Effects of Conservative Interventions on Static and Dynamic Balance in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-analysis

Noninstrumented Clinical Assessment of Static Postural Stability in Chronic Ankle Instability: A Systematic Review and Meta-Analysis

CONTEXT

Several clinical tests are available to assess static postural stability in individuals with chronic ankle instability (CAI); however, it is unclear which test should be used.

OBJECTIVE

To determine which noninstrumented clinical tests should be used to detect static postural stability deficits in individuals with CAI.

EVIDENCE ACQUISITION

We searched 4 databases from their inception to February 2023, and included studies comparing static postural stability in individuals with CAI and healthy controls using noninstrumented assessments. Two reviewers independently extracted study characteristics, participant information, static postural stability assessment methods, and results. We calculated the pooled standardized mean difference (SMD) and 95% confidence interval using a random effects meta-analysis and assessed the certainty of the evidence.

EVIDENCE SYNTHESIS

Fourteen cross-sectional studies (293 participants with CAI and 284 healthy controls) were included. The meta-analysis showed no significant differences between the CAI and healthy groups in the double-leg stance condition of the Balance Error Scoring System (BESS) (SMD, -0.03; low-certainty evidence). Significant group differences were found in the BESS single-leg stance (SLS) on firm and foam surfaces (SLS firm: SMD, 0.47, very low-certainty evidence; SLS foam: SMD, 0.80, very low-certainty evidence), the tandem stance (TS) on firm and foam surfaces (TS firm: SMD, 0.39, low-certainty evidence; TS foam: SMD, 0.76, low-certainty evidence), and the total BESS in the foam conditions (SMD, 1.12, very low certainty evidence). Significant differences were also found between the CAI and healthy groups in the foot-lift (SMD, 1.24; very low certainty evidence) and time-in-balance tests (SMD, -0.94; very low certainty evidence).

CONCLUSIONS

Due to the large magnitude of the differences, the SLS foam, TS foam, and the total BESS in the foam conditions, as well as the foot-lift test or time-in-balance test, may be the most appropriate to clinically identify static postural stability impairment in individuals with CAI.

Acute and chronic effects of stretching on balance: a systematic review with multilevel meta-analysis

Introduction

Balance is a multifactorial construct with high relevance in, e.g., everyday life activities. Apart from sensorimotor control, muscle strength and size are positively linked with balance performance. While commonly trained for via resistance training, stretch training has emerged as a potential substitution in specific conditions. However, no review has investigated potential effects of stretching on balance, yet.

Methods

PubMed, Web of Science and Scopus were searched with inception to February, 2024. Studies were included if they examined acute and/or chronic effects of any stretching type against passive and/or active controls on balance parameters - without any population-related restrictions concerning sex/gender, age, health status, activity level. Methodological quality was assessed using PEDro scale. Meta-analyses were performed if two or more studies reported on the same outcome. Certainty of evidence was determined based on GRADE criteria.

Results

Eighteen acute and eleven chronic effect studies were included. Stretching studies exhibited significant improvements for sway parameters with eyes open against passive controls of moderate magnitude for chronic (ES: 0.63, p = 0.047) and of small magnitude for acute studies (ES: 0.21, p = 0.032). Most other subgroups against passive controls as well as actively-controlled comparisons resulted in trivial and/or non-significant effects.

Conclusion

Even though some pooled effects slightly reached the level of significance, the overall results are biased by (very) low certainty of evidence (GRADE criteria downgrading for risk of bias, imprecision, publication bias). Moderators suggested by literature (strength, muscle size, flexibility, proprioception) were rarely assessed, which prevents conclusive final statements and calls for further, high quality evidence to clarify potential mechanisms-if any exist.

Effects of combination of strength and balance training on postural control and functionality in people with chronic ankle instability: a systematic review and meta analysis

AIM

To identify the effects of strength and balance training on dynamic balance and patient reported outcomes in people with chronic ankle instability(CAI).

METHOD

Five databases(CNKI, WanFang, Web of Science, EBSCO-SPORTD and PubMed were searched in September 2022. The search was conducted on randomized controlled trials(RCTs) that the effects of strength training, balance training and combination of strength and balance training in people with chronic ankle instability compared to a control group. Using Review Manager 5.3 and Stata-SE 15 to conduct Meta-analysis on the included literature. methodological quality and risk of bias were assessed by using the PEDro scale.

RESULTS

A total of 33 Chinese and English RCTs document were screened and 1154 patients with CAI were included in the study. Compared with control group, strength training, balance training and combination of strength and balance training demonstrated to be more effective in terms of improving patient reported outcomes(strength training: SMD = 0.80, 95%CI = 0.39-1.22; balance training: SMD = 0.79, 95%CI = 0.41-1.17; combination of strength and balance training: SMD = 1.28, 95%CI = 0.57, 1.99). Subgroup analysis: Intervention for 6 weeks, more than 3 times a week and more than 30 min each time were the best rehabilitation programs to improve CAI patientreported outcomes. Compared with control group, balance training demonstrated to be more effective in terms of improving Star Excursion Balance Test (SEBT)((anterior: SMD = 0.71, 95%CI = 0.03-1.40; posterolateral: SMD = 0.84, 95%CI = 0.22-1.46; posteromedial: SMD = 0.88, 95%CI = 0.45-1.32). However, strength training and combination of strength and balance training had no improvement effects on SEBT.

CONCLUSIONS

Available evidence showed that, results of the comparison between balance training versus strength training suggest that the combination of strength and balance training achieves greater benefits for patient reported outcomes and balance training could bring greater benefits to dynamic balance. Strength training should be used cautiously in clinic to improve the dynamic balance in individuals with CAI.

TRIAL REGISTRATION

( http://www.crd.york.ac.uk/PROSPERO , Registration No. CRD42022371396).

Randomized controlled trial study of intelligent rehabilitation training system for functional ankle instability

To investigate the intervention effect of an intelligent rehabilitation training system on patients with functional ankle instability (FAI) and to advance the research to optimise the effect of FAI rehabilitation training. Thirty-four FAI patients who participated in this trial in Guilin City from April 2023 to June 2023 were recruited as research subjects, and all subjects were randomly divided into the control group (n = 17) and the observation group (n = 17). Both groups received the conventional rehabilitation training intervention for 6 weeks, and the observation group received the additional training using the intelligent rehabilitation training system training invented by our team. Visual analogue scale (VAS), ankle active mobility, ankle muscle strength and Y-balance test (YBT) were assessed before and after treatment. Two-way repeated measures ANOVA shows that the interaction effect between time and group of VAS scores was significant (F = 35.644, P < 0.05). The interaction effect between time and group of plantar flexion mobility was significant (F = 23.948, P < 0.05), the interaction effect between time and group of dorsiflexion mobility was significant (F = 6.570, P < 0.05), the interaction effect between time and group of inversion mobility was significant (F = 8.360, P < 0.05), the interaction effect between time and group of eversion mobility was significant (F = 10.113, P < 0.05). The interaction effect between time and group of inversion muscle strength was significant (F = 18.107, P < 0.05). The interaction effect between time and group of YBT scores was significant (F = 33.324, P < 0.05). The Intelligent Rehabilitation Training System can effectively reduce pain in FAI patients, improve joint range of motion, increase inversion strength, and improve dynamic balance of the affected limb.

Pain alleviation improves balance control and muscular coordination of lower limbs in patients with chronic ankle instability during sinusoidal perturbations

BACKGROUND

It is well established that individuals with chronic ankle instability manifest deficits in balance control and muscle activation. Given the prevalence of pain as a prominent symptom in this population, there is a need for in-depth investigation of its role in contributing to these impairments.

METHODS

A Stewart platform was used to generate translational sinusoidal perturbations in the antero-posterior direction. Eighteen individuals with chronic ankle instability and concurrent ankle pain were recruited. They were instructed to assume a central stance on the support surface with open eyes both before and 30 min after local analgesia. Data of center of pressure and electromyography of the tibialis anterior and medial gastrocnemius were recorded. Statistical analysis was performed to make comparisons pre- and post-analgesia using two-tailed paired t-test for the continuous variables.

FINDINGS

Pain intensity was significantly decreased after local anesthetic injections. Antero-posterior center of pressure parameters significantly decreased following the injection. Also, there was an increase in the regularity of the center of pressure pattern. The electromyographic pattern of the tibialis anterior and medial gastrocnemius exhibited various activation patterns. After pain alleviation, the characteristic electromyographic response of the tibialis anterior and medial gastrocnemius was reciprocal contraction and relaxation that corresponded with the sinusoidal pattern of the perturbations.

INTERPRETATION

Individuals who had chronic ankle instability and ankle pain demonstrated impaired balance control during sinusoidal perturbations. Mitigating pain improved their balance performance, evident in the center of pressure pattern and the coordination of lower limb muscles.

Effects of Ankle Orthoses, Taping, and Insoles on Postural Stability of Individuals with Chronic Ankle Instability: A Systematic Review

Chronic ankle instability (CAI) is a prevalent condition characterized by recurring instances of the ankle giving way and persistent symptoms, including pain and diminished function. Foot and ankle external supports are commonly used in clinical practice and research for treating CAI. This systematic review aimed to assess the effects of foot and ankle external supports on the postural stability of individuals with CAI to guide clinical practice and inform future research. A comprehensive search was conducted in PubMed, Web of Science, Scopus, and Google Scholar databases from 1 January 2012 to 1 November 2022. Eighteen studies involving individuals with CAI were chosen in this systematic review. The quality of the included studies and risk of bias were assessed using Cochrane Collaboration's tool for randomized controlled trials, the Newcastle-Ottawa Scale for case-control studies, and the DELPHl-list for crossover trial studies. The external supports included in this review were ankle orthoses (elastic, semi-rigid, and active orthoses), taping (kinesiotaping and fibular reposition taping), and insoles (textured and supportive insoles). The outcome measures included static and dynamic postural stability tests, such as the single-leg stance test, star excursion balance test, Y-balance test, single-leg landing test, lateral jump test, walking test, and running test. The results showed that elastic orthoses, Kinesiotaping, and textured insoles demonstrated potential benefits in improving postural stability in individuals with CAI. Elastic orthoses decreased ankle joint motion variability, kinesiotaping facilitated cutaneous receptors and proprioceptive feedback, while textured insoles increased tactile stimulation and foot position awareness. However, the effects of semi-rigid orthoses, fibular reposition taping, and arch support insoles were inconsistent across studies. Future research should explore the long-term effects of these external supports, analyze the effects of different characteristics and combinations of supports, and employ standardized outcome measures and testing protocols for assessing postural stability.

Effects of plantar-sensory treatments on postural control in chronic ankle instability: A systematic review and meta-analysis

OBJECTIVE

This study aimed to examine the effects of plantar-sensory treatments on postural control in individuals with chronic ankle instability (CAI).

METHODS

This study was registered in PROSPERO (registration number CRD42022329985) on May 14, 2022. An extensive search was performed in Pubmed, Embase, Cochrane, Web of Science, and Scopus to identify the potential studies on plantar-sensory treatments affecting postural control before May 2022. The methodological quality of involved studies was assessed using the scale of Physiotherapy Evidence Database (PEDro). The Cochrane Tool and the Risk of Bias in Non-randomized Studies of Interventions assessment tool were used to evaluate the risk of bias in randomised controlled trials (RCTs) and non-RCTs respectively. RevMan 5.4 was utilised to calculate the standardised mean difference (SMD), with 95% confidence interval (CI).

RESULTS

Eight RCTs with a mean PEDro rating of 6 and four non-RCTs with a mean PEDro rating of 4.75 were included in the quantitative analysis. The types of plantar-sensory treatments included plantar massage, whole-body vibration and textured surface-stimulation treatment. A significant effect of static balance with eyes open (SMD = -0.54; 95% CI: -0.81 to -0.27; p < 0.001) was found and subgroup analysis showed that plantar massage (SMD = -0.49; 95% CI: -0.84 to -0.14; p = 0.006) and whole-body vibration (SMD = -0.66; 95% CI: -1.12 to -0.19; p = 0.005) had positive effects. In the subgroup analysis of anterior dynamic balance, whole-body vibration revealed a significant increase (SMD = 0.60; 95% CI: 0.06-1.14; p = 0.03). The pooled results or subgroup analysis including eyes-closed static balance and other directions of dynamic balance indicated no significant difference (p > 0.05).

CONCLUSIONS

This meta-analysis indicated that plantar-sensory treatments could improve postural control in CAI, especially the treatments of plantar massage and long-term whole-body vibration.

Inertial Sensor-Based Assessment of Static Balance in Athletes with Chronic Ankle Instability

The Balance Error Scoring System (BESS), a subjective examiner-based assessment, is often employed to assess postural balance in individuals with chronic ankle instability (CAI); however, inertial sensors may enhance the detection of balance deficits. This study aimed to compare the BESS results between the CAI and healthy groups using conventional BESS scores and inertial sensor data. The BESS test (six conditions: double-leg, single-leg, and tandem stances on firm and foam surfaces, respectively) was performed for the CAI (n = 16) and healthy control (n = 16) groups with inertial sensors mounted on the sacrum and anterior shank. The BESS score was calculated visually by the examiner by counting postural sway as an error based on the recorded video. The root mean square for resultant acceleration (RMS_acc) in the anteroposterior, mediolateral, and vertical directions was calculated from each inertial sensor affixed to the sacral and shank surfaces during the BESS test. The mixed-effects analysis of variance and unpaired t-test were used to assess the effects of group and condition on the BESS scores and RMS_acc. No significant between-group differences were found in the RMS_acc of the sacral and shank surfaces, and the BESS scores (P > 0.05), except for the total BESS score in the foam condition (CAI: 14.4 ± 3.7, control: 11.7 ± 3.4; P = 0.039). Significant main effects of the conditions were found with respect to the BESS scores and RMS_acc for the sacral and anterior shank (P < 0.05). The BESS test with inertial sensors can detect differences in the BESS conditions for athletes with CAI. However, our method could not detect any differences between the CAI and healthy groups.