Can Therapeutic Exercises Improve Proprioception in Chronic Ankle Instability? A Systematic Review and Network Meta-analysis.

OBJECTIVE: To assess exercise therapies that aim to enhance proprioception in individuals with chronic ankle instability (CAI). DATA SOURCES: Five databases (PubMed, Embase, Cochrane Library, Web of Science, and EBSCO) were searched in October 2021. STUDY SELECTION: Randomized controlled trials involving exercise therapy conducted on individuals with CAI were included. DATA EXTRACTION: Data were extracted by 2 independent reviewers using a standardized form. Methodological quality and risk of bias were assessed with the Physiotherapy Evidence Database scale. DATA SYNTHESIS: The end trial weighted mean difference and standard deviations were analyzed, and the synthetic value for the improvement in error scores of ankle joint position sense in multiple directions was evaluated. RESULTS: Eleven trials with 333 participants were eligible for inclusion in this systematic review and were included in the network meta-analysis. Foot and ankle muscle strengthening exercise showed the highest probability of being among the best treatments (surface under the cumulative ranking [SUCRA]=74.6%). The next 2 were static balance exercise only (SUCRA=67.9%) and corrective exercise (SUCRA=56.1%). The SUCRA values of proprioceptive exercise, dynamic balance exercise only, aquatic exercise, rehabilitation exercise with brace, mixed static/dynamic balance exercise, and control were at relatively low levels and scored at 49.6%, 48.8%, 47.8%, 47.7%, 44.0%, and 13.5%, respectively. CONCLUSIONS: Foot and ankle muscle strengthening exercise may have a good effect when used to improve joint position sense in individuals with CAI. The more complex balance exercise intervention becomes, the less effective the proprioceptive outcome.

Stationary cycling exercise for knee osteoarthritis: A systematic review and meta-analysis.

OBJECTIVE: To evaluate effects of stationary cycling exercise on pain, function and stiffness in individuals with knee osteoarthritis. DATA SOURCES: Systematic search conducted in seven databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, and CNKI) from inception to September 2020. REVIEW METHODS: Included studies were randomized-controlled trials involving stationary cycling exercise conducted on individuals with knee osteoarthritis. End-trial weighted mean difference (WMD) and 95% confidence interval (CI) were analyzed, and random-effects models were used. Methodological quality and risk bias were assessed by using the Physiotherapy Evidence Database scale and Cochrane Collaboration tool, respectively. RESULTS: Eleven studies with 724 participants were found, of which the final meta-analysis was performed with eight. Compared to a control (no exercise), stationary cycling exercise resulted in reduced pain (WMD 12.86, 95% CI 6.90-18.81) and improved sport performance (WMD 8.06, 95% CI 0.92-15.20); although most of the meta-analysis results were statistically significant, improvements in stiffness (WMD 11.47, 95% CI 4.69-18.25), function (WMD 8.28, 95% CI 2.44-14.11), symptoms (WMD 4.15, 95% CI -1.87 to 10.18), daily living (WMD 6.43, 95% CI 3.19 to 9.66) and quality of life (WMD 0.99, 95% CI -4.27 to 6.25) for individuals with knee osteoarthritis were not greater than the minimal clinically important difference values for each of these outcome measures. CONCLUSIONS: Stationary cycling exercise relieves pain and improves sport function in individuals with knee osteoarthritis, but may not be as clinically effective for improving stiffness, daily activity, and quality of life.

Do individuals with ankle instability show altered lower extremity kinematics and kinetics during walking? A systematic review and meta-analysis.

OBJECTIVE: To determine if individuals with chronic ankle instability (CAI) demonstrate altered lower extremity kinematics and kinetics during walking. DATA SOURCES: Relevant studies were sourced from PubMed, Embase, Cochrane Library, Web of Science, EBSCO and PEDro. STUDY SELECTION: Kinematic and kinetic studies involving joint angle and/or joint moment measured in individuals with CAI were included. STUDY APPRAISAL AND SYNTHESIS METHODS: The Risk of Bias in Non-randomised Studies - of Interventions (ROBINS-I) tool was used to assess literature quality. Weighted mean differences (WMDs) in joint angles and moments between CAI and controls were analyzed as continuous variables. RESULTS: 1261 articles were screened, with a final selection of 13 studies involving 729 participants. Compared to non-CAI controls, CAI participants showed significantly greater ankle inversion angle (degree) (WMD: 3.71, 95% CI: 3.15 to 4.27, p < 0.001), hip adduction angle (degree) (WMD: 1.60, 95% CI: 0.09 to 3.11, p = 0.04), and knee valgus moment (N m/kg) (WMD: 0.07, 95% CI: 0.01 to 0.13, p = 0.02) during walking. Additionally, there were no consistent findings or specific altered patterns in other lower extremity joint angles, or moment changes, regardless of the motion plane (sagittal, coronal, horizontal), for CAI compared with controls. CONCLUSIONS: This review provides further evidence of altered lower limb kinematics and kinetics in the frontal plane in CAI participants during certain walking phases, which may partially explain the high level of recurrent ankle sprains observed in the CAI population, and support hip abduction and ankle eversion motor control exercises for CAI rehabilitation. SYSTEMATIC REVIEW REGISTRATION NUMBER: Systematic Review Registration Number PROSPERO CRD42023420418. CONTRIBUTION OF THE PAPER.

Is chronic ankle instability associated with contractile thickness of gluteus medius and gluteus maximus during functional movement and exercise? A systematic review and meta-analysis.

INTRODUCTION: The gluteus medius (GMED) and gluteus maximus (GMAX) play a crucial role in postural control, and postural control is impaired in individuals with chronic ankle instability (CAI). However, the association between CAI and the recruitment of these muscles remains unclear. The purpose of this study was to explore the contractile thickness of GMED and GMAX during functional movements in individuals with CAI compared to healthy controls. EVIDENCE ACQUISITION: A systematic search was conducted in six databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, and PEDro). Included studies involved the contractile thickness of GMED and/or GMAX comparing CAI with non-CAI. The extracted data were subjected to meta-analysis for observing the differences between the two. The correlation and difference in contraction between GMED and GMAX were analyzed using the Pearson Correlation Coefficient (PCC) and t-test, respectively. EVIDENCE SYNTHESIS: Six studies with 176 participants were found. Contractile thickness measured by ultrasound showed GMED thickness change to be lower in CAI than in controls during functional movements and exercise (WMD: -0.08; 95% CI: -0.11, -0.04; P<0.00001). There was no significant difference between the two groups with respect to contraction of GMAX (WMD: 0.02; 95% CI: -0.01, 0.05; P=0.25). The PCC and P value (t-test) between the ratio of contractile thickness of GMED and GMAX in CAI were 0.397 and 0.029 respectively, indicating activity differences. CONCLUSIONS: CAI may be associated with weaker GMED recruitment during functional movements and exercise, but the activation of GMAX in CAI may be unaffected.

Modulation of Heart Rate Variability and Brain Excitability through Acute Whole-Body Vibration: The Role of Frequency.

This cross-over study aimed to explore effects of acute whole-body vibration (WBV) at frequencies of 5-35 Hz on heart rate variability and brain excitability. Thirteen healthy physically active college students randomly completed eight interventions under the following conditions: static upright standing without vibration (CON), static squat exercise (knee flexion 150°) on the vibration platform (SSE), and static squat exercise (knee flexion 150°) combined with WBV at vibration frequency of 5, 9, 13, 20, 25, and 35 Hz. Five bouts × 30 s with a 30-s rest interval were performed for all interventions. The brain's direct current potentials (DCPs), frequency domain variables (FDV) including normalized low frequency power (nLF), normalized high frequency power (nHF) and the ratio of LF to HF (LF/HF), along with the mean heart rate (MHR) were collected and calculated before and after the WBV intervention. Results suggested that WBV frequency at 5 Hz had a substantial effect on decreasing DCPs [-2.13 µV, t(84) = -3.82, p < 0.05, g = -1.03, large] and nLF [-13%, t(84) = -2.31, p = 0.04, g = -0.62, medium]. By contrast, 20-35 Hz of acute WBV intervention considerably improved DCPs [7.58 µV, t(84) = 4.31, p < 0.05, g = 1.16, large], nLF [17%, t(84) = 2.92, p < 0.05, g = 0.79, large] and the LF/HF [0.51, t(84) = 2.86, p < 0.05, g = 0.77, large]. A strong (r = 0.7, p < 0.01) correlation between DCPs and nLF was found at 5 Hz. In summary, acute WBV at 20-35 Hz principally activated the sympathetic nervous system and increased brain excitability, while 5-Hz WBV activated the parasympathetic nervous system and reduced brain excitability. The frequency spectrum of WBV might be manipulated according to the intervention target on heart rate variability and brain excitability.

Effects of acupuncture or similar needling therapy on pain, proprioception, balance, and self-reported function in individuals with chronic ankle instability: A systematic review and meta-analysis.

OBJECTIVE: Acupuncture or similar needling therapy has long been used to improve well-being, but its effectiveness in management of chronic ankle instability (CAI) is unclear. To investigate the efficacy of acupuncture or similar needling therapy on pain, proprioception, balance, and self-reported function in individuals with CAI. METHODS: Nine databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, WanFang, and CQVIP) were systematically searched from inception to April 2023. This study included randomized controlled trials involving acupuncture or similar needling therapy as an intervention for individuals with CAI. Data were extracted independently by two assessors using a standardized form. Literature quality and risk bias were assessed by using the PEDro scale. RESULTS: Twelve trials (n = 571) were found, of which the final meta-analysis was conducted with eight. Different studies employ varying treatments, including specific needle types, techniques, and therapeutic frameworks. Compared to control without acupuncture or similar needling therapy, acupuncture or similar needling intervention resulted in improved pain (WMD 1.33, 95 % CI 0.14-2.52, I²=90 %, p = 0.03), proprioception (active joint position sense, WMD 1.71, 95 % CI 0.95-2.48, I²=0 %, p < 0.0001), balance (SMD 0.54, 95 % CI 0.03-1.04, I²=46 %, p = 0.04), and self-reported function (Cumberland Ankle Instability Tool (WMD 2.92, 95 % CI 0.94-4.90, I²=78 %, p = 0.004); American Orthopedic Foot and Ankle Society (WMD 9.36, 95 % CI 6.57-12.15, I²=0 %, p < 0.001); Foot and Ankle Ability Measure: activities of daily living (WMD 5.09, 95 % CI 1.74-8.44, I²=0 %, p = 0.003)) for individuals with CAI. CONCLUSIONS: The available evidence suggests that acupuncture or similar needling therapy may improve pain, proprioception, balance, and self-reported function in individuals with CAI, but more trials are needed to verify these findings. Furthermore, various needles and techniques using in different studies have resulted in methodologic limitations that should be addressed in the future.

Reliability and validity of the ankle inversion discrimination apparatus during walking in individuals with chronic ankle instability.

Purpose: 1) to explore the test-retest reliability of a new device for measuring ankle inversion proprioception during walking, i.e., the Ankle Inversion Discrimination Apparatus-Walking (AIDAW) in individuals with or without Chronic Ankle instability (CAI); 2) to assess its discriminant validity in differentiating individuals with or without CAI; 3) to investigate its convergent validity by examining its association with Cumberland Ankle Instability Tool (CAIT) and the Y Balance Test (YBT). Methods: For test-retest reliability, 15 participants with CAI and 15 non-CAI healthy controls were recruited. Participants completed the AIDAW test twice with a 7-day interval. The area under the receiver operating curve (AUC) was obtained as the AIDAW score. The intraclass correlation coefficient (ICC) and MDC90 were calculated. For the validity study, another 20 individuals with CAI and 20 non-CAI healthy controls were involved. The AIDAW scores were analyzed by an independent samples t-test, and the optimal cutoff value of AIDAW scores to best distinguish individuals with CAI was calculated by Youden's index. Spearman or Pearson correlation analysis was used to analyze the correlation between AIDAW proprioceptive scores and the CAIT and final YBT scores. Results: For test-retest reliability, the ICC values for the CAI, non-CAI, and the whole group were 0.755, 0.757, and 0.761 respectively. The MDC90 of the CAI and non-CAI group was 0.04 and 0.05. Regarding discriminant validity, the AIDAW proprioceptive discrimination scores in the CAI group were significantly lower than those in the non-CAI group (p = 0.003); and the cutoff score for distinguishing CAI from the non-CAI participants was 0.759. For convergent validity, the AIDAW scores were significantly correlated with the functional balance YBT final scores (p = 0.001) and the CAIT scores (p = 0.009). Conclusion: The AIDAW is a reliable and valid device for evaluating ankle inversion proprioception during walking in individuals with and without CAI. AIDAW can be used as a clinical assessment tool to discriminate CAI from non-CAI individuals and to monitor effects of rehabilitation. The AIDAW proprioceptive discrimination scores were significantly and positively correlated with YBT and CAIT scores.

Effects of whole-body vibration on sensorimotor deficits and brain plasticity among people with chronic ankle instability: a study protocol for a single-blind randomized controlled trial.

BACKGROUND: Chronic ankle instability (CAI) is a form of musculoskeletal disease that can occur after a lateral ankle sprain, and it is characterized by pain, recurrent ankle sprains, a feeling of "giving way" at the ankle joint, and sensorimotor deficits. There has been increasing evidence to suggest that plastic changes in the brain after the initial injury play an important role in CAI. As one modality to treat CAI, whole-body vibration (WBV) has been found to be beneficial for treating the sensorimotor deficits accompanying CAI, but whether these benefits are associated with brain plasticity remains unknown. Therefore, the current study aims to investigate the effect of WBV on sensorimotor deficits and determine its correlation with plastic changes in the brain. METHODS: The present study is a single-blind randomized controlled trial. A total of 80 participants with CAI recruited from the university and local communities will be divided into 4 groups: whole-body vibration and balance training (WBVBT), balance training (BT), whole-body vibration (WBV), and control group. Participants will be given the WBV intervention (25-38 Hz, 1.3-2 mm, 3-time per week, 6-week) supervised by a professional therapist. Primary outcome measures are sensorimotor function including strength, balance, proprioception and functional performance. Brain plasticity will be evaluated by corticomotor excitability, inhibition, and representation of muscles, as measured by transcranial magnetic stimulation. Activation of brain areas will be assessed through functional near-infrared spectroscopy. Secondary outcome measures are self-reported functional outcomes involving the Cumberland Ankle Instability Tool and the Foot and Ankle Ability Measure. All tests will be conducted before and after the WBV intervention, and at 2-week follow-up. Per­protocol and intention-to-treat analysis will be applied if any participants withdraw. DISCUSSION: This is the first trial to investigate the role of brain plasticity in sensorimotor changes brought by WBV for individuals with CAI. As plastic changes in the brain have been an increasingly important aspect in CAI, the results of the current study can provide insight into the treatment of CAI from the perspective of brain plasticity. TRIAL REGISTRATION: Chinese Clinical Trial Registry (ChiCTR2300068972); registered on 02 March 2023.

Knee osteoarthritis pain and stretching exercises: a systematic review and meta-analysis.

OBJECTIVE: To evaluate the effectiveness of stretching exercises for pain relief in individuals with knee osteoarthritis (KOA). DATA SOURCES: Nine databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, PEDro, CNKI, WanFang and CQVIP) were searched in December 2020. STUDY SELECTION: Randomised controlled trials (RCTs) involving stretching exercises conducted on individuals with KOA were included. STUDY APPRAISAL AND SYNTHESIS METHODS: Literature quality and risk of bias were assessed with the Physiotherapy Evidence Database scale and Cochrane Collaboration tool, respectively. Data were extracted by two independent assessors using a standardised form. The weighted mean difference (WMD) and standard deviations (SD) with 95% confidence intervals (CI) were analysed. RESULTS: In total, 373 studies were screened, with a final selection of 19 RCTs involving 1250 participants; of these, 18 RCTs were included in the final meta-analysis. When stretching exercises were used alone, the reduction of pain using a visual analogue scale was both significant and clinically meaningful (WMD 1.86; 95% CI 1.31 to 2.41). When stretching exercises were used in combination with other exercises, the pain reduction was still significant but its clinical significance became questionable (WMD 1.31; 95% CI 0.77 to 1.85). LIMITATIONS: The sample size of studies using stretching exercises alone was small, and some of the pooled studies were heterogeneous. CONCLUSIONS: Stretching exercises can be useful in pain management in individuals with KOA, especially when used alone. Programmes involving both stretching exercises and other exercises may improve function but may not achieve a clinically effective reduction in pain. Systematic review registration number Research Registry (No. reviewregistry813).

Is high intensity laser therapy more effective than other physical therapy modalities for treating knee osteoarthritis? A systematic review and network meta-analysis.

Background: The use of physical therapy modalities, especially high intensity laser therapy (HILT), for individuals with knee osteoarthritis (KOA) is still controversial. Objective: To compare the effects of HILT to other physical therapy modalities on symptoms and function in individuals with KOA. Methods: Six databases (PubMed, Embase, Cochrane Library, Web of Science, EBSCO, and PEDro) were searched in March 2022. Included studies were randomized controlled trials involving HILT conducted on individuals with KOA. The end-trial weighted mean difference (WMD) and standard deviations (SD) with 95% confidence intervals (CI) were analyzed. Results: Ten studies with 580 participants were obtained, of which nine were included in the final network meta-analysis. In terms of relieving pain, HILT demonstrated the highest probability of being among the most effective treatments, with surface under the cumulative ranking (SUCRA) = 100%, and compared to a control (placebo laser or exercise or a combination of both) on the visual analog scale (VAS) for pain it demonstrated significant benefits (WMD 1.66, 95% CI 1.48-1.84). For improving self-reported function, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores, the HILT SUCRA value led with 98.9%. When individuals with KOA were treated by HILT, the improvement in stiffness was statistically significant (WMD 0.78, 95% CI 0.52-1.04) but the amount of improvement was smaller than the minimal clinically important difference (MCID). Conclusion: The current evidence suggests that HILT may be more effective than other physical therapy modalities for improving pain and function in individuals with KOA. For improving stiffness, however, it may not be clinically effective. Systematic review registration: [https://www.researchregistry.com], identifier [1148].

Impaired ankle inversion proprioception during walking is associated with fear of falling in older adults.

Background: Ankle proprioception plays a critical role in lower limb movement control. However, the relationship between ankle proprioception and fear of falling (FOF) in older people is still unclear. Objective: (1) This study aims to develop a new device for measuring ankle inversion proprioceptive discrimination sensitivity during walking, i.e., the Ankle Inversion Discrimination Apparatus-Walking (AIDAW), and assess the test-retest reliability of the AIDAW in both young and older adults; (2) to evaluate the discriminant validity of the measure by comparing ankle proprioception during walking between the two groups; and (3) to explore convergent validity by determining to what extent the AIDAW proprioceptive scores correlate with Fall Efficacy Scale-International (FES-I) scores. Materials and methods: The AIDAW was purpose-built to test ankle inversion proprioceptive discrimination sensitivity during walking. The area under the receiver operating curve (AUC) was calculated as the proprioceptive discrimination score. In total, 54 adults volunteered. Test-retest reliability was evaluated in 12 young and 12 older adults, and another 15 young and 15 older adults completed the comparison study. FOF was assessed by using the FES-I. Results: The test-retest reliability intraclass correlation coefficient ICC (3,1) value for the whole group was 0.76 (95% CI: 0.52-0.89). The ICC values of the young and older groups were 0.81 (95% CI: 0.46-0.94) and 0.71 (95% CI: 0.26-0.91), respectively. The Minimal Detectable Change with 90% confidence (MDC90) values for the young and older groups were 0.03 and 0.11, respectively. There was a significant difference between the AIDAW proprioceptive sensitivity scores for the young and older groups (0.78 ± 0.04 vs. 0.72 ± 0.08, F = 5.06, p = 0.033). Spearman's correlation analysis showed that the FES-I scores were significantly and negatively correlated with the AIDAW scores (rho = -0.61, p = 0.015), with higher FOF associated with worse ankle proprioception. Conclusion: The AIDAW is a reliable and valid device for measuring ankle proprioception during walking in both young and older adults. Ankle inversion proprioceptive discrimination sensitivity during walking was found to be impaired in the elderly compared to young adults. This impairment was found to be strongly associated with FOF, suggesting that assessment and intervention for ankle proprioception in this population are needed to reduce the risk of falls.

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.