Journal of Orthopaedic & Sports Physical Therapy®

Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
 the efficiency of individuals’ reactions1,15-17
and by minimizing the effects of external
perturbations.29,42
Several authors have examined the ef-
fect of treatment on balance control fol-
lowing ankle sprains. In 1 study, reduced
postural control was evident 6 weeks after
LAS, but it normalized at 4 months fol-
lowing participation in a program with
an emphasis on balance training.16 In a
study on injured dancers, postural stabil-
ity was impaired for several weeks after an
ankle sprain, but gradually improved dur-
ing the course of rehabilitation and even
after professional dancing had resumed.23
A comparison of the progress of 2 groups
Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.
of injured participants who differed in the
practice of balance exercises in 1-legged
stance during rehabilitation showed that at
8 weeks following their injury, no postural
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
deficit was found for the injured limb of the
subjects who received balance training.10
Various methods have been proposed
to improve postural control following
LAS, including specific exercises and
training on unstable surfaces.13,30,51 These
methods might be further improved with
the application of recent findings in mo-
tor learning research, which focuses on the
Journal of Orthopaedic & Sports Physical Therapy®
principles underlying the acquisition of
motor skills. Motor learning is defined as
a “set of processes associated with practice
or experience leading to relatively perma-
nent changes in the capability for respond-
ing.”41 Several aspects of training have been
found to influence learning, including
type, frequency, and timing of feedback,50
number of training sessions and their dis-
tribution,6,24 amount of practice time and
length of delay between practice sessions,40
presence of contextual interference,25 and
timing and context of instructions.14
One such variable that has been shown
to affect learning is the direction of focus
of attention. When teaching motor tasks,
instructors typically provide information
related to the learner’s body movements,
thus emphasizing an internal focus of
attention (IFA). However, current evi-
dence suggests that instructions direct-
ing subjects to focus on the effect of the
movement, rather than on the movement
journal of orthopaedic & sports physical therapy | volume 37 | number 9 | september 2007 |
itself, thus inducing an external focus of
attention (EFA), may be more effective in
promoting skill acquisition.32,33,45,53,57,58
The effect of focus of attention was ini-
tially tested with healthy participants in
the learning of sports skills, such as a ball-
throwing task,43 golf,53 tennis,56 and soc-
cer skills.54 Other studies used a dynamic
balance task that required participants to
balance on a platform and to minimize
deviations of the platform from the hori-
zontal.31,32,55,59 In these studies, EFA was
achieved by having the participants focus
on stabilizing the platform, while IFA was
achieved by instructing them to focus on
stabilizing the body. Participants repeat-
edly demonstrated enhanced learning of
the balance task when directed to utilize
EFA rather than IFA.
The advantages of EFA at the neuro-
muscular level have been shown in stud-
ies of upper limb motion46 and sports
skill,61 in which not only the outcomes
of the practiced skills were superior but
muscular effort (based on electromyo-
graphic signal) was also lower, indicating
more efficient movement. The disadvan-
tages of IFA were highlighted in a study
of postural control demonstrating that
IFA required increased neuromuscular
activity to ensure standing control.47 This
represents a less efficient task and con-
text adaptation of neuromuscular control
around the ankle. The researchers pro-
posed that the effect of attentional focus
imposed by instructions might be larger
when the tasks require greater accuracy
or are more difficult to perform.47
To account for the observed benefit of
external focus, it is proposed that focusing
on body movements may interfere with
the automatic control processes, while fo-
cusing on the outcome of the movement
may allow unconscious processes to take
over and control the movements.55,57
Other studies have examined the ef-
fect of an important aspect of learning
termed “transfer,” which refers to the
impact of previous experiences on the
performance of a skill in a new context,
or of performance of a variation of the
practiced skill.41 Variations studied in the
literature include throwing at targets set
at a different distance than experienced
in acquisition,48 or performance at dif-
ferent inclinations of walking surface.19 A
study45 of the effect of focus of attention
on transfer of a balance task used multi-
ple variations, including riding a dynamic
apparatus under speed constraints, riding
backward instead of forward, and riding
with additional attentional demands. As
in acquisition, EFA was found to be effec-
tive in promoting transfer.45,59
Although there is extensive evidence
regarding the effect of focus of attention
on several aspects of motor learning,
most research was conducted with non-
impaired subjects. Recently, the positive
effect of EFA was demonstrated among
impaired subjects with a diagnosis of
Parkinson’s disease20 and in a study ex-
amining acquisition of a balance task
with impaired subjects following ankle
sprain.22 The objective of this study was
to further explore the effect of focus of at-
tention on learning a balance task follow-
ing ankle sprain by examining its effect
on the process of transfer.
METHOD
Subjects
P
articipants were 36 male vol-
unteers, with a mean age of 20.9
years (range, 19-33 years), who
were referred to a military outpatient
physical therapy department following
an ankle sprain. Participants were in-
cluded in the study if they (a) had a first
or recurrent grade 1 or 2 lateral ankle
sprain, as diagnosed by a physician or a
physical therapist using clinical exami-
nation and the anterior drawer test in ac-
cordance to the classifications described
by Crichton et al,5 (b) were injured less
than 4 months previously, and (c) were
able to apply full weight bearing on the
injured lower extremity with no more
than mild discomfort. Exclusion criteria
were (a) evidence of a concomitant ad-
ditional injury, such as a bony injury or
significant muscular/tendon injury, (b)
previous ankle surgery or other patho-
565
 [ RESEARCH REPORT
logical conditions or surgical procedures
in either lower extremity, (c) neurologi-
cal disorders, (d) vestibular dysfunction
or any other balance disorder, or (e)
previous training on any stabilometers.
Participants self-reported their previous
lower extremity injuries and absence of
neurological or vestibular disorders. All
participants gave written consent to par-
ticipate in the study, and the study was
approved by the Israel Defense Force
Medical Corps Ethical Review Board.
Eligible participants were randomly as-
signed to the EFA or the IFA group.
Assessment
Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.
Balance assessment and training were
carried out using the Biodex Stability
System (BSS) (Biodex Medical Systems,
Inc, Shirley, NY). The BSS is comprised
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
of an unstable support platform that al-
lows up to 20° of multiaxial surface de-
flection. The BSS can be set at 8 levels of
stability, with a setting of 8 being the most
stable foot platform setting and a setting
of 1 being the least stable setting. Prior to
the intervention program, 3 measures of
postural stability were obtained at sta-
bility level 2: (1) overall stability index
Journal of Orthopaedic & Sports Physical Therapy®
(OSI), which measures the variance of
foot platform displacement in degrees in
all directions (the higher the number, the
greater the amount of movement during a
test), (2) anterior/posterior stability index
(APSI), which measures the variance of
foot platform displacement in degrees for
motion in the sagittal plane, and (3) me-
dial/lateral stability index (MLSI), which
measures the variance of foot platform
displacement in degrees on any given
level for motion in the frontal plane.
The reliability of the BSS has been
previously established, with an internal
consistency coefficient (ICC) ranging
from 0.72 to 0.81.35 Another study recom-
mended a testing protocol consisting of
2 practice trials followed by 2 test trials.
The reliability (r) scores for trials 3 and 4
were 0.90, 0.86, and 0.76 for OSI, APSI,
and MLSI, respectively. Replication of
this 4-trial protocol with a separate group
resulted in reliability (r) estimates of
566 | september 2007 | volume 37 | number 9 | journal of orthopaedic & sports physical therapy
0.92, 0.89, and 0.93 for OSI, APSI, and
MLSI, respectively.4
Assessment was performed before the
initial training session (pretraining) and 2
days following completion of the last train-
ing session (posttraining). The assessment
procedure consisted of four 20-second tri-
als, with a 30-second rest between trials at
the training levels (6 and 4) and at level 2,
which was not used for training. Order of
testing was the same in all tests, starting
with the most stable (level 6) and ending
with the least stable (level 2). Results for
level 4 and 6 were obtained to measure
effect of attentional focus on acquisition,
which has been previously reported.22 The
results for OSI, APSI, and MLSI obtained
for trials 3 and 4 for level 2 were averaged
for use in the data analysis. Assessment was
performed by a researcher who was blind
to the participants’ group assignment.
During the testing sessions, the par-
ticipants were asked to maintain balance
while standing on the injured lower ex-
tremity, without any directions as to
focus of attention. The BSS screen was
covered so that no feedback was available
during tests and training. The dynamic
balance testing was performed with the
participants standing in single-limb
stance, barefoot, in a standardized foot
position in which the posterior aspect of
the calcaneus was placed midway over
the mediolateral midline of the platform
grid, and with the second ray pointing 5°
lateral to midline. Participants were in-
structed to hold the unsupported limb in
a comfortable position so as not to con-
tact the test limb or the test platform.
Training
Both groups participated in 3 training
sessions, held on 3 consecutive days,
each of which included 10 practice tri-
als at stability levels 6 and 4, for a total
of 20 practice trials. Each practice trial
was 20 seconds in duration, with a 30-
second rest between trials. If needed, par-
ticipants were allowed to rest for longer
periods during the training sessions. This
option was seldom used, as the 30-sec-
ond rest was adequate.
]
Following the initial assessment, par-
ticipants were randomly assigned to the
IFA and EFA groups. Before the beginning
of each training session, the participants
in the 2 groups received different instruc-
tions about where to focus their attention.
The EFA group was given the instruction
to “keep your balance by stabilizing the
platform,” whereas the IFA group was told
to “keep your balance by stabilizing your
body.” During training, participants were
required to assume the same foot place-
ment that was used in the assessment.
The instructions and supervision of
training were performed by 2 qualified
physical therapists on staff at the facil-
ity, both blinded to the participants’
initial assessment results. The physical
therapists supervising the training were
provided with a training manual that in-
cluded the exact phrasing of instructions
to participants.
Data Analysis
Independent t tests were used to deter-
mine any significant differences between
groups for age, body mass, height, and
time elapsed since the ankle sprain.
Descriptive statistics (mean  SD, and
change scores) were used to describe OSI,
APSI, and MLSI performance of both
groups pretraining and posttraining.
Separate mixed-design 2-way analyses
of variance (ANOVAs) were utilized for
each variable to determine transfer of skill
to the untrained level 2, with group (IFA,
EFA) and time (pretraining, posttraining)
as the 2 factors. Significant results were
followed by Tukey honestly significant
difference pairwise comparisons post hoc
analyses. Results were regarded as signifi-
cant at a P value less than .05. Statistical
analysis was performed using JMP soft-
ware (SAS Institute, Cary, NC).
RESULTS
haracteristics of the subjects are
C shown in TABLE 1. There was no sig-
nificant difference between groups
for age, height, body mass, and time from
injury (P.05).
 Mean, standard deviations, and
change scores of the stability indexes of
both groups pretraining and posttrain-
ing are presented in TABLE 2. For all 3 out-
TABLE 1
Characteristics
Age (y)
come measures the ANOVA indicated a 6.92, P = .01) (FIGURES 1 through 3). Post
statistically significant group-by-time hoc Tukey honestly significant differ-
interaction (OSI: F1,34 = 12.10, P = .001; ence pairwise comparisons for each of
APSI: F1,34 = 4.95, P = .03; MLSI: F1,34 = the outcome measures indicated no sig-
nificant difference between the groups
either pretraining or posttraining. While
Participants’ Characteristics* change over time for the IFA group was
not significant, the EFA group demon-
IFA Group (n = 20) EFA Group (n = 16) strated significant difference between
21.1  3.3 20.6  1.9 the pretraining and posttraining scores
Body mass (kg) 73.0  12.8 74.3  5.8 (P.05), indicating that training led to
Height (cm) 175.7  8.9 178.9  5.2 a significant improvement in all stability
Time from injury (wk) 4.3  3.1 4.1  2.4 measures only in the EFA group.
Abbreviations: EFA, external focus of attention; IFA, internal focus of attention.
* Data presented as mean  SD. There was no statistically significant difference between groups DISCUSSION
(P.05).
Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.

I
n this study, we show that, fol-
Pretraining and Posttraining Stability lowing an ankle sprain, the use of EFA
TABLE 2 in the training of postural control on
Indices, and Change Scores
moderately unstable surfaces improves
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Group/Stability Index Pretraining* Posttraining* Change Score (95% CI)† postural control on an untrained, less
Internal focus of attention (n = 20) stable surface. These results are especial-
Overall 13.5  4.1 11.9  5.5 –1.59 (–3.13 to –0.05) ly important in rehabilitation following
Anterior posterior 8.3  3.2 6.8  3.2 –1.43 (–3.13 to 0.28) injury, where there is typically a gradual
Medial lateral 10.3  4.2 9.6  5.1 –0.69 (–1.99 to 0.61) increase in difficulty of training in accor-
External focus of attention (n = 16) dance with the constraints induced by the
Overall 15.7  3.3 10.2  3.5 –5.45 (–6.92 to –3.97) injury. The results indicate that utilizing
Anterior posterior 10.1  3.4 6.0  2.0 –4.14 (–5.75 to –2.54) EFA in the early stages of rehabilitation,
Medial lateral 11.5  2.6 8.2  3.4 –3.36 (–4.88 to –1.84) when training is limited to less demand-
Journal of Orthopaedic & Sports Physical Therapy®

* Data presented as mean  SD. ing tasks, has the potential to positively
†
Determined by the mean change score 1.96 SE.
affect the recovery of postural control in

Overall Stability Index Anterior-Posterior Stability Index Medial-Lateral Stability Index

20 16 16
18 14 14
16
12 12
14
Degrees
Degrees

10
Degrees

12 10
10 8 8
8 6 6
6
4 4
4
2 2 2
0 0 0
Pretraining Postraining Pretraining Postraining Pretraining Postraining
IFA EFA IFA EFA IFA EFA

FIGURE 1. Mean overall stability index and standard
deviation pretraining and posttraining of the internal
focus of attention (IFA) and external focus of attention
(EFA) groups. A significant group-by-time interaction
was present (F1,34 = 12.10, P = .001). Post hoc Tukey
honestly significant difference pairwise comparisons
indicated a significant pretraining-posttraining
difference for the EFA group, no significant
pretraining-posttraining difference for the IFA group,
and no significant difference between groups either
preintervention or postintervention.
FIGURE 2. Mean anterior-posterior stability index
and standard deviation pretraining and posttraining
for the internal focus of attention (IFA) and external
focus of attention (EFA) groups. A significant group-
by-time interaction was present (F1,34 = 4.95, P =
.03). Post hoc Tukey honestly significant difference
pairwise comparisons indicated a significant
pretraining-posttraining difference for the EFA group,
no significant pretraining-posttraining difference for
the IFA group, and no significant difference between
groups either preintervention or postintervention.
FIGURE 3. Mean medial-lateral stability index and
standard deviation pretraining and posttraining for
the internal focus of attention (IFA) and external
focus of attention (EFA) groups. A significant group-
by-time interaction was present (F1,34 = 6.92, P =
.01). Post hoc Tukey honestly significant difference
pairwise comparisons indicated a significant
pretraining-posttraining difference for the EFA group,
no significant pretraining-posttraining difference for
the IFA group, and no significant difference between
groups either preintervention or postintervention.

journal of orthopaedic & sports physical therapy | volume 37 | number 9 | september 2007 | 567
 [ RESEARCH REPORT
more highly demanding tasks normally
addressed in later stages.
The advantage of EFA on transfer of
a postural control task, as demonstrated
with impaired participants in this study,
is consistent with the results of a pre-
vious study using a dynamic balance
task,45 in which healthy participants
practiced riding a Pedalo, and with
research examining the effect of atten-
tional focus on suprapostural tasks and
balance learning.59
While the results demonstrate the
advantage of EFA, the changes were not
sufficient to demonstrate differences be-
tween the groups posttraining. Further
Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.
research is necessary to examine wheth-
er changes in the training protocol (for
example, the number of repetitions or
length of trials) will result in greater dif-
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
ferences between the posttraining perfor-
mances of the groups.
Results of the present study are con-
sistent with our previous study that ex-
amined the effect of focus of attention
in acquisition and retention, rather than
transfer, of a postural control task fol-
lowing ankle sprain.22 EFA was found to
be more effective in those phases as well;
Journal of Orthopaedic & Sports Physical Therapy®
but it was not preferential for all stabil-
ity measures. In the present study, we
used a less stable and, therefore, more
difficult task than in the previous study.
This could account for the seemingly
more pronounced effect of instructions,
as it has been suggested that IFA was
specifically less effective in more chal-
lenging tasks.47
As in this study, most studies on train-
ing and learning and the application of
motor learning principles report short-
term effects. These are important in
orthopedic and sports physical therapy
insofar as the expediency of return to full
function is often a significant component
of the rehabilitation goals. Typically, re-
habilitation following an ankle sprain
is of relatively short duration, with re-
turn to activity expected between 4 and
8 weeks after the injury.27 Within such a
time frame, the results of even 3 days of
training seem to have some importance.
568 | september 2007 | volume 37 | number 9 | journal of orthopaedic & sports physical therapy
Furthermore, there is also some evidence
for a long-term effect on postural control
following even short-term practice.44
Yet, the significance of preferential fo-
cus of attention and the effect on long-
term results and early return to function
should be determined by future research
with longer intervention periods and
follow-up.
As is often the case in studies that
measure postural control, it is difficult
to discern whether the differences in im-
provement between groups have clinical
significance. In the present study, the
EFA group improved by 35% in OSI, 41%
in APSI, and 29% in MLSI, while the IFA
group improved only by 12%, 17%, and
7% for the same variables, respectively.
Although the differences found among
participants in the EFA group over the
course of 3 days of training were more
substantial as compared to the IFA group,
the amount of improvement in postural
control that significantly influences func-
tion or is clinically significant has yet to
be established.
Results show that, unlike the EFA
group, the IFA group did not signifi-
cantly improve over time. This could
be a result of the short training period,
or it could imply that IFA is not effec-
tive during the early phase of learning
a balance task. Further investigation of
different phases of rehabilitation, spe-
cific instructions, and possibly a com-
bination of instructions (EFA and IFA)
are warranted to establish preferential
focus of attention in learning a postural
control task throughout the rehabilita-
tion process.
All participants in this study were
male. Although there is some evidence
of gender differences in neuromuscular
control11 and in the performance of cog-
nitive tasks,49 there is no evidence of an
equivalent difference in motor learning
abilities, nor is there evidence for gen-
der-related differences in recovery pat-
terns following LAS. However, further
studies are needed to establish that gen-
der indeed does not affect recovery and
learning of postural control.
]
CONCLUSIONS
T
he results of this study indi-
cate that focusing attention exter-
nally during the acquisition of a
postural skill over a 3-day period signifi-
cantly improved the ability to maintain
balance for an untrained more challeng-
ing condition. A similar training program
using an internal focus of attention did
not result in a significant improvement.
Applying principles of motor learning
to what is usually termed orthopedic or
sports physical therapy may facilitate
skill acquisition. T
REFERENCES
1. Ageberg E, Zatterstrom R, Moritz U, Friden T.
Influence of supervised and nonsupervised
training on postural control after an acute
anterior cruciate ligament rupture: a three-year
longitudinal prospective study. J Orthop Sports
Phys Ther. 2001;31:632-644.
2. Bennett WF. Lateral ankle sprains. Part I:
Anatomy, biomechanics, diagnosis, and natural
history. Orthop Rev. 1994;23:381-387.
3. Bullock-Saxton JE. Sensory changes associated
with severe ankle sprain. Scand J Rehabil Med.
1995;27:161-167.
4. Cachupe W, Shifflett B, Kahanov L, Wughalter E.
Reliability of Biodex Balance System measures.
Meas Phys Educ Exerc Sci. 2001;5:97-108.
5. Crichton KJ, Fricker PA, Purdam C, Watson AS.
Injuries to the pelvis and lower limb. In: Bloom-
field J, Fricker PA, Fitch KD, eds. Science and
Medicine in Sport. Victoria, Australia: Blackwell
Science Pty, Ltd; 1995.
6. Dail TK, Christina RW. Distribution of practice
and metacognition in learning and long-term
retention of a discrete motor task. Res Q Exerc
Sport. 2004;75:148-155.
7. Forkin DM, Koczur C, Battle R, Newton RA. Evalu-
ation of kinesthetic deficits indicative of balance
control in gymnasts with unilateral chronic
ankle sprains. J Orthop Sports Phys Ther.
1996;23:245-250.
8. Garrick JG, Requa RK. The epidemiology of foot
and ankle injuries in sports. Clin Sports Med.
1988;7:29-36.
9. Gerber JP, Williams GN, Scoville CR, Arciero
RA, Taylor DC. Persistent disability associated
with ankle sprains: a prospective examina-
tion of an athletic population. Foot Ankle Int.
1998;19:653-660.
10. Goldie PA, Evans OM, Bach TM. Postural control
following inversion injuries of the ankle. Arch
Phys Med Rehabil. 1994;75:969-975.
11. Henry JC, Kaeding C. Neuromuscular differences
 between male and female athletes. Curr Wom-
ens Health Rep. 2001;1:241-244.
12. Hertel J. Functional anatomy, pathomechanics,
and pathophysiology of lateral ankle instability. J
Athl Train. 2002;37:364-375.
13. Hess DM, Joyce CJ, Arnold BL, Gansneder BM.
Effect of a 4-week agility training program on
postural sway in the functionally unstable ankle.
J Sport Rehabil. 2001;10:24-34.
14. Hodges NJ, Franks IM. Modelling coaching prac-
tice: the role of instruction and demonstration. J
Sports Sci. 2002;20:793-811.
15. Hoffman M, Payne VG. The effects of propriocep-
tive ankle disk training on healthy subjects. J
Orthop Sports Phys Ther. 1995;21:90-93.
16. Holme E, Magnusson SP, Becher K, Bieler T,
Aagaard P, Kjaer M. The effect of supervised
rehabilitation on strength, postural sway, posi-
tion sense and re-injury risk after acute ankle
ligament sprain. Scand J Med Sci Sports.
Downloaded from www.jospt.org at on May 1, 2018. For personal use only. No other uses without permission.
1999;9:104-109.
17. Horak FB, Henry SM, Shumway-Cook A. Postural
perturbations: new insights for treatment of bal-
ance disorders. Phys Ther. 1997;77:517-533.
18. Jackson DW, Ashley RL, Powell JW. Ankle sprains
Copyright © 2007 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
in young athletes. Relation of severity and dis-
ability. Clin Orthop Relat Res. 1974:201-215.
19. Lam T, Dietz V. Transfer of motor performance in
an obstacle avoidance task to different walking
conditions. J Neurophysiol. 2004;92:2010-2016.
20. Landers M, Wulf G, Wallmann H, Guadagnoli
MA. An external focus of attention attenuates
balance impairment in Parkinson’s disease.
Physiotherapy. 2005;91:152-185.
21. Lassiter TE, Jr., Malone TR, Garrett WE, Jr. Injury
to the lateral ligaments of the ankle. Orthop Clin
Journal of Orthopaedic & Sports Physical Therapy®
North Am. 1989;20:629-640.
22. Laufer Y, Rotem-Lehrer N, Ronen Z, Khayutin
G, Rozenberg I. Effect of attention focus on
acquisition and retention of postural control
following ankle sprain. Arch Phys Med Rehabil.
2007;88:105-108.
23. Leanderson J, Eriksson E, Nilsson C, Wykman
A. Proprioception in classical ballet dancers. A
prospective study of the influence of an ankle
sprain on proprioception in the ankle joint. Am J
Sports Med. 1996;24:370-374.
24. Lee TD, Genovese ED. Distribution of practice in
motor skill acquisition: different effects for dis-
crete and continuous tasks. Res Q Exerc Sport.
1989;60:59-65.
25. Lee TD, Swanson LR, Hall AL. What is re-
peated in a repetition? Effects of practice
conditions on motor skill acquisition. Phys Ther.
1991;71:150-156.
26. Liu SH, Nguyen TM. Ankle sprains and other
soft tissue injuries. Curr Opin Rheumatol.
1999;11:132-137.
27. Lynch SA, Renstrom PA. Treatment of acute
lateral ankle ligament rupture in the athlete.
Conservative versus surgical treatment. Sports
Med. 1999;27:61-71.
journal of orthopaedic & sports physical therapy | volume 37 | number 9 | september 2007 |
28. Mack RP. Ankle injuries in athletics. Clin Sports
Med. 1982;1:71-84.
29. Maki BE, McIlroy WE. The role of limb move-
ments in maintaining upright stance: the
“change-in-support” strategy. Phys Ther.
1997;77:488-507.
30. Mattacola CG, Dwyer MK. Rehabilitation of the
ankle after acute sprain or chronic instability. J
Athl Train. 2002;37:413-429.
31. McNevin NH, Shea CH, Wulf G. Increasing the
distance of an external focus of attention en-
hances learning. Psychol Res. 2003;67:22-29.
32. McNevin NH, Wulf G. Attentional focus on supra-
postural tasks affects postural control. Hum Mov
Sci. 2002;21:187-202.
33. McNevin NH, Wulf G, Carlson C. Effects of at-
tentional focus, self-control, and dyad training
on motor learning: implications for physical
rehabilitation. Phys Ther. 2000;80:373-385.
34. Milgrom C, Shlamkovitch N, Finestone A, et al.
Risk factors for lateral ankle sprain: a prospec-
tive study among military recruits. Foot Ankle.
1991;12:26-30.
35. Paterno MV, Myer GD, Ford KR, Hewett TE. Neu-
romuscular training improves single-limb stabil-
ity in young female athletes. J Orthop Sports
Phys Ther. 2004;34:305-316.
36. Perrin PP, Bene MC, Perrin CA, Durupt D. Ankle
trauma significantly impairs posture control—a
study in basketball players and controls. Int J
Sports Med. 1997;18:387-392.
37. Powell JW, Barber-Foss KD. Injury patterns in se-
lected high school sports: a review of the 1995-
1997 seasons. J Athl Train. 1999;34:277-284.
38. Renstrom PA, Kannus P. Injuries to the foot and
ankle. In: DeLee J, Drez DJ, eds. Orthopaedic
Sports Medicine: Principles and Practice. Phila-
delphia, PA: WB Saunders Company; 1994.
39. Safran MR, Benedetti RS, Bartolozzi AR, 3rd,
Mandelbaum BR. Lateral ankle sprains: a
comprehensive review: part 1: etiology, patho-
anatomy, histopathogenesis, and diagnosis. Med
Sci Sports Exerc. 1999;31:S429-437.
40. Savion-Lemieux T, Penhune VB. The effects of
practice and delay on motor skill learning and
retention. Exp Brain Res. 2005;161:423-431.
41. Schmidt R, Lee T. Motor Control and Learning:
A Behavioral Emphasis. Champaign, IL: Human
Kinetics; 1999.
42. Shumway-Cook A, Woollacott M. Motor Control
Theory and Practical Applications. London, UK:
Williams & Wilkins; 2000.
43. Singer RN, Lidor R, Cauraugh JH. Focus of at-
tention during motor skill performance. J Sports
Sci. 1994;12:335-340.
44. Tjernstrom F, Fransson PA, Hafstrom A, Magnus-
son M. Adaptation of postural control to per-
turbations—a process that initiates long-term
motor memory. Gait Posture. 2002;15:75-82.
45. Totsika V, Wulf G. The influence of external
and internal foci of attention on transfer to
novel situations and skills. Res Q Exerc Sport.
2003;74:220-225.
46. Vance J, Wulf G, Tollner T, McNevin N, Mercer J.
EMG activity as a function of the performer’s fo-
cus of attention. J Mot Behav. 2004;36:450-459.
47. Vuillerme N, Nafati G. How attentional focus on
body sway affects postural control during quiet
standing. Psychol Res. 2007;71:192-200.
48. Weeks DL, Kordus RN. Relative frequency of
knowledge of performance and motor skill
learning. Res Q Exerc Sport. 1998;69:224-230.
49. Weiss E, Siedentopf CM, Hofer A, et al. Sex dif-
ferences in brain activation pattern during a vi-
suospatial cognitive task: a functional magnetic
resonance imaging study in healthy volunteers.
Neurosci Lett. 2003;344:169-172.
50. Winstein CJ. Knowledge of results and motor
learning--implications for physical therapy. Phys
Ther. 1991;71:140-149.
51. Wolfe MW, Uhl TL, Mattacola CG, McCluskey LC.
Management of ankle sprains. Am Fam Physi-
cian. 2001;63:93-104.
52. Woollacott MH, Shumway-Cook A. Changes in
posture control across the life span—a systems
approach. Phys Ther. 1990;70:799-807.
53. Wulf G, Lauterbach B, Toole T. The learning ad-
vantages of an external focus of attention in golf.
Res Q Exerc Sport. 1999;70:120-126.
54. Wulf G, McConnel N, Gartner M, Schwarz
A. Enhancing the learning of sport skills
through external-focus feedback. J Mot Behav.
2002;34:171-182.
55. Wulf G, McNevin N, Shea CH. The automaticity
of complex motor skill learning as a func-
tion of attentional focus. Q J Exp Psychol A.
2001;54:1143-1154.
56. Wulf G, McNevin NH, Fuchs T, Ritter F, Toole T.
Attentional focus in complex skill learning. Res
Q Exerc Sport. 2000;71:229-239.
57. Wulf G, Prinz W. Directing attention to movement
effects enhances learning: a review. Psychol Bull
Rev. 2001;8:648-660.
58. Wulf G, Shea C, Park JH. Attention and motor
performance: preferences for and advan-
tages of an external focus. Res Q Exerc Sport.
2001;72:335-344.
59. Wulf G, Weigelt M, Poulter D, McNevin N.
Attentional focus on suprapostural tasks af-
fects balance learning. Q J Exp Psychol A.
2003;56:1191-1211.
60. Yeung MS, Chan KM, So CH, Yuan WY. An epide-
miological survey on ankle sprain. Br J Sports
Med. 1994;28:112-116.
61. Zachry T, Wulf G, Mercer J, Bezodis N. Increased
movement accuracy and reduced EMG activity
as the result of adopting an external focus of at-
tention. Brain Res Bull. 2005;67:304-309.
@
MORE INFORMATION
WWW.JOSPT.ORG
569