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A Comparative Study of Water and Land Based Exercises Training Program on

Stability and Range of Motion

Article  in  International Journal of Engineering and Technology · December 2018

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 International Journal of Engineering & Technology, 7 (4.42) (2018) 68-72

International Journal of Engineering & Technology

Website: www.sciencepubco.com/index.php/IJET

Research paper

A Comparative Study of Water and Land Based Exercises

Training Program on Stability and Range of Motion
1 2 3 4
Fariba Hossein Abadi , Lee Ai Choo , Mohansundar Sankaravel , Srinivas Mondam
1234
Faculty of Sports Science and Coaching, Universiti Pendidikan Sultan Idris, Tanjung Malim, Perak, Malaysia
*Corresponding author E-mail: [email protected]

Abstract

Serious ankle injuries continue to be a strong concern to athletes of many sports. The frequency of ankle injuries in sport is paramount.
The sports which involve the lower limbs usually will cause injuries around ankle and leading to ankle instability as a result recurrences
are very common. Moreover, stability plays an important role in preventing ankle injury for an athlete. Thus, this study was aimed to
identify the influence of exercises in different environments like water-based and land-based exercise over dynamic stability and range of
motion (ROM) there by to prevent ankle injuries among collegiate athletes. A total of 24 amateur athletes who had ankle sprai n during
their sporting activities were recruited for this study and randomly assigned in two groups; water-based (BMI 23.08±3.17 kg.m-2) and
land-based (BMI 23.94±4.86 kg.m-2). The exercises session were carried out twice per week, 45 minutes to an hour for 8 weeks. Both
groups underwent eight weeks of training for the aquatic and land exercises. The changes (by pre and post-test) in dynamic balance were
measured for both groups via Star Excursion Balance Test (SEBT) for the injured legs. The results shows pre and post -test means differ-
ences of SEBT test of water and land-based exercises groups were -5.26 ± 1.5 and -3.77±1.94 cm, respectively. While there was statisti-
cally no significant differences in improvement of dynamic balance between the exercise given in both media (t=0.36; p=0.72); post-test
results of both groups showed significant improvement in both groups p<0.00. There was only significant differences in ROM between
water-based and land-based groups (t=5.37, p=0.000). This study was concluded that water and land-based exercises are useful to im-
prove the stability and range of motion and thereby to prevent ankle injuries.

Keywords: ankle injuries, water-based exercise, dynamic balance, range of motion, athletes.

which may be stretched or torn, as a result of landing on a plantar

1. Introduction flexed and inverted position of the foot [8].
Nualon [8] further explained that a high recurrent rate of ankle
Ankle injuries are the most common injuries in athletics as well in sprain has also been reported in athletes who have residual symp-
non-athletics [1, 2] and people who involved in sports are at high toms such as pain, swelling, weakness and instability. These im-
risk to get ankle injuries [3]. Ankle injury usually occurs in sports pairments could further deteriorate the ankle functional ability of
involving running, cutting, jumping and landing, with higher pos- athletes who have recurrent ankle sprains. While the most com-
sibility in contact sports [2]. It has been estimated that ankle inju- mon injury in athletics is the lateral ankle sprain, and recurrence
ries attributing upward of 45% of all athletic injuries to ankle rates have been found to be as high as 80% [9], ankle sprains are
sprains [4]. more likely to reinjure the same ankle over and over for the in-
Further studies explained that 271 patients were classified as hav- jured athlete.
ing bone injury and 1076 cases had sprain, muscle or soft tissue In addition, previous studies have stated there are two potential
injury. It is assessed that between 10 and 30 percent of individuals mechanisms that can cause chronic ankle instability. The first
who have had acute lateral ligament sprain continue to suffer mechanism is mechanical instability from ligament laxity and
chronic functional instability of the ankle [5]. In addition, athletes excessive joint motion of the talocrural, subtalar and inferior
who suffer from ankle sprains are more likely to reinjure the same tibiofibular joint because of structural damage of the supporting
ankle which can result in disability and can lead to chronic pain or ligamentous tissue. The second mechanism is functional instabil-
instability in 20% to 50% of these cases [6]. According to Oliveira ity, a condition in which a patient has imbalance of the postural
et al., (2016) ankle sprain lesion can be classified as grade 1, 2, or stability and recurrent sprains with or without a feeling of ankle
3, ranging from mild to severe (1 – 3) based on the extent of dam- giving away [8, 10]. These will directly lead to balance deficits
age and number of ligaments affected. The grade 1 sprain is char- and joint position sense deficits which mainly depends of afferent
acterized by the stretching of the anterior talofibular and data which is used for delicate sensory-motor integration [11].
calcaneofibular ligaments. In the grade 2 sprain, the anterior Meanwhile, good proprioception as an ability to integrate the sen-
talofibular ligament partially tears, and the calcaneofibular liga- sory signals from various mechanoreceptors is important for pro-
ment stretches. The grade 3 sprain is characterized by rupture of moting dynamic joint and functional stability in sports (standing,
the anterior talofibular and calcaneofibular ligaments, with partial walking and running) [12]. While previous study discovered the
tearing of the posterior talofibular and tibiofibular ligaments [7]. ankle plays an integral role in maintaining balance [13, 14], based
Ankle sprain usually involves a lateral ankle ligament complex, on clinical experience, the majority of physical therapy clinics and
athletic training for ankle sprain incorporate both strengthening
Copyright © 2018 Authors. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original work is properly cited.
International Journal of Engineering & Technology 69

and proprioception exercises [12]. Numerous studies have looked particularly for athletes who should quickly return to their sports
at the effects of strengthening exercises, proprioceptive exercises, activities. Therefore, this study aimed to compare the effectiveness
or a combination of both on the return of a patient to functional of 8 weeks rehabilitation exercise in water and land media on
activity. Moreover, Han et al., [15] stated that ankle propriocep- dynamic balance and range of motion (ROM) among athlete col-
tion can be altered by general and sports specific training, sports- legiate students who suffering from ankle sprain.
related injuries and sports- induced fatigue, all of which may sub-
sequently lead to altered balance ability. Balance ability of a group
of athletes was significantly correlated with their agility perfor- 2. Methodology
mance [15]. This suggested that balance control is fundamental to
sports performance and similarly, ankle proprioception and sport 2.1. Subjects
performance are related.
Besides that the static balance, dynamic balance also very crucial A total of 24 amateur athletes (10 males, 14 females), age ranging
for an athlete. This is due to the movement presence in the sport- from 20 to 27 years from Sultan Idris Education University (UPSI)
ing activity such as jumping, running, landing, hopping and more. who had experienced ankle sprain during their sporting activities
These movements require pivot action of these ankle joint where were recruited for this study. All the subjects were informed the
the ankle at least need inverted, everted, or flexed up to certain procedures of the study and signed a consent form before enrolled
degree of range of motion (ROM).When the pivot action beyond in this study. The demography of subjects shows in Table I.
the normal level its causes injury to the ankle joint [16, 17]. To
maintain good pivoting action, an athlete needs good dynamic Table I: Demography of the subjects
balance to prevent ankle injury. Furthermore, ROM was evaluated Variables/ Water based (n=12) Land based (n=12)
as a predictor of ankle sprain. Dorsiflexion range strongly predict- Group % / (Mean ± SD) % / (Mean ± SD)
ed risk of ankle sprain. Postural sway and possibly proprioception Gender M: 6 (50%) M: 4(33%)
were also predictors [16]. However, the preliminary evidence F: 6 (50%) F: 8 (67%)
suggests that people with reduced ankle dorsiflexion range may be Injured leg L: 5 (41.7%) L: 7 (58.3%)
at increased risk of ankle sprain. Thus, the study of dynamic bal- R: 7 (58.3%) R: 5 (41.7%)
ance is equally important as static balance and ROM to prevent Age (yrs) 22.6±1.62 23.5 ± 2.02
ankle sprain. Theoretical and scientific bases declared that stabil- Height (cm) 166.1±9.19 165.17 ± 6.89
ity and proprioception are important ability for any athlete and it Weight (kg) 63.91±8.87 65.35 ± 12.86
should be considered as part of any rehabilitation program [18, BMI (kg.m-2) 23.18±2.88 23.91 ± 4.44
19].
There is evidence indicating that land-based exercise can be more Sports involve- 6.3 ±3.74 7.6 ±3.24
beneficial for people who suffering from ankle injuries by improv- ment (yrs)
ing ankle stability and re-educate the muscle and ligament around
the ankle join. Usually, land-based exercise is essential in the re- The athletes involved in the various sports with minimum three
habilitation programs for neuromuscular function improvement in years sports involvement background. They had experienced at
the acute and chronic phase of an ankle sprain [8]. Previous study least one time ankle sprain (grade 1, 2 or 3) within the past six
done by Orna et al., (2011), on impact of plyometric exercises on months with the residual symptoms of “giving way” or instability
land found that the body is exposed to high-impact loading which while walking or running in sports activities. The subjects were
randomly placed into two groups: water-based (6 males, 6
leads to compressions of the spine and lower extremities [20, 21]. females, with age: 22.6±1.62 years, height: 1.66.1±9.19cm,
Most of the sporting activities involve jumping and cutting activi- -2
ty on the land thus, pressure on the land is higher compared to weight: 63.91± 8.87kg, BMI: 23.18±2.88 kg.m , sports
involvements background: 6.3±3.74years), and land-based (4
water and the result shows that the loading impact on the joint is
males, 8 females, with age: 23.5±2.02 years, height:
high on land based exercise. -
Then, considering physical properties of water (buoyancy, viscosi- 1.65.17±6.89cm, weight: 65.35±12.86kg, BMI: 23.91±4.44kg.m
2
ty, Hydrostatic pressure and temperature) [22] may be more effi- , sports involvements background: 7.6 ±3.24years).
cient to improve stability and proprioception on a water-based
program. Water exercise or also known as aquatic exercise have 2.2. Instrumentation
been widely used in physical therapy programs, especially when
exercising under normal conditions of gravity is difficult and pain- A Goniometer (Baseline 12-inch Plastic 360-Degree ISOM/STFR)
ful. Water buoyancy reduces the weight that joints, bones, and was used to measure range of motion (ROM) for Dorsi-flexion,
muscles have to bear [19]. The percentage of weight bearing de- Plantar-flexion; Inversion and Eversion movements. In addition,
creases with greater immersion as an individual standing in water the subjects performed STAR EXCURSION BALANCE TEST
to the level of the xiphoid process will bear approximately 28% to (SEBT) to measure dynamic balance and highlight the loss of
35% body weight depending on gender. The percentage of weight dynamic postural control [23]. SEBT test originally incorporated
bearing will increase with activity walking and increasing speed of reaching in eight directions (anterior, anteromedial, medial,
movement [20]. The warmth and pressure of the water also reduce posteromedial, posterior, posterolateral, lateral and anterolateral)
swelling and increase blood circulation [19]. Consequently, an while standing on each foot, but factor analysis indicated that one
underwater environment allows early active mobilization and reach direction in particular posteromedial was able to accurately
dynamic strengthening. In a study done by Nualon et al., [8], identify individuals with chronic ankle instability as well as
found that the hydrotherapy group and the land based therapy performing eight directions (Figure 1). All data were collected in
group had improved ankle functional ability as demonstrated by two phases as pre-test and post-test. Pre-test was conducted before
the single-limb hopping performance. Likewise Yalfani et al., starting the exercise program and the post-test was performed on
(2015) observed better improvement in pain relief, performance, the same aspect one week after the training done.
static and dynamic balance of people with chronic ankle sprain in
water exercise, but there statistically was no significant difference
with the land exercise group [21].
By way of applying and performing of physical properties of wa-
ter, rehabilitation process for athlete presumably could optimize
the effect of exercise. However, there is still a few studies on the
effect of water-based exercise on improvement of ankle injuries
 70 International Journal of Engineering & Technology

Deep 1 minute 3 ----> 8

water
bicycle
Pool plank 30 second 4 ----> 8
Wall push 10 push-ups 3 ----> 8
up
Cool-down Recreation, ball game ,combination Stretching, 7-10
Joint relaxation and deep breathing

2.4. Statistical analysis

Figure 1: Star Excursion Balance Test Directions
The mean and standard deviation for each parameter were ana-
2.3. Water and land based exercise protocol lyzed using IBM SPSS software (version 23). Paired t-test for the
comparison of the results was obtained from pre-test and post-test
of the same group, which allows estimating if the effect of exer-
All subjects were attended at the rehabilitation exercise class at
cise protocol is significant. Independent t- test were used to com-
gymnasium and swimming pool of Sultan Idris Education Univer-
pare the results by both groups (water-based and land-based) of
sity (UPSI). Both programs were supervised by physiotherapist
subjects if the difference is significant. The significant level were
twice a week (45-60 minutes) in eight weeks’ period. The subjects
statistically considered significant at p<0.05.
received same static stretching program of warming up and cool-
ing down for ten minutes. After that, they participated either in
water-based exercise session or land-based exercise session and 3. Results
progressed according to their assigned group for 40- 45 minutes.
This main exercise section consisted of combination of water
walking/jogging, forward lunges, side lunges, one leg balance, According to descriptive data, both studied groups were
side stepping, marching, hip kickers, deep water bicycle, pool statistically comparable. All subjects had a side ankle sprain
experience (left or right). The demography of physical
plank and wall push up, which similarly were performed for land-
characteristics of the subjects based on exercise media
based group [8, 19, 21]. Between each repetition, 30 to 45 seconds
(water/land-based) is showed in Table I. It should mention that no
break was considered.
significant difference found in age, weight, height, and BMI and
The land-based exercise session was conducted in the exercise
sports involvement background between both groups.
room, and the water-based exercise was conducted at UPSI out-
door swimming pool with 1.2 meters depth (shallow swimming Analyzing of the depending variables; dynamic balance
pool) which the subjects nearly immersed to the xiphoid flow. The (SEBT) and ROM, illustrated significant differences between pre-
temperature of the pool was unable to maintain due to the weather test in water-based and land-based groups (p=0.000), while no
changes. The intensity and frequency of the exercise were gradual- significant difference found in pre-tests. The results of paired t-test
ly increased followed by week [13, 24, 25]. The summary of wa- revealed that eight weeks exercise could improve dynamic balance
ter-based progressive exercise protocol showed in Table II. and ROM in both media which the changes showed in Table III.
The results also revealed that no significant differences in
Table II: A summary of eight weeks water-based exercise protocol dynamic balance between water-based and land-based groups
Exercise Intensity Frequency Time (t=0.36; p=0.72). Although dynamic balance increased in poost-
Protocol (week 1---> (sets of repe- (mins) test for both groups, there was no significant difference between
week 8) tition) water and land-based exercise. There was only significant
(week 1--> differences in ROM between water-based and land-based groups
week 8) (t=5.37, p=0.000).
Warm-up: Static walk, jog
in a place, step side to - - 7-10 Table III: The effects of eight weeks exercise programs on dynamic bal-
side, ance (SEBT) and ROM of subjects in water and land media
combination stretching Variables Me- Pre-test Post- test Mean t p
Water 20×4 ---- 20 steps dia (Mean (Mean diff (DV
walking/ >20×8 walking ---> ±SD) ±SD) )
jogging (forward and jogging
(steps) backward) Dynamic Water 55.82±8.0 60.83± 5.01± 10.6 .00
Forward 10 steps of 2 ----> 8 Balance (n=12 9 6.98 1.63 5 0
lunges lunges (cm) ) 56.44±7.1 59.79± 3.36±
Main Exer- Side lung- 10 steps of 0----> 8 Land 1 7.14 2.01 5.78 .00
cise es lunges (n=12 0
(dynamic One leg Front (hold 3 3----> 8 40-45 )
balance & balance; counts), t-test for df= t = .201 t = .36
ROM) Right & Side to side independ- 22 p =.84 p =.72
Left (hold 3 counts) ent
Side step- 10--->15 steps 0-----> 8 variables
ping;
Right & ROM Water 20.77º±1.3 27.72º± 6.95° 18.9 .00
Left (°degree) (n=12 9 1.01 ± 8 0
Standing 10 steps 3 ----> 8 ) 21.66º±1.2 25.14°±1.3 1.27
knee lift; Land 1 2 3.52º 13.3 .00
Right & (n=12 ± .92 5 0
Left )
(marching) t-test for df= t= 1.6 t=5.37
Hip kick- 10 steps 3 ----> 8 independ- 22 p =.13 p=.000
ers ent
Right & variables
Left DV = Dependent variables
International Journal of Engineering & Technology 71

4. Discussions Additionally, in this study, eight weeks water-based exercise

caused a significant improvement on ROM compare to the similar
land-based exercise. Earlier studies have declared the greater ef-
This study investigated the comparison of eight weeks water and
fectiveness of water-based exercise on flexibility and ROM among
land-based exercise on improving dynamic balance and ROM of
patients, older adults and individual with illness problems [29-31].
the athletes who experienced ankle sprain within the past six
Poyhonen et al., (2002) showed ten weeks aquatic resistance train-
months. The findings revealed that the progressive intervention
ing could change the knee extensors and flexors between 10 to
exercise was resulted in increasing dynamic balance and ROM in
27% among healthy adult women [29].
both media after eight weeks. Even though, the improvement of
Our findings in land-based exercise group and Zouita et al., (2006)
dynamic balance of land-based (+3.36±2.01cm) was smaller than
studies had similarity in significant differences in postural sway
water-based group (+5.01±1.63cm), there was statistically no sig-
after eight weeks proprioceptive exercise program among athletes
nificant differences between the exercise given in both media.
with ankle sprain. They also reported a significant decrease in
While the findings of the study indicated increasing in ROM for
times of acceleration and deceleration at the level of plantar flex-
water-based (+6.95º±1.27) and land-based (+3.52°±.92) group, for
ors, better stability and postural control of the injured leg [12].
water-based group was significantly different with land-based
These findings was consistent with a similar study by Wang et al.,
group (t = 5.37, p = .000).
(2006) that reported approximately10% improvements in ROM of
It is notable that although several studies have postulated the
knee flexion, hip flexion and hip abduction in adults with osteoar-
aquatic or water-based exercise for the therapeutic purpose, only
thritis during 50 minutes aquatic exercise, three sessions for 12
limited studies presented to specifically support if water-based
weeks[30], although their subjects were not athlete. Nevertheless,
exercise is more effective in healing process for athletes with an-
it might be clarified by the fact of buoyancy of the water which
kle sprain. While, in this study, there was no significant different
made stretching easier to perform and optimal positions easier to
in dynamic balance improvement as a result of eight weeks be-
maintain stretching[19].However, the duration of stretching can
tween land and water-based exercise groups, contrary findings by
differ in a low intensity and duration of stretch (20-30 seconds) in
Rewald et al., (2015) revealed aqua-cycling is remarkably easy to
water as a relaxing environment compare to land.
incorporate in circuit training and provide an increase in dynamic
Recently, Welton et al., (2018) study’s in a decade of patterns and
postural stability scores compare to control group. They reported
trends of injury recurrence stated only 10.5% of all injuries result-
an improvement in self-reported pain relief after eight weeks train-
ed to reinjures which caused the athletes missing less than three
ing, even though the subjects (N=10) were non-athlete and 46-77
weeks of their playing time[17].While athletes with ankle injuries
year old patients with knee osteoarthritis [26].
temporarily should break their training or increasing risk of injury
Similarly, these results support by Nualon et al., (2013) that re-
recurrence in this period of time, water-based exercise can provide
ported hydrotherapy exercise could improve ankle functional per-
a safe, non-painful and joyful opportunity to improve ROM, sta-
formance among amateur athletes (N=24) with chronic ankle in-
bility of ankle and reduce risk of re-injury.
stability, alike a combining of ankle taping and land-based exer-
Even though, there was no differences in baseline characteristics
cise (N=23). They recommended a combination of ankle taping,
in both groups, all the subjects were athletes with ankle sprain
land-based exercise or hydrotherapy exercise can uses for clinical
within the past six months, the current study has limitation to con-
program in athletes with chronic ankle instability [8]. Likewise,
trol if the athletes participate in their sports training or having
Yelfani et al., (2015) have found that women (N=20), 20-30 years
other daily activities. A further limitation associated with the se-
old, who suffering from chronic ankle sprain could improve pain
verity of ankle sprain injury. It would be interesting to classify the
relief, performance, static and dynamic stability in land and water-
similar groups with different grade of ankle sprain (1, 2 and 3) for
based exercises. They noted, while there was significant difference
further study to investigate the effect of this intervention treat-
between the pre-test and post-test, no any significant difference
ment.
detected in improvement of dynamic stability between land and
water exercising groups [21].
An explanation for non-significant difference between land and 5. Conclusion
water-based intervention programs was probably resulted due to
minimal proprioceptive deficits in athletes who had chronic ankle
Though, water-based exercise program has shown a considerable
instability [27]. Perhaps buoyancy of water and non-weight bear-
enhancement on range of motion than dynamic balance, however
ing provide a minimizing dynamic postural stability effected on
the finding of this study has been reporting that the land-based
the speed and direction of movements during exercise. Therefore,
exercise training group and the water-based training group had
while the buoyancy acts in the opposite direction to the gravity, it
gradual increment in both balance and the range of motion (ROM)
gives the muscles, tendons and joint sense of feeling lighter in
which could be effected in preventing ankle injuries. Including the
water media comparing to land [8, 19, 21, 22]. Another available
subjects with different levels of severity of ankle sprain could be a
evidence to support this arguments could be related to viscosity
potential reason for a lack of significant difference between pro-
and resistance of water that resulted the slower motion, response
grams in the current study.
and reaction time [28]. It could be more difficult to maintain sta-
bility in upright position, less joint flexion and increasing drag due
to arm swing through the water [20]. Subsequently, the number of Acknowledgement
repetitions would be reduced in water-based group compare to the
land-based.
The authors wish to thanks the participants for their voluntary
Therefore, even though water-based exercise give the impression
involvement in this study. This study has been financially sup-
to be safer and very beneficial media of exercise than land-based
ported by University Research Grant code: 2016-0165-105-01
exercise, a larger sample size and more focused studies among
from Research Management and Innovation Centre, Sultan Idris
athletes needed since the primary goal of rehabilitation is to return
Education University..
the athlete to their sports participation as quickly as possible. It
should mention that in all studies, the sample size of injured sub-
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