Effect of Training on Postural Control in Figure Skaters
A Randomized Controlled Trial of Neuromuscular Versus Basic Off-Ice Training Programs Emily J. Kovacs, MSc,* Trevor B. Birmingham, PhD, PT, Lorie Forwell, MSc, PT, and Robert B. Litchfield, MD, FRCS(C) Objectives: To compare the effect of a neuromuscular training pro- gram and a basic exercise program on postural control in figure skat- ers. Design: Two groups; parallel design; prospective, randomized con- trolled trial. Setting: Postural control laboratory, arenas, September 2001 to De- cember 2002. Participants: Forty-four young, healthy figure skaters (18 years 3 years). Interventions: Participants were randomly assigned to receive a neuromuscular training program (n = 22) or a basic exercise training program (n = 22). Both programs were completed 3 times per week for 4 weeks, and each session was supervised. Main Outcome Measurements: Participants completed baseline and postintervention measures of postural control on a force plate. Postural control was quantified as the center of pressure (CoP) path length during tests of single-limb standing balance that mimicked fig- ure skating skills and challenged the postural control system to vary- ing degrees. The primary outcome measure was the CoP path length observed during a landing jump test completed with eyes closed. Results: The post intervention CoP path lengths during the more challenging tests were significantly (P < 0.05) lower (indicating bet- ter postural control) for the neuromuscular trained group than for the basic exercise-trained group. For the landing jump test completed with eyes closed, the percent improvement in the neuromuscular trained group was significantly greater (mean = 21.0 22.0%) than the basic exercise trained group (mean = 4.9 24.9%; P< 0.05). The magnitude of improvement in the neuromuscular-trained group ranged from approximately 1% to 21%, depending on the specific postural control test used. Conclusions: The results suggest that off-ice neuromuscular train- ing can significantly improve postural control in figure skaters, whereas basic exercise training does not. Key Words: postural control, neuromuscular training, exercise train- ing, figure skating, randomized controlled trial, center of pressure (Clin J Sport Med 2004;14:215224) T he popularity of figure skating has increased dramatically over the past 20 years, including substantial increases in membership in figure skating organizations at both the com- petitive and the recreational levels. 1 According to the Interna- tional Skating Union, there are 73 Member Federations in 57 countries. 2 Skate Canada is the largest figure skating govern- ing organization in the world, with 191,000 members and 1448 affiliated clubs. 3 Figure skating is both an athletic and an artistic sport that combines strength, flexibility, artistry, aerobic, and anaerobic capacity and balance. In particular, figure skaters must have exceptional postural control to help maintain balance during the technical elements they perform. Several studies have ex- amined factors suggested to be important for figure skating performance, including muscular strength, 4 flexibility, 5,6 and numerous physiologic variables. 79 However, only one pub- lished study has evaluated postural control in figure skaters. 10 The term postural control has often been used inter- changeably with the term balance. 11 For the present study, we operationally defined postural control as the combination of sensory and motor processes involved in the maintenance of standing balance. Postural control is dependent on the interac- tion among three sensory systems: the visual, vestibular, and neuromuscular (also termed somatosensory). Proprioception is defined as the conscious and unconscious sense of limb posi- Received for publication August 2003; accepted March 2004. From the *School of Kinesiology, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada; the School of Physical Therapy, University of Western Ontario, London, Ontario, Canada; and Fowler Kennedy Sport Medicine Clinic, University of Western Ontario, London, Canada. Supported by financial awards from the National Science and Engineering Research Council of Canada and the Canadian Academy of Sport Medi- cine. Reprints: Emily Kovacs, c/o Dr. Trevor B. Birmingham, Elborn College, Room1444, School of Physical Therapy, Faculty of Health Sciences, Uni- versity of Western Ontario, London, Ontario, Canada N6G 1H1 (e-mail: emily.kovacs@utoronto.ca, tbirming@uwo.ca). Copyright 2004 by Lippincott Williams & Wilkins Clin J Sport Med Volume 14, Number 4, July 2004 215 tion in space, including an awareness of both joint position and movement. 12 The neuromuscular systemconsists of mechano- receptors (specialized sensory neurons that respond to me- chanically applied pressure or tissue deformation) located in muscles, tendons, joints, and skin. 12 Optimal performance of the neuromuscular system is particularly important during fig- ure skating because information pertaining to the position and movement of the limbs is necessary for the successful comple- tion of jumps, spins, and field movements. Postural control has typically been assessed during the performance of various standing balance tests completed on a force plate. Previous investigations of postural control have used tasks that challenged the sensory systems by altering vi- sion, stance, or support surface conditions. 10,13,14 For ex- ample, Riva et al 10 studied postural control in international skaters, young skaters, and international ice dancers using single-limb stance tests completed under different visual con- ditions (eyes open, eyes closed, and eyes open with real-time visual feedback of their postural control). The authors sug- gested that skaters should attempt to improve their neuromus- cular strategies to enhance their skating abilities. Similarly, in a review article, Smith 15 suggested that although much of bal- ance ability may be intrinsic to an athlete, it might be enhanced with training. Currently, off-ice training is recommended for figure skaters 15,16 and may include strength and flexibility training, ballet, aerobic and anaerobic conditioning, and ply- ometric jump training. 1518 However, the effect of an off-ice training program with a focus on postural control has yet to be investigated in figure skaters. Training programs that have been designed to challenge and enhance the proprioceptive contribution to postural con- trol have been given different terms, including neuromuscular, proprioceptive, and dynamic stability training programs. Typi- cal exercises involve the performance of single-limb balance tasks, increasing in difficulty as the training program pro- gresses. For example, exercises would first be performed on a stable surface such as the floor, then on an unstable surface such as foam, and then on a reduced base of support such as a wobble board. 14,1926 Researchers have examined the effects of neuromuscular training programs on injury prevention 1921 and on postural control following lower extremity in- jury. 14,22,23 However, prospective studies evaluating the effect of training on postural control in healthy subjects and nonin- jured athletes are limited. 24,2729 Information regarding the effects of neuromuscular training is particularly important for sports that depend heavily on postural control such as dance, gymnastics, and figure skat- ing. While neuromuscular training has been recommended, it has not been investigated in a group of figure skaters. Also, off-ice conditioning programs consisting of strength and flex- ibility training are currently recommended in figure skat- ing, 15,16 and investigations of these programs have not in- cluded evaluations of postural control. Therefore, the purpose of the present study was to investigate the effects of neuromus- cular training compared with basic off-ice training on postural control in figure skaters. METHODS Participants Participants were recruited from The University of Western Ontario varsity figure skating team, local figure skat- ing clubs, and a synchronized skating team, all within the area surrounding London, Canada. Forty-five figure skaters (Table 1) were enrolled in this study from September 2001 until De- cember 2002. The eligible participants were either Intermedi- ate or Senior Level skaters (as defined by the Skate Canada STARSkate [Test] Program), 30 in good health (determined by a questionnaire), between the ages of 12 and 28 years, attend- ing a minimum of 2 hours per week of on-ice practice, and willing to be available for follow-up. Participant exclusion cri- teria included a documented balance disorder or a medical con- dition that might affect postural control (e.g., an inner ear in- fection), a significant musculoskeletal injury in the past 6 months, pregnancy, or current injury making the subject un- able to practice or compete. Asignificant injury was defined as an injury that caused the skater to miss 7 or more consecutive days of normal training. 31 Eligible participants made an appointment with the pri- mary investigator to complete the baseline measurements of postural control. Prior to any testing, the primary investigator confirmed the inclusion and exclusion criteria. Then, all par- ticipants read the information letter and signed a consent form. Each participant also completed a background questionnaire regarding health status, level of figure skating tests completed, current level of participation, respective discipline (singles, TABLE 1. Participants Descriptive Information (mean SD) Neuromuscular Training Group (n = 22) M SD Basic Exercise Training Group (n = 23) M SD Age (y) 18 3 19 3 Mass (kg) 59.6 9.2 57.4 7.5 Height (m) 1.64 0.06 1.63 0.06 Years skating 12 4 12 4 Landing leg Right 17 22 Left 5 1 Discipline Singles 11 11 Pairs 0 0 Dancers 5 4 Synchronized 6 7 Kovacs et al Clin J Sport Med Volume 14, Number 4, July 2004 216 2004 Lippincott Williams & Wilkins pairs, dance, or synchronized skating), dominant and non- dominant leg, and a history of any previous injury. A skaters dominant leg was the leg that a skater would normally use to land a jump on the ice. Study Design and Randomization This study was designed as a prospective, randomized controlled trial (Fig. 1). It was an unblinded study, as both the participant and investigator were aware of the intervention ad- ministered. Following the baseline assessment of postural con- trol (described below), participants were randomly assigned to 1 of 2 groups: an intervention group that received a neuromus- cular training program, or the control group that received a basic exercise training program. After participating in the training programs for 4 weeks, all participants were retested with the same postural control testing procedures used in the baseline assessment. In figure skating, there are 4 major disciplinessingles, pairs, dance, and synchronized skatingeach with different technical requirements. Because the skills involved in each discipline were distinct enough that a skaters discipline might influence the effect of training, randomization was stratified based on a skaters discipline: (1) singles, (2) pairs, (3) dance, and (4) synchronized skating. Randomization was completed by the London Clinical Trials Group using a blocked random- ization design. Sealed envelopes were prepared by the primary investigator and kept in locked cabinets throughout the trial. The envelopes were opened, and the identified intervention group was revealed to each participant after completing the baseline assessment. This study protocol was approved by the University Eth- ics Review Board at The University of Western Ontario. Postural Control Testing Procedures Postural control was assessed by measuring changes in the center of pressure (CoP) signal provided by a force plate during various tests of single-limb standing balance. The force plate (AMTI model; OR6 6, Boston, MA) was 51 cm 46 cm and mounted level with a walkway built on the laboratory floor. During each test trial, Biomechanics Data-Acquisition and Analysis Software (AMTI version 3.1) was used to acquire 15 seconds of force plate output at a sampling rate of 100 Hz. The variation in the CoPthroughout each trial was summarized as the CoP path length, the CoP path area (an ellipse that en- closes 95% of the CoP data), and the SDs of the CoP along the x-axis and y-axis. The CoP path length (cm), the CoP path area (cm 2 ), and the SDs of the CoP in the x-axis and y-axis were determined for each of 3 repetitions of each test situation. Based on the mean of the 3 repetitions, a final score was cal- culated for each test. For each of these CoPsummary variables, higher values indicated decreased postural control, while lower values indicated increased postural control. Because the summary variables are highly correlated, the more commonly reported CoP path length was first used in the analysis. Other measures were then evaluated, and any differences in the find- ings were reported. Prior to any testing, participants were informed that the purpose of each trial was to examine howstill they could stand while performing each test. Each participant was asked to re- main as still as possible. The primary investigator read a stan- dard set of instructions of the testing procedures to each par- ticipant. Participants were then asked to remove their shoes and socks, as all but 1 test situation was completed barefoot. Once the participants felt comfortable to begin, they placed one foot on the force plate, aligning their second toe on the anteroposterior midline of the force plate and the medial mal- leoli along the mediolateral midline of the force plate. Each participant was given 3 practice trials before each test to be- come familiar with the test situation and to minimize any learn- ing effects with repeated testing. Following the practice trials, participants performed 3 consecutive trials of each test. Tests were completed on the dominant leg in the follow- ing order: (1) single-limb stance test (performed with eyes open and then eyes closed), (2) landing jump test (performed with eyes open and then eyes closed), and (3) single-limb stance test with the skate on (performed with eyes open). Rest periods of 30 seconds were given between each trial and each test situation. During the single-limb stance tests, participants stood with the stance leg centered on the force plate, the other knee flexed at 90, and their arms crossed at their chest. The same procedures were followed for the eyes open and eyes closed test situations. Participants were asked if they were ready, and FIGURE 1. Summary of the study design. Clin J Sport Med Volume 14, Number 4, July 2004 Effect of Training on Postural Control in Figure Skaters 2004 Lippincott Williams & Wilkins 217 once they had clearly stated a yes answer, data collection began with a computer keystroke. Participants were asked to focus on a large X marked at approximately eye level on a black board 5 m away during the eyes open test situations. During the test situations completed with eyes closed, partici- pants looked at the same X before firmly closing their eyes. For the landing jump tests, participants simulated a land- ing position used in figure skating, landing on the force plate without their skates on (Fig. 2). A box that was 46 cm 51 cm 18 cm was placed 10 cm in front of the force plate. Partici- pants placed both heels at the edge of the box and jumped down fromthe box, off of two feet and landing on 1 foot. Participants were instructed to land as they would on the ice, with their arms extended to the sides and their free leg extended in the posterior direction. For the eyes closed condition, participants were asked to close their eyes before jumping off the box. CoP data collection started when a threshold of 20 N of vertical ground reaction force was detected by the force plate. For the single-limb stance test with the skate on, partici- pants stood with their skate wearing their skate blade guard, centered on the force plate. All participants wore a standard skate guard (a firmplastic protector that attaches onto the skate blade). With their opposite foot in contact with the force plate, participants were instructed to lift that limb when they were ready. When their foot was completely lifted off the force plate, the test trial commenced with a computer keystroke. Par- ticipants were allowed to have their arms outstretched during this testing situation and their opposite leg in a self-selected position. During this test, participants looked straight ahead at the large X marked on the black board 5 m away. Participants were asked to remain as still as possible dur- ing each test. If they did feel themselves losing balance, they were to try to correct their position as quickly as possible. For each test trial, if participants were unable to maintain their po- sition for the full duration of the trial (i.e., they touched down with their nonstance foot), that individual trial was recorded as a failed trial and repeated. Training Programs Neuromuscular Training Group Participants randomly allocated to the neuromuscular training group followed a four-week off-ice training program that was designed to progressively challenge the neuromuscu- lar systems contribution to postural control. Exercises for this group were designed by the primary investigator, a kinesiolo- gist and a physiotherapist, and are comparable to neuromuscu- lar exercises in previous studies. 14,1929 However, this pro- gram also incorporated various sport-specific skills related to figure skating (Fig. 3). The training program was performed three times per week, with each session lasting approximately 20 to 25 minutes. The training program was divided into 4 phases; each phase was completed in one training week. In brief, the first week included single-limb stance exercises per- formed on the floor, round wobble board (16 Fixed Angle Intermediate; Fitter International, Calgary, Alberta, Canada) exercises on two feet (Fig. 3A), and a waffle (16 Disco Sit; Fitter International) exercise on two feet (Fig. 3B). Exercises in week 2 consisted of single-limb standing on the floor with eyes open and then closed, and single-limb standing exercises on the minitrampoline (Stamina InStride 36 Mini-trampoline; Walmart; Fig. 3C) and on the waffle. In the third week, par- ticipants used the rectangular wobble board (Basic Fixed Angle 8 Degree Rocker Board; Fitter International) to perform single-limb balancing exercises (Fig. 3D) and the minitrampo- line to perform landing exercises and catching a ball while maintaining balance on one foot. The participants also used the waffle to performsingle-limb standing exercises while moving their arms froman outstretched position to a position with their arms crossed at their chest (Fig. 3E). The final week consisted of sport-specific exercises, including landing exercises on the minitrampoline, simulating landing positions on the waffle (Fig. 3F), and performing spiral (a common field movement in figure skating) exercises on the floor (Fig. 3G). Participants also used a sport specific device known as a Spinner (a rota- tional disk, 7 7; Jerrys Skating World, Markham, Ontario, Canada) to perform off-ice backspins (Fig. 3H). A backspin is one of the most basic spins in figure skating; a skater starts with the arms and free leg in an outstretched position and begins to FIGURE 2. Landing jump test. Kovacs et al Clin J Sport Med Volume 14, Number 4, July 2004 218 2004 Lippincott Williams & Wilkins pull in both the arms and free leg into a tight position. The arms are crossed at the chest, and the free leg is crossed tightly over the spinning leg in the final position. The skater is revolving backward on the right foot in a counterclockwise direction. Progress with the training program was assessed on the third training day of each week by the training program super- visor. One of the exercises for each week was randomly se- lected for the assessment. A pass was given if the participant was able to perform the exercise correctly for the specified amount of time. A pass on the assessment exercise was neces- sary for the participant to progress to the following weeks ex- ercises. Basic Exercise Training Group Participants in the basic exercise training group com- pleted a standard set of stretching and strengthening exercises that were also performed three times per week, with each ses- sion lasting 10 to 15 minutes. The exercises for this group were designed by the primary investigator using the Physiotools Software Program (Physiotools 3.0 Software, Version 3.0). This exercise program consisted of the following activities: 5-minute aerobic warm-up (running or skipping), quadriceps stretch, gluteus stretch (Fig. 4A), hip flexor stretch (Fig. 4B), calf stretch, hamstring stretch, 10 push-ups, 20 abdominal crunches (Fig. 4C), and a wall-sit exercise (Fig. 4D). All stretching exercises were held for 20 seconds each and per- formed one time on each side. In both groups, the exercises were performed in a class format that had a circuit-training design. All sessions were carefully supervised by 1 of 4 supervisors and were completed three times per week. For any exercise that was timed, the su- pervisor kept time for a participant with a stopwatch. All ses- FIGURE 3. Neuromuscular training exercises. A, Round wobble board ex- ercise, two feet (controlled move- ments, side to side). B, Waffle exer- cise, two feet. C, Minitrampoline ex- ercise, single-limb hop and land on other foot. D, Rectangular wobble board exercise, one foot (controlled movements, front to back). E, Waffle exercise, one foot, moving arms from an outstretched position to a position with the arms crossed at the chest. F, Waffle exercise, simulating a landing position. G, Spiral exercise. H, Back- spin exercise performed on the Spin- ner. Clin J Sport Med Volume 14, Number 4, July 2004 Effect of Training on Postural Control in Figure Skaters 2004 Lippincott Williams & Wilkins 219 sions were held before or after an on-ice session and were com- pleted at the arena in a large dressing room with rubber floor- ing. The groups trained separately in different rooms and were asked not to discuss the exercises in their respective training programs. Adherence with the programs was monitored for each group with the use of sign-in sheets for each participant and exercise checklists. Outcome Measures The primary outcome measure was the CoP path length observed during the landing jump test completed with eyes closed. This test was selected as the primary outcome because it was thought to be the most challenging to the neuromuscular system and most functionally relevant to the sport. Secondary outcome measures included the CoP path lengths observed during each of the remaining balance tests. The reliability of standing balance tests using a force plate has been previously reported to be moderate to excellent, 32 and these types of tests are appropriate for comparing groups undergoing different in- terventions. 32 Statistical Analysis Estimates of sample size were based on previous find- ings of force plate measurements that occur during single-limb standing balance tests. 32 Using the equation for a comparison of 2 independent samples, 33 a 2-sided alpha level of 5%, and power set at 80%, 24 participants per group were required to detect a difference of 16 cmin the CoP path length between the groups (corresponding to an improvement of approximately 20% of previously reported normative values). For the primary analysis, CoP path length during the landing jump test completed with eyes closed was assessed using an analysis of covariance at the end of the four-week training period, adjusting for baseline measures. The second- ary analysis evaluated change scores and the potential interac- tion between the intervention group and the type of test used to assess postural control. A two-way repeated-measures analy- sis of variance was used, with the type of balance test defined as the within-subjects factor (5 levels) and the intervention group defined as the between-subjects factor (2 levels). All analyses were based on the assigned treatment at the time of randomization, regardless of adherence status (inten- tion to treat). The 0.05 level was used to denote statistical sig- nificance throughout the analysis. Statistical analyses were performed using the Statistical Package for the Social Sciences (Version 10.0, 2000; SPSS, Chicago, IL) and Statistica for Windows (Version 5.0, 1996; StatSoft, Tulsa, OK). RESULTS A total of 61 potential participants (all female) were re- cruited from the University of Western Ontario varsity figure skating team, local figure skating clubs, and a synchronized skating team. Of these, 2 potential participants were ineligible, and 14 were eligible but unable to commit to the required num- ber of training sessions per week. Forty-five figure skaters were subsequently enrolled in the study, with the average age FIGURE 4. Basic training exercises. A, Glu- teus stretch. B, Hip flexor stretch. C, Ab- dominal crunches. D, Wall-sit exercise. Kovacs et al Clin J Sport Med Volume 14, Number 4, July 2004 220 2004 Lippincott Williams & Wilkins of participants being 18 years 3 years (range, 1228 years). The distribution of participants according to discipline in fig- ure skating was as follows: 51% identified themselves as singles skaters, 29% as synchronized skaters, 20% as dancers, and none as pairs skaters. All of the participants enrolled in the study had been figure skating for a considerable time; the mean and SDof the number of years skating were 12 years 4 years. The majority of skaters (87%) indicated that their dominant leg, the one that they landed on, was their right. The baseline characteristics for both groups are reported in Table 1 and were similar with respect to age, mass, height and the number of years skating. Among the 45 participants, 22 were randomly assigned to receive the neuromuscular training program and 23 to re- ceive the basic exercise training program. During the course of the study, one participant dropped out of the basic exercise training group and did not return for the posttesting. Adherence with both training programs was excellent. In the neuromuscular trained group (n = 22), all except 3 partici- pants completed the required number of training sessions, which corresponded to 9/264 missed training sessions. Simi- larly, in the basic exercise trained group (n = 22), all except 5 participants completed the required number of training ses- sions. This also corresponded to 9/264 missed training ses- sions. Two participants, one from each group, missed a con- siderable amount of the training program (>3 sessions), but as outcome data were available, they were included in the inten- tion-to-treat analysis. Forty-four figure skaters completed the neuromuscular training program or the basic exercise training program, and their data were analyzed according to the proto- col. Intention-to-Treat Analysis Means and SDs for the CoP path lengths for all of the standing balance tests, before and after the training programs, are given in Table 2. The baseline values were similar in the two groups. The analysis of covariance indicated that the postintervention CoP path length during the landing test com- pleted with eyes closed was significantly (P = 0.001) lower (indicating better postural control) for the neuromuscular- trained group (mean = 183.3; SD = 43.9 cm) than the basic exercise-trained group (mean = 227.5; SD = 60.5 cm). The mean difference between the neuromuscular-trained group and the basic exercise-trained group, postintervention, was 44.2 cm (95% CI for difference = 11.676.3). Results were similar when this analysis was repeated using the CoP path area and the SDs of the CoP in the x-axis and y-axis. Results of the repeated measures analysis of variance of the change scores indicated a significant main effect for group (P = 0.004), with the neuromuscular-trained group demon- strating significantly greater improvement for the balance tests from baseline than the basic exercise group. There was no sig- nificant main effect for the test situation (P = 0.093). There was, however, a significant intervention group by balance test interaction (P = 0.008), suggesting that the effect of the inter- vention depended on which balance test was used. Newman- Keuls post hoc tests indicated that the neuromuscular-trained group had greater improvements for the landing jump test completed with the eyes closed and the single-limb stance test completed with the skate on (P < 0.05). To aid in interpreta- tion, means and SDerror bars for the percent change in the CoP path lengths during all balance tests are illustrated in Figure 5. DISCUSSION The observation of improved postural control following the neuromuscular training program is consistent with previ- ous studies evaluating the effect of training in healthy, nonin- jured subjects 24,28,29 and some clinical populations. 22,23 Hoff- man and Payne 24 reported that following a 10-week training TABLE 2. Means SDs for the Preintervention and Postintervention COP Path Lengths (cm), the Change in the COP Path Length (cm), and the Percent Improvement (%) for the Postural Control Tests Tests Basic Exercise Group (n = 22) Neuromuscular Group (n = 22) Single limb stance, eyes open Baseline 63.1 12.2 62.6 10.5 Postintervention 64.2 14.5 59.2 7.7 Change 1.0 7.1 3.5 7.5 Percent change 1.9 11.3 4.3 12.0 Single limb stance, eyes closed Baseline 126.9 31.7 125.7 37.5 Postintervention 125.2 41.2 118.9 27.6 Change 1.8 35.7 6.8 29.7 Percent change 0.3 22.5 1.3 22.0 Landing, eyes open Baseline 119.2 29.8 121.5 24.8 Postintervention 118.3 34.9 111.8 15.1 Change 0.89 23.3 9.7 24.4 Percent change 0.02 17.9 5.3 18.5 Landing, eyes closed Baseline 224.0 65.3 243.7 67.2 Postintervention 227.5 60.5 183.3 43.9 Change 3.5 50.6 60.4 67.6 Percent change 4.9 24.9 21.0 22.0 Single limb stance, skate on, eyes open Baseline 409.8 121.3 435.8 85.4 Postintervention 394.9 109.0 357.1 79.4 Change 14.9 76.4 78.7 88.9 Percent change 0.6 21.4 16.7 19.4 Clin J Sport Med Volume 14, Number 4, July 2004 Effect of Training on Postural Control in Figure Skaters 2004 Lippincott Williams & Wilkins 221 program using the Biomechanical Ankle Platform System, participants in the experimental group showed significant im- provements in postural control in the medial-lateral and ante- rior-posterior directions (P < 0.05). In their study, participants in the experimental group completed a 10-week training pro- gram using the Biomechanical Ankle Platform System, while the control group did not receive any training. In another study, Balogun et al 29 investigated postural control in healthy male participants following a 6-week wobble board training pro- gram. The control group in that study did not receive any train- ing during the 6 weeks. Standing balance was assessed with eyes open and eyes closed using a single-limb stance test; the number of seconds a participant was able to maintain balance was used as the outcome measure. Following training, Balo- gun et al 29 observed significant improvements in standing bal- ance in the experimental group for both the eyes open and eyes closed conditions, while standing balance in the control group remained unchanged. Although the present findings are similar to previous re- ports describing the effect of neuromuscular training, caution must be used when attempting to compare studies because of the different measures used to evaluate postural control. The present study used CoP parameters to evaluate postural con- trol, and the suitability of such measures has been previously established. 34 Also, previous studies have typically included male participants, whereas the present study included only fe- males. It is important to note that gender differences have been reported in postural control measurements. 35 The results of this study suggest that neuromuscular training leads to greater improvements in postural control dur- ing more challenging tests, but results in only small changes for more basic tests. The largest improvement in postural con- trol for the neuromuscular-trained group was seen during the landing jump test completed with the eyes closed (21%), whereas the single-limb stance test and the landing jump test completed with eyes open showed only small improvements (4.3% and 5.3%, respectively). This finding may be explained by the suggestion that when a training programwith a focus on the neuromuscular systemis performed, the resulting improve- ment in postural control may be seen during tests that chal- lenge the neuromuscular systems contribution to postural control, such as during tests completed with eyes closed. These results are in contrast with the study by Balogun et al, 29 who reported a larger improvement in standing balance during the single-limb stance test completed with eyes open (201.2%) compared with the single-limb stance test completed with eyes closed (58.8%) following a wobble board training program. The differences in criteria for selecting participants and differ- ences in training programs may help to explain these findings. The present study was specific to a cohort of figure skaters, whereas the study by Balogun et al 29 consisted of sedentary young males. In the present study, the participants had an av- erage of 12 years of figure skating experience and during these years of training had, in all probability, developed skillful pos- tural control strategies. For the relatively simpler tests, it may have been difficult to detect large differences following a neu- romuscular or a basic exercise training program because the participants were already performing at a very high level on these tests. In contrast, improvements in postural control for basic tests following a training program may be more easily observable in a population performing at a lower level initially. In contrast to previous studies that included a control group that received no special training, 19,21,24,27,29 the control group in the present study completed a basic exercise training program. Aspecific training programfor the control group was designed for several reasons. Firstly, previous research evalu- ating off-ice conditioning programs for figure skaters had not investigated the effects on postural control. 10,18 Secondly, one of the goals of the present study was to determine if neuromus- cular training provided an additional benefit over standard off- ice conditioning. Thirdly, a specific program for the control group was also administered to prevent the Hawthorne effect; that is, simply the thought of participating in and fulfilling the requirements of a research study may alter participants behav- ior, thereby contributing to an improvement. It is interesting to note that this study demonstrated im- provements in postural control after only a four-week training program. This is a shorter training period than that of previous studies. 14,24 Rozzi et al 22 also demonstrated significant im- provements in postural control following a four-week training program. These results are, however, in contrast to the findings from a study by Cox et al, 27 who reported no significant gains in postural control after a 4-week training program. In that study, there were two training groups (foam surface training and hard surface training) and a control group (nontraining). Although there was a consistent improvement in the postural control measurements for the hard surface training group, there was no significant improvement within any group and no significant difference between groups. The training protocol FIGURE 5. Means and SD error bars illustrating the percent improvement in the CoP path length during standing balance tests for the neuromuscular trained group and the basic exer- cise-trained group. *Significant difference between the neuro- muscular trained group and the basic exercise-trained group (P < 0.05). Kovacs et al Clin J Sport Med Volume 14, Number 4, July 2004 222 2004 Lippincott Williams & Wilkins consisted of 5-minute training sessions three times per week for four weeks, and may have been insufficient (15 minutes total training per week) or too demanding to elicit a training effect. Alternatively, the number of participants (9 per group) may have been too small to detect a significant difference. In the present study, working with university and high school athletes presented challenges to our research team; therefore, to ensure that this study was feasible for the partici- pants, a four-week training period was selected. In addition, summer training programs for figure skating are typically scheduled as four-week intervals. The design of a four-week training program helped to optimize recruitment of partici- pants and may also be easier to implement in the future. Al- though the training duration was only four weeks, the findings suggest that this is sufficient time to promote improvements in postural control in figure skaters. This time period may, how- ever, be different (weeks, months, or years), depending on the clinical population. In addition to documenting the effects of a training pro- gram on postural control in figure skaters, another aspect of this study was to document how well the participants adhered to the training programs. Some previous investigations have not monitored adherence 20,21 ; therefore, the frequency and in- tensity of the prescribed exercises (including home programs) may have varied between groups and individuals and may have influenced the results. In the present study, adherence to both training programs was closely monitored, as it was important to determine if neuromuscular training could be feasibly incor- porated into off-ice conditioning for figure skaters. In the neu- romuscular-trained group (n = 22), all except 3 participants completed the required number of training sessions, which corresponded to 9/264 missed training sessions. Similarly, in the basic exercise-trained group (n = 22), all but 5 participants completed the required number of training sessions. This also corresponded to 9/264 missed training sessions. To monitor adherence, the participants were given a sign-in sheet for the entire duration of the study and an exercise checklist. Further- more, each training session was supervised by 1 of 4 supervi- sors, and the primary investigator was in regular contact with each participant. Adherence might have been lower had we not monitored the participants as closely. However, the present findings suggest that a neuromuscular training program can be feasibly incorporated into current off-ice conditioning pro- grams, particularly at elite training centers, with highly moti- vated athletes. Limitations in the present study and ideas for future re- search should also be emphasized. Due to the participants un- familiarity with the specific exercises in the neuromuscular training program, each training session lasted 5 to 10 minutes longer than for the basic exercise training group. Therefore, it is possible that the longer training duration in the neuromus- cular training group may have contributed to the improvement in postural control. Also, although adherence to the training protocols was excellent for study participants, several indi- viduals approached during recruitment refused to participate in the study due to the time requirements, and one study partici- pant dropped out of the study for the same reason. We ac- knowledge that requiring participants to train off-ice three times a week (in addition to the 2 on-ice sessions) did add a considerable time commitment, and this is a potential limita- tion to the generalizability of the results of the present study. Specifically, these results are applicable for high-level com- petitive figure skaters. The neuromuscular training program may be less feasible for recreational figure skaters who may train only 1 to 2 sessions per week. The results of the present study can also only be generalized to female skaters. Although two males in the surrounding figure skating community were approached, they were unable to participate. Gender differ- ences have been reported in postural control measurements, 35 and the potential effect of gender on improvement in postural control following off-ice training requires further research. Similarly, it is not clear how the observed changes are main- tained over the long term. Further studies are needed to iden- tify if detraining occurs and if maintenance programs are indi- cated. While the present study provides initial data for an im- provement in postural control following a neuromuscular training program in figure skaters, future research is also needed to understand better the underlying physiologic mecha- nisms and clinical implications. It has been suggested that an improvement in postural control may be related to the changes in muscle strength, 36 while others have reported that an altered neuromuscular response, such as an improvement in the pe- ripheral feedback to the central nervous system, may be re- sponsible. 26,37 A combination of these mechanisms are likely involved, and further studies are needed. Future studies should also focus on the use of specific performance outcome mea- sures for the sport of figure skatingfor example, assessment of an individuals performance during a practice session (i.e., number of missed attempts on a particular element) or the ath- letes perception of the training program. In addition, the effect of neuromuscular training on decreasing the incidence of fig- ure skating injuries should be investigated. CONCLUSION Neuromuscular training has been shown to improve measures of postural control significantly in a group of figure skaters when compared with a basic exercise training program. The present findings suggest that four weeks of neuromuscular training can improve measures of postural control during tests that challenge the neuromuscular system and are functionally relevant to the sport of figure skating. 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