RESEARCH REPORT

flotante

The_effects_of_Kinesio_Tape_o.pdf

Home >Biology homework help >Physiology homework help >RESEARCH REPORT

THE EFFECTS OF KINESIOTM TAPE ON PERONEAL MUSCLE ACTIVITY IN

PATIENTS WITH CHRONIC ANKLE INSTABILITY

An Abstract of

A Thesis

Presented to the Faculty of

The Department of Kinesiology

Western Illinois University

In Partial Fulfillment

Of the Requirement for the Degree

Master of Science

JASON JOHNSON

July 2014

ABSTRACT

The purpose of this study was to investigate the effect of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI). Fifteen college students with CAI performed a single leg stance

(SLS)-eyes open, SLS-eyes closed, and a SLS on a BOSU® ball exercise protocol.

Surface electromyography (EMG) was used to measure peroneal muscle activity. The

protocol sequence for each participant was: (a) complete the exercises without tape, (b)

repeat the exercises with tape, (c) continue to wear the tape for 24 hours, (d) repeat the

exercises with tape, and (e) repeat the exercises without tape.

The dependent variable, peroneal muscle activity amplitude (MAA), for each of

the three conditions was analyzed using a 2x2 (Tape/No Tape Condition x Day)

repeated measures ANOVA. An alpha level of p < .05 was used for all hypothesis

testing. All significant ANOVA effects were further analyzed using a post-hoc analysis

of simple main effects.

The results indicated a significant increase in peroneal MAA when wearing

Kinesio ™ tape during the performance of a SLS-eyes closed exercise on a stable

surface. No statistically significant differences in peroneal MAA for the SLS-eyes open

on stable surface or when balancing on the BOSU™ balance trainer were found.

Kinesio™ tape may improve peroneal activity when the visual component is

removed from rehabilitation exercises. However, from these preliminary findings,

Kinesio™ tape cannot be recommended as a means for muscle re-education and

proprioception enhancement in patients with chronic ankle instability. Further research

examining the rehabilitative properties of Kinesio™ tape on muscle activity is needed.

THE EFFECTS OF KINESIOTM TAPE ON PERONEAL MUSCLE ACTIVITY IN

PATIENTS WITH CHRONIC ANKLE INSTABILITY

A Thesis

Presented to the Faculty of

The Department of Kinesiology

Western Illinois University

In Partial Fulfillment

Of the Requirement for the Degree

Master of Science

JASON JOHNSON

July 2014

INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed,

a note will indicate the deletion.

unauthorized copying under Title 17, United States Code

ProQuest LLC. 789 East Eisenhower Parkway

P.O. Box 1346 Ann Arbor, MI 48106 - 1346

UMI 1564042 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author.

UMI Number: 1564042

ACKNOWLEDGMENTS

Thank you to all of those who helped me through some of the most trying months

of my life to date. I would not have been able to go on without your encouragement and

aide. I am grateful to have this experience to build upon professionally.

I would like to thank my thesis chair, Dr. Jennifer Plos. Thank you for never

giving up on this project, I truly couldn’t have asked for a better mentor. Thank you to

Dr. Miriam Satern and Dr. Janet Wigglesworth. Your assistance and constructive

feedback pushed me to my full potential. A special thank you to Dr. Noelle Selkow, this

project couldn’t have happened without your donation. Additionally I would like to thank

Dr. Timothy Piper for his enthusiasm and support that drove me to pursue a thesis in the

first place.

I would also like to thank all of the individuals who participated in my study.

Thank you for taking time out of your busy days. A special thanks also goes to Western

Illinois University for allowing me the opportunity to complete this thesis.

None of this would have been possible without my parents, Sherry and Robert. Thank

you for instilling me with a positive work ethic, determination, and perseverance. Your

love and support allowed me to further myself as a professional.

Lastly, thank you to all my friends. Thank you for helping me to decompress and

remember the bigger picture. Thank you Stephanie Rendall, we’ve come so far.

TABLE OF CONTENTS

Page

ACKNOWLEDGMENTS ...................................................................................................... ii

TABLE OF CONTENTS ........................................................................................................ iii

LIST OF TABLES .................................................................................................................. vii

LIST OF FIGURES ................................................................................................................ viii

CHAPTERS

1. Introduction ................................................................................................................ 1

Statement of the Problem .................................................................................... 5

Hypotheses ........................................................................................................... 6

Definitions ........................................................................................................... 6

Assumptions ........................................................................................................ 7

Delimitations ....................................................................................................... 8

Limitations ........................................................................................................... 8

Significance of the Problem................................................................................. 9

2. Review of Literature ..................................................................................................... 10

Chronic Ankle Instability (CAI) .......................................................................... 10

Assessment of CAI ................................................................................ 11

Proprioception .................................................................................................... 12

Peroneal latency (stretch reflex) .............................................................. 13

iii

Assessment of proprioception ................................................................. 15

Reproduction of joint position .................................................. 16

Electromyography (EMG) ........................................................ 16

Balance testing ........................................................................... 18

Neuromuscular Control ....................................................................................... 19

Rehabilitation for CAI ......................................................................................... 19

Balance Training ................................................................................................. 21

Balance Training on Stable and Unstable Surfaces ............................... 23

BOSU™ Balance Trainer for Proprioceptive Enhancement ................ 24

Kinesio™ Tape .................................................................................................... 26

Benefits of Kinesio™ Tape.................................................................... 27

Effects of Kinesio™ Tape on Ankle Proprioception ............................. 27

Summary .............................................................................................................. 30

3. Research Methodology .............................................................................................. 32

Participants ......................................................................................................... 32

Instrumentation ................................................................................................... 33

Pilot Study .......................................................................................................... 33

Procedures ........................................................................................................... 34

Day 1: Informed Consent and Inclusion Determination .......................... 34

Day 2: MAA for SLS-Eyes Open, No-Tape followed by Tape .............. 34

EMG protocol ............................................................................ 35

Rehabilitation exercise protocol ................................................ 35

Peroneal muscle activity measurements .................................... 38

Kinesio™ Tape Application ...................................................... 38

Day 3: MAA for SLS-Eyes Open, Tape followed by No-Tape .............. 39

Days 4-6: Rest and Recovery .................................................................. 40

Day 7: MAA for SLS-Eyes Closed, No-Tape followed by Tape ............ 40

Rehabilitation exercise protocol ................................................ 40

Day 8: MAA for SLS-Eyes Closed, Tape followed by No-Tape ............ 41

Statistical Analysis .............................................................................................. 41

4. Results & Discussion .................................................................................................. 43

Participants .......................................................................................................... 43

Results ................................................................................................................. 43

Results of MAA during SLS-Eyes Open ................................................ 43

Results of MAA during SLS-Eyes Closed ............................................. 44

Results of MAA during SLS-BOSU ...................................................... 45

Summary of Results ............................................................................................ 47

Discussion of Findings ........................................................................................ 49

Hypothesis 1 ............................................................................................ 49

Hypothesis 2 ............................................................................................ 50

Hypothesis 3 ............................................................................................ 51

Additional Findings ............................................................................................ 52

Concepts for Consideration ................................................................................. 54

5. Summary, Conclusions, & Recommendations .......................................................... 58

Summary ............................................................................................................. 58

Conclusions ........................................................................................................ 59

Recommendations .............................................................................................. 60

REFERENCES ............................................................................................................... 63

APPENDICES

A. INFORMED CONSENT ............................................................................... 73

B. HEALTH HISTORY QUESTIONNAIRE .................................................... 77

C. FOOT & ANKLE DISABILITY INDEX (FADI).......................................... 80

D. INDIVIDUAL TRIAL MAA SCORES ......................................................... 82

LIST OF TABLES

Page

Table 1: Means and Standard Deviations for MAA (mV) during Single Leg Stance –

Eyes Open ............................................................................................................... 44

Table 2: ANOVA Summary Table of MAA Single Leg Stance – Eyes Open

(Tape/No Tape) x (Day)........................................................................................... 44

Table 3: Means and Standard Deviations for MAA (mV) during Single Leg Stance –

Eyes Closed .............................................................................................................. 45

Table 4: ANOVA Summary Table of MAA Single Leg Stance – Eyes Closed

(Condition) x (Day).................................................................................................. 45

Table 5: Summary of Results from the Post-Hoc Analysis of the Day x Condition

Interaction for Single Leg Stance – Eyes Closed .................................................... 45

Table 6: Means and Standard Deviations for MAA (mV) during Single Leg Stance on

BOSU™ Balance Trainer ........................................................................................ 46

Table 7: ANOVA Summary Table of MAA Single Leg Stance on (BOSU™)

(Tape/No Tape) x (Day)........................................................................................... 46

Table 8: Summary of Kinesio Tape Studies for the Ankle ..................................................... 55

vii

LIST OF FIGURES

Page

Figure 1: Mechanism of an inversion ankle sprain and involved ligaments ........................... 1

Figure 2: Peroneus brevis and longus complex on lateral side of ankle ................................. 2

Figure 3: Mechanical and functional insufficiencies that contribute to chronic ankle

instability .................................................................................................................. 3

Figure 4: Overview of procedures by day.............................................................................. 35

Figure 5: Markings for electrode placement .......................................................................... 36

Figure 6: BOSU balance trainer with inflatable bladder side up ........................................... 37

Figure 7: Summary of the mean peroneal MAA during SLS-eyes closed trials ................... 46

Figure 8: Means and standard deviations for peroneal muscle activity measured by

EMG ....................................................................................................................... 48

Figure 9: Sample research protocol to investigate fatigue factors ......................................... 62

viii

CHAPTER 1

INTRODUCTION

Over 23,000 inversion ankle sprains occur in the athletic population each year

(Hertel, 2002) and account for 10-28% of all athletic injuries (Barrett et al., 1993).

Inversion ankle sprains occur when an athlete lands on the lateral aspect of the foot and

rolls the sole of the foot up and in (Hertel, 2002). Stress from the excessive inversion

mechanism on the lateral, or outer, aspect of the foot/ankle causes a stretch or tear of the

lateral ligamentous complex, commonly called a sprain. The ligaments that are damaged

during a lateral ankle sprain include the anterior talofibular, calcaneofibular, and

posterior talofibular ligaments (see Figure 1).

Figure 1. Mechanism of an inversion ankle sprain and involved ligaments. Adapted from: http://www.consultant360.com/articles/weekend-athlete-common-foot-and-ankle-injuries

In addition to ligamentous damage, inversion ankle sprains also cause

neuromuscular deficits in the peroneal brevis and longus complex (see Figure 2),

potentially leading to functional ankle instability and a decrease in the ability to prevent

further ankle sprains (Hertel, 2002). Inversion ankle sprains are painful, debilitating, and

often lead to chronic ankle instability for the athlete (Yeung, Chan, So, & Yuan, 1994).

Chronic Ankle Instability (CAI) is defined as “the occurrence of repetitive bouts

of lateral ankle instability, resulting in numerous ankle sprains” (Hertel, 2002, p. 364).

While the mechanism of the initial lateral ankle sprain is well documented, the direct

causes of CAI are still unknown. However, Herman, Magrum, and Hertel (2013)

describe two potential contributors to CAI: mechanical and functional instability (see

Figure 3).

Figure 2. Peroneus brevis and longus complex on lateral side of ankle. Adapted from: http://www.cps.ca/documents/position/ankle-sprains-athlete

Figure 3. Mechanical and functional insufficiencies that contribute to chronic ankle instability. Adapted from “Functional anatomy, pathomechanics, and pathophysiology of lateral ankle instability,” by J. Hertel, 2002, Journal of Athletic Training, 37(4), p. 369.

Mechanical instability following an ankle injury is the result of multiple

deficiencies predisposing the injured part to future injury. These deficiencies include

increased pathological laxity, synovial disruption, degenerative changes, and impaired

biomechanics (Hertel, 2002). Treatment for these insufficiencies requires a patient to be

referred to an orthopedic surgeon for surgical intervention.

Functional instability is the result of deficiencies in the neuromuscular

system caused by injury to the muscle complex following a lateral ankle sprain.

These deficiencies can reduce the dynamic support at the ankle (Freeman, Dean,

& Hanham, 1965). Functional instability is identified by impairments of

proprioception and neuromuscular control, thus resulting in inadequacies of the

dynamic defense mechanism protecting against recurrent ankle sprains (Lephart,

Pincivero, & Rozzi, 1998). It also includes strength deficits and impaired

postural control of the ankle. Treatment for these insufficiencies can be

addressed through rehabilitative measures implemented under the direction and

supervision of an athletic trainer or physical therapist.

According to Hertel (2002), comprehensive rehabilitation programs for treating

CAI must emphasize proprioception, neuromuscular control, and balance training. To

assist in improving proprioception and neuromuscular control during rehabilitation,

Kinesio™ tape has been proposed to offer potential proprioceptive benefits (Murray &

Husk, 2001), essential to proper rehabilitation following an ankle sprain. Kinesio™ tape

relies on several therapeutic mechanisms of treatment. According to Kase, Tatsuyuki, and

Tomoko (1996), Kinesio™ tape assists in: (a) correcting muscle function by

strengthening weakened muscles, (b) improving circulation of blood and lymph by

eliminating tissue fluid or bleeding beneath the skin by moving the muscle, (c) decreasing

pain through neurological suppression, (d) repositioning subluxed joints by relieving

abnormal muscle tension, and (e) helping to return the function of fascia and muscle. In

addition, Kinesio™ tape has been proposed to enhance proprioception through increased

stimulation to cutaneous mechanoreceptors (Murray & Husk, 2001).

In ankle rehabilitation, there are multiple goals that must be achieved for a safe

and stable recovery. These goals include: (a) strengthening, (b) re-education of the

muscles that are considered dynamic stabilizers of the ankle (i.e. peroneal muscles as the

primary everters), and (c) re-establishing proprioception and kinesthesia.

Proprioception is the ability to determine the position of a joint in space, while

kinesthesia refers to the ability to detect movement (Grigg, 1994). Restoration of

proprioception and kinesthesia is traditionally attained through rehabilitation exercises

that focus on balance and coordination training of the ankle following a sprain

(Konradsen, 2002). Numerous studies have found success using balance boards to

improve strength and balance measures in subjects with acute ankle injury and CAI

(Osborne, Shan-Chou, Laskowski, Smith & Kaufman 2001; Soderman, Werner, Pietila,

Engstrom, & Alfredson, 2000; Wester, Jespersen, Nielsen, & Neumann, 1996). However,

minimal studies have promoted the addition of Kinesio™ tape to further enhance the

proprioception outcomes of traditional rehabilitation exercises.

Although it has been proposed that Kinesio™ tape is capable of correcting muscle

function by strengthening weakened muscles (Kase et al., 1996) and is also capable of

enhancing proprioception through increased stimulation to cutaneous mechanoreceptors

(Murray & Husk, 2001), little research exists on its proprioceptive effects and ability to

facilitate muscle re-education. Research specifically related to the effect of Kinesio™

tape on peroneal re-education in the CAI patient is minimal. These limited studies have

postulated that Kinesio™ tape’s ability to stretch to 140% of its original length allows

the tape to move as the body does; thus potentially enhancing the stimulation of

mechanoreceptors within the skin (Kase, 2013). Stimulation of these cutaneous

mechanoreceptors may play a role in proprioception and kinesthesia (Riemann &

Lephart, 2002).

Statement of the Problem

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI).

Hypotheses

The hypotheses investigated in this study were as follows: 1) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes open) exercise on a stable surface.

2) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes closed) exercise on a stable surface.

3) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes open), on the bladder portion of a BOSU™ balance

trainer.

Definition of Terms

The following terms have been defined to provide clarity:

Acute pain refers to pain at the time of assessment (Prentice & Arnheim, 2006).

Arthokinematics refers to the movement, which occurs in the joint surface

(Narayana, 2005).

Chronic ankle instability (CAI) refers to repetitive bouts of lateral ankle instability

resulting in numerous ankle sprains (Hertel, 2002).

Electromyography (EMG) is a diagnostic test that records the electrical activity of

muscles (Horowitz, 2014).

Eversion refers to a movement of the calcaneus such that the sole of the foot turns

outward or laterally (Prentice & Arnheim, 2006).

Functional instability implies an inability to control either arthrokinematic or

osteokinematic movement in the available range of motion, either consciously or

unconsciously, during functional movement (Magee, 2008).

Inversion refers to a movement of the calcaneus such that the sole of the foot

turns inward or medially (Prentice & Arnheim, 2006).

Kinesio™ Tape refers to therapeutic tape that is an elastic cotton strip with an

acrylic adhesive used for treating athletic injuries and a variety of physical disorders

(Kase, 1996).

Kinesthesia refers to the ability to detect movement (Grigg, 1994).

Osteokinematic refers to small amplitude motions of bones at a joint surface

(Thompson, 2000).

Neuromuscular control describes the brain’s attempt to teach the body conscious

control of a specific movement (Swanik, 2004). In this study, neuromuscular control

refers to the peroneal brevis and longus muscles’ ability to contract in order to maintain

stability.

Prophylactic refers to guarding against injury or disease (Prentice, 2006). The

peroneal muscles serve as a protective guard against excessive inversion of the ankle.

Proprioception refers to the ability to determine the position of a joint in space

(Grigg, 1994).

Sprain refers to stretch or tear of a ligament that limits movements of a joint in the

body (Prentice, 2006).

Assumptions

The assumptions regarding this study were as follows: 1) The participants understood and followed all of the instructions given.

2) The participants performed all exercises to the best of their abilities.

3) The participants did not shower for a 24 hr time period to protect the EMG electrode.

4) The participants refrained from watching the EMG recordings while

participating in the exercises.

Delimitations

The delimitations regarding this study were as follows:

1) The study was limited to college student volunteers from one Midwestern

University.

2) The participants were limited to 18-30 year old males and females.

3) The participants were required to have a score of 90% or less on the Foot and

Ankle Disability Index (FADI) sport survey.

4) The participants could not have a history of lower extremity fracture, surgery, or

conditions which altered sensory perception or balance.

Limitations

The limitations of this study included: 1) No universally accepted definition for CAI exists, thus limiting generalization

to the population.

2) Cross talk interference resulting from the use of electromyography possibly

influenced the results.

3) Participants’ (collegiate athletes and general students) overall peroneal muscle

activity may have differed, depending on whether or not they underwent

rehabilitation to strengthen the muscles following their initial ankle injuries.

4) Electrode placement and taping techniques used in this study only addressed

the peroneal longus and brevis muscles.

5) Mechanical properties of the tape may have been altered when a cut out space

was made in the center of the tape to accommodate the EMG electrode nodes.

Significance of the Problem

Ankle sprains are the most common orthopedic injury in sports (Fong, Hong,

Chan, Yung, & Chan, 2007). While the initial symptoms resolve fairly quickly, many

individuals report recurrent symptoms months to even years after the initial injury

(Vanrijn et al., 2008). Chronic Ankle Instability (CAI) is the most common of these

residual problems (Vanrijn et al., 2008). The competitive nature of sports requires all

medical practitioners to seek out the most up to date modalities for the treatment of their

patients. Kinesio™ tape is a current modality that may assist in the recovery of the

peroneal muscle group following a lateral ankle sprain by assisting in proprioception

and neuromuscular control to help reduce the incidence of CAI.

Athletic tape has been used in the athletic training profession for decades, while the

use of Kinesio™ tape has yet to gain such prevalence. The use of athletic tape at the ankle

has been associated most often with prophylactic benefits during competition and practice.

While some studies have investigated the potential preventative benefits of Kinesio™ tape,

the results have yielded no conclusive data (Briem, Eythorsdottir, Magnusdottir,

Palmarsson, & Runarsdotter, 2011). While Kinesio™ tape may not replace athletic tape,

athletic trainers should continue to explore the potential therapeutic benefits of Kinesio™

tape post injury. If effectiveness is found with the use of Kinesio™ tape, it may serve as a

means to speed the neural re-education process, ultimately helping an athlete’s recovery

from CAI. Proper muscle re-education may also help to provide greater functional stability,

allowing athletes to become less dependent on external ankle support following injury.

CHAPTER 2

REVIEW OF LITERATURE

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic ankle

instability (CAI). In order to provide background information pertinent to this study, the

following topics will be discussed: (a) Chronic Ankle Instability (CAI), (b) Proprioception,

(f) Kinesio™ tape.

Chronic Ankle Instability (CAI)

The sensation of “giving way” that is often described by patients with CAI

results from damage to mechanoreceptors that compromise the prophylactic benefits of

the central nervous system by inhibiting proprioception and neuromuscular control

(Freeman et al., 1965). Gross (1987) studied the effects of recurrent lateral ankle sprains

on active and passive judgments of joint position. Participants were blindfolded while

performing active and passive attempts at replicating pre-determined ankle joint

positions in the inversion-eversion range of motion. The researcher used an isokinetic

dynamometer to measure joint position. The results showed that passive judgments were

significantly better than active judgments of joint position in the non-sprained group.

Based on these results, Gross concluded that joint receptors play a dominant role in joint

angle detection and that muscle receptors are more valuable in the perception of joint

movement.

In support of Gross’ conclusions, Lentell, Bass, Lopez, Sarrels, and Snyder

(1995) found that 58% of participants (n=42) with CAI demonstrated clinical

impairments in at least one of three categories (proprioceptive deficits, muscle function,

and anatomic laxity). Deficits in passive movement sense (proprioception) and anatomic

laxity were found to be statistically significant in the CAI ankles, while muscle function

deficits were not significantly different when compared to non-CAI ankles. Lentell et al.

concluded that the joint receptors responsible for passive movement sense

(proprioception) and anatomic stability need to be addressed more than strength deficits

when managing an ankle with functional instability.

Assessment of CAI

The Foot and Ankle Disability Index (FADI) is a survey used to determine if an

individual has CAI. The primary FADI assessment tool contains 26 items related to

activities of daily living. The extended version FADI Sport contains an additional eight

items that evaluate perceived disability due to foot or ankle injury in activities

associated with physical activity and sport participation (Hale & Hertel, 2005).

Hale and Hertel (2005) examined the FADI and FADI Sport intersession

reliability during 1- and 6-wk intervals, sensitivity to differences between healthy

subjects and subjects with chronic ankle instability (CAI), and sensitivity to changes in

function in those with CAI after rehabilitation. Subjects were classified as having CAI

if they reported having the following: (a) a history of ankle sprain with pain and/or

limping for more than one day, (b) chronic weakness, pain, or instability that they

attributed to the initial injury, and (c) giving way in the last six mos. The researchers

concluded that their results indicated that the FADI and FADI Sport are: (a) reliable in

detecting functional limitations in subjects with CAI, (b) sensitive to differences

between healthy subjects and subjects with CAI, and (c) responsive to improvements in

function after rehabilitation in subjects with CAI.

Proprioception

Proprioception is the ability to determine the position of a joint in space;

kinesthesia refers to ability to detect movement (Grigg, 1994). As previously mentioned,

muscle mechanoreceptors are vital to the interpretation of joint position. Every muscle

in the body is innervated by a number of these receptors that trigger reflexes throughout

the body. The simplest of these reflex arcs entails the response to muscle stretch, which

provides direct excitatory feedback to the motor neurons innervating the muscle that has

been stretched (Purves, Augustine & Fitzpatrick, 2001).

Proper proprioception from mechanoreceptors to detect joint position and

movement is essential to the body’s ability to prevent inversion ankles sprains and

reduce functional instability within the ankle (Delahunt, Monaghan & Caulfield, 2006).

While many studies focus on the afferent component of proprioception, it is important to

explore the efferent (motor) response. Karlsson and Andreasson (1992) explored firing

patterns of the peroneal muscles of taped and untaped ankles when exposed to a

simulated ankle sprain via a tilting trap door. They measured the reaction time of the

peroneus muscles using surface EMG signals and used non-elastic, white, athletic tape

on the ankles. The researchers found that in 20 athletes with unilateral ankle instability,

the reaction times and firing patterns of the peroneal muscles were significantly slower

than in the stable contra-lateral ankles (Karlsson & Andreasson, 1992). They concluded

that ankle tape may help shorten the reaction time of the peroneus muscles by improving

the proprioceptive function of the ankle. Since the tape significantly reduced peroneus

muscle reaction time, Karlsson and Andreasson further concluded that tape might

improve functional stability in patients with CAI.

Peroneal Latency (Stretch Reflex)

It has been reported by Palmieri-Smith, Hopkins, & Brown (2009) that the

timely activation of the peroneal muscles after an ankle is forced into inversion is

critical to maximizing ankle stability. When the ankle is forced into inversion, the

muscles and tendons that cross the foot/ankle complex on the lateral side, specifically

the peroneus longus and peroneus brevis, play a key role in preventing or limiting the

severity of a lateral ankle sprain (Heckman, Hyngstrom, & Johnson, 2008). The muscle

spindles in the peroneus longus and brevis are activated when the ankle is rapidly forced

into inversion, causing a reflexive contraction of these muscles to counteract the

lengthening associated with inversion (Heckman et al., 2008). If there is a time delay

from initiation of the ankle inversion movement to onset of the response of peroneus

longus and brevis, the reflex is identified as a peroneal latency, or closed loop reflex,

response (Vaes, Duguet, & Gheluwe, 2002).

Studies have presented conflicting results with respect to the possibility of a

longer peroneal latency response in individuals with functional ankle instability

(Fernandes, Allison, & Hopper, 2000; Freeman et al., 1965; Karlsson & Andreasson,

1992; Myers, Riemann, Hwang, Fu, & Lephart, 2003; Palmieri-Smith et al., 2009).

Myers et al. (2003) examined the muscle-firing characteristics of the anterior tibialis and

peroneus muscles in response to a high speed inversion perturbation and during gait in

13 healthy subjects. The subjects’ anterior talofibular and calcaneofibular ligaments

were injected bilaterally with a 1.5% lidocaine solution or a placebo saline solution to

alter peripheral afferent influence. The results of this study showed a reduction in the

productive response of the anterior tibialis and peroneus muscles during perturbation

and a decrease in mean muscle activation amplitude during running after both injections.

However, no significant differences in muscle reflex latencies, maximum amplitude, and

times to maximum amplitude during inversion perturbation, or mean amplitude during

walking were found. The researchers concluded that the lateral ankle ligaments have a

sensorimotor influence on muscle activation and that dynamic stability may be

compromised because of swelling after joint injury.

Hopkins, Brown, Christensen, and Palmieri-Smith (2009) compared alterations

in peroneal latency and electromechanical delay (EMD) following an inversion

perturbation during walking in patients with functional ankle instability and a control

group. Latencies were collected during a random inversion perturbation while walking

and EMD measures were collected during stance using a percutaneous stimulus. Similar

to the Myers et al. (2003) findings, Hopkins et al. observed delayed peroneus longus

latencies and EMD in the ankles of the functional instability group when compared to

the control group. Hopkins et al. concluded that it was unclear to what extent peroneal

latency and EMD deficits contributed to functional ankle instability, but that muscle

spindle sensitivity likely plays a role in functional ankle instability.

Other research suggests reflex latency may not play a role in patients with a

history of ankle sprains (Ebiq, Lephart, Miller, & Pincivero, 1997; Palmieri-Smith et al.,

2009). Ebiq et al. (1997) examined the electromyographic (EMG) response time of the

peroneal and tibialis anterior muscles in 13 subjects with self-reported functional ankle

instability and 13 subjects with healthy ankles during a sudden plantar flexion/inversion

stress. A platform that forced each foot to suddenly drop into plantar flexion/inversion

from a standing neutral position was used. The results indicated no significant

differences in reflex latency for the peroneal or the tibialis anterior muscles in the stable

or unstable ankles. From these results, Ebiq et al. concluded that diminished reflex

response time of the peroneal and tibialis anterior muscles may not play a role in self-

reported functional ankle instability.

Similarly, Palmieri-Smith et al. (2009) hypothesized that altered afference

resulting from damaged mechanoreceptors after an ankle sprain may lead to reflex

inhibition in the peroneal muscles of functionally unstable ankles and was related to

dynamic peroneal muscle activity. After testing 21 patients having unilateral functional

ankle instability and 21 healthy patients during sudden ankle inversion perturbation

during walking via EMG recordings, the researchers found that peroneal latency was

present in persons with functional ankle instability. However, they also found that the

peroneal latency was not related to dynamic muscle activation. The researchers

concluded that improving the peroneal latency may not assist in protecting a

functionally unstable ankle from further episodes of instability; however, restored

dynamic muscle activation is needed to maximize ankle stabilization.

Assessment of Proprioception

Currently researchers employ one of three techniques to measure proprioception

at the ankle. These techniques include (a) reproduction of joint position,

(b) electromyography, and (c) balance testing using a protocol such as the Star

Excursion Balance Test (Hertel, 2002).

Reproduction of joint position. Perhaps the most widely used methodology for

proprioception assessment is reproduction of joint position (Halseth, McChesney,

DeBeliso, Vaughn, & Lien, 2004; Simoneau, Denger, Kramper, & Kittleson, 1997).

Within this method of testing, the subject’s ankle is passively placed in a specific or

random joint angle, held for 5-10 s, and then returned to neutral position. The subject is

then asked to actively reproduce the joint position by repositioning his/her foot as

closely to the target angle as possible. The closer the subject is able to reproduce the

target angle, the stronger the score and the better the proprioception (Halseth et al.,

2004; Simoneau et al., 1997).

Halseth et al. (2004) used this methodology to investigate the effects of

Kinesio™ taping on proprioception at the ankle. Plantar flexion and inversion with 20°

of plantar flexion reproduction of joint position sense (RJPS) was determined using an

ankle RJPS apparatus. Subjects were barefooted, blindfolded, and equipped with

headphones playing white noise to eliminate visual and auditory cues. Thirty subjects

performed five trials in both plantar flexion and inversion with 20° plantar flexion,

before and after application of the Kinesio™ tape to the anterior/lateral portion of the

ankle to recreate the joint target angle they were initially placed in by the researchers.

No significant differences in the ability of subjects to correctly reposition the joint with

or without the Kinesio™ tape were found. Halseth et al. concluded that Kinesio™ tape

does not enhance proprioception in terms of RJPS.

Electromyography (EMG). A more sensitive method of assessment includes

the use of Electromyography (EMG) to evaluate and record the electrical activity

produced by skeletal muscles (Kamen, 2004). Two types of EMG can be used to

determine muscle activity: (a) intramuscular and (b) surface EMG. Intramuscular EMG

inserts one or more electrodes under the skin into the muscles to be tested via needles.

Surface EMG applies pre-gelled self-adhesive electrode pads to the surface of the skin

over the muscles to be tested (Farr, 2012). In both EMG methods, the electrical activity

of the muscles is measured by the electrodes and displayed on an oscilloscope (a

monitor that displays electrical activity in the form of waves).

Soderberg, Cook, Rider, and Stephenitch (1991) used surface EMG to evaluate

the magnitude and temporal features of the peroneus longus and other muscles in

subjects with CAI and healthy ankles while performing exercises on the Biomechanical

Ankle Platform System (BAPS®) board. The researchers placed the surface EMG

electrode for the peroneus longus muscle 7 cm directly distal to the head of the fibula.

The 14 participants’ maximally evoked EMG signal for the peroneal longus muscle was

recorded while performing three isometric dorsiflexion, eversion, and plantar flexion

contractions. Normalized data sets were determined using the contraction producing the

greatest amount of EMG activity for each exercise. The participants were then

positioned on the BAPS® board to complete as many clockwise and counter-clockwise

rotations within 20 s at a constant velocity of 40 rpm. The results showed that healthy

and CAI ankles responded similarly to the BAPS® board exercises, with the peroneus

longus and other tested muscles ranging from 20-80% of the evoked maximal isometric

contractions.

Laudner and Koschnitzky (2010) used surface EMG to analyze differences in

anterior tibialis, peroneus longus, and medial gastrocnemius muscle activity while

performing rehabilitation exercises on the flat compared to the bladder sides of a

BOSU™ balance trainer. The 20 participants were required to perform three trials of a

single leg stance for 10 s on each side of the BOSU™ balance trainer. The researchers

saw overall increases in muscle activity when using either side of the BOSU™ balance

trainer, but no significant difference in muscle activity when comparing the results from

alternating sides of the BOSU™ balance trainer.

Balance testing. The least invasive method of evaluating proprioceptive deficits

is through participation in balance testing/functional fatigue protocols. The most

common protocol used to achieve this methodology is the Star Excursion Balance Test

(SEBT) (Gribble, Hertel, & Denegar, 2007; Hertel, Braham, Hale, & Olmsted-Kramer,

2006; Olmsted, Carcia, & Shultz, 2002). The SEBT is performed with the subject

standing at the center of a grid placed on the floor, with eight lines extending at 45°

increments from the center of the grid (Hertel et al., 2006). The eight lines positioned on

the grid are labeled according to the direction of excursion relative to the stance leg: (a)

anterolateral (AL), (b) anterior (A), (c) anteromedial (AM), (d) medial (M),

(e) posteromedial (PM), (f) posterior (P), (g) posterolateral (PL), and (h) lateral (L).

During a single leg stance on the ankle with chronic ankle instability, subjects perform

three trials trying to touch the furthest point possible on a line with the most distal part

of their non-injured foot. The distance between the axis of where all the lines meet on

the center of the grid and the furthest point reached with the foot is measured to

compare reach deficits between the CAI and healthy ankles (Hertel et al., 2006).

Olmsted et al. (2002) enlisted 20 subjects with unilateral CAI and 20 uninjured

subjects matched by sex, sport, and position to participate in a SEBT study.

Measurements were taken in all eight directions and then averaged over three trials

while the subject stood on each leg for data analysis. They found significantly decreased

reach in the CAI group while standing on the injured limb compared with the matched

limb of the uninjured group. Additionally, subjects with CAI reached significantly less

when standing on their injured limbs as compared with their uninjured limbs (Olmsted

et al., 2002).

Neuromuscular Control

The exact mechanism for altered neuromuscular control following an ankle

sprain is not completely understood. Neuromuscular control relies on the central

nervous system to interpret and integrate proprioceptive and kinesthetic information to

control individual muscles and joints to produce coordinated movement (Swanson,

1998). The ability to sense the position of a joint in space is mediated by

mechanoreceptors found in both muscle and joint and by cutaneous, visual, and

vestibular input (Lephart, Swanik, & Fu, 2004). Muscle mechanoreceptors have been

shown to play a more important role in signaling joint position (Tripp, 2006). The joint

mechanoreceptors likely serve in collaboration with the muscle mechanoreceptors to

establish neuromuscular control. Due to the working relationship between the joint and

muscle mechanoreceptors, rehabilitation exercises should focus on both neuromuscular

control and proprioception to decrease the functional insufficiencies found in CAI.

Rehabilitation for CAI

Due to the relatively common nature of ankle sprains, clinicians may elect to

follow a number of different protocols when rehabilitating an ankle sprain. While

ultimately the treatment varies depending on the severity of the condition and the

clinician’s preferences, there are some foundational guidelines that must be addressed

throughout the course of rehabilitation.

Rehabilitation of the injured ankle is divided into five phases: (a) acute, (b) sub-

acute, (c) rehabilitative, (d) functional, (e) and prophylactic (Safran, Zachazewski,

Benedetti, Bartolozzi, & Mandelbaum, 1999). Clinicians should design their treatment

protocol to fit the requirements of each phase. The primary focus of the acute phase of

rehabilitation is centered around controlling swelling and minimizing pain by using rest,

ice, compression, and elevation (RICE) immediately after injury (Prentice & Arnheim,

2006). The sub-acute phase is centered on decreasing and eliminating pain, increasing

pain free range of motion, continuing protection against re-injury with bracing, limiting

loss of strength with isometric exercises, and continued utilization of ultrasound and

electro-stimulation modalities (Safran et al., 1999). The rehabilitative phase emphasizes

regaining range of motion with joint mobilization and stretching, increasing strength

with isotonic and isokinetic exercises, and employing proprioceptive training (Safran et

al., 1999). The functional phase focuses on the sports-specific exercises with a goal of

returning the patient to sport participation (Safran et al., 1999). The prophylactic phase

attempts to prevent the recurrence of injury through strengthening, functional

proprioceptive drills, and support as needed (Safran et al., 1999).

Although all five phases are important to the recovery process from ankle

sprains, the rehabilitative phase must significantly address the inhibited proprioception

and neuromuscular control in CAI, if functional instability wants to be decreased as a

contributing factor (Mattacola & Dwyer, 2002). As previously mentioned,

proprioception and kinesthesia are responsible for joint position sense and detection of

movement, respectively (Prentice & Arnheim, 2006). Reestablishing proprioception and

kinesthesia is necessary to enhance neuromuscular control and should be of primary

concern to the athletic trainer (Lephart et al., 2004).

Balance Training

Several studies have found that balance training enhances proprioceptive and

neuromuscular control in functionally unstable ankles and/or stable ankles (Elis &

Rosenbaum, 2001; Emery, Cassidy, Klassen, Rosychuk, & Rowe, 2005; McKeon et al.,

2008; Rozzi, Lephart, Sterner, & Kuligowski, 1999; Yaggie & Campbell, 2006).

Balance training assists in restoring ankle joint stability and existing proprioceptive

deficits by retraining altered afferent neuromuscular pathways (Rozzi et al., 1999).

Rozzi et al. (1999) examined the effectiveness of balance training in improving

proprioception in stable and unstable ankles. Twenty-six subjects (13 with self-reported

functionally unstable ankles and 13 with healthy ankles) participated in a unilateral,

multilevel, static and dynamic balance training program 3 times a week for 4 weeks.

The results of the study demonstrated significant improvements in balance ability and

overall perceived ankle joint functional stability in both unstable and stable ankles. The

researchers concluded that balance training is an effective means of improving

proprioception in stable and unstable ankles.

Using only healthy adolescents and a different methodological approach, Emery

et al. (2005) studied the effectiveness of a home-based balance-training program using a

wobble board to improve static and dynamic balance and reduce sports-related injuries.

Subjects were recruited from the physical education classes of 10 schools and randomly

assigned, by school, to either the intervention (n = 66) or the control (n = 61) group.

Students in the intervention group participated in a daily 6-week, followed by a weekly

6-month, home-based balance-training program using a wobble board. Students in the

control group received testing only. The primary outcome measures were timed static

and dynamic balance, 20-m shuttle run, and vertical jump. Improvements in static and

dynamic balance were seen only for the intervention group (difference in static balance

20.7 s, difference in dynamic balance 2.3 s). Similar to the conclusions of Rozzi et al.

(1999) toward the overall concept of using balance training, Emery et al. concluded that

balance training using a wobble board is effective in improving static and dynamic

balance among healthy adolescents.

In further support for the use of balance training, specifically for patients with

CAI, McKeon et al. (2008) investigated the effect of a 4-week balance training program

on static and dynamic postural control and self-reported functional outcomes in those

with CAI. Thirty-one subjects with self-reported CAI were randomly assigned to an

intervention group or a control group. The intervention group participated in a 4-week

supervised balance training program that emphasized dynamic stabilization during a

single-limb stance. Main outcome measures included self-reported disability on the Foot

and Ankle Disability Index (FADI) and the FADI Sport scales, time-to-boundary (TTB)

measures of postural control during a single-leg stance with eyes open and closed, and

reach distance while performing the Star Excursion Balance Test (SEBT). The results

indicated that the balance training group had significant improvements in the FADI and

the FADI Sport scores, in the magnitude and the variability of TTB measures with eyes

closed, and in reach distances with the posteromedial and the posterolateral directions of

the SEBT. From these results, McKeon et al. concluded that balance training

significantly improved self-reported function, as well as static and dynamic postural

control in individuals with CAI.

Balance Training on Stable and Unstable Surfaces

Within the realms of athletic training, physical therapy, and sports medicine,

commonly used rehabilitation protocols for the progression of balance training exercises

are followed. Common progressions when performing balance exercises include:

(a) moving from a position of non-weight bearing to weight bearing, (b) bilateral stance

to unilateral stance, (c) eyes open to eyes closed, (d) firm surface to soft surface, and (d)

uneven to moving surface (Hintermann, 1999).

The progression of balance exercises for proprioception starts with simple static

balance activities, including the single-leg stance with eyes open. The patient stands on

a hard, flat, stable surface (e.g., the floor), weight supported on the foot of the involved

leg, and arms at sides. The goal of the single-leg stance with eyes open exercise is for

the patient to stand/balance on the involved leg for 30 s without touching the elevated

foot to the floor (Houglum, 2001).

Once the patient completes the single-leg stance for 30 s with eyes open, the

exercise progresses in difficulty by having the patient perform the single-leg stance with

eyes closed. Removing the patient’s visual ability by closing the eyes eliminates the

patient’s ability to focus and concentrate on stationary items to help control balance;

thereby, forcing the body to rely on its mechano- and sensory receptors to work harder

to maintain balance.

After the patient masters the single-leg stance for 30 s with eyes closed, the

balance training activity progresses to single-leg stance with eyes open and closed on an

unstable surface (Houglum, 2001). This progression causes a heightened mechano- and

sensory receptor response to counteract the change in surface so balance can be

maintained. The unstable surface also affects the vestibular (inner ear) component of

proprioception by causing the inner ear fluid, which assists with balance when it is

standing still within the ear, to shift and throw balance off.

To accomplish balance activities on an unstable surface, clinicians have a wide

variety of equipment (i.e. wobble board, foam balance mat, BOSUTM balance trainer)

available to them that is designed to improve proprioception. Any of the static balance

exercises described above can be performed on these pieces of equipment to enhance

proprioception of the ankle.

BOSU™ Balance Trainer for Proprioceptive Enhancement

The Both Sides Up balance trainer (BOSU; FitnessQuest, Canton, OH) is one

apparatus that was designed for balance training on an unstable surface. The BOSU™

balance trainer has a solid plastic base on one side and an inflatable rubber half ball

bladder on the other side. When the BOSU™ balance trainer’s solid surface is facing

down, it provides an unstable surface on stable ground (Yaggie & Campbell, 2006).

The BOSU™ balance trainer is designed for use during the rehabilitative and

prophylactic phases of rehabilitation. Its use has been shown to effectively return

patients to a high functional level following CAI (Coughlin & Caulfield, 2007).

“Exercise on an unstable surface such as the BOSU results in distorted somatosensory

feedback, placing greater demands on the subject to react to an unexpected perturbation

and, thus, to develop consistent motor patterns (Coughlin and Caulfield, 2007, p.55).”

The BOSU™ balance trainer is more advantageous in proprioceptive training than other

devices (e.g., a wobble board or ankle disk) because it allows more dynamic exercises to

be performed safely by the patient (Coughlin & Caulfield, 2007).

Wahl and Behm (2008) examined EMG activity during standing and squatting

postures while balancing on a variety of unstable platforms (Dyna Disc, BOSU® ball,

wobble board, and a Swiss ball) and a stable floor. Results of this study, specific to the

BOSU® ball, revealed that the BOSU® ball did not exhibit significant differences in

muscle activation under any conditions. They concluded that the use of moderately

unstable training devices, including the BOSU® ball, did not provide sufficient

challenges to the neuromuscular system in highly resistance-trained individuals.

Laudner and Koshnitzky (2010) examined which side of the BOSU™ balance

trainer would generate a greater amount of tibialis anterior, peroneus longus, or medial

gastrocnemius muscle activity using electromyography (EMG). Twenty healthy

collegiate male subjects performed three single-leg stance trials on each side of the

BOSU™ balance trainer. The average EMG data from these trials were compared with

maximal voluntary isometric contraction (MVIC) measures. The researchers observed

an increase in muscle activity for the tibialis anterior, peroneus longus and medial

gastrocnemius during the exercise protocol. However, the results indicated no

significant differences in EMG activity for all three muscles between the stable and

unstable sides of the BOSU™ balance trainer (p > 0.54). They concluded that no

particular side of the BOSU™ balance trainer provides any increase in muscle activity

compared with the other side when used for improvements in balance or during the

rehabilitation of lower extremity injuries. However, the BOSU™ balance trainer does

elicit overall increases in muscle activity during proprioceptive exercises.

The debate over the use of unstable training devices is mostly due to

incomparable methodologies that include different body parts (i.e. knee, ankle), exercise

protocols, and equipment being used in each study. No conclusive evidence has been

shown in the effectiveness of the BOSU™ balance trainer compared to other balance

equipment (i.e. wobble board, DynaDisk). Therefore, the use of the BOSU™ balance

trainer is still considered a valuable piece of rehabilitation equipment and is widely used

in rehabilitation clinics and athletic training rooms for improving proprioception in the

functionally unstable ankle.

Kinesio™ Tape

Ankle taping is not a new concept; Robbins and Waked (1998) reported that

taping is still the prime means of preventing ankle sprains in sports. Traditional white

athletic tape is the accepted choice for trying to prevent ankle sprains because it is

structurally supportive of the ligaments. However, it is of limited value in a

rehabilitation setting because its rigidity interferes with normal function (Bicici,

Karatas, & Baltaci, 2012). To address this issue, clinicians have recently turned to

using a relatively new product called Kinesio™ tape and its associated method of

taping, called kinesiotaping, to examine its therapeutic effects and functionality to

rehabilitate CAI (Bicici et al., 2012; Halseth et al., 2004).

Kinesio™ tape is different from traditional white athletic tape in that it has

elasticity in one direction that provides a constant pulling force to the skin. Before

applying it to the skin, it can be stretched to 140% of its original length (Halseth et al.,

2004). Unlike traditional white tape, Kinesio™ tape relies on tension and

approximation of placement in relation to tissue for it to elicit therapeutic effects on the

body. Tension can be defined as light (15-25%), moderate (25-50%), severe (50-75%),

and full (75-100%). Kinesio tape application may be used to inhibit or facilitate

movement (Bicici, et al., 2012; Halseth et al., 2004, Kase, 1996). The application of

tape depends on the rehabilitative goal of the practitioner. In order to inhibit motion,

the tape is applied from the insertion to origin of the muscle. To facilitate movement,

the tape is applied from the muscle’s origin to insertion (Bicici et al, 2012; Halseth et

al., 2004, Kase, 1996). Kinesio™ tape is also air permeable, water resistant, and can be

worn for several days without removal (Bicici et al, 2012; Halseth et al., 2004, Kase,

1996).

Benefits of Kinesio™ Tape

Rather than being structurally supportive, Kinesio ™ tape appears to be more

therapeutic in nature. Kase (1996) reports the benefits of Kinesio ™ tape include:

(a) correction of muscle function by strengthening weakened muscles, (b) improved

circulation of blood and lymph by eliminating tissue fluid or bleeding beneath the skin

by microscopically lifting the skin, (c) decreased pain through neurological

suppression, and (d) repositioning of subluxed joints by relieving abnormal muscle

tension, thereby helping to return function to fascia and muscle. Murray and Husk

(2001) have suggested increased proprioception through increased stimulation to

cutaneous mechanoreceptors as another potential benefit of Kinesio™ tape.

Effects of Kinesio™ Tape on Ankle Proprioception

Kinesio™ tape’s ability to mimic the movement of the body’s skin allows for a

constant sheer force on the skin (Halseth et al., 2004). Murray and Husk (2001) propose

that this constant sheer force from the Kinesio™ tape provides increased enhancement of

ankle proprioception by way of cutaneous facilitation.

Murray and Husk (2001) examined the effect of Kinesio™ tape compared to no

tape and white athletic tape on proprioception in the ankle. Twenty-six healthy subjects,

ages 20-49, with normal ligamentous stability in their dominant ankles participated in this

study. A single group, repeated measures design was used to compare replicated target

angles while wearing Kinesio™ tape, white tape, and no tape. The researchers asked

subjects to replicate target joint angles at 26o and 10o of plantarflexion and at 8o of

dorsiflexion. The replication angles were measured using an electrogoniometer and a

dynamometer set at W/sec with the axis of rotation inferior to the lateral malleolus.

Absolute differences between the target/reference angle and each replication for each

condition were calculated, deviation scores were formed for each condition at each test

angle, and then scores were compared using repeated measures ANOVA for each of the

three angles. The results indicated significant differences for the Kinesio™ tape at 10o

plantar flexion, but not at the other angles. No significant differences were found between

tape conditions. The researchers concluded that Kinesio™ tape improved proprioception

in healthy subjects at a region of facilitation (mid-range) where ligament

mechanoreceptors are normally inactive and supported the use of Kinesio™ tape to

further enhance proprioception during rehabilitation of the ankle.

In a similar study, Halseth et al (2004) explored the potential proprioceptive

benefits associated with Kinesio™ taping of the anterior and lateral portions of the ankle.

Thirty healthy subjects performed five trials of joint angle reproduction in both plantar

flexion and inversion with 20o plantar flexion before and after application of Kinesio™

tape to the anterior and lateral portion of the ankle. Reproduction of joint position sense

(RJPS) was determined using an ankle RJPS apparatus. No significant difference was

found in either absolute or constant error between the no tape and Kinesio™ taped

conditions in either plantar flexion or inversion with 20o of planter flexion. The

researchers concluded that Kinesio ™ tape does not enhance proprioception when

measured by active ankle RJPS in healthy subjects.

Briem et al. (2011) examined the effects of Kinesio™ tape and traditional athletic

tape compared to no tape on peroneal muscle activity during a sudden inversion

perturbation. Fifteen participants with high functional ankle stability and 15 participants

with high functional ankle instability were tested under three conditions: (a) ankle taped

with Kinesio™ tape, (b) ankle taped with nonelastic sports tape, and (c) ankle not taped.

Muscle activity of the peroneal longus was recorded with surface EMG. Differences in

peak muscle activity and in time to peak muscle activity were evaluated. Kinesio ™ tape

was found to have no significant effect on mean muscle activity compared to the no tape

condition, while traditional athletic tape caused a significantly greater mean muscle

activity compared to the no tape condition. None of the conditions had a significant effect

on the amount of time to peak muscle activity. The researchers concluded that because

Kinesio™ tape had no effect on peroneal muscle activity, it would not be beneficial for

use in preventing ankle sprains. On the other hand, traditional white tape enhanced

dynamic muscle activity of the peroneus longus and would have a positive effect in

preventing ankle sprains.

Simon, Garcia, and Docherty (2014) examined the effect of Kinesio™ tape on

force sense in people with functional ankle instability. Twenty-eight subjects (14 healthy

and 14 with functional ankle instability) participated in this study. Kinesio™ tape was

applied to the lateral ankles of the subjects with functional ankle instability and the

healthy subjects received no tape. Proprioception in both groups was measured using

eversion force sense at 30% of the eversion maximum voluntary isometric contraction

before Kinesio™ tape application, immediately after Kinesio™ tape application, and 72

hrs post Kinesio™ tape application. The results showed that the Kinesio™ tape group

had significantly more force sense errors than the control group at baseline and

immediately after tape application. However, after wearing the tape for 72 hrs, no

significant differences were identified between the groups. The researchers concluded

that Kinesio™ tape improves proprioceptive deficits and increases conscious

proprioceptive awareness if worn for an extended amount of time.

Summary

One goal of rehabilitation for CAI focuses around improving proprioception and

neuromuscular control deficits that are commonly seen in the functionally unstable ankle.

Rehabilitative exercises that required patients with CAI to perform balance training on

stable and unstable surfaces have been shown to provide increases in proprioception. The

BOSU™ balance trainer is one type of balance training device that has demonstrated

positive results in proprioceptive enhancement in those with CAI.

Within the rehabilitation setting, clinicians have begun examining the use of

Kinesio™ tape for its therapeutic effects in improving proprioception. However, only a

limited number of studies have examined the proposed proprioceptive benefits that

Kinesio™ tape has on the ankle and even fewer studies have tested it on subjects with

CAI. These studies have reported conflicting findings toward the ability of Kinesio™

tape to enhance proprioception in the ankle and no conclusive decisions have been made;

thus promoting the need for more studies on its use in the patient with CAI.

To date, no studies examining the effect of Kinesio™ tape on muscle activity in

patients with CAI while performing balance training rehabilitation exercises on the

BOSU™ balance training system have been conducted. The purpose of this study was to

investigate the effects of Kinesio™ tape on peroneal muscle activity during common

therapeutic exercises (i.e. single leg stance on a stable surface with eyes open, single leg

stance on a stable surface with eyes closed, single leg stance on BOSU™ balance trainer

with eyes open) in patients with CAI. If Kinesio™ tape is shown to provide

proprioceptive enhancement and increased peroneal muscular activity during balance

training rehabilitation exercises, it may serve as a means to speed the neural re-education

process and improve ankle stability in those with CAI.

CHAPTER 3

RESEARCH METHODOLOGY

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI). This chapter contains information describing the

(a) Participants, (b) Instrumentation, (c) Procedures, and (d) Statistical Analysis of the

study.

Participants

Eighteen college students age 18-30 yrs (12 Male and 6 Female) with Chronic

Ankle Instability (CAI) were recruited from a Midwestern University to participate in

this study. Fifteen participants completed the entire study. Participants were recruited

via flyers posted throughout the University’s athletic training rooms and by word of

mouth. Prior to starting the study, participants were asked to read and sign an informed

consent form that was approved by the University’s Institutional Review Board (see

Appendix A).

Inclusion criteria for the study required participants to self-report a history (see

Appendix B) of ankle trauma with repeated bouts of injury or “giving way”. A score of

90% or less on the Foot and Ankle Disability Index (FADI) sport survey (see Appendix

C) was used to confirm CAI in each participant prior to starting the testing protocol.

Participants were excluded if they met any of the following criteria:

(a) an ankle trauma within the last three months, (b) a history of any surgical

intervention to the ankle, (c) disorders/diseases affecting the musculoskeletal system or

balance, (d) fractures or other associated injuries to the ankle, knee, and hip, and (e)

deformities of the foot or ankle. This information was collected in the Health History

Questionnaire prior to participation (see Appendix B).

Instrumentation

A BIOPAC MP-150 EMG system was used to record peroneal muscle activity

amplitude (MAA) at a frequency of 1,000 Hz per. Disposable pre-gelled Ag-AgCl

surface electrodes with a circular contact area of 1-cm-diameter on a 41-mm-diameter

moisture resistant backing (BIOPAC Systems, Inc., Goleta, CA, USA) were applied to

the skin to measure MAA.

A three-step process was used for calibration of the BIOPAC MP-150 EMG.

The first step was the establishment of baseline noise thresholds. With the input

terminals to the receiving amplifier grounded, the acquired noise signal was achieved

when a flat-line trace with an amplitude range of 150 mV peak or less was noted on the

EMG system (Macey, 2001). The second step was the time delay measurement. Precise

time delay calibration between the trigger of the auditory signal to the sensing of the

signal was required to elicit confidence in the actual measurements of the Auditory

Brainstem Response (Macey, 2001). The third and final calibration step was the artifact

rejection. Spurious signals from ambient outside noise sources were filtered prior to

peroneal muscle measurements being recorded (Macey, 2001). All EMG procedures

were applied and conducted by a single certified athletic trainer.

Pilot Study

A pilot study consisting of two volunteers (1 Male, 1 Female) from the Midwest

University was conducted in order to evaluate the effectiveness and efficiency of the

measurement and treatment methods to be used in this study. Measurements were taken

and recorded, but no data analysis was conducted. The preliminary study allowed the

researcher to become familiar with the procedures to be followed for collecting data for

the study and for modifications to be made prior to the start of the true experimental

testing procedures.

Procedures

Participants reported to the lab on five different occasions over an eight day time

span (Days 1-8). An overview of the procedures for each day is represented in Figure 4.

Day 1: Informed Consent and Inclusion Determination

Participants were familiarized with the experimental procedures, risks or

discomforts, benefits, and rights associated with the study. Participants then signed the

informed consent form approved by the University’s Institutional Review Board (see

Appendix A). After participants voluntarily consented to be involved in this study, they

completed the health history (see Appendix B) and the FADI survey (see Appendix C).

Participants that met the criteria for inclusion with a score of 90% or less on the FADI

and a health history identifying no ankle surgeries or recent ankle trauma, were

instructed to report back to the lab the next day (24 + 1 hr) at their assigned times.

Day 2: MAA for SLS-Eyes Open, No-Tape followed by Tape

Participants returned to the lab and were connected to the EMG system to record

peroneal muscle activity amplitude (MAA). Disposable pre-gelled electrodes were

applied to the skin after the areas were shaved with a Bic razor, abraded with sandpaper,

and cleansed with 70% isopropyl alcohol. Three electrodes were utilized during data

collection.

EMG protocol. Electrode #1 was placed on the tibial tuberosity of the testing

leg to serve as a ground. Electrode #2 was responsible for MAA collection and was

placed 3-cm proximal and 1-in posterior to the lateral malleolus. Electrode #3 was

placed 2-cm superior to electrode #2 when measured from center of electrode to center

of electrode. These positions were marked with a permanent marker to ensure matching

placement on subsequent days (see Figure 5). Before being connected to the EMG unit,

the MP-150 EMG system was calibrated to ensure the reliability of signal collection.

Utilizing surface electrodes, peroneal muscle activity was measured over the course of

three exercises, each lasting a total of 30 s respectively.

Rehabilitation exercise protocol. Once connected to the EMG system, the

participant completed proprioceptive rehabilitation exercises without Kinesio ™ tape in

Figure 4: Overview of procedures by day. HHQ = Health History Questionnaire; FADI = Foot and Ankle Disability Index; SLS = Single Leg Stance; BOSU = Both Sides Up balance training system.

order to compile baseline MAA readings. The exercise protocol for Day 2 included: (a) a

single leg stance with eyes open (SLS-eyes open) on a stable surface (i.e. the floor) and

(b) a single leg stance with eyes open on a BOSU ™ balance trainer (SLS-BOSU).

The BOSU™ (Both Sides Up) balance trainer is so named because both sides of

the piece of equipment can be used for balance training. One side has a flat solid base to

provide a stable surface while the other side has an inflatable bladder that provides an

unstable surface (see Figure 6). Both sides can be used to progress a patient through

proprioceptive rehabilitation. In recent years, the BOSU™ balance trainer has become

increasingly popular for athletic trainers and physical therapist who wish to introduce a

dynamic surface training into ankle rehabilitation. The inflatable bladder portion is used

Figure 5. Markings for electrode placement.

to help challenge the mechanoreceptors to respond to the dynamically changing surface

through increased muscle activity when the patient is balancing on it.

In accordance with manufacture recommendations, this study utilized the

inflatable bladder portion The participant was instructed to perform a barefoot SLS with

his/her eyes open, hands on the hips, and the opposite leg flexed under the body, but not

touching the balancing leg, which was allowed to be slightly flexed. The participant was

advised to focus on a specific point in front of him/her. If at any point the participant

broke form, the data was discarded and the trial repeated. A break in form included

removing the hands from the waist, touchdown of the non-balancing leg, touching the

balancing leg, or leaving the surface of the BOSU™ balance trainer.

Each participant was allowed one practice test to become familiar with the

exercise. Following the practice test, the participant was required to perform three trials

of the SLS-eyes open on a stable surface exercise, followed by three trials of the SLS-

eyes open on the BOSU™ balance trainer (bladder side up). For each exercise, one trial

involved a SLS performed for 10 s, followed by a 30 s rest period before moving to the

Figure 6. BOSU™ balance trainer with inflatable bladder side up. Bladder provides a dynamic surface for the patient to balance on; while the grey flat solid base (side down in this figure) provides a stable surface to balance on. Adapted from: www.kodiaksports.com

next trial. Additionally, each participant was allowed to establish balance prior to the

participant being given the command to begin each trial.

Peroneal muscle activity measurements. To quantify proprioception, EMG

was utilized to measure muscle activity amplitude (MAA). The raw EMG signals

were filtered with 1.0 Hz high-pass and 5,000 Hz low pass frequencies. A root mean

square analysis was utilized with gain set to 2,000. The overall sampling rate was

1,000 samples per second. Before every participant was connected to the EMG

system, the unit was calibrated using the aforementioned protocol. For this study, a

root mean square (RMS) was applied to raw movement EMG signals collected

during the exercises, via the AcqKnowledge (BIOPAC Systems, Inc.) as

recommended by Basmajian and DeLuca (1985).

Once the no-tape recordings were completed, Kinesio™ tape was applied to the

participant’s CAI ankle. Following tape application, the participant repeated the Day 2

protocol: SLS-eyes open on stable surface and SLS-eyes open on BOSU™ balance

trainer rehabilitation exercise protocol while wearing the tape.

After completion of the rehabilitation exercise protocol while wearing the

Kinesio™ tape, the participant was instructed to keep the Kinesio™ tape on until he/she

returned on Day 3 (24 + 1 hr) unless allergic reaction occurred. In cases of allergic

reaction, the participant was told to immediately remove the tape, seek medical attention

as needed, and contact the researcher to be excluded from the study.

Kinesio™ tape application. To assist with reliability, all taping applications

were applied by only the researcher, who is a certified athletic trainer. Kinesio™ Tex

Brand tape was used throughout the study. The researcher was trained in Kinesio™

taping techniques by a Certified Kinesio™ Tape Specialist from the Kinesio™ Tape

Company. Prior to tape application, the participant was placed in a side-lying position

on the uninvolved side. The involved foot was positioned hanging off the table with the

ankle dorsiflexed and inverted to increase tissue tension. The researcher applied the

tape using the facilitation method (tape applied from origin to insertion of the muscle),

from the fibular head to the sesamoid bones located under the first metatarsal, using a

30% stretch on the tape. The tape covered the inferior two thirds of the lateral surface of

the fibula, over the peroneals, and the base of the 5th metatarsal. A cut-out was made in

the tape to accommodate the electrode nodes and EMG wires.

Day 3: MAA for SLS-Eyes Open, Tape followed by No-Tape

Still wearing the Kinesio™ tape that was applied on Day 2, participants returned

to the lab 24 hr + 1 hr after completing the Day 2 protocol. Following the same EMG

protocol from Day 2, participants were connected to the EMG system. Continuity of

electrode placement was ensured by using the markers applied to the skin on the

previous day.

Next, participants repeated the three trials of SLS-eyes open on a stable surface

and on the BOSU™ balance trainer exercise protocol that was used on Day 2. Peroneal

MAA during the exercises was collected again using the peroneal muscle activity

measurement protocol from Day 2. Following the MAA data collection, the Kinesio™

tape was removed and the SLS-eyes open exercise on a stable surface and on the

BOSU™ balance trainer exercise protocol was repeated for a final time with no tape on

the involved ankle.

Days 4-6: Rest and Recovery

No testing procedures were conducted on days 4-6 of this study. Participants

were recruited to come back for final testing on Day 7. The rest period allowed for

peroneal muscle recovery before progressing the testing procedures to a more advanced

proprioception balance exercise.

Day 7: MAA for SLS-Eyes Closed, No-Tape followed by Tape

Participants returned to the lab to complete a new exercise protocol. The same

electrode placement, peroneal muscle activity measurements, and Kinesio™ tape

application protocols were followed as on Day 2.

Rehabilitation exercise protocol. Once connected to the EMG system, the

participant completed CAI rehabilitation exercises without Kinesio ™ tape, in order to

compile MAA readings for a SLS with eyes closed on a flat, stable surface exercise

protocol. Similar to the SLS-eyes open protocol, each participant was allowed one

practice test in order to familiarize himself/herself with the exercise. Following the

practice test, the participant was required to perform three trials of the SLS-eyes closed

on a stable surface. For each exercise, one trial of the SLS was performed for 10 s,

followed by a 30 s rest period before moving on to the next trial. Additionally, each

participant was allowed to establish balance prior to the participant being given the

command to begin each trial.

Once no-tape MAA recordings were completed, Kinesio™ tape was applied to

the participant’s involved ankle using the same taping technique from Day 2. Following

the Kinesio™ tape application, the participant was asked to repeat the eyes closed

protocol while wearing the tape.

After completion of the rehabilitation exercise protocol while wearing the

Kinesio™ tape, the participant was disconnected from the EMG system. The participant

was then instructed to keep the Kinesio™ tape on until he/she returned on Day 8 (24 hr +

1 hr); unless allergic reaction occurred, in which case the participant was to immediately

remove the tape, seek medical attention as needed, and contact the researcher to be

excluded from the study.

Day 8: MAA for SLS-Eyes Closed, Tape followed by No-Tape

Participants returned to the lab within 24 + 1hr after completing the testing

procedures on Day 7. Participants were once again connected to the EMG system and

required to complete another series of the SLS-eyes closed on a stable surface exercise

for three trials of 10 s, with 30 s rest periods between trials. Once the exercise protocol

was completed, the Kinesio™ tape was removed and the SLS-eyes closed on a stable

surface protocol was repeated for a final time. Following the completion of the

exercises, participants were disconnected from the EMG system and thanked for their

time and participation.

Statistical Analysis

Means and standard deviations for the conditions of Single Leg Stance with

eyes open (SLS-eyes open) on a stable surface Day 1 and Day 2, Single Leg Stance

with eyes closed (SLS-eyes closed) on a stable surface Day 1 and Day 2, and Single

Leg Stance on bladder portion of BOSUTM balance training system (SLS-BOSU) Day 1

and Day 2 were calculated and reported. The dependent variable, peroneal muscle

activity amplitude (MAA), for each of the three conditions was analyzed using a 2

(Tape/No Tape Condition) x 2 (Day) repeated measures ANOVA. An alpha level of

p < .05 was used for all hypothesis testing statistics. All significant ANOVA effects

were further analyzed using a post-hoc analysis of simple main effects.

CHAPTER 4

RESULTS & DISCUSSION

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI). Results and discussion of the analyzed data are included in this

chapter.

Participants

Eighteen subjects volunteered to participate in this study. A total of 15

participants (age = 20.8 ± 1.7 yrs) completed the study (5 females, 10 males). The

mean age of the female population was 20.6 ± 2.3 yrs, while the mean age of the male

population was 21± 1.8 yrs. Of the three participants that withdrew, two withdrew due

to scheduling conflicts and one due to an unrelated injury.

Results

Peroneal MAA was measured in millivolts (mV) while participants completed the

Single Leg Stance (SLS) therapeutic exercise protocol. Muscle activity was measured

over the course of three trials; each trial lasting 10 s respectively, with a 30 s rest period

between trials (see Appendix D). The dependent variable (peroneal MAA) was

statistically analyzed using a 2 x 2 (Tape/No Tape Condition x Day) repeated measures

ANOVA. The results of the study are presented below.

Results of MAA during SLS-Eyes Open

The descriptive statistics for the MAA during SLS-eyes open on a stable surface

are located in Table 1. The results of the ANOVA analysis are listed in Table 2. The main

effect for Tape/No Tape Condition was not statistically significant (F (1, 16) = 0.47, p =

0.51). Likewise no significant effect was found for the main effect of Day (F (1, 16) =

0.05, p = 0.82). The interaction of Tape/No Tape Condition x Day was not statistically

significant (F (1, 16) =1.83, p = 0.20).

Table 1 Means and Standard Deviations for MAA (mV) during Single Leg Stance-Eyes Open Day 1 Day 2 Group a M SD M SD No Tape 5.73 2.00 5.38 1.78 Tape 5.57 1.73 5.76 1.61 Note. an = 17. Table 2 ANOVA Summary table of MAA Single Leg Stance-Eyes Open (Tape/No Tape) x (Day)

dF MS F p Tape/No Tape 1 0.21 0.47 0.51 Day 1 0.98 0.05 0.82 Tape/No Tape x Day 1 1.16 1.83 0.20

Results of MAA during SLS-Eyes Closed

The descriptive statistics for the MAA during SLS-eyes closed on a stable

surface are located in Table 3. The results of the ANOVA analysis are listed in Table 4.

The main effect for the Tape condition was not statistically significant (F (1, 14) = 4.27,

p = 0.06). The main effect for Day was also not significant (F (1, 14) = 0.13, p = 0.71).

However, an interaction between Tape x Day was found (F (1, 14) = 30.60, p = 0.00).

As indicated by a post-hoc analysis of simple main effects, there was a significant

difference in peroneal MAA on Day 2 (Tape M = 10.38, SD = 2.78, No Tape M = 8.72,

SD = 2.38), No Tape x Day (Day 1 M = 9.96, SD = 2.38, Day 2 M = 8.72, SD = 2.38),

and Tape x Day (Day 1 M = 9.39, SD = 2.39, Day 2 M = 10.38, SD = 2.7).

Table 5 summarizes the results of the post-hoc analysis for the Condition x Day

interaction. Figure 7 summarizes the peroneal MAA for the SLS-eyes closed trials.

Table 3 Means and Standard Deviations for MAA (mV) during Single Leg Stance-Eyes Closed

Day 1 Day 2 Groupa M SD M SD No Tape 9.96 2.38 8.72 2.38 Tape 9.39 2.39 10.38 2.78 Note. an = 15. Participants completing this section of the study represented 15 of 18 volunteers. Table 4 ANOVA Summary table of MAA Single Leg Stance-Eyes Closed (Condition) x (Day) dF MS F p Tape/No Tape 1 4.43 4.27 0.06 Day 1 0.25 0.13 0.71 Tape/No Tape x Day 1 18.78 30.60 0.00 Table 5 Summary of results from the post-hoc analysis of the Day x Condition Interaction for Single Leg Stance- Eyes Closed. An analysis of simple main effects was used to identify significant differences. Type of Interaction

Mean Difference

SE Difference

Condition within Day Day 1 Tape vs. No-Tape 0.57 0.31 0.08 Day 2 Tape vs. No-Tape 1.70 0.35 0.00

Day within Condition No-Tape Day 1 vs. Day 2 1.25 0.35 0.00

Tape Day 1 vs. Day 2 0.99 0.43 0.04

Results of MAA during SLS-BOSU.

The descriptive statistics for the MAA during SLS-eyes open on the BOSU™

balance trainer are presented in Table 6. The results of the ANOVA analysis are

listed in Table 7. The main effect for condition (Tape/No Tape) was not statistically

significant (F (1, 16) = 0.62, p = 0.44). In addition, no significant differences were

found for the main effect of Day (F (1, 16) = 0.83, p = 0.38) nor for the Tape/No

Tape Condition x Day interaction (F (1, 16) = 3.07, p = 0.09).

Figure 7. Summary of the mean peroneal MAA during SLS-eyes closed trials. An analysis of simple main effects was used to analyze the significant interaction found between condition and day [F(1,14) = 30.60, p = 0.00]. During Day 2, a significant difference was found between the Tape and No-tape conditions. In addition a significant decrease in peroneal MAA was found when subjects were not wearing tape (p= 0.00), while a significant increase in peroneal MAA was found when subjects were wearing tape (p=0.04) Table 6 Means and Standard Deviations for MAA (mV) during Single Leg Stance on BOSU™ Balance Trainer

Day 1 Day 2 Groupa M SD M SD No Tape 11.1 3.02 9.98 2.20 Tape 10.6 3.18 10.98 2.60 Note. an = 17. Table 7 ANOVA Summary table of MAA Single Leg Stance (BOSU TM) (Tape/No Tape) x (Day) dF MS F p Tape/No Tape 1 1.26 0.62 0.44 Day 1 2.82 0.83 0.38 Tape/No Tape x Day 1 9.08 3.07 0.10

Day 1 Day 2

P er

on ea

l M A

A in

m V

Tape *

No Tape

Summary of Results

Day 1 EMG showed drops in peroneal MAA between the SLS eyes open-no tape

(5.72mV) to tape group (5.57mV). Day 1 EMG showed drops in peroneal MAA from the

BOSU™ - no tape (11.12mV) to tape group (10.66mV). Lastly, Day 1 EMG showed

drops in peroneal muscle activity between the SLS-eyes closed-no tape (9.96mV), to tape

group (9.39mV).

As was the case with the Day 1 EMG muscle activity, Day 2 peroneal MAA

showed drops from the first condition to the next. Unlike Day 1, Day 2 began with the

tape on the peroneal longus and brevis complex. Day 2 EMG showed drops in peroneal

MAA between the SLS-eyes open-tape (10.38mV) to no tape group (8.72mV). Day 2

EMG muscle activity showed drops in peroneal MAA from the BOSU™-tape

(10.99mV) to no tape group (9.98mV). Lastly, Day 2 EMG showed drops in peroneal

MAA between the SLS-eyes closed-tape (10.38mV) to no tape group (8.72mV).

The creator of Kinesio™ tape, Kenzo Kase, suggests that the tape can be worn for

3 to 5 days. Within this study, when examining the SLS-eyes open exercises performed

on a stable surface, the No Tape Condition showed a decrease in EMG activity from Day

1 (5.72mV) to Day 2 (5.38mV); while the Tape Condition demonstrated an increase in

EMG activity from Day 1 (5.57mV) to Day 2 (5.76mV). However, this increase was

deemed to be non-significant. For SLS exercises performed on the BOSU™ balance

training system, the No Tape Condition showed a decrease in EMG activity from Day 1

(11.12mV) to Day 2 (9.98mV); while the Taped Condition demonstrated an increase

from Day 1(10.66mV) to Day 2 (10.98mV). Once again, this increase was shown to be

non-significant. Finally, for SLS-eyes closed exercises performed on a stable surface, the

No Tape Condition showed a decrease in EMG activity from Day 1 (9.96mV) to Day 2

(8.72mV); while the Taped Condition demonstrated an increase from Day 1 (9.39mV) to

Day 2 (10.38mV). Unlike the changes shown for SLS-eyes open and SLS-BOSU, both

changes in peroneal muscle activity during SLS-eyes closed exercises performed on a

stable surface were determined to be statistically significant (p< .05). Figure 8 provides a

summary of these results.

Figure 8. Means and standard deviations for peroneal muscle activity measured by EMG. A significant

increase in muscle activity was observed when performing single leg stance (SLS) with eyes closed when

wearing Kinesio™ tape while a significant decrease in muscle activity was found when no tape was worn.

No significant differences were found while performing SLS with eyes open or while performing SLS on

a BOSU™ balance trainer with eyes open.

Discussion of Findings

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI). Three directional hypotheses were proposed for this

investigation: (a) Kinesio™ tape will increase EMG activity of the peroneal muscle

group during a single leg stance-eyes open exercise, (b) Kinesio™ tape will increase

EMG activity of the peroneal muscle group during a single leg stance-eyes closed

exercise, and (c) Kinesio™ tape will increase EMG activity of the peroneal muscle

group during a single leg stance, on the bladder portion of a BOSU™ balance trainer.

The findings of this study rejected two of the three hypotheses.

Hypothesis 1

Hypothesis 1 proposed that: Kinesio™ tape will increase EMG activity of the

peroneal muscle group during a single leg stance (eyes open) exercise on a stable

surface. Results of the present study did not support Hypothesis 1. No statistical

differences in peroneal MAA were noted between the taped and non-taped ankle when

participants performed the SLS-eyes open while balancing on a stable surface. The

taped ankle had slightly higher electrical activity than the non-taped ankle; however, the

results were not statistically significant. This finding suggests that the addition of

KinesioTM tape may stimulate the neural receptors located on the skin, but without

significant effects to elicit increases in peroneal muscle activity.

To date, limited studies examining the effect of Kinesio™ tape on peroneal

muscle activity were found in the literature (Briem et al., 2011). Briem et al. (2011)

reported Kinesio™ tape had no significant effect on mean peroneal muscle activity

compared to a no tape condition. Based purely on the concept of Kinesio tape’s effect

on peroneal muscle activity, the results from the present study support the findings of

Briem et al.

Hypothesis 2

Hypothesis 2 proposed that: Kinesio™ tape will increase EMG activity of the

peroneal muscle group during a single leg stance eyes closed exercise on a stable

surface. The results of the present study support Hypothesis 2. Significant increases in

peroneal muscle activity with the application of Kinesio™ tape, during an eyes closed,

single leg stance on a stable surface were revealed. Peroneal muscle activity

significantly increased from Day 1 to Day 2 when the ankle was taped with Kinesio™

tape. On Day 2, a significant increase in peroneal muscle activity was also observed

when participants completed a SLS-eyes closed exercise with Kinesio™ tape applied

compared to the No Tape Condition.

These results conflicted with the findings reported by Briem et al. (2011). As

discussed earlier, Briem et al. reported that Kinesio ™ tape was found to have no

significant effect on mean muscle activity compared to the no tape condition; whereas

the current study found a significant effect. During the Briem et al. study, subjects wore

the tape just long enough to complete the tape testing protocol (~ 1 hour); while in the

present study, participants wore the tape continuously from the start of the tape testing

protocol on Day 1 until the end of the tape testing protocol on Day 2 (~24 hours). The

effects of Kinesio™ tape on muscle activity may be influenced by wear time.

Hypothesis 3

Hypothesis 3 proposed that: Kinesio™ tape will increase EMG activity of the

peroneal muscle group during a single leg stance eyes open, on the bladder portion of a

BOSU™ balance trainer. The results of the present investigation did not support

Hypothesis 3. No statistical difference was noted between the taped group and the non-

taped group during the BOSU™ balance trainer-SLS exercise. As expected, the mean

electrical activity seen during the BOSU™ balance exercise was higher than the other

two conditions due to the unstable surface of the BOSU™ bladder in both the taped and

non-taped ankles. The dynamic surface of the BOSU™ balance training system offered

a noticeable challenge for all subjects. As for the peroneal muscle activity during the

Tape and No Tape conditions, the taped ankles showed minimal increases in activity

compared to the decreases observed in the non-taped ankles. The taped ankles had

slightly higher electrical activity than the non-taped ankles; however, the results were

not statistically significant. These results suggest that the addition of KinesioTM tape

may stimulate the neural receptors located on the skin, but without significant effects to

elicit increases in peroneal muscle activity.

The results of the BOSU™ balance training trials agree with those reported by

Briem et al. (2011) who found no significant effect on mean or maximum muscle

activity in taped verse non-taped peroneals while balancing on a wobble board that was

rigged to cause sudden inversion to the ankle. Unlike Briem et al., this study did not

investigate the potential of Kinesio™ tape as a prophylactic device. While it is unlikely

that Kinesio™ tape will ever serve as a prophylactic measure, its role in muscle re-

education and proprioception is still unclear.

Additional Findings

Table 8 provides a summary of the additional findings from this study compared

with the limited number of studies that could be found in the literature regarding the

effects of Kinesio™ tape on the ankle. The similarities, differences and implications are

further discussed in the upcoming sections. For example, in all studies reported, the

Kinesio™ Tape Condition had no significant difference on peroneal muscle activity

when compared to the No Tape Condition. This finding has warranted some researchers

to dismiss the potential proprioceptive effects of Kinesio™ tape in rehabilitating CAI,

even though only few studies (Bicici et al., 2012; Halseth et al., 2004; Murray & Husk,

2001) including the current one examined it for its therapeutic effects in rehabilitation

protocols.

In the present study no significant difference was found for Day as a main

effect. This result was in contrast to the findings reported by Simon et al. (2014), in

which the number of force sense errors was decreased so significantly after wearing the

tape for 72 hours, that the improvement caused no further significant differences

between the taped and non-taped groups. Simon et al. concluded that Kinesio™ tape

improved proprioceptive deficits and increased conscious proprioceptive awareness if

worn for an extended amount of time. Although Kinesio™ tape is promoted for its

therapeutic effects and ability to be worn for multiple days, research examining the

therapeutic effects of the tape for proprioception and muscle activity need to be

expanded to compare muscle activity changes following wearing the tape over multiple

days.

In general, the present study is one of only two studies that have specifically

examined the effect of Kinesio™ tape on patients that have chronic ankle instability.

Bicici et al. (2012) utilized basketball players with CAI performing the Star Excursion

Balance Test (SEBT). The SEBT measures the distance a subject can reach outside of

their natural center of gravity rather than peroneal muscle activity. The current study

required the participants to maintain a single leg stance on stable and unstable surfaces

with eyes open and closed. Bicici et al. required subjects to maintain a single leg stance

to perform the SEBT. Additionally, Bicici et al. utilized a more comprehensive taping

method across multiple muscles and ligaments than the taping technique used in this

current study. Although the methods were substantially different between the studies,

Bicici et al. saw no significant differences among all the trials of the SEBT when

wearing the tape. This current study found no significant differences for the Tape

Condition during SLS-eyes open and the SLS-BOSU exercises; however, significant

differences were seen during the SLS-eyes closed exercises. Thus promoting the

potential positive impact Kinesio™ tape may have on peroneal muscle activity during

advanced proprioceptive exercises for ankle rehabilitation.

After comparison of the current study with the literature, it is apparent that

further research with standardized methodologies is warranted. Three main

inconsistencies arise among the various methodologies: (1) the dependent variable, (2)

the injury status/history of the participants, and (3) the type of exercise employed. The

four different dependent variables that have been assessed include; (1) joint angle

replication (2 studies); (2) peroneal muscle activity (2 studies); (3) SEBT reach scores

(1 study); and (4) force sense errors (1 study). In addition, some of the studies used only

healthy ankles (Halseth et al, 2004; Murry & Husk, 2001). The injury status of the

subjects included: (1) a combination of both healthy and functionally unstable ankles

(Briem et al., 2011; Simon et al., 2014); or (2) only ankles suffering from CAI (Bicici,

et al., 2012). Finally, the exercise protocols have included: (1) the BOSU™ balance

trainer; (2) an RJPS apparatus; (3) a wobble board; and (4) the use of a preventative

versus rehabilitative strategy. These differences limit the ability of researchers to

directly compare the effects of Kinesio™ tape.

Concepts for Consideration

The current study is the first to examine the effects of Kinesio™ tape on

peroneal muscle activity in individuals with CAI during rehabilitative exercises

typically utilized by Athletic Trainers. The exercises included the SLS-eyes open on a

stable surface, SLS-eyes closed on a stable surface, and SLS-eyes open on the BOSU™

balance trainer. The results of this study have identified two limitations that need to be

considered when drawing conclusions and using the results for development of future

research on this topic.

First, a potential error with the BOSU™ balance training system, that may have

influenced the results of the current study, focuses on its dynamic surface. The bladder

portion of the BOSU™ balance training system may cause recruitment of other stronger

muscles for balance to compensate for a weak peroneal muscle complex, thus hindering

the proprioceptive and neuromuscular stimulation needed for re-education of the

muscles.

Although Laudner and Koshnitzky (2010) examined which side of the BOSU™

balance trainer would generate a greater amount of tibialis anterior, peroneus longus, or

Table 8 Summary of Kinesio™ Tape Studies for the Ankle Study KT vs No Tape Day Methods Murray & Husk (2001) No Sig Dif NA Jt Angle Replicate Healthy Ankles RJPS Apparatus Halseth et al. (2004) No Sig Dif NA Jt Angle Replicate Healthy Ankles RJPS Apparatus Briem et al. (2011) No Sig Dif NA Muscle Activity Healthy Ankles & FAI Wobble Board for

Inversion Perturbation

Bicici et al. (2012) No Sig Dif NA Reach Scores CAI SEBT Simon et al. (2014) No Sig Dif 72 Hrs Force Sense Error Healthy Ankles & FAI Present Study Muscle Activity CAI Floor & BOSU SLS-Eyes Open No Sig Dif No Sig Dif SLS-Eyes Closed Sig Interaction Sig Interaction

SLS-BOSU No Sig Dif No Sig Dif Note. KT = Kinesio Tape; No Sig Dif = No Significant Difference; Sig Interaction = Significant Interaction; NA = Not Assessed; Jt Angle Replicate = Joint Angle Replication; RJPS = Reproduction of joint position sense apparatus FAI = Functional Instability; SEBT = Star Excursion Balance Test; CAI = Chronic Ankle Instability; SLS = Single Leg Stance; BOSU = Both Sides Up Balance Training System.

medial gastrocnemius muscle activity using electromyography (EMG) and reported no

significant increases in muscle activity for either side of the BOSU™ balance trainer,

they recruited only healthy ankles to participate in the study. The findings of the study

suggest that individuals with CAI might utilize muscular coping mechanisms more than

expected when performing exercises on the BOSU™ balance trainer. However, because

the present study is the first to examine the effects of the BOSU™ balance trainer on

muscle activity, the results and conclusions cannot be warranted as definitive.

Further studies on the efficacy of the BOSU™ balance trainer in the

rehabilitation of subjects suffering from CAI need to be conducted to add to the overall

literature. A better assessment would incorporate a single plane movement in order to

isolate the peroneals. While these findings do not directly support the value of

Kinesio™ tape during rehabilitation, this information is still useful for athletic trainers

interested in incorporating the BOSU™ balance training system into their CAI

rehabilitation protocols.

Second, the overall means for Tape/No Tape conditions while performing the

SLS-eyes open exercises were lower than the means for Tape/No Tape conditions while

performing SLS-eyes closed exercises. One possible explanation for this apparently

large difference between the mean values for the SLS-eyes open and SLS-eyes closed

exercises may be related to the visual component associated with balance.

Balance is derived from three central components: vestibular, visual, and

proprioceptive (Shumway-Cook, & Woollacott, 2001). The visual component derives

from the receptors in the eyes that provide visual cues identifying how a person is

oriented relative to other objects (Watson & Black, 2012). When an individual is

performing a SLS-eyes open exercise, his/her visual cues from the visual receptors of

the eye allow the individual to focus on a point or object within the room to help

maintain balance and orientation relative to other objects in the room. When the

individual is asked to perform the SLS-eyes closed exercises, the receptors in the eyes

are “shut down” thus removing the visual component of balance. By removing the

visual component, individuals are forced to rely upon the vestibular and proprioceptive

components, thus serving as an accurate assessment of the body’s proprioceptive

mechanisms. The eyes closed protocol may have been the truest representation of the

proprioception by eliminating one of the key elements, visual horizon, from overall

balance.

CHAPTER 5

SUMMARY, CONCLUSIONS, & RECOMMENDATIONS

The purpose of this study was to investigate the effects of Kinesio™ tape on

peroneal muscle activity during common therapeutic exercises in patients with chronic

ankle instability (CAI). This chapter will provide a summary, conclusions, and

recommendations in consideration of the findings of this study.

Summary

The hypotheses for this investigation were as follows:

1) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes open) exercise performed on a stable surface. The results of

this study did not support this research hypothesis.

2) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes closed) exercise following the application of Kinesio™ tape.

The results of this study supported this research hypothesis.

3) Kinesio™ tape will increase EMG activity of the peroneal muscle group during a

single leg stance (eyes open), on the bladder portion of a BOSU™ balance trainer.

The results of this study did not support this research hypothesis.

A total of 15 subjects (5 Females and 10 Males) completed all aspects of the

study in which they were asked to complete a single leg stance (SLS) under 3 different

conditions (i.e. SLS on a stable surface with eyes open, SLS on a BOSU™ balance

trainer with eyes open, SLS on a stable surface with eyes closed) with and without

Kinesio™ tape applied to their ankle). The dependent variable was the amount of

peroneal muscle activity amplitude (measured in mV) recorded during the exercises. All

variables were first analyzed using a 2-Way ANOVA (Tape x Day) to determine

statistical significance of the dependent variables. If a significant interaction was found,

a Post-hoc analysis of simple main effects was used (p < 0.05).

The results of this investigation indicated a significant increase in peroneal

muscle activity amplitude (MAA) electrical activity when wearing Kinesio ™ tape

during the performance of a SLS-eyes closed exercise on a stable surface. There were

no statistically significant differences in peroneal MAA for the SLS-eyes open on stable

surface, nor when balancing on the BOSU™ balance trainer.

Conclusions

Based on the findings from this study, the following conclusions were made: 1) Kinesio™ tape has no effect on peroneal activity during a single leg stance on a

stable surface with eyes open.

2) Kinesio™ tape has no effect on peroneal activity during a single leg stance on the

bladder portion of BOSU™ ball.

3) Kinesio™ tape may increase peroneal activity during an eyes closed rehabilitation

exercise. Although significant increases in peroneal activity were noted with the

application of Kinesio™ tape, during a single leg stance on a stable surface with

eyes closed, these preliminary results cannot be directly connected to cutaneous

stimulation of mechanoreceptors located in the skin at this time. The interaction

noted in this study warrants further research on the potential neural facilitation

properties of Kinesio™ tape.

Recommendations

Based on the procedures and results of this study, the following are

recommendations that may be used in future investigations of Kinesio™ tape:

1) Future research should examine the effects of Kinesio™ tape on peroneal MAA by

using intramuscular EMG rather than surface EMG. Within this study, surface EMG

electrodes were used to record peroneal MAA. The electrodes may have disrupted

the properties of the tape because a cut-out had to be made in the tape to facilitate

the electrode recording node and alleviate any interference of the tape on the

electrode. The electrodes may have lost some sensitivity due to prolonged exposure

to environmental factors (i.e. sweat). Intramuscular EMG would enhance the MAA

recordings and eliminate the disrupted tape.

2) Future research should explore the effects of Kinesio™ tape on a wider variety of

muscles essential to ankle stability (i.e. gastrocnemius, tibialis anterior). This study

only examined the tape’s effects on peroneal muscle activity. However, in daily

activities and sporting events, the peroneal muscles are not isolated from the other

muscles. They function together as a dynamic unit, so they should be studied

together to determine the effects of Kinesio™ tape in rehabilitating ankles with CAI.

3) Future research should investigate different dynamic surfaces (i.e. Dyna Disc,

wobble board, sand, and turf); specifically surfaces that isolate the sagittal plane at

the ankle.

4) Future research should compare and contrast the different brands of kinesio taping

tapes to the original Kinesio™ tape to determine if any or all of them have effects on

peroneal muscle activity and proprioception in ankles with CAI.

5) Future research should replicate this study to further investigate the effects of

Kinesio™ tape on peroneal muscle activity during common therapeutic exercises in

patients with chronic ankle instability (CAI). This inaugural study provided a

foundation for future studies to look at the rehabilitative properties of Kinesio™ tape

and to provide conclusive evidence for or against its use for proprioception and

neuromuscular enhancement.

6) Future research should examine the effects of Kinesio™ tape on peroneal muscle

activity over time. Kinesio™ tape can be worn for 3-5 days, so future studies should

investigate if the length of time the tape is worn promotes significant changes in

muscle activity and proprioception.

7) Future research should investigate potential time to fatigue when wearing Kinesio™

tape compared to a control group. It is unknown if peroneal muscle fatigue is

positively or negatively affected when a patient is wearing Kinesio™ tape. It is

recommended that future studies be spanned over multiple days to better mimic an

actual clinical rehabilitation protocol. Each treatment group (no tape, tape) should be

tested on individual days. Finally, each exercise (SLS-eyes open, single SLS-eyes

closed, Bosu™ Balance trainer) should also be conducted over separate days. Figure

9 demonstrates a sample of this protocol.

Group Day Exercise Reps x Time

No Tape 1 Single leg stance-eyes open

3 x 30 s 30 s rest between reps

2 Rest 3

Single leg stance-eyes closed 3 x 30 s

30 s rest between reps 4 Rest 5 BOSU™ Balance trainer 3 x 10 s

30 s rest between reps Tape 6

Single leg stance-eyes open 3 x 30 s

30 s rest between reps

7 Rest 8

Single leg stance-eyes closed 3 x 30 s

30 s rest between reps 9 Rest 10

BOSU™ Balance trainer 3 x 30 s

30 s rest between reps Figure 9. Sample research protocol to investigate fatigue factors.

REFERENCES

Barrett, J. R., Tanji, J. L., Drake, C., Fuller, D., Kawasaki, R. I., & Fenton, R. M.

(1993). High- versus low-top shoes for the prevention of ankle sprains in

basketball players: A prospective randomized study. The American Journal of

Sports Medicine, 21(4), 582-585. doi: 10.1177/036354659302100416

Basmajian, J. V., & DeLuca, L. C. (1985). Muscles alive: Their functions revealed by

electromyography. Baltimore, MD: Williams & Wilkins.

Bicici, S., Karates, N., & Baltaci, G. (2012). Effect of athletic taping and kinesio taping

on measurements of functional performance in basketball players with chronic

inversion ankle sprains. International Journal of Sports Physical Therapy, 7(2),

154-166.

BIOPAC Systems Inc. (2005). Biopac student lab pro manual [Brochure]. Goleta, CA:

Author.

Briem, K., Eythorsdottir, H., Magnusdottir, R., Palmarsson, R., & Runarsdotter, T.

(2011). Effects of kinesio tape compared with nonelastic sports tape and the

untaped ankle during a sudden inversion perturbation in male athlete. Journal of

Orthopaedic and Sports Physical Therapy, 41(5), 328-334.

doi: 10.2519/jospt.2011.350

Coughlan, G., & Caulfield, B. (2007). A 4-week neuromuscular training program and

gait patterns at the ankle joint. Journal of Athletic Training, 42(1), 51-59.

Retrieved June 21, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/

PMC1896080

Delahunt, E., Monaghan, K., & Caulfield, B. (2006). Altered neuromuscular control and

ankle joint kinematics during walking in subjects with functional instability of

the ankle joint. The American Journal of Sports Medicine, 34(12), 1970-1976.

doi: 10.1177/0363546506290989

Ebiq, M., Lephart, S. M., Miller, M. C., & Pincivero, D. M. (1997). The Effect of

sudden inversion stress on EMG activity of the peroneal and tibialis anterior

muscles in the chronically unstable ankle. Journal of Orthopaedic & Sports

Physical Therapy, 26(2), 73-77. Retrieved August 6, 2013, from

http://www.ncbi.nlm.nih.gov/pubmed/9243405

Elis, E., & Rosenbaum, D. (2001). A multi-station proprioceptive exercise program in

patients with ankle instability. Medicine & Science in Sports and Exercise,

33(12), 1991-1998.

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 randomized control trial.

Canadian Medical Association Journal, 172(6), 749-754.

Farr, G. (2012, October 28). Surface electromyography. Retrieved June 21, 2014, from

http://www.becomehealthynow.com/article/diagelectrical/625/

Fernandes, N., Allison, G. T., & Hopper, D. (2000). Peroneal latency in normal and

injured ankles at varying angles of perturbation. Current Orthopedic Practice,

375, 193-201. doi: 10.1097/00003086-200006000-00023

Fong, D. T., Hong, Y., Chan, L., Yung, P. S., & Chan, K. (2007). A systematic review

on ankle injury and ankle sprain in sports. Journal of Sports Medicine, 37(1), 73-

94. doi: 10.2165/00007256-200737010-00006

Freeman, M., Dean, M., & Hanham, I. (1965). The etiology and prevention of

functional instability of the foot. The Journal of Bone & Joint Surgery (British

Volume), 47-B (4), 678-685.

Gribble, P., Hertel, J., & Denegar, C. (2007). Chronic ankle instability and fatigue

create proximal joint alterations during performance of the star excursion

balance test. International Journal of Sports Medicine, 28(3), 236-242.

doi: 10.1055/s-2006-924289

Grigg, P. (1994). Peripheral neural mechanisms in proprioception. Journal of Sport

Rehabilitation, 3, 2-17.

Gross, M. T. (1987). Effects of recurrent lateral ankle sprains on active and passive

judgments of joint position. Physical Therapy, 67(10), 1505-1509.

Hale, S., & Hertel, J. (2005). Reliability and sensitivity of the foot and ankle disability

index in subjects with chronic ankle instability. Journal of Athletic Training,

40(1), 35-40.

Halseth, T., McChesney, J., Debeliso, M., Vaughn, R., & Lien, J. (2004). The effects of

kinesio taping on proprioception at the ankle. Journal of Sports Science and

Medicine, 3, 1-7. Retrieved March 1, 2004, from http://www.jssm.org/vol3/

n1/1/v3n1-1pdf.pdf

Heckman, C. J., Hyngstrom, A. S., & Johnson, M. D. (2008). Active properties of motor

neuron dendrites: Diffuse descending neuromodulation, focused local inhibition.

The Journal of Physiology, 586(5), 1225-1231.

doi: 10.1113/jphysiol.2007.145078

Herman, D., Magrum, E., & Hertel, J. (2013) Chronic ankle instability. In J. Wyss & A.

Patel (Eds.), Therapeutic programs for musculoskeletal disorder (pp. 227-232).

New York, NY: Demos Medical.

Hertel, J. (2002). Functional anatomy, pathomechanics, and pathophysiology of lateral

ankle instability. Journal of Athletic Training, 37(4), 364.

Hertel, J., Braham, R. A., Hale, S. A., & Olmsted-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(3), 131-

137. doi: 10.2519/jospt.2006.36.3.131

Hintermann, B. (1999). Biomechanics of the unstable ankle joint and clinical

implications. Medicine and Science in Sports and Exercise, 31(7 Suppl), S459-

469. doi: 10.1097/00005768-199907001-00007

Hopkins, J. T., Brown, T. N., Christensen, L., & Palmieri-Smith, R. M. (2009). Deficits

in peroneal latency and electromechanical delay in patients with functional ankle

instability. Journal of Orthopaedic Research, 27(12): 1541-1546.

doi: 10.1002/jor.20934

Horowitz, S. H. (2014, February 17). Overview of electromyography. Retrieved June 19,

2014, from http://www.uptodate.com/contents/overview-of-electromyography

Houglum, P. A. (2001). Therapeutic exercise for musculoskeletal injuries. Champaign,

IL: Human Kinetics.

Kamen, G (2004). Electromyography in Kinesiology. In D. Robetsron, (Ed.), Research

Methods in Biomechanics (pp. 764-785). Champaign, IL: Human Kinetics.

Karlsson, J., & Andreasson, G. O. (1992). The effect of external ankle support in

chronic lateral ankle joint instability: An electromyographic study. The

American Journal of Sports Medicine, 20(3), 257-261.

doi: 10.1177/036354659202000304

Kase, K. (2013). About Kinesio®. Retrieved October 21, 2013, from

http://www.kinesiotaping.com/about

Kase, K., Hashimoto, T., & Okane, T. (1996). Kinesio taping perfect manual: Amazing

taping therapy to eliminate pain and muscle disorders. Albuquerque, NM:

Kinesio USA.

Konradsen L. (2002), Factors contributing to chronic ankle instability kinesthesia and

joint position sense. Journal of Athletic Training, 37(4), 381-385.

Laudner, K. G., & Koschnitzky, M. M. (2010). Ankle muscle activation when using the

both sides utilized (BOSU) balance trainer. Journal of Strength and

Conditioning Research, 24(1), 218-222. doi: 10.1519/JSC.0b013e3181c490d4

Lentell, G. L., Bass, B., Lopez, D., Sarrels, M., & Snyder, P. (1995). The contributions

of proprioceptive deficits, muscle function, and anatomic laxity to functional

instability of the ankle. Journal of Orthopaedic and Sports Physical Therapy,

21, 206-215.

Lephart, S. M., Pincivero, D. M., & Rozzi, S. L. (1998). Proprioception of the ankle and

knee. Sports Medicine, 25(3), 149-155. doi: 10.2165/00007256-199825030-

00002

Lephart, S., Swanik, C., & Fu, F. (2004). Reestablishing neuromuscular control. In W.

Prentice (Ed.), Rehabilitation techniques in sports medicine and athletic training

(pp. 27-29). St. Louis, MO: McGraw-Hill.

Macey, H. T. (2001). ABR calibration and test for mp150 & acqknowledge. #App Note

105c- ABR Calibration & Testing. Retrieved June 5, 2014, from

http://www.biopac.com/Manuals/app_pdf/app105c.pdf

Magee, D. J. (2008). Orthopedic physical assessment (5th ed.). St. Louis, MO: Saunders

Elsevier Science.

Mattacola, C. G., & Dwyer, M. K. (2002). Rehabilitation of the ankle after acute sprain

or chronic instability. Journal of Athletic Training, 37(4), 413-429. Retrieved

June 21, 2014, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC164373/

McKeon, P. D., Ingersoll, C. D., Kerrigan, D. C., Saliba, E., Bennett, B. C., & Hertel, J.

(2008). Balance training improves function and postural control in those with

chronic ankle instability. Medicine & Science in Sports and Exercise, 40(10),

1810-1819.

Murray, H., & Husk, L. (2001). Effect of kinesio™ taping on proprioception in the

ankle. Journal of Orthopaedic and Sports Physical Therapy, 31, A-37.

Myers, J. B., Riemann, B. L., Hwang, J. H., Fu, F. H., & Lephart, S. M. (2003). Effect

of peripheral afferent alteration of the lateral ankle ligaments on dynamic

stability. The American Journal of Sports Medicine, 31(4), 498-506.

Narayana, S. (2005). Texbook of Therapeutic Exercises. New Delhi: Jaypee Brothers

Medical. doi: 8180614697

Olmsted, L., Carcia, C., & Shultz, S. (2002). Efficacy of the star excursion balance tests

in detecting reach deficits in subjects with chronic ankle instability. Journal of

Athletic Training, 37(4), 501-506.

Osborne, M. D., Shan-Chou, L., Laskowski, E. R., Smith, J., & Kaufman, K. R. (2001).

The effect of ankle disk training on muscle reaction time in subjects with a

history of ankle sprain. American Journal of Sports Medicine, 29(5), 627-632.

Retrieved August 21, 2013, from http://ajs.sagepub.com/content/29/5/627.short

Palmieri-Smith, R. M., Hopkins, J. T., & Brown, T. N. (2009). Peroneal activation

deficits in persons with functional ankle instability. The American Journal of

Sports Medicine, 37(5), 982-988. doi: 10.1177/0363546508330147

Prentice, W. E., & Arnheim, D. D. (2006). The Foot. In W. Prentice (Ed.), Arnheim's

principles of athletic training: A competency-based approach (12th ed., p. 520).

Boston, MA: McGraw-Hill.

Purves, D., Augustine, G. J., & Fitzpatrick, D. (2001). Part III movement and its central

control. In D. Purves (Ed.), Neuroscience (2nd ed., 371-375). Sunderland, MA:

Sinauer Associates.

Riemann, B. L., & Lephart, S. M. (2002). The sensorimotor system, part II: The role of

proprioception in motor control and functional joint stability. Journal of Athletic

Training, 37(1), 80-84.

Robbins, S., & Waked, E. (1998). Factors associated with ankle injuries. Sports

Medicine, 25(1), 63-72. doi: 10.2165/00007256-199825010-00005

Rozzi, S. L., Lephart, S. M., Sterner, R., & Kuligowski, L. (1999). Balance training for

persons with functionally unstable ankles. Journal of Orthopedic Sports

Physical Therapy, 29(8): 478-86.

Safran, M. R., Zachazewski, J. E., Benedetti, R. S., Bartolozzi, A. R., & Mandelbaum,

R. (1999). Lateral ankle sprains: A comprehensive review part 2: Treatment and

rehabilitation with an emphasis on the athlete. Medicine & Science in Sports and

Exercise, 3,438-447. doi: 10.1097/00005768-199907001-00005

Shumway-Cook A, & Woollacott, (2001). Motor Control: Theory and Practical

Applications. Philadelphia: Lippincott, Williams & Wilkins.

Simon, J., Garcia, W., & Docherty, C. (2014). The effect of kinesio tape on force sense

in people with functional ankle instability. Clinical Journal of Sports Medicine,

4, 289-294. doi: 10.1097/JSM.0000000000000030

Simoneau, G. G. Degner, R. M. Kramper, C. A. & Kittleson, K. H (1997). Changes in

ankle joint proprioception resulting from strips of athletic tape applied over the

skin. Journal of Athletic Training, 32(2), 141-147. Retrieved October 21, 2013,

from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1319817/

Soderberg, G. L., Cook, T. M., Rider, S. C., & Stephenitch, B. L. (1991).

Electromyographic activity of selected leg musculature in subjects with normal

and chronically sprained ankles performing on a baps board. Physical

Therapy, 71(7), 514-522. Retrieved July 16, 2014, from

http://ir.uiowa.edu/oeh_pubs/173/

Soderman, K., Werner, S., Pietila, T., Engstrom, B., & Alfredson, H. (2000). Balance

board training: Prevention of traumatic injuries of the lower extremities in

female soccer players: A prospective randomized intervention study. Knee

Surgery, Sports Traumatology, Arthroscopy, 8(6), 356-363.

Swanik, C. (2004). Reestablishing neuromuscular control. In W. Prentice (Ed.),

Rehabilitation techniques in sports medicine and athletic training (p. 101). St.

Louis, MO: McGraw-Hill.

Swanson, K. (1998). Improving proprioception and neuromuscular control following

shoulder injury. Athletic Therapy Today, 3(5), 30-34.

Thompson, D. (2000, November 3). Arthrokinematics and osteokinematics. Retrieved

June 5, 2014, from http://moon.ouhsc.edu/dthompso/namics/arthkin.htm

Tripp, B. (2006). Integrating sensorimotor control into rehabilitation. Athletic Therapy

Today, 1(5), 24-29.

Vaes, P., Duquet, W., & Gheluwe, B. V. (2002). Peroneal reaction times and eversion

motor response in healthy and unstable ankles. Journal of Athletic Training,

37(4), 475-480. Retrieved December 2, 2013, from http://www.ncbi.nlm.nih.gov

/pmc/articles/PMC164380/

Vanrijn, R., Vanos, A., Bernsen, R., Luijsterburg, P., Koes, B., & Biermazeinstra, S.

(2008). What is the clinical course of acute ankle sprains? A systematic literature

review. The American Journal of Medicine, 121(4), 324-331. doi:

10.1016/j.amjmed.2007.11.018

Wahl, M. J., & Behm, D. G. (2008). Not all instability training devices enhance muscle

activation in highly resistance-trained individuals. Journal of Strength and

Conditioning Research, 22(4), 1360-1370. doi: 10.1519/JSC.0b013e318175ca3c

Watson, M. A., & Black, O. F. (2012, March 12). The human balance system. Retrieved

July 16, 2014, from http://vestibular.org/understanding-vestibular-

disorder/human-balance-system

Wester, J. U., Jespersen, S. M., Nielsen, K. D., & Neumann, L. (1996). Wobble board

training after partial sprains of the lateral ligaments of the ankle: A prospective

randomized study. Journal of Orthopaedic & Sports Physical Therapy, 23(5),

332-336. doi: 10.2519/jospt.1996.23.5.332

Yaggie, J. A., & Campbell, B. M. (2006). Effects of balance training on selected

skills. Journal of Strength and Conditioning Research, 20(2), 422-428. doi:

10.1519/00124278-200605000-00031

Yeung, M. S., Chan, K. M., So, C. H., & Yuan, W. Y. (1994). An epidemiological

survey on ankle sprains. British Journal of Sports Medicine, 28(2), 112-116.

doi: 10.1136/bjsm.28.2.112

APPENDIX A

INFORMED CONSENT

Informed Consent

The Effect of Kinesio Tape on Peroneal Activity at the Ankle Purpose You are being asked to participate in a research study about the effect of Kinesio Tape on peroneal activity at the ankle. The purpose of this study is to determine the effect of Kinesio Tape on peroneal activity during common therapeutic exercises in patients with chronic ankle instability (CAI).You were selected as a possible participant because you fit the criteria of an individual suffering from chronic ankle instability. Please read this form and ask any questions that you may have before agreeing to be in the research study. Participants’ Involvement in the Study The study will take place in the Brophy Hall Biomechanics Lab (221A). It should take you less than 1 hour per day for 3 days, 2 of which must be consecutive days to complete the treatment and testing for this research study. Completion of the research activities should take no longer than 3 hours in total time outside of your daily activities. If you agree to be a participant in this research, we would ask you to do the following things: Session 1 (approx. 60 minutes)-Informed Consent, Health History, FADI Survey Baseline results. You will report to the Brophy Hall Room 221A (Biomechanics Lab) for a brief introductory meeting, followed by screening to determine your inclusion criteria. On the first day, participants will be familiarized with the experimental procedures, risks or discomforts, benefits, rights, etc. associated with this study and sign the informed consent form. Session 2 (approx. 60 minutes) - Electromyography application, baseline exercises, tape application, re-attempt exercises. On the second day, you will be connected to the MP-100 System (BIOPAC Systems, Inc.) to record peroneal muscle activity. Once connected you will participate in pre-test CAI rehabilitation exercises without Kinesio Tape, in order to compile baseline readings. The exercises included in this protocol will include a single leg stance with eyes open, single leg stance with eyes closed, single leg stance on and finally on a BOSU® ball eyes open. For each of the previously mentioned exercises, you will be asked to complete 3 trials at 10 seconds for each trial. Once baseline recordings have been completed, Kinesio Tape will be applied to your ankle. Following application of the tape, you will be asked to repeat the previous exercises while wearing the tape. Once completed, you will be disconnected from the MP-100 System (BIOPAC Systems, Inc.). You will be asked to keep the Kinesio Tape on until you return to the lab in 24 hours + 1 hour, unless allergic reaction occurs, in which case you will be excluded from the study.

Session 3 (approx. 60 minutes) - 2nd trail of exercises with tape application, removal of tape, 2nd attempt of exercises without tape. You will return to the Brophy Hall Biomechanics Lab 24 hours following initial trials. Once connected to the MP-150 system (BIOPAC Systems, Inc.), you will be asked to complete the aforementioned mentioned exercises. Once the data is collected, the Kinesio Tape will be removed and the exercises will be repeated for a final time. Session 4(approx. 60 min) - 1st trial of separate exercise, tape application, reattempt exercise. On the third day, you will be connected to the MP-150 System (BIOPAC Systems, Inc.) to record peroneal muscle activity. Once connected you will participate in pre-test CAI rehabilitation exercise, this time completing a single leg stance eyes closed. You will be asked to complete 3 trials at 10 seconds for each trial. Once baseline recordings have been completed, Kinesio Tape will be applied to your ankle. Once completed, you will be disconnected from the MP-150 System (BIOPAC Systems, Inc.). You will be asked to keep the Kinesio Tape on until you return to the lab in 24 hours + 1 hour. Session 5(approx. 60 min) -2nd trial of exercise with tape application, removal of tape, 2nd attempt of exercises You will return to the Brophy Hall Biomechanics Lab 24 hours following initial trials. Once connected to the MP-150 system (BIOPAC Systems, Inc.), you will be asked to complete the aforementioned mentioned exercises. Once the data is collected, the Kinesio Tape will be removed and the exercise will be repeated for a final time. Following the completion of the exercises, you will be disconnected from the MP-150 System (BIOPAC Systems, Inc.) and be done with the study. Risks This research has the following risks:

1) Allergic Reaction: There is a very rare possibility that you may have a minor allergic reaction to the tap. If so, appropriate medical attention will be administered and you will be removed from the study.

2) Injury: While the exercises are very unlikely to cause injury there is a minor risk involved. The exercises will be monitored under close attention of a certified athletic trainer. Any injury incurred will be cared for by the Athletic trainer.

Benefits The benefit of participation is the potential for increased literature on the reeducation of the neuromuscular system in chronic ankle instability (CAI) patients. Participating in this study will contribute to treatment protocols in physical therapy and athletic training professions in patients with CAI. Additionally this research will add to the collection of literature already published on Kinesio® tape. Confidentiality The information in this research will be kept confidential. The data will be coded using a letter and number sequence so your information cannot be linked back to you. Only the researchers will have access to the code and any confidential information that may be linked to you, nor will your survey results be available to anyone other than you and the researcher. Research data will be stored on password secure computer. The data will be made available only to the persons

conducting the research. No reference will be made in oral or written reports that could link participants to the research. Voluntary Participation You do not have to perform any activity you do not want to. You do not have to answer any question you do not want to answer. Participation in this study is voluntary. If you decide to participate, you may withdraw from the study at any time without penalty and without loss of benefits to which you are otherwise entitled. Contact Information If there are any questions at any time about the study or the procedures, or you experience adverse effects as a result of participating in this study, please contact: Jason Johnson, Western Illinois, [email protected], 630-664-2472; Dr. Jennifer Plos, Kinesiology Department, Western Illinois University, 309-298-1506, [email protected]. This project has been reviewed and approved by the WIU Institutional Review Board. Questions concerning your rights as a participant in this research may be directed to Jacqueline Tharpe, Compliance Specialist, at (309) 298-1191 or [email protected]. Consent: I have read the above information, and I have received a copy of this form. I agree to participate in this study.

Participant’s Printed Name Signature Date Investigator’s Printed Name Signature Date

APPENDIX B

HEALTH HISTORY QUESTIONNAIRE

Health History Questionnaire

Name Sex Age

Email Phone # Date

1. Have you experienced an ankle sprain?

Yes No

a. If yes, approximately how long ago did you experience the ankle sprain?

_____years ago _____months ago _____days ago

2. Did you ever receive treatment for your sprain? Yes No

a. If yes, please briefly describe the treatment you received.

3. In your opinion, do you have a history of chronic ankle instability (ankle trauma with repeated

bouts of injury or giving way)? Yes No

a. If yes, in what ankle do you suffer most from chronic ankle instability?

Left Ankle Right Ankle Equal in both Ankles

4. Have you ever had surgery on your injured ankle?

Yes No

a. If yes, please provide the date(s) and a brief description of each surgery

Date(s) & Description(s):

5. Do you currently have any muscle or nervous system condition(s) that affect your balance? Yes No

a. If yes, please list your condition(s).

6. Have you ever experienced any fractures or other associated injuries to the ankle, knee, or hip? Yes No

a. If yes, please provide the date(s) and a brief description of the injury/injuries.

Date(s) & Description(s):

7. Approximately how many hours per week to you participate in physical activity?

8. Are you currently a collegiate athlete at WIU? Yes No

a. If yes, please list the sport you play.

APPENDIX C

FOOT & ANKLE DISABILITY INDEX (FADI)

www.orthopaedicscores.com Date of completion

May 28, 2014February 7, 2014

The Foot & Ankle Disability Index (FADI) Score - Sports Module

Clinician's name (or ref)

Patient's name (or ref

Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your foot or ankle, mark N/A

No difficulty at all

Slight difficulty

Moderate difficulty

Extreme difficulty

Unable to do

1. Running 2. Jumping 3. Landing 4. Squatting and stopping quickly 5. Cutting, lateral movements 6. Low-impact activities

7. Ability to perform activity with your normal technique

8. Ability to participate in your desired sport as long as you would like

Thank you very much for completing all the questions in this questionnaire.

Reset

To save this data please print or

Nb: This page cannot be saved due to patient data protection so please print the filled in form before closing the window.

The Foot & Ankle Disability Index (FADI) Score is 0

Reference for Score: Martin RL, Burdett RG, Irrgang JJ. Development of the Foot and Ankle Disability Index (FADI) J

Orthop Sports Phys Ther. 1999;29:A32â€“A33

Web Design London - James Blake Internet

APPENDIX D

INDIVIDUAL TRIAL MAA SCORES

SLS Eyes Closed Day 1 Subject No Tape 1 No Tape 2 No Tape 3 Tape 1 Tape 2 Tape 3 B2 8.77100 9.21692 7.11300 10.10021 7.10081 6.00390 C3 10.54169 8.50586 9.04907 10.05707 8.74603 7.31750 D4 8.08990 9.90570 8.91510 9.71161 9.07867 10.44891 F5 7.95044 7.53601 6.82068 12.17957 6.04431 5.87830 G6 14.67346 10.21973 12.80914 12.03400 11.83685 12.71614 H7 7.70813 9.75677 8.77686 4.54041 9.79401 7.02911 J9 8.49976 10.79559 8.35052 9.97864 9.10217 8.29529 K10 9.79919 10.2536 12.30835 7.90070 10.46417 9.35822 L11 13.90259 9.10706 12.01080 8.62488 7.92786 7.72522 M12 12.31049 9.81049 7.51434 12.30225 9.23645 11.98517 N13 11.86432 12.73163 13.76740 11.56952 12.72339 10.0238 O14 6.66962 7.57355 8.22571 6.72852 6.43921 5.72144 P15 13.89832 16.83075 12.46521 15.62500 14.39362 13.94348 Q16 12.11030 9.76192 9.01942 11.04192 10.29841 8.19316 R17 9.72107 10.53040 12.32971 8.58870 11.50879 9.76501 S18 5.31616 4.61456 5.03143 4.93042 5.64300 5.11923

SLS Eyes Closed Day 2 Subject Tape1 Tape 2 Tape 3 No Tape 1 No Tape 2 No Tape 3

C3 9.93225 12.61383 11.96106 6.54053 8.12286 10.10223 D4 8.50708 10.26093 11.59698 10.00793 5.71320 7.60315 F5 5.68817 7.87871 4.60663 5.54138 5.40649 8.04535 G6 12.88147 15.73914 15.0351 12.00001 14.58535 16.18042 H7 12.11853 8.87634 10.26123 10.10834 8.87177 5.82489 J9 12.11182 11.43219 13.67157 8.88245 11.00708 9.76074 K10 9.66003 7.76110 11.00708 9.10126 8.96759 8.55621 L11 9.75739 12.83285 11.76025 13.00812 9.13422 10.34485 M12 11.84357 11.30981 11.42456 9.78760 4.31624 9.27155 N13 12.33521 11.00031 9.73172 10.99100 9.88915 9.210094 O14 6.48597 7.55005 7.19757 7.03674 4.02832 4.83124 P15 12.92175 16.19446 13.77228 11.26282 9.28650 11.96808 Q16 11.45539 9.00019 10.65773 10.36551 9.93629 8.16620 R17 10.63843 11.92718 10.63843 7.09076 8.19366 9.31793 S18 4.50104 4.34974 4.19922 5.43274 4.35516 4.21021

SLS Eyes Open Day 1 Subject No Tape 1 No Tape 2 No Tape 3 Tape 1 Tape 2 Tape 3 B2 4.17938 6.30676 6.33515 4.87345 6.78893 7.02213 C3 6.02966 5.34058 3.74969 4.03931 6.70563 5.12435 D4 7.26227 6.14014 7.04315 6.79443 5.52490 7.06242 F5 4.99420 4.82086 5.04883 8.63861 7.74017 4.28610 G6 9.42413 12.01111 9.80103 9.99359 9.21378 11.04309 H7 4.63043 3.90320 3.59619 5.32013 4.32513 3.21045 I8 5.50385 4.11621 3.88702 5.47333 6.13190 5.47330 J9 4.13818 4.18467 3.91083 3.61816 3.98762 3.90090 K10 5.80475 7.57416 8.93463 5.39866 6.80817 5.28076 L11 7.18506 6.14594 5.39276 6.04095 4.30716 5.31234 M12 4.42322 4.11324 3.19916 3.80006 4.50932 3.45245 N13 3.75824 3.96362 2.93549 4.17069 3.36029 2.19543 O14 4.87091 5.60394 3.64807 4.06830 3.31360 3.36578 P15 6.76819 5.29633 4.54224 6.53351 5.12421 6.14624 Q16 8.08929 6.96960 9.51080 6.79321 7.27600 10.38177 R17 5.48279 9.49280 11.31836 4.68201 6.56311 4.97498 S18 3.82904 3.29407 3.14911 4.09698 5.42786 4.37927 SLS Eyes Open Day 2 Subject Tape 1 Tape 2 Tape 3 No Tape 1 No Tape 2 No Tape 3 B2 6.23420 6.41242 4.43573 5.54214 5.82101 4.93214 C3 5.25391 3.71399 4.13660 4.57886 4.29943 3.74969 D4 6.75476 5.29602 6.19202 5.39003 6.98792 4.69025 F5 5.48540 5.25471 6.66213 8.11420 6.11621 4.19925 G6 10.06958 7.92380 9.71283 12.58911 9.87885 8.29132 H7 9.57489 4.40399 4.59290 4.29565 6.36749 2.15668 I8 3.44391 5.42389 4.18274 4.02863 2.85919 2.87872 J9 4.96887 4.99451 5.19745 6.30341 4.20187 3.85406 K10 8.56781 7.96509 9.13971 6.63849 6.10748 6.31561 L11 6.62659 5.52704 5.85297 8.58459 6.93166 5.46570 M12 4.66064 5.60669 5.81055 5.13641 3.79639 4.20563 N13 4.23279 4.55597 4.46167 3.60291 4.50806 4.51691 O14 4.64264 4.81598 5.29327 4.67255 4.12689 4.50287 P15 8.45673 8.40454 7.79144 10.37201 6.85791 6.79840 Q16 5.93994 5.05096 3.44879 4.46625 5.97229 4.27673 R17 6.07056 6.21136 4.86481 5.77759 5.05798 4.40887 S18 3.25513 3.49701 2.43652 4.28528 2.46613 2.49969

BOSU Ball Day 1 Subject No Tape 1 No Tape 2 No Tape 3 Tape 1 Tape 2 Tape 3 B2 11.94230 11.73240 9.89824 10.52704 11.16821 13.39355 C3 13.77594 11.53290 11.82000 14.98138 18.60077 13.40729 D4 13.14818 16.38275 15.15594 14.87236 14.12332 16.71273 F5 6.38763 6.29028 7.17529 6.12707 8.10315 5.69489 G6 15.09979 16.05896 15.50293 12.71620 10.08606 11.34094 H7 8.34259 9.66156 6.91345 6.46210 7.13250 5.77759 I8 14.35028 13.54560 12.23433 13.96942 13.67944 12.55688 J9 10.30121 11.26526 10.30121 12.89825 11.23300 7.82043 K10 11.29291 11.46637 8.55103 9.57123 9.21661 9.57123 L11 9.18457 10.59570 10.59570 11.07605 11.43280 10.59570 M12 5.73975 9.68452 9.72341 9.44916 10.23144 13.62982 N13 9.84009 8.09082 5.85968 11.39862 10.32028 12.56012 O14 8.30841 6.52802 7.35138 6.93024 6.51550 5.96404 P15 10.65094 12.79510 10.76874 6.93024 6.51550 5.96405 Q16 19.45740 15.14709 15.36743 12.69104 9.72809 14.60846 R17 17.08008 11.65070 14.38446 14.01917 13.39569 17.25250 S18 9.57794 8.91785 9.59167 4.91211 7.46948 8.28369 BOSU Ball Day 2 Subject Tape 1 Tape 2 Tape 3 No Tape 1 No Tape 2 No Tape 3 B2 12.32452 13.13532 12.34256 11.43904 10.97301 9.98547 C3 13.87207 11.97447 11.02103 10.69397 10.84351 10.20013 D4 17.27356 14.09912 10.56488 15.15594 11.61957 9.62036 F5 8.12664 7.51153 6.33173 8.56638 8.00268 7.57622 G6 10.56488 14.09912 17.27356 13.8855 12.44259 12.12040 H7 11.75934 8.98804 8.72234 8.23212 8.30627 6.67908 I8 8.90167 9.45801 12.03156 8.66486 8.43170 9.83063 J9 8.08105 9.66034 9.06403 9.58038 8.59436 8.85406 K10 13.18451 14.67255 14.63104 12.93274 11.46637 8.55103 L11 10.80261 10.12177 10.39581 9.96826 10.92041 8.17749 M12 11.99066 10.65979 12.16705 10.82123 15.29083 12.91870 N13 9.25781 8.00135 7.87689 11.53320 9.34002 7.91053 O14 8.31451 7.35138 7.44011 7.94180 6.71722 6.51672 P15 14.09058 12.47284 11.64093 10.37201 6.79840 6.85791 Q16 8.66364 10.19440 15.51727 16.89110 13.80066 11.60280 R17 15.44556 16.66748 12.08588 11.54421 10.53680 10.11215 S18 6.80167 5.89386 6.60400 6.05164 5.64056 7.40387