Predicting dynamic balance improvements following 4-weeks of balance training in chronic ankle instability patients

Meta-analysis of the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability

OBJECTIVE

To explore and compare the dosage of balance training on ankle function and dynamic balance ability in patients with chronic ankle instability (CAI).

METHODS

The PubMed, Embase, Web of Science, Medline, and Cochrane databases were searched up to December 2023. Quality assessment was carried out using the risk-of-bias guidelines of the Cochrane Collaboration, and the standardized mean differences (SMD) or mean differences (MD) for each outcome were compute.

RESULTS

Among 20 eligible studies, including 682 participants were analyzed in this meta-analysis. The results of the meta-analysis demonstrated that balance training was effective in enhancing ankle function with self-functional scores (SMD = 1.02; 95% CI, 0.61 to 1.43; p < 0.00001; I2 = 72%) and variables associated with the ability of dynamic balance such as SEBT-A (MD = 5.88; 95% CI, 3.37 to 8.40; p < 0.00001; I2 = 84%), SEBT-PM (MD = 5.47; 95% CI, 3.40 to 7.54; p < 0.00001; I2 = 61%), and SEBT-PL (MD = 6.04; 95% CI, 3.30 to 8.79; p < 0.0001; I2 = 79%) of CAI patients. Meta-regression indicated that the intervention time might be the principal cause of heterogeneity (p = 0.046) in self-functional scores. In subgroup analyses of self-functional score across intervention types, among the intervention time, more than 20 min and less than 30 min had the most favorable effect (MD = 1.21, 95% CI: 0.96 to 1.46, p < 0.00001, I2 = 55%); among the intervention period, 4 weeks (MD = 0.84, 95% CI: 0.50 to 1.19, p < 0.00001, I2 = 78%) and 6 weeks (MD = 1.21, 95% CI: 0.91 to 1.51, p < 0.00001, I2 = 71%) had significant effects; among the intervention frequency, 3 times (MD = 1.14, 95% CI: 0.89 to 1.38), p < 0.00001, I2 = 57%) had significant effects. Secondly, in subgroup analyses of SEBT across intervention types, a 4-week and 6-week intervention with balance training 3 times a week for 20-30 min is the optimal combination of interventions to improve SEBT (dynamic balance) in patients with chronic ankle instability.

CONCLUSION

Balance training proves beneficial for ankle function in patients with CAI. Intervention time constitutes a major factor influencing self-function in patients with CAI. It is recommended that the optimal dosage of balance training for CAI involves intervention three times a week, lasting for 20 to 30 min over a period of 4 to 6 weeks for superior rehabilitation.

The Effects of Augmenting Balance Training with Stroboscopic Goggles on Postural Control in Chronic Ankle Instability Patients: A Critically Appraised Topic

CLINICAL SCENARIO

Individuals with chronic ankle instability (CAI) typically complete balance training protocols to improve postural control and reduce recurrent injury risk. However, the presence of CAI persists after traditional balance training protocols suggesting that such programs may be missing elements that could be beneficial to patients. Visual occlusion modalities, such as stroboscopic goggles, may be able to augment balance training exercises to further enhance postural control gains in those with CAI. However, a cumulative review of the existing evidence has yet to be conducted.

FOCUSED CLINICAL QUESTION

Does wearing stroboscopic goggles during balance training result in greater improvements to postural control than balance training alone in those with CAI?

SUMMARY OF KEY FINDINGS

All 3 studies indicated that the stroboscopic goggles group had statistically significant improvements in either a measure of static or dynamic postural control relative to the standard balance training group. However, significant improvements were not consistent across all postural control outcomes assessed in the included studies.

CLINICAL BOTTOM LINE

Postural control may improve more in those with CAI when stroboscopic goggles were worn while completing balance training exercises relative to completing balance training exercises alone.

STRENGTH OF RECOMMENDATION

Overall, consistent moderate- to high-quality evidence was present in the 3 studies, suggesting grade C evidence for the use of stroboscopic goggles during balance training in those with CAI.

What interventions can treat arthrogenic muscle inhibition in patients with chronic ankle instability? A systematic review with meta-analysis

PURPOSE

To identify, critically appraise, and synthesize the existing evidence regarding the effects of therapeutic interventions on arthrogenic muscle inhibition (AMI) in patients with chronic ankle instability (CAI).

MATERIALS AND METHODS

Two reviewers independently performed exhaustive database searches in Web of Science, PubMed, Medline, CINAHL, and SPORTDiscus.

RESULTS

Nine studies were finally included. Five types of disinhibitory interventions were identified: focal ankle joint cooling (FAJC), manual therapy, fibular reposition taping (FRT), whole-body vibration (WBV), and transcranial direct current stimulation (tDCS). There were moderate effects of FAJC on spinal excitability in ankle muscles (g = 0.55, 95% CI = 0.03-1.08, p = 0.040 for the soleus and g = 0.54, 95% CI = 0.01-1.07, p = 0.046 for the fibularis longus). In contrast, manual therapy, FRT, WBV were not effective. Finally, 4 weeks of tDCS combined with eccentric exercise showed large effects on corticospinal excitability in 2 weeks after the intervention (g = 0.99, 95% CI = 0.14-1.85 for the fibularis longus and g = 1.02, 95% CI = 0.16-1.87 for the tibialis anterior).

CONCLUSIONS

FAJC and tDCS may be effective in counteracting AMI. However, the current evidence of mainly short-term studies to support the use of disinhibitory interventions is too limited to draw definitive conclusions.

Participant-Level Analysis of the Effects of Interventions on Patient-Reported Outcomes in Patients With Chronic Ankle Instability

CONTEXT

Intervention studies for chronic ankle instability (CAI) often focus on improving physical impairments of the ankle complex. However, using an impairments-focused approach may miss psychological factors that may mediate function and recovery. Patient-reported outcome (PRO) measures can be used to assess several dimensions of the health-related quality of life (HRQoL) and deliver enhanced patient-centered care. Therefore, the purpose of this investigation was to evaluate group-level improvements in HRQoL and treatment response rates following various interventions in patients with CAI.

DESIGN

Cross-sectional.

METHODS

Data from 7 previous studies were pooled by the chronic ankle instability outcomes network for participant-level analysis, resulting in 136 patients with CAI. Several interventions were assessed including balance training, gait biofeedback, joint mobilizations, stretching, and strengthening, with treatment volume ranging from 1 to 4 weeks. Outcome measures were PROs that assessed ankle-specific function (Foot and Ankle Ability Measure), injury-related fear (Tampa Scale of Kinesiophobia and Fear Avoidance Belief Questionnaire), and global well-being (Disablement in the Physically Active); the PROs assessed varied between studies. Preintervention to postintervention changes were evaluated using separate Wilcoxon signed-rank tests and effect sizes, and a responder analysis was conducted for each PRO.

RESULTS

Significant, moderate to large improvements were observed in PROs that assessed ankle-specific function, injury-related fear, and global well-being following intervention (P < .001). Responder rates ranged from 39.0% to 53.3%, 12.8% to 51.4%, and 37.8% for ankle specific function, injury-related fear, and global well-being, respectively.

CONCLUSIONS

Various interventions can lead to positive improvements in HRQoL in patients with CAI. Treatment response rates at improving HRQoL are similar to response rates at improving impairments such as balance, further reinforcing the need for individualized treatment approaches when treating a patient with CAI.

Effects of exercise habituation and aging on the intersegmental coordination of lower limbs during walking with sinusoidal speed change

Background

The time courses of the joint elevation angles of the thigh, shank, and foot in one stride during walking can be well approximated by a “plane” in a triaxial space. This intersegmental coordination (IC) of the lower limb elevation angles is referred to as the planar covariation law. We examined the effects of exercise habituation and aging on the thickness of the IC plane of the lower limbs under sinusoidal speed changing conditions.

Methods

Seventeen sedentary young (SY), 16 active young (AY), and 16 active elderly (AE) adults walked on a treadmill in accordance with a sinusoidal speed changing protocol at 120, 60, and 30 s periods with an amplitude of ± 0.56 m·s⁻¹. Motion of the lower limbs from the sagittal direction was recorded to calculate the elevation angles of the lower limbs. When the best-fit IC plane was determined, the smallest standard deviation of the IC plane was considered as the anteroposterior gait variability of the lower limbs. The coefficient of variance of the step width was also quantified to evaluate the lateral step variability (CV_SW).

Results

The standard deviation of the IC plane was significantly greater in the order of SY, AY, and AE, regardless of the sinusoidal wave periods of the changing speed. The CV_SW was not significantly different among the three groups.

Conclusions

Exercise habituation influences anteroposterior gait variability of the lower limbs, but not lateral step variability, even in young adults. Given these, gait adaptability for sinusoidal speed changes does not always decline with aging.

Trial registration

UMIN000031456 (R000035911; registered February 23, 2018).

Supplementary Information

The online version contains supplementary material available at 10.1186/s40101-022-00298-w.

Predicting the success of multimodal rehabilitation in chronic ankle instability based on patient-reported outcomes

Background

The aim of this study was to identify potential indicators to predict the success of multimodal rehabilitation in chronic ankle instability (CAI) patients based on patient-reported outcomes.

Methods

Sixty patients with self-reported CAI participated. Their demographic information, injury history, and symptoms were recorded. Physical examinations and dynamic posture control tests were performed. The participants underwent sixteen 30-min treatment sessions of multimodal rehabilitation over 8 weeks. Fifty-one patients (85.0%) were available for follow-up after 8 weeks of the intervention. Treatment success was defined based on the participants’ perceived recovery using the global rating of change (GRC). Potential predictor variables were entered into a stepwise logistic regression model to identify variables for the prediction of treatment success.

Results

Forty of 51 participants (78.4%) were considered to have a successful outcome. Of the variables assessed, time since last sprain ≤ 8 months was a predictor of treatment success (p < 0.05). If a patient met the criteria, there was an 88.03% probability of successful multimodal rehabilitation.

Conclusion

A time since the last sprain ≤ 8 months may predict successful patient-reported outcomes after multimodal rehabilitation in CAI patients.

Level of evidence

Prospective study, Level 2.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-022-05676-0.

A pilot randomised control trial of the efficacy of stability-based training with visualisation for people with chronic ankle instability

Chronic ankle instability (CAI) is associated with recurring symptoms that inhibit daily activity. Stability-based rehabilitative training is recommended for CAI. Visualisation (VIS) produces real-time feedback using motion capture and virtual reality. This pilot study aimed to determine the feasibility, adherence, safety, and efficacy of incorporating VIS into stability training for people with CAI. Efficacy was examined through effect of VIS training on dynamic stability, perception of stability, and rehabilitative experience. Individuals with CAI completed a 4-week stability-based training programme with VIS, or without visualisation (NO-VIS). Participants completed the Star Excursion Balance Test (SEBT) and Cumberland Ankle Instability Tool (CAIT) prior to, and after training. Enjoyment of training was recorded using the Physical Activity Enjoyment Scale (PACES-8). Of 17 participants (VIS = 10, NO-VIS = 7), there were 2 drop outs (VIS = 1, NO-VIS = 1). No adverse events were reported, and participant drop-out was due to injury unrelated to the study. The VIS group showed a significantly greater increase in average SEBT reach distance (d = 1.7, p = 0.02). No significant differences were reported for the CAIT or PACES-8. This study supports the feasibility and safety of stability-based training with VIS in those with CAI. The enhanced performance outcome on the SEBT suggests VIS may enhance stability-based training.

Effectiveness of balance training in patients with chronic ankle instability: protocol for a systematic review and meta-analysis

INTRODUCTION

Lateral ankle sprains are one of the most common musculoskeletal injuries. Up to 70% of individuals who sustain lateral ankle sprains develop chronic ankle instability (CAI). Balance training has been used in patients with CAI, but the evidence for its efficacy is inconsistent. This systematic review and meta-analysis aims to determine the short-term (end of the treatment period) and long-term (6 months after treatment) effectiveness of balance training for patients with CAI.

METHODS AND ANALYSIS

We will search PubMed, EMBASE, the Cochrane Library, Ovid, EBSCO-host, Pedro, ClinicalKey, ScienceDirect, Springer, China National Knowledge Infrastructure, Technology Periodical Database (VIP), WanFang Data and China Biology Medicine for reports of randomised trials of balance training in patients with CAI, from inception to 1 October 2021. The language will be restricted to English and Chinese, and articles will be screened and collected by two reviewers independently. Dynamic balance and functional ankle instability are the primary outcomes of this study. Secondary outcomes include pain, ankle range of motion, ankle strength and health-related quality of life. Review Manager V.5.3 software will be used for meta-analysis, and stratification analysis will be conducted for study quality according to the Jadad score. Subgroup and sensitivity analyses will be conducted. Grading of Recommendations, Assessment, Development and Evaluation will be used to assess confidence in the cumulative evidence. The protocol follows the Cochrane Handbook for Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required for literature-based studies. The results will be disseminated through peer-reviewed publications.

Effect of Functional Rehabilitation on Performance of the Star Excursion Balance Test Among Recreational Athletes With Chronic Ankle Instability: A Systematic Review

OBJECTIVE

To determine (1) the effectiveness of rehabilitation for chronic ankle instability as measured by the Star Excursion Balance Test (SEBT) and (2) the relative efficacy and the long-term effects of these rehabilitation interventions.

DATA SOURCES

Ten electronic databases were searched (2009-2019).

STUDY SELECTION

Included articles were randomized controlled trials in English investigating recreational athletes aged ≥18 years with chronic ankle instability. At least 1 functional rehabilitation intervention had to be included and the SEBT test (or the modified version) used as an outcome measure.

DATA EXTRACTION

Two researchers (L.A., O.N.) extracted data regarding participant demographics; intervention characteristics; trial size; and results at baseline, postintervention, and at follow-up, where appropriate.

DATA SYNTHESIS

A systematic review and narrative synthesis was conducted. Methodological quality of included studies was assessed using the Cochrane Risk of Bias Tool and the van Tulder scale. The review was registered with PROSPERO (ID: 164468). Ten studies (n=368), 2 high-quality, 1 moderate-quality, and 7 low-quality, were included in the review. Interventions included balance training, strength training, vibration training, and mixed training. Results suggest that rehabilitation of chronic ankle instability that includes wobble board exercises (average percentage change: 14.3%) and hip strengthening exercises (average percentage change: 12.8%) are most effective. Few studies compared different types of rehabilitation for chronic ankle instability. However, improvements on the SEBT suggest that a rehabilitation program focusing on wobble board training and hip strengthening performed 3 times weekly for 4-6 weeks is the optimal rehabilitation program to improve dynamic postural control in recreational athletes with chronic ankle instability.

CONCLUSIONS

Few studies directly compared different rehabilitation interventions, and there was limited long-term follow-up; therefore, the relative efficacy of different rehabilitation programs remains unclear. However, it seems that rehabilitation of chronic ankle instability should include proprioceptive and strengthening exercises of relatively short duration.

Examining the Use of Kinesiology Tape During Weight Bearing Exercises on Proprioception in Participants With Functional Ankle Instability

The aim of this study was to examine the effect of tape worn during weight bearing exercises on proprioception (i.e., ankle angle repositioning error) in participants with functional ankle instability. We employed a randomized, controlled clinical study in a laboratory setting, with 56 participants with functional ankle instability. Participants were randomly assigned to three groups: (a) weight bearing exercises without tape (n = 18), (b) weight bearing exercises with tape (n = 19) and controls not engaged in weight bearing exercises (n = 19). Weight bearing exercises included six weeks of bilateral squats in partial form with up to 45 degrees of knee flexion, and unilateral partial squats with full heel raise, and with full toe raise. In the taped condition, participants wore tape for six weeks with up to three tape replacements per week. Proprioception was measured as ankle repositioning error. Results showed that the mean angle repositioning error among participants in the active weight bearing groups was decreased by the taping intervention, relative to the control group's performance (p = 0.042). There were no significant differences between weight bearing exercise groups and control groups. The addition of kinesiology tape in weight bearing exercises can improve proprioception in active conditions.

Progressive Visual Occlusion and Postural Control Responses in Individuals With and Without Chronic Ankle Instability

CONTEXT

Prophylactic and rehabilitative balance training is needed to maximize postural control and develop appropriate sensory organization strategies. Partially occluding vision during functional exercise may promote appropriate sensory organization strategies, but little is known about the influence of partially occluded vision on postural control in those with and without a history of musculoskeletal injury.

OBJECTIVE

To determine the effect of increasing levels of visual occlusion on postural control in a heterogeneous sample of those with and without chronic ankle instability (CAI). The secondary objective was to explore postural control responses to increasing levels of visual occlusion among those with unilateral and bilateral CAI relative to uninjured controls.

DESIGN

Cross-sectional.

SETTING

Sports medicine research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-five participants with unilateral CAI, 10 with bilateral CAI, and 16 participants with no history of lower extremity injury.

MAIN OUTCOME MEASURES

All participants completed four 3-minute postural control assessments in double-limb stance under the following 4 visual conditions: (1) eyes open, (2) low occlusion, (3) high occlusion, and (4) eyes closed. Low- and high-occlusion conditions were produced using stroboscopic eyewear. Postural control outcomes included time-to-boundary minima means in the anteroposterior (TTB-AP) and mediolateral directions (TTB-ML). Repeated-measures analysis of variances tested the effects of visual condition on TTB-AP and TTB-ML.

RESULTS

Postural control under the eyes-open condition was significantly better (ie, higher) than the limited visual occlusion and eyes-closed conditions (P < .001) for TTB-AP and TTB-ML. For TTB-AP only, partially occluded vision resulted in better postural control than the eyes-closed condition (P ≤ .003).

CONCLUSIONS

Partial and complete visual occlusion impaired postural control during dual-limb stance in a heterogeneous sample of those with and without CAI. Stroboscopic eyewear appears to induce postural control impairments to the same extent as complete visual occlusion in the mediolateral direction.

Submaximal Force Steadiness and Accuracy in Patients With Chronic Ankle Instability

CONTEXT

Patients with chronic ankle instability (CAI) have demonstrated sensorimotor impairments. Submaximal force steadiness and accuracy measure sensory, motor, and visual function via a feedback mechanism, which helps researchers and clinicians comprehend the sensorimotor deficits associated with CAI.

OBJECTIVE

To determine if participants with CAI experienced deficits in hip and ankle submaximal force steadiness and accuracy compared with healthy control participants.

DESIGN

Case-control study.

SETTING

Research laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty-one patients with CAI and 21 uninjured individuals.

MAIN OUTCOME MEASURE(S)

Maximal voluntary isometric contraction (MVIC) and force steadiness and accuracy (10% and 30% of MVIC) of the ankle evertors and invertors and hip abductors were assessed using the central 10 seconds (20%-87% of the total time) of the 3 trials.

RESULTS

Relative to the control group, the CAI group demonstrated less accuracy of the invertors (P < .001). Across all motions, the CAI group showed less steadiness (P < .001) and less accuracy (P < .01) than the control group at 10% of MVIC. For MVIC, the CAI group displayed less force output in hip abduction than the uninjured group (P < .0001).

CONCLUSIONS

Patients with CAI were unable to control ongoing fine force (10% and 30% of MVIC) through a feedback mechanism during an active test. These findings suggested that deficits in sensorimotor control predisposed patients with CAI to injury positions because they had difficulty integrating the peripheral information and correcting their movements in relation to visual information.

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.

Change in dynamic postural control after a training program in collegiate soccer players with unilateral chronic ankle instability

BACKGROUND

Improving dynamic postural stability after lateral ankle sprain due to chronic ankle instability helps prevent recurrence, and changes in dynamic postural stability can be assessed with the Star Excursion Balance Test. To date, no studies have examined the change in Star Excursion Balance Test score after the end of a balance training program or whether chronic ankle instability affects the rate of change. To examine the effect of chronic ankle instability on changes in Star Excursion Balance Test. score over time after a balance training program.

METHODS

Fifteen collegiate soccer players with chronic ankle instability selected with the Cumberland Ankle Instability Tool and ultrasonography. Participants completed a 6-week balance training program. We assessed the Star Excursion Balance Test 5 times (before and immediately after the program and 2, 4, and 6 weeks later) and examined differences in the duration of training effects by a 2-way analysis of variance, with Bonferroni correction for post hoc comparisons to explain any significant interactions. The significance level for all analyses was set at P < .05. We performed statistical analyses with SPSS version 25.

RESULTS

Analysis of the posterolateral and posteromedial scores in Star Excursion Balance Test showed a significant effect of time. Post hoc analysis of the posterolateral score showed that for each leg, participants reached significantly farther after the program than before (P = .012). The posterolateral scores at 2, 4, and 6 weeks after the training program did not differ from before the program, but the posteromedial score was significantly improved immediately after the program (P = .008) and also 2 (P = .004) and 4 weeks later (P = .006).

CONCLUSIONS

A 6-week balance training program to improve dynamic postural control can improve posterolateral and posteromedial scores in people with chronic ankle instability, and the improvements in posteromedial are still present 4 weeks after program completion.

Does the Method of Administration Affect Reliability of the Foot and Ankle Ability Measure?

BACKGROUND

Region-specific patient-reported outcomes (PROs) are commonly used in rehabilitation medicine. Digital versions of PROs may be implemented into electronic medical records and are also commonly used in research, but the validity of this method of administration (MOA) must be established.

PURPOSE

To determine the agreement between and compare the test-retest reliability of a paper version (FAAM-P) and digital version (FAAM-D) of the Foot and Ankle Ability Measure (FAAM).

STUDY DESIGN

Randomized, nonblinded, crossover observational study.

METHODS

A total of 90 adults were randomized to complete the FAAM-P or FAAM-D first, and then completed the second MOA (first day [D1]). The FAAM-D was a digital adaptation of both FAAM-P subscales on Qualtrics. Identical test procedures were completed 1 week later (D2). Data were removed if a participant scored 100% on both MOA, reported injury between D1 and D2, or did not complete both MOA. Agreement was assessed on 46 participants between the 2 MOA using intraclass correlation coefficients (ICC) at D1. There was good-to-excellent test-retest reliability for the FAAM activities of daily living.

RESULTS

The authors observed good agreement between the FAAM-P and FAAM-D for the activities of daily living (ICC = .88) and sport scales (ICC = .87). Test-retest reliability was good-to-excellent for the FAAM activities of daily living (FAAM-P: ICC = .87; FAAM-D: ICC = .89) and sport (FAAM-P: ICC = .71; FAAM-D: ICC = .91).

CONCLUSIONS

The MOA does not appear to affect the responses on the FAAM; however, the authors observed slightly higher reliability on the FAAM-D. The FAAM-D is sufficient to be used for generating practice-based evidence in rehabilitation medicine.