The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial

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).

Immediate Effect of Ankle Mobilization on Range of Motion, Dynamic Knee Valgus, and Knee Pain in Women With Patellofemoral Pain and Ankle Dorsiflexion Restriction: A Randomized Controlled Trial With 48-Hour Follow-Up

CONTEXT

Restriction in ankle dorsiflexion range of motion (ROM) has been previously associated with excessive dynamic knee valgus. This, in turn, has been correlated with knee pain in women with patellofemoral pain.

OBJECTIVES

To investigate the immediate effect of 3 ankle mobilization techniques on dorsiflexion ROM, dynamic knee valgus, knee pain, and patient perceptions of improvement in women with patellofemoral pain and ankle dorsiflexion restriction.

DESIGN

Randomized controlled trial with 3 arms.

SETTING

Biomechanics laboratory.

PARTICIPANTS

A total of 117 women with patellofemoral pain who display ankle dorsiflexion restriction were divided into 3 groups: ankle mobilization with anterior tibia glide (n = 39), ankle mobilization with posterior tibia glide (n = 39), and ankle mobilization with anterior and posterior tibia glide (n = 39).

INTERVENTION(S)

The participants received a single session of ankle mobilization with movement technique.

MAIN OUTCOME MEASURES

Dorsiflexion ROM (weight-bearing lunge test), dynamic knee valgus (frontal plane projection angle), knee pain (numeric pain rating scale), and patient perceptions of improvement (global perceived effect scale). The outcome measures were collected at the baseline, immediate postintervention (immediate reassessment), and 48 hours postintervention (48 h reassessment).

RESULTS

There were no significant differences between the 3 treatment groups regarding dorsiflexion ROM and patient perceptions of improvement. Compared with mobilization with anterior and posterior tibia glide, mobilization with anterior tibia glide promoted greater increase in dynamic knee valgus (P = .02) and greater knee pain reduction (P = .02) at immediate reassessment. Also compared with mobilization with anterior and posterior tibia glide, mobilization with posterior tibia glide promoted greater knee pain reduction (P < .01) at immediate reassessment.

CONCLUSION

In our sample, the direction of the tibia glide in ankle mobilization accounted for significant changes only in dynamic knee valgus and knee pain in the immediate reassessment.

Does Strength Training for Chronic Ankle Instability Improve Balance and Patient-Reported Outcomes and by Clinically Detectable Amounts? A Systematic Review and Meta-Analysis

OBJECTIVE

Strength training as a form of exercise therapy has long been used to maintain or promote strength, but its effectiveness as a treatment intervention in chronic ankle instability (CAI) is not fully understood. The purpose of this study was to evaluate the effects of strength training compared with no exercise and neuromuscular control training on balance and self-reported function in people with CAI.

METHODS

Eight databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, and WanFang) were searched in June 2020. Randomized controlled trials (RCTs) involving strength training conducted on individuals with CAI were included. Data were extracted by 2 independent reviewers using a standardized form. Methodological quality and risk of bias were assessed by using the PEDro Scale. In addition, the GRADE evaluation system (Grading of Recommendations Assessment, Development and Evaluation) was used to determine the strength of evidence. A total of 554 studies were initially screened, resulting in a final selection of 11 RCTs involving 428 participants, and 8 RCTs were included in the final meta-analysis. Compared with no exercise, strength training demonstrated some benefits in the Star Excursion Balance Test (anterior: weighted mean difference [WMD] = 2.39, 95% CI = 0.60-4.18; posteromedial: WMD = 3.30, 95% CI = 0.24-6.35; posterolateral: WMD = 2.97, 95% CI = 0.37-5.57), but these intervention results did not reach the minimal detectable change values.

CONCLUSION

Available evidence showed that, compared with controls, strength training did not produce any minimal detectable changes on Star Excursion Balance Test or Foot and Ankle Ability Measure scores in individuals with CAI. Clinicians should use strength training cautiously for improving balance and symptoms in CAI.

IMPACT

The results of this study may have an impact on selecting effective physical therapy interventions for managing symptoms associated with CAI.

Assessments of Sensorimotor Deficits Used in Randomized Clinical Trials With Individuals With Ankle Sprains and Chronic Ankle Instability: A Scoping Review

The main purpose of this scoping review was to summarize the most common tasks and outcome measures in randomized control trials (RCTs) used to assess sensorimotor function following ankle sprain and chronic ankle instability (CAI). We also aimed to summarize the description of inclusion criteria used in articles. We searched for RCTs published between 2008 and 2018 using the following databases: MEDLINE, PubMed, SPORTDiscus, and Web of Science. Eligible studies included participants of either sex who had had at least one ankle sprain with/without subsequent CAI. All articles assessed sensorimotor function. The tasks, outcome measures, and inclusion criteria were categorized, and frequencies of use in each category were calculated. Of 272 publications, 31 met the eligibility criteria. The most common task was single-limb stance (58% of 31). The most common outcome measure was the posterior-medial reach distance of the Star Excursion Balance Test (SEBT) (13 of 16 articles, 81%). Different inclusion criteria for a history of ankle sprains or CAI were used. A wide range of sensorimotor assessments and inclusion criteria was used among studies involving individuals with a history of ankle sprain with or without CAI, which could make it difficult to compare and generalize study results. This scoping review provides a baseline for planning future studies exploring outcome measures to assess sensorimotor function of individuals with a history of ankle sprain with or without CAI.

RETURNING A SPECIAL OPERATIONS CANDIDATE TO DUTY FOLLOWING AN AIRBORNE OPERATION INJURY: A CASE REPORT

BACKGROUND

Musculoskeletal injuries are recognized as the leading health problem and primary source of injury, disability, and financial burden across the military.^1-5 Special Operations Forces are at an increased risk of musculoskeletal injury due to increased physical demands, precipitous deployments, and continual training and deployment cycles.^6,4 Multiple injury screening tools exist, yet decisions to return to duty are frequently deferred to individual institutional protocol or provider clinical decision making, with no accepted gold standard.^2,3,4,5.

PURPOSE

The purpose of this case report is to describe the application of a system to return a Special Operations Forces candidate to duty following an ankle injury sustained during a military static line airborne operation while in the Special Forces Qualification Course.

CASE DESCRIPTION

The subject was a 34-year-old male with surgical fixation of a left distal fibular fracture with syndesmotic tear after landing from a static line airborne jump during the Special Forces Qualification Course. This case report provides a system to determine return to duty following an ankle fracture and provides a guide to returning a subject to participation, duty, and tactical performance training.

OUTCOMES

Outcome measures recorded were vast, as the use of multiple measures are more indicative of overall function than any single measure. Impairment based measures included Global Rating of Change Scale (GROC), Numeric Pain Rating Scale (NPRS), lateral step down and Closed Chain Dorsiflexion (CCDF). Functional outcome measures included: the Functional Movement Screen™ (FMS™), Lower Quarter Y-Balance (LQYB), three hop tests for distance, and physical performance metrics.

DISCUSSION

The most substantial challenge to this process was the lack of standardized and validated military return to duty testing and guidelines in the literature. Ideally, pre-injury assessment would provide a baseline; however, compared to peers, the subject was well within acceptable ranges for all physical performance metrics at final Return to Duty testing. The subject was returned to duty 10 months after initial injury being physically comparable to his cohorts and being able to complete all military requirements.

LEVELS OF EVIDENCE

5.

Identifying Meaningful Patient Outcomes After Lower Extremity Injury, Part 1: Patient Experiences During Recovery

CONTEXT

Determining meaningful aspects of health is crucial for outcome assessment; however, limited literature exists on the aspects of health that are deemed meaningful by the athletic patient population.

OBJECTIVE

To identify experiences and meaningful outcomes after lower extremity (LE) musculoskeletal injury among collegiate athletes.

DESIGN

Qualitative study.

SETTING

University laboratory.

PATIENTS OR OTHER PARTICIPANTS

A purposive sample of 20 athletes (10 men, 10 women; age = 20.1 ± 1.83 years) from a National Collegiate Athletic Association Division I institution in the Midwest who had sustained an LE injury.

DATA COLLECTION AND ANALYSIS

Semistructured face-to-face interviews and inductive data analysis were conducted. Trustworthiness of the data was established using member checks and peer debriefing.

RESULTS

Four themes emerged from the data, revealing that physical changes, psychological changes, personal and lifestyle changes, and support were the most meaningful outcomes among athletes with an LE injury. The 4 themes were associated with 21 subthemes, indicating the complexity with which LE injury affects individuals.

CONCLUSIONS

Our findings demonstrate the importance of caring for the whole person. Athletic trainers must broaden their focus to provide the best patient care and consider the person's activities and life demands outside of athletic participation. The themes identified in this study provide a basis for selecting appropriate health markers and outcome measures.

Does Multimodal Rehabilitation for Ankle Instability Improve Patients' Self-assessed Functional Outcomes? A Network Meta-analysis

BACKGROUND

Although there are many nonsurgical treatment options for the primary management of chronic ankle instability, the most effective nonoperative intervention has not been defined.

QUESTIONS/PURPOSES

The purpose of this study was to perform a network meta-analysis to compare the results of different standalone and/or combined nonsurgical interventions on chronic ankle instability as measured by (1) the Cumberland Ankle Instability Tool (CAIT) at 0 to 6 months after treatment and (2) treatment-related complications.

METHODS

We searched PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), and Scopus in August 2017 for completed studies published between 2005 and 2016. We conducted random-effects pairwise and network meta-analysis considering randomized trials, which compared the effects of various nonoperative therapies for ankle instability. Studies assessing patients with functional ankle instability and/or mechanical ankle instability and/or recurrent ankle sprains were eligible for inclusion. After combining data from self-administered questionnaires, we analyzed patient self-reported outcomes of function at the end of the rehabilitation period and 1 to 6 months after treatment. We thereafter reexpressed standardized mean differences to mean differences with CAIT. For this instrument, scores vary between 0 and 30, and higher scores indicate better ankle stability. We included 21 trials involving 789 chronically unstable ankles. The rehabilitation interventions included, but were not limited to, balance training, strengthening exercises, a combination of the balance and strengthening exercises, manual therapy, and multimodal treatment. The implemented multistation protocols were targeted at four main areas of rehabilitation (ROM, balance, strength, and overall activity). Control was defined as placebo and/or wait and see. Treatment-related complications were defined as any major or minor adverse event observed after rehabilitation as reported by the source studies. Statistically, we did not detect significant inconsistency in the network meta-analysis. We also assessed the quality of the trials using the Cochrane risk of bias tool and judged 12, eight, and one studies to be at a low, unclear, and high risk of bias, respectively. We also considered the quality of evidence to be of moderate strength utilizing the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We defined the minimum clinically important difference (MCID) in the CAIT to be 3 points.

RESULTS

A 4-week supervised rehabilitation program, which included balance training, strengthening, functional tasks, and ROM exercises, was favored over control according to the results of four trials by a clinically important margin (mean difference between multimodal and control groups in the CAIT was -10; 95% confidence interval [CI], -16 to -3; p = 0.001). Among the standalone interventions, only balance training was better than control according to the findings of seven trials (mean difference between balance training and control in the CAIT was -5; 95% CI, -10 to -0.03; p = 0.049); this difference likewise exceeded the MCID and so is believed to be a clinically important difference. Adverse events associated with the enrolled rehabilitation protocols were transient, mild, and uncommon.

CONCLUSIONS

Although a supervised impairment-based program after chronic ankle instability was superior to control, we note that followup in the included trials tended to be short and inconsistent, although the effect size exceeded the MCID and so likely would be identified as clinically important by patients. Future randomized trials should determine whether the short-term benefits of these interventions are sustained over time.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Efficacy of non-surgical interventions on dynamic balance in patients with ankle instability: A network meta-analysis

OBJECTIVES

To identify non-surgical treatments which were deemed to be more effective in improving dynamic postural control in patients with chronic ankle instability (CAI).

DESIGN

Systematic review and random-effects network meta-analysis.

METHODS

We searched Scopus, CENTRAL, and PubMed until 26 August 2017. We used data from randomized trials comparing the results of different non-surgical interventions for lateral CAI. We assessed dynamic postural control in terms of the star-excursion balance test in the posteromedial direction. We evaluated this outcome at the end of the rehabilitation protocols (i.e., short term) and 6months after treatment (i.e., medium term). We assessed the quality of the included studies with the Cochrane risk of bias tool and evaluated the quality of evidence from the network of interventions using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

Nineteen trials were eligible for inclusion in this systematic review. A 4-6-week supervised balance training program and a 4-6-week strengthening rehabilitation protocol provided significant improvements compared to control (8 studies, standardized mean difference [SMD] was -0.75, 95% CIs [-1.28 to -0.23]); and 2 studies, SMD was -1.2, 95% CIs [-2.36 to -0.08], respectively). A 6-week combined intervention that addressed balance and strength had the highest probability of being among the best treatments. However, the latter rehabilitation intervention was included in only one trial.

CONCLUSIONS

The network meta-analysis showed that supervised balance training protocols and strengthening programs significantly improved dynamic balance in patients with CAI. A combination of these interventions may further increase the efficacy of non-surgical treatment options for the first-line management of CAI.

Rehabilitation and Improvement of Health-Related Quality-of-Life Detriments in Individuals With Chronic Ankle Instability: A Meta-Analysis

OBJECTIVE

  To conduct a systematic review with meta-analysis assessing the effectiveness of conservative rehabilitation programs for improving health-related quality of life (HRQL) in individuals with chronic ankle instability (CAI).

DATA SOURCES

  PubMed, MEDLINE, CINAHL, and SPORTDiscus were searched from inception to January 2016.

STUDY SELECTION

  Studies were included if the researchers examined the effects of a conservative rehabilitation protocol in individuals with CAI, used validated patient-reported outcomes (PROs) to quantify participant-perceived HRQL, and provided adequate data to calculate the effect sizes (ESs) and 95% confidence intervals (CIs). Studies were excluded if the authors evaluated surgical interventions, prophylactic taping, or bracing applications or examined only the immediate effects of 1 treatment session.

DATA EXTRACTION

  Two investigators independently assessed methodologic quality using the Physiotherapy Evidence Database (PEDro) Scale. Studies were considered low quality if fewer than 60% of the criteria were met. Level of evidence was assessed using the Strength of Recommendation Taxonomy. Preintervention and postintervention sample sizes, means, and standard deviations of PROs were extracted.

DATA SYNTHESIS

  A total of 15 studies provided 24 participant groups that were included in the analysis. Seven high-quality studies with a median PEDro score of 50% (range = 10%-80%) and a median level of evidence of 2 (range = 1-2) were identified. The magnitudes of preintervention to postintervention PRO differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analysis was performed to synthesize PRO changes across all participant groups. Positive ES values indicated better PRO scores at postintervention than at preintervention. The α level was set at .05. Meta-analysis revealed a strong ES with a nonoverlapping 95% CI (ES = 1.20, CI = 0.80, 1.60; P < .001), indicating HRQL improved after conservative rehabilitation.

CONCLUSIONS

  Based on the quality of the evidence and the results of the meta-analysis, grade A evidence showed that conservative rehabilitation produces large improvements in HRQL for people with CAI.

Therapeutic interventions for improving self-reported function in patients with chronic ankle instability: a systematic review

OBJECTIVE

To identify which therapeutic intervention may be most effective for improving self-reported function in patients with chronic ankle instability (CAI).

DESIGN

Systematic literature review. Articles were appraised using the Downs and Black Checklist by 3 reviewers.

DATA SOURCES

PubMed along with CINAHL, MEDLINE and SPORTDiscus within EBSCOhost for pertinent articles from their inception through August 2016.

ELIGIBILITY CRITERIA FOR SELECTED STUDIES

Articles included were required to (1) be written in English, (2) report adequate data to calculate effect sizes, (3) identify patients with CAI, (4) use some form of therapeutic intervention and (5) use a self-reported questionnaire as a main outcome measurement.

RESULTS

A broad spectrum of therapeutic interventions were identified related to balance training, multimodal rehabilitation, joint mobilisation, resistive training, soft-tissue mobilisation, passive calf stretching and orthotics. All of the articles included in the balance training category had moderate-to-strong Hedges g with none of the 95% CIs crossing 0. Hedges g effect sizes ranged from -0.67 to -2.31 and -0.51 to -1.43 for activities of daily living and physical activity, respectively. The multimodal rehabilitation category also produced moderate-to-strong Hedges g effect sizes but with large CIs crossing 0. Hedges g effect sizes ranged from -0.47 to -9.29 and -0.62 to -24.29 for activities of daily living and physical activity, respectively.

CONCLUSIONS

The main findings from this systematic review were balance training provided the most consistent improvements in self-reported function for patients with CAI.