Predicting Manual Therapy Treatment Success in Patients With Chronic Ankle Instability: Improving Self-Reported Function

Patients Experience Significant and Meaningful Changes in Self-Report of Function During the First 2 Weeks After an Ankle Sprain Injury: A Report From the Athletic Training Practice-Based Research Network

CONTEXT

Ankle sprains are common during sport participation and associated with long-term deficits in self-report of function. However, little is known of short-term changes in self-report of function following injury. The authors aimed to assess statistical and clinically meaningful changes in self-report of function, as measured by the Foot and Ankle Ability Measure (FAAM), during the first 2 weeks after an ankle sprain injury.

DESIGN

A retrospective analysis of electronic medical records.

METHODS

Eighty-eight patients, who were diagnosed with an ankle sprain injury by an athletic trainer, received usual care from an athletic trainer, and completed the FAAM during treatment at weeks 1 and 2 postinjury. The authors calculated the percentage of patients who reported clinically meaningful changes and used Wilcoxon signed-rank tests to compare differences in FAAM scores between time points.

RESULTS

Between weeks 1 and 2, significant differences were noted for the FAAM Activities of Daily Living (FAAM-ADL) (P < .001) and FAAM Sport (FAAM-Sport) (P < .001). At the patient level, 86.5% (64/74) and 85.2% (69/81) of patients reported changes that exceeded the minimal clinically important difference value for the FAAM-ADL and FAAM-Sport, respectively, between weeks 1 and 2. At week 2, 31.8% (28/88) and 47.7% (42/88) of patients reported a score below 90% on the FAAM-ADL and below 80% on the FAAM-Sport subscale, respectively. Also, 36.4% (32/88) and 25.0% (22/88) of patients reported a score of 100% on the FAAM-ADL and FAAM-Sport subscales, respectively, at week 2.

CONCLUSIONS

Patients report statistically significant and meaningful improvements in self-report of function during the first 2 weeks following ankle sprain injury. However, almost half of patients still report deficits in sport function at 2 weeks postinjury. Patient-reported outcome measures such as the FAAM, can help capture the patient's perception of function and inform patient care decisions. Research efforts should explore individual response patterns to treatment.

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.

Effects of global postural reeducation on postural control, dynamic balance, and ankle range of motion in patients with hallux abducto valgus. A randomized controlled trial

Hallux abducto valgus (HAV) is a common musculoskeletal disorder that has been addressed surgically. Nevertheless, the manual therapy approach may play an important role in the management of this condition. The present study aimed to determine the effectiveness of global postural reeducation (GPR) in subjects with symptomatic mild to moderate HAV in static postural control, dynamic stability, and ankle dorsiflexion range of motion (DFROM). A total of 80 patients with mild to moderate symptomatic HAV were allocated to the intervention group (GPR) or control group (CG) (no treatment) for 8 weeks. Outcome measures were assessed at baseline at 4 and 8 weeks including static postural control (Romberg test), dynamic balance (Star Excursion Balance Test [SEBT]), and ankle DFROM (Weight-Bearing Lunge Test [WBLT]). No improvements were observed at 4 weeks, but there were improvements at 8 weeks in: static postural control mediolateral displacement (X) of center of pressure (CoP) in both eyes open (EO) and eyes closed (EC): XEO (t(36) = 2.892, p = .006, d = 0.67); XEC (t(68) = 2.280, p = .026, d = 054); and velocity (V) of CoP displacement: VEO (t(68) = 2.380, p = .020, d = 0.57); VEC (t(36) = 2.057, p = .047, d = 0.37). It were also improvements in: WBLT (t(36) = -2.869, p = .007, d = 0.54) and SEBT at three directions (anterior, ANT; posteromedial, PM; and posterolateral, PL): SEBT.ANT (t(36) = -2.292, p = .028, d = 0.23); SEBT.PM (t(36) = -4.075, p < .001, d = 0.43); SEBT.PL (t(62) = -3.506, p = .001, d = 0.34). The present study showed that GPR compared to the CG might be effective in enhancing ankle function including postural control, dynamic balance, and DFROM.

Effects of myofascial release of the ankle plantar flexors on static postural balance of young men: A randomized clinical trial

BACKGROUND

Myofascial release (MR) has been widely used in sports and clinical environment. There are studies that have already evaluated the effect of MR on postural control, however, the data found are inconclusive.

OBJECTIVES

Investigate the effect of MR on ankle plantar flexor muscles over static postural balance.

METHOD

Sixty-five young men were randomized allocated into one of three groups: 1) MR group (n = 25, Myofascial Release); 2) Sham (n = 25, fake intervention); or 3) Control group (n = 15). Both MR and Sham techniques were applied during 5 min in the ankle flexors of each leg. The bipodal static postural balance test was performed before and 2 min post each intervention on a force plate with eyes closed during the test. All subjects performed 3 sets of 30-s with 1 min of rest. Mean values to the center of pressure velocity (COPvel) was used for analysis.

RESULTS

The bipodal balance test showed that there was no significant difference between groups (p > 0.05), but there was a significant time effect (p < 0.05). A significant decrease (p < 0.05) in post-test COPvel (cm.s^-1) values (sham 4.9 ± 1.2; MR 4.5 ± 0.6; CON 4.22 ± 0.8) was found when compared to values of pre-test (sham 5.3 ± 1.0; MR 5.0 ± 0.8; CON 4.94 ± 1.3) for all groups.

CONCLUSIONS

The results demonstrated that MR performed on ankle flexors did not affect static postural balance in young man. This study is a clinical trial (Register Number: RBR-48k5jm).

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.

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.

Six Sessions of Anterior-to-Posterior Ankle Joint Mobilizations Improve Patient-Reported Outcomes in Patients With Chronic Ankle Instability: A Critically Appraised Topic

Clinical Scenario: Chronic ankle instability (CAI) is a complex musculoskeletal condition that results in sensorimotor and mechanical alterations. Manual therapies, such as ankle joint mobilizations, are known to improve clinician-oriented outcomes like dorsiflexion range of motion, but their impact on patient-reported outcomes remains less clear. Focused Clinical Question: Do anterior-to-posterior ankle joint mobilizations improve patient-reported outcomes in patients with chronic ankle instability? Summary of Key Findings: Three studies (2 randomized controlled trials and 1 prospective cohort) quantified the effect of at least 2 weeks of anterior-to-posterior ankle joint mobilizations on improving patient-reported outcomes immediately after the intervention and at a follow-up assessment. All 3 studies demonstrated significant improvements in at least 1 patient-reported outcome immediately after the intervention and at the follow-up assessment. Clinical Bottom Line: At least 2 weeks of ankle joint mobilization improves patient-reported outcomes in patients with chronic ankle instability, and these benefits are retained for at least a week following the termination of the intervention. Strength of Recommendation: Strength of recommendation is grade A due to consistent good-quality patient-oriented evidence.

A 4-Week Multimodal Intervention for Individuals With Chronic Ankle Instability: Examination of Disease-Oriented and Patient-Oriented Outcomes

CONTEXT

Individuals with chronic ankle instability (CAI) experience disease- and patient-oriented impairments that contribute to both immediate and long-term health detriments. Investigators have demonstrated the ability of targeted interventions to improve these impairments. However, the combined effects of a multimodal intervention on a multidimensional profile of health have not been evaluated.

OBJECTIVE

To examine the effects of a 4-week rehabilitation program on disease- and patient-oriented impairments associated with CAI.

DESIGN

Controlled laboratory study.

SETTING

Laboratory.

PATIENTS OR OTHER PARTICIPANTS

Twenty adults (5 males, 15 females; age = 24.35 ± 6.95 years, height = 169.29 ± 10.10 cm, mass = 70.58 ± 12.90 kg) with self-reported CAI participated. Inclusion criteria were at least 1 previous ankle sprain, at least 2 episodes of "giving way" in the 3 months before the study, and a Cumberland Ankle Instability Tool score ≤24.

INTERVENTION(S)

Individuals participated in 12 sessions over 4 weeks that consisted of ankle stretching and strengthening, balance training, and joint mobilizations. They also completed home ankle-strengthening and -stretching exercises daily.

MAIN OUTCOME MEASURE(S)

Dorsiflexion range of motion (weight-bearing-lunge test), isometric ankle strength (inversion, eversion, dorsiflexion, plantar flexion), isometric hip strength (abduction, adduction, flexion, extension), dynamic postural control (Y-Balance test), static postural control (eyes-open and -closed time to boundary in the anterior-posterior and medial-lateral directions), and patient-reported outcomes (Foot and Ankle Ability Measure-Activities of Daily Living and Foot and Ankle Ability Measure-Sport, modified Disablement in the Physically Active scale physical and mental summary components, and Fear-Avoidance Beliefs Questionnaire-Physical Activity and Fear-Avoidance Beliefs Questionnaire-Work) were assessed at 4 times (baseline, preintervention, postintervention, 2-week follow-up).

RESULTS

Dorsiflexion range of motion, each direction of the Y-Balance test, 4-way ankle strength, hip-adduction and -extension strength, the Foot and Ankle Ability Measure-Activities of Daily Living score, the modified Disablement in the Physically Active scale-physical summary component score, and the Fear-Avoidance Beliefs Questionnaire-Physical Activity score were improved at postintervention (P < .001; effect-size range = 0.72-1.73) and at the 2-week follow-up (P < .001; effect-size range = 0.73-1.72) compared with preintervention. Hip-flexion strength was improved at postintervention compared with preintervention (P = .03; effect size = 0.61). Hip-abduction strength was improved at the 2-week follow-up compared with preintervention (P = .001; effect size = 0.96). Time to boundary in the anterior-posterior direction was increased at the 2-week follow-up compared with preintervention (P < .04; effect-size range = 0.61-0.78) and postintervention (P < .04) during the eyes-open condition.

CONCLUSION

A 4-week rehabilitation program improved a multidimensional profile of health in participants with CAI.

Assessing Outcomes in People With Chronic Ankle Instability: The Ability of Functional Performance Tests to Measure Deficits in Physical Function and Perceived Instability

Study Design Laboratory-based, cross-sectional study. Background Functional performance tests (FPTs) assess short bouts of unilateral hops for either distance or speed. More research is needed to identify specific FPTs that may be useful for measuring asymmetry outcomes related to functional performance and perceived instability deficits in individuals with chronic ankle instability (CAI). Objectives To identify FPTs that are sensitive to subjective and objective deficits associated with CAI. Methods Twenty-four subjects with unilateral CAI (10 male, 14 female; mean ± SD age, 20.7 ± 3.0 years) and 24 healthy, matched controls (10 male, 14 female; age, 20.1 ± 2.6 years) completed 5 unilateral FPTs in random order. Mean FPT scores and functional symmetry percentages were calculated and compared between groups using 2 separate 1-way multivariate analyses of variance (MANOVAs). Perceived instability symmetry percentages were compared between groups using a Mann-Whitney U analysis. Results There were no differences in the mean FPT scores (P>.05) or functional symmetry percentages (P>.05) between groups for any of the 5 FPTs. However, participants with CAI perceived greater instability when using their involved limb during the side hop (P = .02), 6-meter crossover hop (P = .003), lateral hop (P = .007), and figure-of-eight hop (P = .008). Conclusion There were no differences in mean functional scores between groups for all 5 FPTs, and each group performed symmetrically. Regardless, administering a visual analog scale following the completion of the side hop, 6-meter crossover hop, lateral hop, and figure-of-eight hop tests captures subjective reports of perceived instability in the involved limb that can be compared bilaterally throughout treatment. J Orthop Sports Phys Ther 2018;48(5):372-380. Epub 30 Mar 2018. doi:10.2519/jospt.2018.7514.