Health-related quality of life is decreased in middle-aged adults with chronic ankle instability

Effects of Blood Flow Restriction on Balance Performance During Dynamic Balance Exercises in Individuals With Chronic Ankle Instability

CONTEXT

Blood flow restriction (BFR) is a rehabilitation tool which may introduce a constraint, similar to muscle fatigue, that challenge patients' sensorimotor system during balance exercises. The purpose of our study was to examine whether adding BFR to dynamic balance exercises produced a decrease in balance performance and an increase in ratings of perceived exertion and instability in individuals with chronic ankle instability (CAI) compared with dynamic balance exercises without BFR.

DESIGNS

Crossover design.

METHODS

Our sample included N = 25 young adults with a history of CAI. Participants completed 2 laboratory visits. At each visit, participants completed 4 sets (30×-15×-15×-15×) of dynamic balance exercises, performed similar to the modified star excursion balance test (SEBT), once with BFR and once with control (no BFR) conditions. We measured composite SEBT scores at baseline and during the final repetitions of each set of balance exercise (sets 1-4). We also measured ratings of perceived exertion and instability following each balance exercise set.

RESULTS

We observed no difference in composite SEBT scores between conditions at baseline; however, composite SEBT scores were significantly lower during all balance exercises sets 1 to 4 with the BFR condition compared with control. During the BFR condition, composite SEBT scores were significantly lower during all balance exercise sets compared with baseline. During the control condition, composite SEBT scores did not significantly change between baseline and each balance exercise set. Ratings of perceived exertion and instability scores were significantly greater in the BFR group compared with the control group during all balance exercise sets.

CONCLUSIONS

Individuals with CAI demonstrated lower composite SEBT scores and greater perceived instability and exertion during dynamic balance exercise with BFR compared to without BFR. BFR introduced a novel muscle fatigue constraint during dynamic balance exercises in individuals with CAI. Additional research is needed to determine if adding BFR to balance training could improve clinical outcomes in CAI patients.

Three-dimensional ankle kinematics of the full gait cycle in patients with chronic ankle instability: A case-control study

Objectives

The ankle kinematic characteristics of chronic ankle instability (CAI) at different gait phases and dimensions were not directly and overall explained. These characteristics have yet to be established. This study aimed to observe ankle kinematic changes of CAI, and explore their mechanisms, at different gait phases and dimensions in full gait cycle.

Methods

A three-dimensional (3D) motion capture system measured the 3D ankle movements of 53 individuals with CAI (meanage = 25.11 ± 6.01years, meanheight = 170.77 ± 7.80 cm, meanmass = 64.28 ± 9.28 kg) and 53 healthy controls (meanage = 24.66 ± 6.32 years, meanheight = 169.98 ± 9.00 cm, meanmass = 63.11 ± 9.62 kg) during barefoot walking overground at a self-selected speed. Once the acquisition results were processed with visual 3D software, the kinematics data were exported, and the eight phases of the gait cycle were identified.

Results

As compared with the control group, individuals with CAI displayed a significantly smaller plantarflexion in toe off (P = 0.049, Cohen's d = 0.387), a significantly increased inversion in heel strike (P = 0.007, Cohen's d = 0.271) and initial swing (P = 0.035, Cohen's d = 0.233), mid-swing (P = 0.019, Cohen's d = 0.232) and end-swing (P = 0.021, Cohen's d = 0.214), and significantly smaller eversion in mid stance（P = 0.010, Cohen's d = 0.288）and heel off (P = 0.033, Cohen's d = 0.089). Significant between-group differences in ankle kinematics were observed in the sagittal and frontal planes, but not in the horizontal plane, during walking.

Conclusion

When walking, patients with CAI have altered sagittal- and frontal-plane kinematics during different stance and swing phases. These kinematic changes require multi-dimensional, dynamic, continuous functional assessment and specialized rehabilitation intervention.

Biomechanical Analysis of Latin Dancers' Lower Limb during Normal Walking

Latin dance involves fundamental walking steps, integral to the dance process. While resembling daily walking, Latin dance demands higher balance levels, necessitating body adjustments by dancers. These adaptations affect dancers' gait biomechanics, prompting our study on gait differences between Latin dancers (LDs) and non-dancers (NDs). We enlisted 21 female Latin dancers and 21 subjects based on specific criteria. Participants executed walking tasks, with an independent sample t-test for 1-dimensional statistical parameter mapping (SPM 1d) analyzing stance phase variations between LDs and NDs. Notably, significant differences in ankle and hip external rotation were evident during the 16.43-29.47% (p = 0.015) and 86.35-100% (p = 0.014) stance phase. Moreover, pronounced distinctions in rectus Achilles tendon force (ATF) (12.83-13.10%, p = 0.049; 15.89-80.19%, p < 0.001) and Patellofemoral joint contact force (PTF) (15.85-18.31%, p = 0.039; 21.14-24.71%, p = 0.030) during stance were noted between LDs (Latin dancers) and NDs (Non-dancers). The study revealed dancers' enhanced balance attributed to external ankle rotation for dance stability, coupled with augmented Achilles tendon and patellofemoral joint strength from prolonged practice. Moreover, integrating suitable Latin dance into rehabilitation may benefit those with internal rotation gait issues.

Yoga as a balance intervention for middle-age and older adults with history of lateral ankle sprain: An exploratory study

INTRODUCTION

Balance deficiencies are common among aging adults. Musculoskeletal injuries such as lateral ankle sprains (LAS) also contribute to compromised balance; potentially amplifying the postural insufficiencies in these age groups with a history of LAS. Yoga has emerged as an effective balance training intervention for aging adults; but limited application exists in these age cohorts with LAS history. This study may provide important guidance for the implementation of this intervention in these populations.

METHODS

In this cohort design study, middle-age and older adults with a history of LAS completed an 8-week beginner-level yoga class. Balance was measured before and after the yoga intervention statically (force plate) and dynamically (star excursion balance test [SEBT]) using single-limb balance tasks.

RESULTS

Following the yoga intervention, older adults improved static postural control in the anterior-posterior direction, as well as dynamic postural control in selected reach directions of the SEBT relative to the middle-age adults.

CONCLUSION

This is an important step in exploring how to help the aging population that likely has amplifications in balance deficiencies due to a common musculoskeletal injury, LAS. While more work is needed to determine how to optimize and document balance improvements in aging adults with LAS history, yoga appears to be a promising form of intervention, particularly for older adults.

Instrumented measures of postural control in college dancers with and without chronic ankle instability

OBJECTIVES

To determine whether collegiate dancers with chronic ankle instability (CAI) demonstrated impaired postural control during instrumented measures of single-leg static balance compared to dancers without CAI.

DESIGN

Cross sectional design.

SETTING

University dance studios.

PARTICIPANTS

We included N = 39 dance majors from a large, public university. We stratified participants into CAI (n = 20, age = 20 ± 1.8, IdFAI = 17.3 ± 5.7, number of sprains = 1.9 ± 1.1) and Control groups (n = 19, age = 20 ± 1.2, IdFAI = 2.5 ± 3.0).

MAIN OUTCOME MEASURES

Participants performed 3 x 10-s single-leg, static balance trials on a pressure mat in two different conditions, foot-flat eyes closed and demi-pointe eyes open. We measured six different time-to-boundary (TTB) measurements during each balance trial and calculated the average of the 3 trials for each condition. Participants also completed the Foot and Ankle Ability Measure (FAAM) sport and activities of daily living (ADL) questionnaires.

RESULTS

The CAI group reported greater IdFAI and lower FAAM-ADL and FAAM-Sport scores compared to the control group. We observed no significant differences in TTB measurements between the CAI and control groups during either balance conditions.

CONCLUSIONS

Instrumented measures of static postural control were not impaired in college dancers with CAI compared dancers without CAI.

Health-Related Quality of Life Among Patients With Painful Chronic Ankle Instability

More than half of individuals with chronic ankle instability (CAI) experience lingering pain from a previous injury. However, there is little empirical evidence investigating the role pain has on health-related quality of life (HRQL). The purpose of this cross-sectional study was to compare physical and psychological HRQL between CAI individuals with and without pain. Group comparisons demonstrated that CAI individuals with pain displayed a lower physical and mental HRQL than those without pain. In addition, CAI individuals with pain reported greater injury-related fear. These findings suggest that persistent pain compounds the negative effect that ankle joint instability has on physical and mental HRQL outcomes. Therefore, conservative therapies should consider multimodal approaches rather than focusing on joint stability alone.

Validation of the Indonesian version of the foot and ankle score in patients with chronic lateral ankle instability

Background

This study aimed to examine the psychometric performance of the Foot and Ankle Outcome Score (FAOS) used in Indonesian patients with chronic lateral ankle instability (CLAI).

Methods

The FAOS was translated into Indonesian through standardized procedures. Among 224 patients with unilateral CLAI recruited from 14 physical therapy clinics during a 1-year period, reliabilities, construct validities, and responsiveness levels of the FAOS were examined. Active and passive range of motion of ankle dorsiflexion or plantiflexion, figure-of-eight, numeric pain rating scale (NPRS), and Short Form (SF)-36 were used to test the construct validities.

Results

The five subscales indicated adequate internal consistency (Cronbach’s alpha, 0.74 ~ 0.96) and interrater test-retest reliabilities (interclass correlation coefficients, 0.80 ~ 0.94). Subscales of the FAOS moderately converged with those selected measures with similar constructs (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r values, 0.32 ~ 0.53), with the exception of the correlation of pain with the NPRS (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$r$$\end{document}r, -0.06). Results of the principal component analysis showed that the five-factor structure of the FAOS was appropriate for the Indonesian data, although six items (four in the pain and two in the other symptoms (OSs) subscales) did not perfectly fit their original subscales. Guyatt’s responsiveness index for the FAOS’s subscales changed in the SF-36’s physical function over a 1-month period and ranged 0.37 to 1.27.

Conclusions

The Indonesian version of the FAOS demonstrated acceptable reliabilities and responsiveness, and fair construct validities among CLAI patients, although certain items in the pain and OSs subscales may need to be further explored and improved.

Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021

This revised clinical practice guideline (CPG) addresses the distinct but related lower extremity impairments of those with a first-time lateral ankle sprain (LAS) and those with chronic ankle instability (CAI). Depending on many factors, impairments may continue following injury. While most individuals experience resolution of symptoms, complaints of instability may continue and are defined as CAI. The aims of the revision were to provide a concise summary of the contemporary evidence since publication of the original guideline and to develop new recommendations or revise previously published recommendations to support evidence-based practice. J Orthop Sports Phys Ther 2021;51(4):CPG1-CPG80. doi:10.2519/jospt.2021.0302.

Using arthroscopy combined with fluoroscopic technique for accurate location of the bone tunnel entrance in chronic ankle instability treatment

Background

Minimally invasive reconstruction techniques are used for anatomical ligament construction of the lateral collateral ligament complex of the ankle, but the two key elements, the bone tunnel and the appropriate graft tension, for the identification of the anatomic location during the surgery are not clearly stated.

Methods

The patients with chronic ankle instability who received arthroscopic anatomic lateral ligament complex reconstruction were retrospectively analyzed. The anatomical location of the bone tunnel was performed under arthroscopy combined with fluoroscopy for accurate location of the bone tunnel entrance. The graft tension and routing were controlled under arthroscopic visualization. The clinical outcomes were assessed using the Karlsson-Peterson score, Sefton articular stability scale, and Visual Analogue Scale (VAS). The complications were recorded during the follow-up.

Results

A total of 18 patients were enrolled in this study. The mean follow-up was 33.33 ± 3.69 (range from 24 to 36) months. No patient had recurrence of ankle instability after the operation. According to the Sefton articular stability scale, 94.5% of the patients had excellent/good function. The mean value of the anterior drawer tests and the talar tilt angle examination were decreased. The mean of the Karlsson-Peterson score and the Visual Analogue Scale(VAS) score were both improved significantly.

Conclusions

The anatomic reconstruction of the ankle lateral ligament complex to treat chronic ankle instability using the arthroscopy combined with the fluoroscopic technique could improve the clinical functions, satisfaction, and reduced pain of patients.

Effects of Blood Flow Restriction on Muscle Activation During Dynamic Balance Exercises in Individuals With Chronic Ankle Instability

CONTEXT

Dynamic balance exercises are commonly utilized during ankle sprain and chronic ankle instability (CAI) rehabilitation. Blood flow restriction (BFR) has been used to enhance muscle activity during exercise and improve outcomes of traditional rehabilitation exercises in clinical populations.

OBJECTIVE

Examine the effects of BFR on lower-extremity muscle activation during dynamic balance exercises in individuals with CAI.

DESIGN

Crossover study design.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-five (N = 25) young adults with a history of CAI.

INTERVENTIONS

Participants performed dynamic balance reaching exercises during 2 randomized order conditions, BFR, and control. For each condition, participants performed 2 trials of balance exercises. Each trial included 4 sets (30 × 15 × 15 × 15) of reaches in anterior, posteromedial, and posterolateral directions. For the BFR condition, the authors placed a cuff around the proximal thigh at 80% of arterial occlusion pressure. For the control condition, no cuff was worn.

MAIN OUTCOME MEASURE(S)

The authors recorded normalized electromyography muscle activation of the vastus lateralis, soleus, tibialis anterior, and fibularis longus during balance exercise trials and recorded participants' ratings of perceived postural instability and exertion after each trial of balance exercises.

RESULTS

The authors observed greater vastus lateralis (P < .001, d = 0.86 [0.28 to 1.44]) and soleus (P = .03, d = 0.32 [-0.24 to 0.87]) muscle activation during balance exercises with BFR than control. The authors observed no differences in tibialis anterior (P = .33, d = 0.09 [-0.46 to 0.65]) or fibularis longus (P = .13, d = 0.06 [-0.50 to 0.61]) muscle activation between the conditions. The authors observed greater ratings of perceived postural instability (P = .004) and exertion (P < .001) during balance exercises with BFR than control.

CONCLUSIONS

Individuals with CAI demonstrated large increases in vastus lateralis and small increases in soleus muscle activation during dynamic balance exercises with BFR. The BFR had no effect on fibularis longus and tibialis anterior muscle activation. Individuals with CAI perceived greater postural instability and exertion during dynamic balance exercises with BFR.

Health-Related Quality of Life Among Middle-Aged Adults With Chronic Ankle Instability, Copers, and Uninjured Controls

CONTEXT

People with chronic ankle instability (CAI) display a lower regional and global health-related quality of life (HRQoL). Examinations of HRQoL outcomes associated with CAI have addressed younger adults, restricting our understanding of the long-term consequences of CAI.

OBJECTIVE

To compare ankle regional and global HRQoL in middle-aged participants with and those without CAI.

DESIGN

Cross-sectional study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

A total of 59 middle-aged volunteers, consisting of 18 with CAI (age = 50.2 ± 9.3 years), 17 who were ankle-sprain copers (age = 54.5 ± 8.7 years), and 24 uninjured controls (age = 56.7 ± 10.0 years).

MAIN OUTCOME MEASURE(S)

Participants completed the Foot and Ankle Disability Index (FADI) and the Patient-Reported Outcomes Measurement Information System Adult Profile. Regional HRQoL was assessed using the FADI Activities of Daily Living and Sport subscales. Global HRQoL was measured using the 43-item Patient-Reported Outcomes Measurement Information System Adult Profile, which contains 7 short forms-Physical Function, Pain Interference, Fatigue, Depression, Sleep Disturbance, Anxiety, and Ability to Participate in Social Roles and Activities. Separate Kruskal-Wallis tests were used to determine between-groups differences.

RESULTS

Middle-aged participants with CAI had lower scores on both subscales of the FADI than the coper and control groups (all P values <.001). Participants with CAI scored lower on the Physical Function (U = 116.0, z = -2.78, P = .005) and Ability to Participate in Social Roles and Activities (U = 96.0, z = -3.09, P = .002) subscales but higher on the Pain Interference (U = 144.0, z = -2.36, P = .02), Fatigue (U = 110.0, z = -2.72, P = .006), and Depression (U = 110.5, z = -2.91, P = .004) subscales than the control group. Participants with CAI also scored lower on the Physical Function (U = 74.5, z = -2.79, P = .005) and Ability to Participate in Social Roles and Activities (U = 55.0, z = -3.29, P = .001) subscales but higher on the Fatigue (U = 90.0, z = -2.09, P = .04) and Depression (U = 96.5, z = -1.97, P = .048) subscales than the coper group.

CONCLUSIONS

Middle-aged participants with CAI displayed worse ankle regional and global HRQoL than their age-matched healthy counterparts and copers. These results demonstrated that CAI can affect HRQoL outcomes in middle-aged adults.

Manipulative Therapy Plus Ankle Therapeutic Exercises for Adolescent Baseball Players with Chronic Ankle Instability: A Single-Blinded Randomized Controlled Trial

Manipulative therapies and exercises are commonly used for the management of chronic ankle instability (CAI), but there is no evidence regarding the efficacy of high-velocity low-amplitude manipulation (HVLA) in addition to ankle therapeutic exercise to improve CAI in adolescent baseball players (ABP). To compare the effects of HVLA plus ankle therapeutic exercise and ankle therapeutic exercise alone on ankle status, pain intensity, pain pressure threshold (PPT), range of motion (ROM) of the ankle joint, and balance ability in ABP with CAI, a single-blinded randomized controlled trial was conducted. A total of 31 ABP with CAI were randomly allocated to the intervention (n = 16) or control (n = 15) groups. The intervention group received HVLA plus resistance exercise twice a week for 4 weeks, while the control group received resistance exercise alone. Ankle status, pain intensity, PPT, ROM, and balance ability were assessed before and after the intervention. The American Orthopedic Foot and Ankle Society scores showed significant group and time interactions (total, p = 0.002; pain, p < 0.001; alignment, p = 0.001). There were significant group and time interactions in pain intensity (resting pain, p = 0.008; movement pain, p < 0.001). For ROM, there were significant group and time interactions on dorsiflexion (p = 0.006) and eversion (p = 0.026). The unipedal stance of the balance ability showed significant group and time interactions in path length (p = 0.006) and velocity (p = 0.006). Adding HVLA to resistance exercises may be synergistically effective in improving the ankle status, pain intensity, ROM, and balance ability in ABP with CAI.

The Effects of Blood Flow Restriction on Muscle Activation and Hypoxia in Individuals With Chronic Ankle Instability

CONTEXT

Muscle dysfunction is common in patients with chronic ankle instability (CAI). Blood flow restriction (BFR) may enhance muscle responses during exercise and provide an opportunity to enhance muscle adaptations to ankle rehabilitation exercises; however, there is no evidence examining the effect of BFR on muscle function in CAI patients.

OBJECTIVE

Examine the effects of BFR on muscle activation and oxygen saturation during submaximal ankle eversion and dorsiflexion exercises in individuals with CAI.

DESIGN

Cross-over study design.

SETTING

Laboratory setting. Patients (or Other Participants): Nineteen young adults with a history of CAI.

INTERVENTIONS

Participants performed 4 sets (30, 15, 15, and 15) of eversion and dorsiflexion resistance exercises at 30% of maximum voluntary isometric contraction during 2 conditions, BFR and control. For BFR, a cuff was applied above the knee at 80% of blood flow occlusion. For control, the cuff was not inflated.

MAIN OUTCOME MEASURES

Fibularis longus and tibialis anterior electromyography muscle activation, lower-leg muscle oxygen saturation, and ratings of perceived exertion were recorded during exercises.

RESULTS

Average grand mean muscle activation was 5.6% greater during eversion (P = .03) and 7.7% greater during dorsiflexion (P = .01) resistance exercises with BFR compared with control; however, the magnitudes of the effects of BFR were only clinically important during the dorsiflexion exercises. Lower-leg muscle oxygen saturation was 31% to 44% lower (P < .001) during BFR exercises. Ratings of perceived exertion were significantly higher during BFR exercises (P < .001).

CONCLUSIONS

Greater muscle activation and hypoxia were present during submaximal resistance exercise with BFR in participants with CAI. Greater muscle activation and hypoxia during BFR exercises may be important acute responses mediating the training-related muscle adaptations that have been observed with BFR. The presence of these acute responses in CAI patients supports further research examining BFR as a potential ankle rehabilitation tool.

The Impact of a Previous Ankle Injury on Current Health-Related Quality of Life in College Athletes

CONTEXT

There has been an increased interest in understanding how ankle injuries impact patient outcomes; however, it is unknown how the severity of a previous ankle injury influences health-related quality of life (HRQOL).

OBJECTIVE

To determine the impact of a previous ankle injury on current HRQOL in college athletes.

DESIGN

Cross-sectional study.

SETTING

Athletic training clinics.

PARTICIPANTS

A total of 270 participants were grouped by the severity of a previous ankle injury (severe = 62, mild = 65, and no injury = 143).

MAIN OUTCOME MEASURES

Participants completed the Foot and Ankle Ability Measure (FAAM) and the Short Form 12 (SF-12).

METHODS

A 2-way analysis of variance with 2 factors (injury group and sex) was used to identify interaction and main effects for the FAAM and SF-12.

RESULTS

No interactions were identified between injury group and sex. Significant main effects were observed for injury group, where the severe injury group scored lower than athletes with mild and no injuries on the FAAM activities of daily living, FAAM Global, and SF-12 mental health subscale scores. In addition, a main effect was present for sex in the SF-12 general health, social functioning, and mental health subscales in which females reported significantly lower scores than males.

CONCLUSIONS

Our findings suggest that a severe ankle injury impacts HRQOL, even after returning back to full participation. In addition, females tended to report lower scores than males for aspects of the SF-12, suggesting that sex should be considered when evaluating HRQOL postinjury. As a result, clinicians should consider asking athletes about their previous injury history, including how much time was lost due to the injury, and should mindful of returning athletes to play before they are physiologically and psychologically ready, as there could be long-term negative effects on the patients' region-specific function as well as aspects of their HRQOL.

Changes in Spinal and Corticospinal Excitability in Patients with Chronic Ankle Instability: A Systematic Review with Meta-Analysis

The objective of this systematic review with meta-analysis was to determine alterations in spinal and corticospinal excitability of ankle muscles in patients with chronic ankle instability (CAI) compared to uninjured controls. Independent researchers performed comprehensive literature searches of electronic databases and included studies that compared groups with and without CAI and investigated neural excitability with Hoffmann reflex (H-reflex) and/or transcranial magnetic stimulation (TMS). A fixed-effect meta-analysis was conducted to determine group differences for (1) soleus and fibularis maximal H-reflex (Hmax)/maximal M-wave (Mmax)-ratios, and (2) soleus and fibularis longus cortical motor thresholds (CMTs). Seventeen studies were included in the current meta-analysis. They showed that the Hmax/Mmax-ratios of the soleus and the fibularis longus in the CAI group were significantly lower than those in the uninjured control group (soleus: d = −0.41, p < 0.001; fibularis longus: d = −0.27, p = 0.04). There was no evidence for changes in the CMT. This systematic review is the first to demonstrate evidence that patients with CAI present decreased spinal reflex excitability in the soleus and fibularis longus. However, there is no evidence of changes in supraspinal excitability when considering only the CMT. The latter result needs to be interpreted with caution as all except one study demonstrate some changes at the supraspinal level with CAI.