Immediate effects of vibration biofeedback on ankle kinematics in people with chronic ankle instability.

BACKGROUND: People with chronic ankle instability are more inverted during initial contact and loading response which may increase the risk of subsequent ankle injuries. Vibration feedback gait retraining causes medial center of pressure shifts but its impact on ankle kinematics remains unknown. The purpose of this study was to understand kinematic ankle changes in people with chronic ankle instability following vibration feedback gait retraining. METHODS: Nineteen participants with chronic ankle instability walked with vibration feedback for 10 min on a treadmill and for one mile in the real-world. A vibration stimulus occurred at the lower leg when pressure under the 5th metatarsal exceeded a threshold. Three-dimensional kinematics of the ankle were recorded in the lab before and after training. Paired t-tests compared baseline and posttest ankle, hindfoot, and forefoot positions during initial contact and loading response for the lab and real-world conditions. FINDINGS: After lab training the ankle (mean difference:-1.68 ± 1.62°, effect size:0.95) and forefoot (mean difference:-1.68 ± 1.67°, effect size:0.92) were more abducted. After real-world training, the ankle (mean difference:-1.19 ± 2.12°, effect size:0.54) and forefoot (mean difference:-1.87 ± 3.00°, effect size:0.63) were more everted. Similarly the ankle (mean difference:-2.37 ± 4.79°, effect size:0.46) and forefoot (mean difference:-2.78 ± 4.91°, effect size:0.51) were more abducted after real-world training. INTERPRETATION: Vibration feedback decreases inversion and adduction during loading response. However, RW compared to lab training may have more beneficial frontal plane changes for people with chronic ankle instability.

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.

The effect of sensory-targeted ankle rehabilitation strategies on single-leg center of pressure elements in those with chronic ankle instability: A randomized clinical trial.

OBJECTIVES: To determine the effects of sensory-targeted ankle rehabilitation strategies on laboratory-oriented measures of single-leg balance in those with chronic ankle instability. DESIGN: Non-inferiority randomized controlled trial. METHODS: Seventy-seven participants with self-reported chronic ankle instability were randomized into 4 treatment groups: Ankle joint mobilization, plantar massage, triceps surae stretching, and a control group. All participants performed 3 trials of single-leg balance on a force plate with eyes open and closed at 3 time points (baseline, immediately after the first treatment, and following 6 treatments over 2 weeks). The spatial (standard deviation), temporal (velocity), and spatiotemporal (time-to-boundary) elements of center of pressure excursions in single-leg balance were evaluated with eyes open and eyes closed at each time point. Immediate and final change scores were calculated for each group from the baseline values on these variables. RESULTS: Joint mobilization produced immediate improvements in the temporal elements with eyes open and closed that exceeded the minimum detectable changes for these measures. Plantar massage and triceps surae stretching also enhanced the temporal element after a single treatment, but only with eyes closed. No substantial benefit of any of the interventions were found after 2-weeks of treatment, regardless of treatment group. CONCLUSIONS: Sensory-targeted ankle rehabilitation strategies substantially improve single-leg postural control after one treatment, but these changes are short-lived. Future research is needed to determine whether combinations of sensory-targeted ankle rehabilitation strategies with other therapeutic interventions potentially improve single-leg balance stability in those with CAI compared to use in isolation. CLINICAL TRIAL REGISTRATION NUMBER: NCT01541657.

Comparative Effectiveness of Plantar-Massage Techniques on Postural Control in Those With Chronic Ankle Instability.

CONTEXT: One of the major concerns after an acute lateral ankle sprain is the potential for development of chronic ankle instability (CAI). The existing research has determined that clinician-delivered plantar massage improves postural control in those with CAI. However, the effectiveness of self-administered treatments and the underlying cause of any improvements remain unclear. OBJECTIVES: To determine (1) the effectiveness of a self-administered plantar-massage treatment in those with CAI and (2) whether the postural-control improvements were due to the stimulation of the plantar cutaneous receptors. DESIGN: Crossover study. SETTING: University setting. PATIENTS OR OTHER PARTICIPANTS: A total of 20 physically active individuals (6 men and 14 women) with self-reported CAI. INTERVENTION(S): All participants completed 3 test sessions involving 3 treatments: a clinician-delivered manual plantar massage, a patient-delivered self-massage with a ball, and a clinician-delivered sensory brush massage. MAIN OUTCOME MEASURE(S): Postural control was assessed using single-legged balance with eyes open and the Star Excursion Balance Test. RESULTS: Static postural control improved (P ≤ .014) after each of the interventions. However, no changes in dynamic postural control after any of the interventions were observed (P > .05). No differences were observed between a clinician-delivered manual plantar massage and either a patient-delivered self-massage with a ball or a clinician-delivered sensory brush massage in any postural-control outcome. CONCLUSIONS: In those with CAI, single 5-minute sessions of traditional plantar massage, self-administered massage, and sensory brush massage each resulted in comparable static postural-control improvements. The results also provide empirical evidence suggesting that the mechanism for the postural-control improvements is the stimulation of the plantar cutaneous receptors.

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

CONTEXT: Therapeutic modalities that stimulate sensory receptors around the foot-ankle complex improve chronic ankle instability (CAI)-associated impairments. However, not all patients have equal responses to these modalities. Identifying predictors of treatment success could improve clinician efficiency when treating patients with CAI. OBJECTIVE: To conduct a response analysis on existing data to identify predictors of improved self-reported function in patients with CAI. DESIGN: Secondary analysis of a randomized controlled clinical trial. SETTING: Sports medicine research laboratories. PATIENTS OR OTHER PARTICIPANTS: Fifty-nine patients with CAI, which was defined in accordance with the International Ankle Consortium recommendations. INTERVENTION(S): Participants were randomized into 3 treatment groups (plantar massage [PM], ankle-joint mobilization [AJM], or calf stretching [CS]) that received six 5-minute treatments over 2 weeks. MAIN OUTCOME MEASURE(S): Treatment success, defined as a patient exceeding the minimally clinically important difference of the Foot and Ankle Ability Measure-Sport (FAAM-S). RESULTS: Patients with ≤5 recurrent sprains and ≤82.73% on the Foot and Ankle Ability Measure had a 98% probability of having a meaningful FAAM-S improvement after AJM. As well, ≥5 balance errors demonstrated 98% probability of meaningful FAAM-S improvements from AJM. Patients <22 years old and with ≤9.9 cm of dorsiflexion had a 99% probability of a meaningful FAAM-S improvement after PM. Also, those who made ≥2 single-limb-stance errors had a 98% probability of a meaningful FAAM-S improvement from PM. Patients with ≤53.1% on the FAAM-S had an 83% probability of a meaningful FAAM-S improvement after CS. CONCLUSIONS: Each sensory-targeted ankle-rehabilitation strategy resulted in a unique combination of predictors of success for patients with CAI. Specific indicators of success with AJM were deficits in self-reported function, single-limb balance, and <5 previous sprains. Age, weight-bearing-dorsiflexion restrictions, and single-limb balance deficits identified patients with CAI who will respond well to PM. Assessing self-reported sport-related function can identify CAI patients who will respond positively to CS.

The Effect of 2 Forms of Talocrural Joint Traction on Dorsiflexion Range of Motion and Postural Control in Those With Chronic Ankle Instability.

CONTEXT: Talocrural joint mobilizations are commonly used to address deficits associated with chronic ankle instability (CAI). OBJECTIVE: Examine the immediate effects of talocrural joint traction in those with CAI. DESIGN: Blinded, crossover. SETTING: Laboratory. PARTICIPANTS: Twenty adults (14 females; age = 23.80 ± 4.02 y; height = 169.55 ± 12.38 cm; weight = 78.34 ± 16.32 kg) with self-reported CAI participated. Inclusion criteria consisted of a history of ≥1 ankle sprain, ≥2 episodes of giving way in the previous 3 mo, answering "yes" to ≥4 questions on the Ankle Instability Instrument, and ≤24 on the Cumberland Ankle Instability Tool. INTERVENTION: Subjects participated in 3 sessions in which they received a single treatment session of sustained traction (ST), oscillatory traction (OT), or a sham condition in a randomized order. Interventions consisted of four 30-s sets of traction with 1 min of rest between sets. During ST and OT, the talus was distracted distally from the ankle mortise to the end-range of accessory motion. ST consisted of continuous distraction and OT involved 1-s oscillations between the mid and end-range of accessory motion. The sham condition consisted of physical contact without force application. Preintervention and postintervention measurements of weight-bearing dorsiflexion, dynamic balance, and static single-limb balance were collected. MAIN OUTCOME MEASURES: The independent variable was treatment (ST, OT, sham). The dependent variables included pre-to-posttreatment change scores for the WBLT (cm), normalized SEBTAR (%), and time-to-boundary (TTB) variables(s). Separate 1-way ANOVAs examined differences between treatments for each dependent variable. Alpha was set a priori at P < .05. RESULTS: No significant treatment effects were identified for any variables. CONCLUSION: A single intervention of ST or OT did not produce significant changes in weight-bearing dorsiflexion range of motion or postural control in individuals with CAI. Future research should investigate the effects of repeated talocrural traction treatments and the effects of this technique when combined with other manual therapies.

Balance Training Versus Balance Training With STARS in Patients With Chronic Ankle Instability: A Randomized Controlled Trial.

CONTEXT: Both balance training and selected interventions meant to target sensory structures (STARS) have been shown to be effective at restoring deficits associated with chronic ankle instability (CAI). Clinicians often use multiple treatment modalities in patients with CAI. However, evidence for combined intervention effectiveness in CAI patients remains limited. OBJECTIVE: To determine if augmenting a balance-training protocol with STARS (BTS) results in greater improvements than balance training (BT) alone in those with CAI. DESIGN: Randomized-controlled trial. SETTING: Research laboratory. PATIENTS: 24 CAI participants (age 21.3 ± 2.0 y; height 169.8 ± 12.9 cm; mass 72.5 ± 22.2 kg) were randomized into 2 groups: BT and BTS. INTERVENTIONS: Participants completed a 4-week progression-based balance-training protocol consisting of 3 20-min sessions per week. The experimental group also received a 5-min set of STARS treatments consisting of calf stretching, plantar massage, ankle joint mobilizations, and ankle joint traction before each balance-training session. MAIN OUTCOME MEASURES: Outcomes included self-assessed disability, Star Excursion Balance Test reach distance, and time-to-boundary calculated from static balance trials. All outcomes were assessed before, and 24-hours and 1-week after protocol completion. Self-assessed disability was also captured 1-month after the intervention. RESULTS: No significant group differences were identified (P > .10). Both groups demonstrated improvements in all outcome categories after the interventions (P < .10), many of which were retained at 1-week posttest (P < .10). Although 90% CIs include zero, effect sizes favor BTS. Similarly, only the BTS group exceeded the minimal detectable change for time-to-boundary outcomes. CONCLUSIONS: While statistically no more effective, exceeding minimal detectable change scores and favorable effect sizes suggest that a 4-week progressive BTS program may be more effective at improving self-assessed disability and postural control in CAI patients than balance training in isolation.

Predicting balance improvements following STARS treatments in chronic ankle instability participants.

OBJECTIVES: Sensory Targeted Ankle Rehabilitation Strategies that stimulate sensory receptors improve postural control in chronic ankle instability participants. However, not all participants have equal responses. Therefore, identifying predictors of treatment success is needed to improve clinician efficiency when treating chronic ankle instability. Therefore, the purpose was to identify predictors of successfully improving postural control in chronic ankle instability participants. DESIGN: Secondary data analysis. METHODS: Fifty-nine participants with self-reported chronic ankle instability participated. The condition was defined as a history of at least two episodes of "giving way" within the past 6 months; and limitations in self-reported function as measured by the Foot and Ankle Ability Measure. Participants were randomized into three treatment groups (plantar massage, ankle joint mobilization, calf stretching) that received 6, 5-min treatment sessions over a 2-week period. The main outcome measure was treatment success, defined as a participant exceeding the minimal detectable change score for a clinician-oriented single limb balance test. RESULTS: Participants with ≥3 balance test errors had a 73% probability of treatment success following ankle joint mobilizations. Participants with a self-reported function between limb difference <16.07% and who made >2.5 errors had a 99% probability of treatment success following plantar massage. Those who sustained ≥11 ankle sprains had a 94% treatment success probability following calf stretching. CONCLUSIONS: Self-reported functional deficits, worse single limb balance, and number of previous ankle sprains are important characteristics when determining if chronic ankle instability participants will have an increased probability of treatment success.

Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability.

INTRODUCTION: Deficient sensory input from damaged ankle ligament receptors is thought to contribute to sensorimotor deficits in those with chronic ankle instability (CAI). Targeting other viable sensory receptors may then enhance sensorimotor control in these patients. The purpose of this randomized controlled trial was to evaluate the effects of 2 wk of sensory-targeted ankle rehabilitation strategies (STARS) on patient- and clinician-oriented outcomes in those with CAI. METHODS: Eighty patients with self-reported CAI participated. All patients completed patient-oriented questionnaires capturing self-reported function as well as the weight-bearing lunge test and an eyes-closed single-limb balance test. After baseline testing, patients were randomly allocated to four STARS groups: joint mobilization, plantar massage, triceps surae stretching, or control. Each patient in the intervention groups received six 5-min treatments of their respective STARS over 2 wk. All subjects were reassessed on patient- and clinician-oriented measures immediately after the intervention and completed a 1-month follow-up that consisted of patient-oriented measures. Change scores of the three STARS groups were compared with the control using independent t-tests and Hedges' g effect sizes with 95% confidence intervals. RESULTS: The joint mobilization group had the greatest weight-bearing lunge test improvement. Plantar massage had the most meaningful single-limb balance improvement. All STARS groups improved patient-oriented outcomes with joint mobilization having the most meaningful effect immediately after the intervention and plantar massage at the 1-month follow-up. CONCLUSION: Each STARS treatment offers unique contributions to the patient- and clinician-oriented rehabilitation outcomes of those with CAI. Both joint mobilization and plantar massage appear to demonstrate the greatest potential to improve sensorimotor function in those with CAI.