Comparative effectiveness of floss band-augmented perceptual balance training on balance, proprioception, and lower limb function in women with chronic ankle instability: Implications for injury prevention and rehabilitation in public health

Melika Hamzehzadeh; Seyed Kazem Mosavi Sadati; Abdulrasol Daneshjoo; Hadi Mohammadi Nia Samakosh; Sameer Badri Al-Mhanna; Georgian Badicu; Melika Hamzehzadeh; Seyed Kazem Mosavi Sadati; Abdulrasol Daneshjoo; Hadi Mohammadi Nia Samakosh; Sameer Badri Al-Mhanna; Georgian Badicu

doi:10.3934/publichealth.2026034

AIMS Public Health

2026, Volume 13, Issue 2: 640-658. doi: 10.3934/publichealth.2026034

Previous Article Next Article

Research article

Comparative effectiveness of floss band-augmented perceptual balance training on balance, proprioception, and lower limb function in women with chronic ankle instability: Implications for injury prevention and rehabilitation in public health

1.
Department of Sports Injuries and Corrective Exercises, Faculty of Humanities, Islamic Azad University, East Tehran Branch, Tehran 1866113118, Iran
2.
Department of Motor behavior, SR.C. Islamic Azad University, Tehran 1477893855, Iran
3.
Department of Biomechanics and Corrective Exercises and Sports Injuries, University of Kharazmi, Tehran 15719-14911, Iran
4.
Department of Physiology, Saveetha Medical College and Hospital, Saveetha Institute of Medical and Technical Sciences, Chennai, Tamil Nadu, India
5.
Department of Higher Studies, Al-Qasim Green University, Babylon, Iraq
6.
Department of Physical Education and Special Motricity, Faculty of Physical Education and Mountain Sports, Transilvania University of Braşov, Braşov, 500068, Romania

Received: 12 February 2026 Revised: 24 March 2026 Accepted: 31 March 2026 Published: 25 May 2026

In this study, an assessor-blinded randomized trial with concealed allocation was conducted. Thirty women aged 25–35 years with chronic ankle instability (CAIT score ≤ 24 on the affected ankle) were randomly assigned (1:1) to perceptual balance (PB) training with floss bands (FB group, n = 15) or PB training alone (n = 15). Both groups completed a 6-week program (3 sessions/week), progressing from static to dynamic and plyometric tasks. FBs were applied at perceived occlusion pressure of 5–7/10 (0–10 scale); no adverse events occurred. Outcomes (assessed on the affected limb only) included static balance (single-leg stance time), dynamic balance (Y-balance test–normalized reaches in anterior, posteromedial, and posterolateral directions and composite score), ankle proprioception [joint position sense (JPS) error at 20° plantarflexion], and functional performance (single-leg hop and triple-hop for distance). A 2 × 2 mixed ANOVA (time × group) was used, with Bonferroni post hoc tests. Effect sizes were partial η² (ANOVA interactions) and Cohen's d_z (repeated-measures within-group changes with 95% CI). Both groups improved significantly (p < 0.01). The FB group showed greater improvements in static balance (25.7 ± 2.9 s vs. 22.3 ± 2.8 s, p = 0.015), dynamic balance (composite and all directions, p < 0.015), JPS (4.2 ± 1.1° vs. 6.1 ± 1.3°, p = 0.022), single-leg hop (1.80 ± 0.15 m vs. 1.65 ± 0.18 m, p = 0.032), and triple-hop (5.10 ± 0.30 m vs. 4.70 ± 0.35 m, p = 0.039). Interaction effect sizes (dz) ranged from 0.143 to 0.234 (large). These findings suggest that floss band augmentation may provide additional short-term benefit to PB training in women with CAI, although mechanisms remain speculative, and larger, longitudinal trials are needed.
- chronic ankle instability,
- perceptual balance training,
- floss bands,
- balance,
- joint position sense,
- lower limb performance,
- women,
- injury prevention
Citation: Melika Hamzehzadeh, Seyed Kazem Mosavi Sadati, Abdulrasol Daneshjoo, Hadi Mohammadi Nia Samakosh, Sameer Badri Al-Mhanna, Georgian Badicu. Comparative effectiveness of floss band-augmented perceptual balance training on balance, proprioception, and lower limb function in women with chronic ankle instability: Implications for injury prevention and rehabilitation in public health[J]. AIMS Public Health, 2026, 13(2): 640-658. doi: 10.3934/publichealth.2026034

Related Papers:

Abstract

In this study, an assessor-blinded randomized trial with concealed allocation was conducted. Thirty women aged 25–35 years with chronic ankle instability (CAIT score ≤ 24 on the affected ankle) were randomly assigned (1:1) to perceptual balance (PB) training with floss bands (FB group, n = 15) or PB training alone (n = 15). Both groups completed a 6-week program (3 sessions/week), progressing from static to dynamic and plyometric tasks. FBs were applied at perceived occlusion pressure of 5–7/10 (0–10 scale); no adverse events occurred. Outcomes (assessed on the affected limb only) included static balance (single-leg stance time), dynamic balance (Y-balance test–normalized reaches in anterior, posteromedial, and posterolateral directions and composite score), ankle proprioception [joint position sense (JPS) error at 20° plantarflexion], and functional performance (single-leg hop and triple-hop for distance). A 2 × 2 mixed ANOVA (time × group) was used, with Bonferroni post hoc tests. Effect sizes were partial η² (ANOVA interactions) and Cohen's d_z (repeated-measures within-group changes with 95% CI). Both groups improved significantly (p < 0.01). The FB group showed greater improvements in static balance (25.7 ± 2.9 s vs. 22.3 ± 2.8 s, p = 0.015), dynamic balance (composite and all directions, p < 0.015), JPS (4.2 ± 1.1° vs. 6.1 ± 1.3°, p = 0.022), single-leg hop (1.80 ± 0.15 m vs. 1.65 ± 0.18 m, p = 0.032), and triple-hop (5.10 ± 0.30 m vs. 4.70 ± 0.35 m, p = 0.039). Interaction effect sizes (dz) ranged from 0.143 to 0.234 (large). These findings suggest that floss band augmentation may provide additional short-term benefit to PB training in women with CAI, although mechanisms remain speculative, and larger, longitudinal trials are needed.

Acknowledgments

We express our sincere gratitude to all individuals who provided financial support for this research. This research was supported by internal departmental funding from Islamic Azad University (no grant number assigned).

Authors' contributions

The study was designed and planned by HMNS and MH. The investigation was conducted and the initial manuscript was drafted by MH, GB, ARD, and GB. The methodology was reviewed by SKMS, ARD, and GB. Data interpretation was performed by HMNS, GB, MH, and SKMS. The manuscript was critically revised by HMNS, MH, ARD, S.B.A-M and SKMS. All authors approved the final version of the manuscript.

Conflicts of interest

The authors declare no conflict of interest.

References

[1]	Hertel J (2008) Sensorimotor deficits with ankle sprains and chronic ankle instability. Clin Sports Med 27: 353-370, vii. https://doi.org/10.1016/j.csm.2008.03.006
[2]	Donovan L, Hetzel S, Laufenberg CR, et al. (2020) Prevalence and impact of chronic ankle instability in adolescent athletes. Orthop J Sports Med 8: 2325967119900962. https://doi.org/10.1177/2325967119900962
[3]	Prados-Barbero FJ, Sánchez-Romero EA, Cuenca-Zaldívar JN, et al. (2024) Differences in movement patterns related to anterior cruciate ligament injury risk in elite judokas according to sex: A cross-sectional clinical approach study. Electron J Gen Med 21: em574. https://doi.org/10.29333/ejgm/14285
[4]	Anandacoomarasamy A, Barnsley L (2005) Long term outcomes of inversion ankle injuries. Br J Sports Med 39: e14. https://doi.org/10.1136/bjsm.2004.011676
[5]	Gant H, Ghimire N, Min K, et al. (2024) Impact of the quadriceps angle on health and injury risk in female athletes. Int J Environ Res Public Health 21: 1547. https://doi.org/10.3390/ijerph21121547
[6]	Fort-Vanmeerhaeghe A, Benet A, Mirada S, et al. (2019) Sex and maturation differences in performance of functional jumping and landing deficits in youth athletes. J Sport Rehabil 28: 606-613. https://doi.org/10.1123/jsr.2017-0292
[7]	Wright CJ, Linens SW, Cain MS (2017) A randomized controlled trial comparing rehabilitation efficacy in chronic ankle instability. J Sport Rehabil 26: 238-249. https://doi.org/10.1123/jsr.2015-0189
[8]	Mohammadi Nia Samakosh H, Brito JP, Shojaedin SS, et al. (2022) What does provide better effects on balance, strength, and lower extremity muscle function in professional male soccer players with chronic ankle instability? Hopping or a balance plus strength intervention? A randomized control study. Healthcare (Basel) 10: 1822. https://doi.org/10.3390/healthcare10101822
[9]	Dunsky A (2019) The effect of balance and coordination exercises on quality of life in older adults: a mini-review. Front Aging Neurosci 11: 318. https://doi.org/10.3389/fnagi.2019.00318
[10]	Winter L, Huang Q, Sertic JVL, et al. (2022) The effectiveness of proprioceptive training for improving motor performance and motor dysfunction: a systematic review. Front Rehabil Sci 3: 830166. https://doi.org/10.3389/fresc.2022.830166
[11]	Martínez-Lozano P, Sánchez-Romero EA, Martínez-Pozas O, et al. (2026) Effectiveness of balance training in people with chronic ankle instability: An umbrella review with meta-meta-analysis. J Back Musculoskelet Rehabil 12: 10538127261419234. https://doi.org/10.1177/10538127261419234
[12]	Yilmaz O, Soylu Y, Erkmen N, et al. (2024) Effects of proprioceptive training on sports performance: a systematic review. BMC Sports Sci Med Rehabil 16: 149. https://doi.org/10.1186/s13102-024-00936-z
[13]	McKeon PO, Hertel J (2008) Systematic review of postural control and lateral ankle instability, part I: can deficits be detected with instrumented testing. J Athl Train 43: 293-304. https://doi.org/10.4085/1062-6050-43.3.293
[14]	Kim KM, Estepa-Gallego A, Estudillo-Martínez MD, et al. (2022) Comparative effects of neuromuscular- and strength-training protocols on pathomechanical, sensory-perceptual, and motor-behavioral impairments in patients with chronic ankle instability: randomized controlled trial. Healthcare (Basel) 10: 1364. https://doi.org/10.3390/healthcare10081364
[15]	Wang L, Yu G, Chen Y (2023) Effects of dual-task training on chronic ankle instability: a systematic review and meta-analysis. BMC Musculoskelet Disord 24: 814. https://doi.org/10.1186/s12891-023-06944-3
[16]	Sargent D, Hughes JD, Julian R (2024) Maximizing female performance: uncovering the power of menstrual cycles, hormonal contraception, and training optimization in female athletes. Cond Strength Hum Perform 2024: 449-486. https://doi.org/10.4324/9781003366140-20
[17]	Macdonald B (2017) An investigation into the immediate effects of pelvic taping on hamstring eccentric force in an elite male sprinter - A case report. Phys Ther Sport 28: 15-22. https://doi.org/10.1016/j.ptsp.2017.08.001
[18]	Abdulla SY (2014) Becoming a supple leopard: the ultimate guide to resolving pain, preventing injury, and optimizing athletic performance. J Can Chiropr Assoc 58: 328.
[19]	Driller MW, Overmayer RG (2017) The effects of tissue flossing on ankle range of motion and jump performance. Phys Ther Sport 25: 20-24. https://doi.org/10.1016/j.ptsp.2016.12.004
[20]	Cheatham SW, Baker R (2024) Tissue flossing: a commentary on clinical practice recommendations. Int J Sports Phys Ther 19: 477-489. https://doi.org/10.26603/001c.94598
[21]	Moon BH, JW Kim (2022) Effects of floss bands on ankle joint range of motion and balance ability. Phys Ther Korea 29: 274-281. https://doi.org/10.12674/ptk.2022.29.4.274
[22]	Cheatham SW, Nadeau J, Jackson W, et al. (2024) Effects of tissue flossing on athletic performance measures: a systematic review. Sports (Basel) 12: 312. https://doi.org/10.3390/sports12110312
[23]	Rosier E (2022) The long-term effects of tissue flossing on ankle dorsiflexion range of motion in athletes with chronic ankle instability. Illinois State University.
[24]	Gao J, Thung JS, Chee CS, et al. (2024) The potential mechanisms of tissue flossing with Flossband application around the joints or soft tissues: A theoretical framework. Apunts Sports Med 59: 100453. https://doi.org/10.1016/j.apunsm.2024.100453
[25]	Docherty CL, Valovich McLeod TC, et al. (2006) Postural control deficits in participants with functional ankle instability as measured by the balance error scoring system. Clin J Sport Med 16: 203-208. https://doi.org/10.1097/00042752-200605000-00003
[26]	Alahmari KA, Kakaraparthi VN, Reddy RS, et al. (2020) Combined effects of strengthening and proprioceptive training on stability, balance, and proprioception among subjects with chronic ankle instability in different age groups: evaluation of clinical outcome measures. Indian J Orthop 55: 199-208. https://doi.org/10.1007/s43465-020-00192-6
[27]	Fakontis C, Iakovidis P, Kasimis K, et al. (2023) Efficacy of resistance training with elastic bands compared to proprioceptive training on balance and self-report measures in patients with chronic ankle instability: A systematic review and meta-analysis. Phys Ther Sport 64: 74-84. https://doi.org/10.1016/j.ptsp.2023.09.009
[28]	Chang NJ, Hung WC, Lee CL, et al. (2021) Effects of a single session of floss band intervention on flexibility of thigh, knee joint proprioception, muscle force output, and dynamic balance in young adults. Appl Sci 11: 12052. https://doi.org/10.3390/app112412052
[29]	Hahn H (2009) The effect of sex differences and hormone fluctuation on ankle stability and function. University of Toledo.
[30]	Peng D, Tang H, Mao M, et al. (2024) Correlations of strength, proprioception, and dynamic balance to the Cumberland Ankle Instability Tool Score among patients with chronic ankle instability: a cross-sectional study. BMC Musculoskelet Disord 25: 970. https://doi.org/10.1186/s12891-024-08092-8
[31]	Han J, Anson J, Waddington G, et al. (2015) The role of ankle proprioception for balance control in relation to sports performance and injury. Biomed Res Int 2015: 842804. https://doi.org/10.1155/2015/842804
[32]	Behm D (2024) The science and physiology of flexibility and stretching: implications and applications in sport performance and health. Taylor & Francis . hhttps://doi.org/10.4324/9781032709086
[33]	Lorenz DS, Bailey L, Wilk KE, et al. (2021) Blood flow restriction training. J Athl Train 56: 937-944. https://doi.org/10.4085/418-20
[34]	Verhagen E (2024) Prevention strategies of ankle injuries. Orthopaedic sports medicine: An encyclopedic review of diagnosis, prevention, and management . Cham: Springer International Publishing 1-15. https://doi.org/10.1007/978-3-030-65430-6_61-1
[35]	Brighenti J, Battaglino A, Bompard A, et al. (2023) The correlation between chronic ankle instability and strength deficit of the hip and knee musculature: a review of the literature. Retos 50: 904-912. https://doi.org/10.47197/retos.v50.97830
[36]	Hertel J, Corbett RO (2019) An updated model of chronic ankle instability. J Athl Train 54: 572-588. https://doi.org/10.4085/1062-6050-344-18
[37]	Wright CJ, Arnold BL (2012) Fatigue's effect on eversion force sense in individuals with and without functional ankle instability. J Sport Rehabil 21: 127-136. https://doi.org/10.1123/jsr.21.2.127
[38]	Gribble PA, Hertel J, Plisky P (2012) Using the star excursion balance test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review. J Athl Train 47: 339-357. https://doi.org/10.4085/1062-6050-47.3.08
[39]	Romero-Franco N, Montaño-Munuera JA, Jiménez-Reyes P (2017) Validity and reliability of a digital inclinometer to assess knee joint-position sense in a closed kinetic chain. J Sport Rehabil 26: jsr.2015–0138. https://doi.org/10.1123/jsr.2015-0138
[40]	Mourcou Q, Fleury A, Diot B, et al. (2015) Mobile phone-based joint angle measurement for functional assessment and rehabilitation of proprioception. Biomed Res Int 2015: 328142. https://doi.org/10.1155/2015/328142
[41]	Ikarashi K, Iguchi K, Yamazaki Y, et al. (2020) Influence of menstrual cycle phases on neural excitability in the primary somatosensory cortex and ankle joint position sense. Womens Health Rep (New Rochelle) 1: 167-178. https://doi.org/10.1089/whr.2020.0061
[42]	Samakosh HMN, Maktoubian M, Doost SPR, et al. (2025) Active and sham transcranial direct-current stimulation (tDCS) plus core stability on the knee kinematic and performance of the lower limb of the soccer players with dynamic knee valgus; two armed randomized clinical trial. AIMS Neurosci 12: 312-331. https://doi.org/10.3934/Neuroscience.2025017
[43]	Cohen J Statistical power analysis for the behavioral sciences (2013). https://doi.org/10.4324/9780203771587
[44]	Moon BH, Kim JW (2024) The effects of a floss band on ankle range of motion, balance, and gait in chronic stroke: a randomized controlled study. Healthcare (Basel) 12: 2384. https://doi.org/10.3390/healthcare12232384
[45]	Bermúdez-Egidos M, Pérez-Llanes R, Cuesta-Barriuso R (2025) Effectiveness of a flossing protocol and manual therapy in improving the clinical and functional status of subjects with recurrent ankle sprains; a double-blind randomized clinical trial. Med Sci (Basel) 13: 149. https://doi.org/10.3390/medsci13030149
[46]	Wu SY, Tsai YH, Wang YT, et al. (2022) Acute effects of tissue flossing coupled with functional movements on knee range of motion, static balance, in single-leg hop distance, and landing stabilization performance in female college students. Int J Environ Res Public Health 19: 1427. https://doi.org/10.3390/ijerph19031427
[47]	Tedeschi R, Giorgi F (2024) Stretching the limits: a systematic review of tissue flossing's impact on exercise performance. Sports Orthop Traumatol 40: 338-347. https://doi.org/10.1016/j.orthtr.2024.08.003
[48]	Maemichi T, Ogawa Y, Wakamiya K, et al. (2025) Elucidation of the effect of flossing on improving joint range of motion. J Sports Sci Med 24: 75-83. https://doi.org/10.52082/jssm.2025.75
[49]	Yin Y, Wang J, Lin Q, et al. (2025) Effect of proprioceptive neuromuscular facilitation on patients with chronic ankle instability: A systematic review and meta-analysis. PLoS One 20: e0311355. https://doi.org/10.1371/journal.pone.0311355
[50]	Cuenca-Zaldívar JN, Del Corral-Villar C, García-Torres S, et al. (2025) Fourteen-year retrospective cohort study on the impact of climatic factors on chronic musculoskeletal pain: a spanish primary care analysis. Int J Rheum Dis 28: e70125. https://doi.org/10.1111/1756-185X.70125
[51]	Mills B, Mayo B, Tavares F, et al. (2020) The effect of tissue flossing on ankle range of motion, jump, and sprint performance in elite rugby union athletes. J Sport Rehabil 29: 282-286. https://doi.org/10.1123/jsr.2018-0302
[52]	Pisz A, Kralova K, Blazek D, et al. (2020) Meta-analyses of the effect of flossing on ankle range of motion and power jump performance. Balt J Health Phys Act 12: 3. https://doi.org/10.29359/BJHPA.12.2.03
[53]	de Vries JS, Krips R, Sierevelt IN, et al. (2011) Interventions for treating chronic ankle instability. Cochrane Database Syst Rev 10: CD004124. https://doi.org/10.1002/14651858.CD004124.pub3
[54]	Liu N, Yang C, Song Q, et al. (2024) Patients with chronic ankle instability exhibit increased sensorimotor cortex activation and correlation with poorer lateral balance control ability during single-leg stance: a FNIRS study. Front Hum Neurosci 18: 1366443. https://doi.org/10.3389/fnhum.2024.1366443
[55]	Graham JE, Karmarkar AM, Ottenbacher KJ (2012) Small sample research designs for evidence-based rehabilitation: issues and methods. Arch Phys Med Rehabil 93: S111-S116. https://doi.org/10.1016/j.apmr.2011.12.017
[56]	Wang J, Zhang D, Zhao T, et al. (2021) Effectiveness of balance training in patients with chronic ankle instability: protocol for a systematic review and meta-analysis. BMJ Open 11: e053755. https://doi.org/10.1136/bmjopen-2021-053755

Reader Comments

Your name:*

Email:*
© 2026 the Author(s), licensee AIMS Press. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0)