S. A., & Olmstead-Kramer, L. C.
(2006). Simplifying the Star Excursion Balance Test: Analyses of
subjects with and without chronic ankle instability. Journal of
Orthopaedic and Sports Physical Therapy, 36, 131137.
Hertel, J., Miller, S. J., & Denegar, C. R. (2000). Intratester and
intertester reliability during the Star Excursion Balance Tests.
Journal of Sport Rehabilitation, 9, 104116.
Hoffman, M., & Payne, V. G. (1995). The effects of proprioceptive
ankle disk training on healthy subjects. Journal of Orthopaedic and
Sports Physical Therapy, 21, 9093.
Holmer, P., Sondergaard, L., Konradsen, L., Nielsen, P. T., &
Jorgensen, L. N. (1994). Epidemiology of sprains in the lateral
ankle and foot. Foot and Ankle International, 15(2), 7274.
Lee, M., & Carroll, T. J. (2007). Cross-education: Possible mechanisms
for the contralateral effects of unilateral resistance training. Sports
Medicine, 37, 114.
Lofvenberg, R., Karrholm, J., Sudelin, G., & AhIgren, O. (1995).
Prolonged reaction time in patients with chronic lateral instability
of the ankle. American Journal of Sports Medicine, 23, 414417.
Lord, S., & Castell, S. (1994). Physical activity program for older
persons: Effect on balance, strength, neuromuscular control, and
reaction time. Archives of Physical Medicine and Rehabilitation, 75,
648652.
Lord, S., Ward, J., & Williams, P. (1996). Exercise effect on dynamic
stability in older women: A randomized controlled trial. Archives of
Physical Medicine and Rehabilitation, 77, 232236.
Munn, J., Herbert, R. D., & Gandevia, S. C. (2004). Contralateral
effects of unilateral resistance training: A meta-analysis. Journal of
Applied Physiology, 96, 18611866.
Olmsted, L. C., Carcia, C. R., Hertel, J., & Shultz, S. J. (2002). Efcacy
of the Star Excursion Balance Tests in detecting reach decits in
subjects with chronic ankle instability. Journal of Athletic Training,
37(4), 501506.
Rozzi, S. L., Lephart, S. M., Sterner, R., & Kuligowski, L. (1999).
Balance training for persons with functionally unstable ankles.
Journal of Orthopaedic and Sports Physical Therapy, 29(8),
478486.

ARTICLE IN PRESS
184

J. Rasool, K. George / Physical Therapy in Sport 8 (2007) 177184

Stromber, B. V. (1986). Contralateral therapy in upper extremity

rehabilitation. American Journal of Physical Medicine, 65, 135143.
Sveistrup, H., & Woollacott, M. (1997). Practice modies the
developing automatic postural response. Experimental Brain
Research, 114, 3343.

Tononi, G., & Edelman, G. M. (1998). Consciousness and complexity.

Science, 282, 18461851.
Wiley, M., & Damiano, D. (1998). Lower-extremity strength proles in
spastic cerebral palsy. Developmental Medicine and Child Neurology, 40, 100107.