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.

Association of Ankle Sprain Frequency With Body Mass and Self-Reported Function: A Pooled Multisite Analysis.

CONTEXT: Ankle sprains result in pain and disability. While factors such as body mass and prior injury contribute to subsequent injury, the association of the number of ankle sprains on body anthropometrics and self-reported function are unclear in this population. Therefore, the purpose of this investigation was to assess differences in anthropometric measurements and self-reported function between the number of ankle sprains utilizing a large, pooled data set. DESIGN: Cross-sectional. METHODS: Data were pooled from 14 studies (total N = 412) collected by the Chronic Ankle Instability Outcomes Network. Participants were categorized by the number of self-reported sprains. Anthropometric data and self-reported function were compared between those who reported a single versus >1 ankle sprain as well as among groups of those who had 1, 2, 3, 4, and ≥5 ankle sprains, respectively. RESULTS: Those who had >1 ankle sprain had higher mass (P = .001, d = 0.33) and body mass index (P = .002, d = 0.32) and lower Foot and Ankle Ability Measure-Activities of Daily Living (P < .001, r = .22), Foot and Ankle Ability Measure-Sport (P < .001, r = .33), and Cumberland Ankle Instability Tool (P < .001, r = .34) scores compared to the single ankle sprain group. Those who had a single ankle sprain weighed less than those who reported ≥5 sprains (P = .008, d = 0.42) and had a lower body mass index than those who reported 2 sprains (P = .031, d = 0.45). CONCLUSIONS: Some individuals with a history of multiple ankle sprains had higher body mass and self-reported disability compared to those with a single sprain, factors that are likely interrelated. Due to the potential for long-term health concerns associated with ankle sprains, clinicians should incorporate patient education and interventions that promote physical activity, healthy dietary intake, and optimize function as part of comprehensive patient-centered care.

Changes of Ankle Dorsiflexion Using Compression Tissue Flossing: A Systematic Review and Meta-Analysis.

CONTEXT: Impaired dorsiflexion range of motion (DFROM) has been established as a predictor of lower-extremity injury. Compression tissue flossing (CTF) may address tissue restrictions associated with impaired DFROM; however, a consensus is yet to support these effects. OBJECTIVES: To summarize the available literature regarding CTF on DFROM in physically active individuals. EVIDENCE ACQUISITION: PubMed and EBSCOhost (CINAHL, MEDLINE, and SPORTDiscus) were searched from 1965 to July 2019 for related articles using combination terms related to CTF and DRFOM. Articles were included if they measured the immediate effects of CTF on DFROM. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The level of evidence was assessed using the Strength of Recommendation Taxonomy. The magnitude of CTF effects from pre-CTF to post-CTF and compared with a control of range of motion activities only were examined using Hedges g effect sizes and 95% confidence intervals. Randomeffects meta-analysis was performed to synthesize DFROM changes. EVIDENCE SYNTHESIS: A total of 6 studies were included in the analysis. The average Physiotherapy Evidence Database score was 60% (range = 30%-80%) with 4 out of 6 studies considered high quality and 2 as low quality. Meta-analysis indicated no DFROM improvements for CTF compared with range of motion activities only (effect size = 0.124; 95% confidence interval, -0.137 to 0.384; P = .352) and moderate improvements from pre-CTF to post-CTF (effect size = 0.455; 95% confidence interval, 0.022 to 0.889; P = .040). CONCLUSIONS: There is grade B evidence to suggest CTF may have no effect on DFROM when compared with a control of range of motion activities only and results in moderate improvements from pre-CTF to post-CTF. This suggests that DFROM improvements were most likely due to exercises completed rather than the band application.

Dynamic Balance Measures in Healthy and Chronic Ankle Instability Participants While Wearing Ankle Braces: Systematic Review With Meta-Analysis.

CONTEXT: Ankle braces have been theorized to augment dynamic balance. OBJECTIVES: To complete a systematic review with meta-analysis of the available literature assessing the effect of ankle braces on dynamic balance in individuals with and without chronic ankle instability (CAI). EVIDENCE ACQUISITION: Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to October 2019 using combinations of keywords related to dynamic balance, ankle braces, Star Excursion Balance Test (SEBT), Y-Balance Test (YBT), and Time to Stabilization. Inclusion criteria required that studies examined the effects of ankle braces on dynamic balance. Studies were excluded if they evaluated other conditions besides CAI, did not access dynamic balance, or did not use an ankle brace. Methodological quality was assessed using the Physiotherapy Evidence Database scale. The level of evidence was assessed using the Strength of Recommendation Taxonomy. The magnitude of brace effects on dynamic balance was examined using Hedges g effect sizes (ESs) and 95% confidence intervals (CIs). Random-effects meta-analysis was performed to synthesize SEBT/YBT and Time to Stabilization data separately. DATA SYNTHESIS: Seven studies were included with a median Physiotherapy Evidence Database score of 60% (range 50%-60%), and 4 were classified as high quality. Overall meta-analysis indicated a weak to no effect of braces on SEBT/YBT (ES = 0.117; 95% CI, -0.080 to 0.433; P = .177) and Time to Stabilization (ES = -0.064; 95% CI, -0.211 to 0.083, P = .083). Subanalysis of SEBT/YBT measures indicated a weak negative effect in healthy participants (ES = -0.116; 95% CI, -0.209 to -0.022, P = .015) and a strong positive effect in individuals with CAI (ES = 0.777; 95% CI, 0.418 to 1.136; P < .001). CONCLUSION: The current literature supports a strong effect of ankle braces on the SEBT/YBT in those with CAI. However, little to no dynamic balance changes were noted in healthy participants. Future research should include consistent ankle brace types, pathologic populations, and the examination of dynamic balance changes contribution to injury risk reduction.

The Examination of Repeated Self-Mobilizations With Movement and Joint Mobilizations on Individuals With Chronic Ankle Instability.

CONTEXT: Chronic ankle instability (CAI) is one of the most common chronic conditions in the world, resulting in millions of dollars contributed to the health care system. Joint mobilizations have been shown to effectively improve patient and disease-specific impairments secondary to CAI. The ability for patients to complete an effective manual therapy intervention without the need for continuous visits to a health care provider can alleviate burdens on the health care system and improve patient satisfaction. OBJECTIVE: To examine the effect of clinician-applied Maitland talocrural joint mobilization and self-mobilization (Self-Mob) on dorsiflexion range of motion (DFROM), dynamic balance, strength, and perceived function in those with CAI. DESIGN: Single-blind randomized trial. SETTING: Research laboratory. PARTICIPANTS: A total of 18 participants (7 males and 11 females; age = 20.78 [2.02] y, height = 67.66 [3.83] cm, limb length = 87.74 [5.05] cm) with self-reported CAI participated. INTERVENTIONS: The participants received 6 interventions over a 2-week period. The participants received either Maitland grade III anterior-to-posterior talocrural joint mobilizations or weight-bearing lunge Self-Mob. Each intervention consisted of four 2-minute sets, with a 1-minute rest between sets. MAIN OUTCOME MEASURES: The DFROM (weight-bearing lunge), dynamic balance (Y-Balance Test), isometric strength, Foot and Ankle Ability Measure Quick, Disablement of the Physically Active modified, Fear Avoidance Beliefs Questionnaire, and Tampa Scale of Kinesiophobia-11 were measured preintervention and postintervention. RESULTS: Dynamic balance, isometric strength, and perceived function significantly improved in both groups at postintervention. The DFROM significantly improved in the Self-Mob group. Higher individual responder rates were demonstrated within the Self-Mob group compared with clinician-applied mobilizations. CONCLUSIONS: Clinician-applied mobilizations and Self-Mobs are effective interventions for improving dynamic balance, isometric strength, and perceived function. Application of Self-Mobs can effectively improve DFROM compared with joint mobilization. Self-Mobs may be an effective intervention to incorporate into a home care plan.

The Evaluation of Joint Mobilization Dosage on Ankle Range of Motion in Individuals With Decreased Dorsiflexion and a History of Ankle Sprain.

CONTEXT: Mulligan's Mobilization with Movement (MWM) is a common intervention used to address dorsiflexion range of motion (DFROM) impairments. However, the treatment dosage of MWMs varies within the literature. OBJECTIVE: The aim of this study was to examine the effect of serial MWM application on DFROM. DESIGN: Repeated-measures cohort. SETTING: A Midwestern University and the surrounding community. PARTICIPANTS: A total of 18 adults (13 females; age = 29 [12.87] y; DFROM = 30.26° [4.60°]) with decrease dorsiflexion (<40°) participated. Inclusion criteria consisted of a history of ≥1 ankle sprain, ≥18 years old, no lower-extremity injury in the last 6 months, and no history of foot/ankle surgery. INTERVENTION: Participants completed a single data collection session consisting of 10 individual sets of MWMs. MAIN OUTCOME MEASURES: DFROM was taken at baseline and immediately after each intervention set (post 1, post 2, … post 10). DFROM was measured with a digital inclinometer on the anterior aspect of the tibia during the weight-bearing lunge test with the knee straight and knee bent. Analysis of variances examined DFROM changes over time. Post hoc analysis evaluated sequential pairwise comparisons and changes from baseline at each time point. RESULTS: Analysis of variance results indicated a significant time main effect for weight-bearing lunge test with knee bent (P < .001) and a nonsignificant effect for weight-bearing lunge test with knee straight (P < .924). Post hoc analysis indicated improvements in the weight-bearing lunge test with knee bent at each timepoint compared with baseline (P < .005). Post 2 improved compared with post 1 (P = .027). No other pairwise sequential comparisons were significant (P > .417). CONCLUSIONS: MWMs significantly improved acute knee bent DFROM and indicated that after 2 sets of MWMs, no further DFROM improvements were identified. Future research should investigate the lasting effects of DFROM improvements with variable MWM dosages.

Comparison of the Y-Balance Test and Star Excursion Balance Test: Utilization of a Discrete Event Simulation.

CONTEXT: The Y-Balance Test (YBT) and Star Excursion Balance Test (SEBT) are commonly used to detect deficits in dynamic postural control. There is a lack of literature on the differences in reach distances and efficiency of the tests. OBJECTIVE: To compare the reach distances of the YBT and SEBT. An additional aim was to compare the time necessary to administer the 2 tests and utilize a discrete event simulation to determine the number of participants who could be screened within different scenarios. DESIGN: Cross-sectional. Laboratory Patients: Twenty-four physically active individuals between the ages of 18-35 years volunteered to participate in this study (M/F: 11/13; age 22.78 [2.63] y, height 68.22 [4.32] cm, mass 173.27 [10.96] kg). INTERVENTION: The participants reported to the laboratory on one occasion and performed the YBT and SEBT. The anterior, posteromedial, and posterolateral reach distances were recorded for each test. In addition, the time to administer each test was recorded in seconds. MAIN OUTCOME MEASURES: The average reach distances and time for each test were used for analysis. Paired t tests were utilized to compare the reach distances and time to administer the 2 tests. A discrete event simulation was used to determine how many participants could be screened using each test. RESULTS: The anterior reach for the SEBT (64.52% [6.07%]) was significantly greater than the YBT (61.66% [6.37%]; P < .01). The administration time for the YBT (512.42 [123.97] s) was significantly longer than the administration time for the SEBT (364.96 [69.46] s; P < .01). The discrete event simulation revealed more participants could be screened using the SEBT when compared with the YBT for every situation. CONCLUSION: Scores on the anterior reach of the SEBT are larger when compared with the YBT. The discrete event simulation can successfully be used to determine how many participants could be screened with a certain amount of resources given the use of a specific test.

Comparison of Myofascial Release Techniques on Pectoralis Minor Length, Glenohumeral Total Arc of Motion, and Skin Temperature: A Pilot Study.

CONTEXT: The pectoralis minor (PM) is an important postural muscle that may benefit from myofascial techniques, such as Graston Technique® (GT) and self-myofascial release (SMR). OBJECTIVE: To examine the effects of GT and SMR on PM length, glenohumeral total arc of motion (TAM), and skin temperature. DESIGN: Cohort. SETTING: Laboratory. PARTICIPANTS: Twenty-six healthy participants (19 females and 7 males; age = 20.9 [2.24] y, height = 170.52 [8.66] cm, and weight = 72.45 [12.32] kg) with PM length restriction participated. INTERVENTIONS: Participants were randomized to the intervention groups (GT = 12 and SMR = 14). GT and SMR interventions were both applied for a total of 5 minutes during each of the 3 treatment sessions. MAIN OUTCOME MEASURES: PM length, TAM, and skin temperature were collected before and after each intervention session (Pre1, Post1, Pre2, Post2, Pre3, and Post3) and at 1-week follow-up (follow-up). Separate intervention by time analyses of variance examined differences for each outcomes measure. Bonferroni post hoc analyses were completed when indicated. Significance was set a priori at P ≤ .05. RESULTS: No significant intervention by time interactions were identified for PM length, TAM, or temperature (P > .05). No significant intervention main effects were identified for PM length (P > .05), TAM (P > .05), or temperature (P > .05) between the GT or SMR technique groups. Overall, time main effects were found for PM length (P = .02) and temperature (P < .001). Post hoc analysis showed a significant increase in PM length for both intervention groups at follow-up (P = .03) compared with Post2. Furthermore, there were significant increases in temperature at Post1 (P < .001), Post2 (P = .01), and Post3 (P < .001) compared with Pre1; Post2 was increased compared with Pre2 (P = .003), Pre3 (P < .001), and follow-up (P = .01); Post3 increased compared with Pre3 (P = .01) and follow-up (P = .01). CONCLUSION: Serial application of GT and SMR to the PM did not result in increases in PM length or TAM. Regardless of intervention, skin temperature increased following each intervention.

THE RELIABILITY OF THE STAR EXCURSION BALANCE TEST AND LOWER QUARTER Y-BALANCE TEST IN HEALTHY ADULTS: A SYSTEMATIC REVIEW.

BACKGROUND: Dynamic balance is often an important criterion used during lower extremity musculoskeletal injury prediction, prevention, and rehabilitation processes. Methods to assess lower extremity dynamic balance include the Star Excursion Balance Test (SEBT) and Lower Quarter Y-Balance Test (YBT). Due to the importance of dynamic balance it is imperative to establish reliable quantification techniques. PURPOSE: To conduct a systematic review to assess the reliability and responsiveness of the SEBT/YBT. STUDY DESIGN: Systematic Review. METHODS: Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to August 2018. Included studies examined the intra- and inter-rater reliability of the SEBT/YBT in healthy adults. Two investigators independently assessed methodological quality, level of evidence and strength of recommendation with the Qualtiy Appraisal of Reliability Studies (QAREL) scale. Relative intra and inter-rater reliability was examined through intraclass correlation coefficients (ICC) and responsiveness was evaluated through minimal detectable change (MDC). Data was analyzed based on reach direction (Anterior, Posteromedial, and Posterolateral) and normalization (normalized and non-normalized). Additionally, data were then synthesized using the strength of recommendation taxonomy to provide a grade of recommendation. RESULTS: A total of nine studies were included in this review. Six studies examined the inter-rater reliability and seven assessed intra-rater reliability. The included studies had a median QAREL score of 66.89% (range = 55.56% to 75.00%) and 59.03% (range = 33.33 to 66.67%) for inter and intra-rater reliability respectively. Median ICC values for inter-rater reliability were 0.88 (Range = 0.83 - 0.96), 0.87 (range = 0.80 - 1.00), and 0.88 (range = 0.73 - 1.00) for the anterior, posteromedial, and posterolateral directions respectively. Median ICC values for intra-rater reliability were 0.88 (Range = 0.84 - 0.93), 0.88 (Range = 0.85 - 0.94), and 0.90 (Range = 0.68 - 0.94) for the anterior, posteromedial, and posterolateral directions, respectively. CONCLUSIONS: There is grade A evidence to support that the SEBT/YBT have excellent inter and intra-rater reliability when used in healthy adults. Furthermore, minimal detectable change values have been provided that can be used in practice to aid clinical decision making. Future research is needed to assess the reliability, responsiveness, and validity of the SEBT/YBT in pathologic populations. LEVEL OF EVIDENCE: 1a.

Response Shift After a 4-Week Multimodal Intervention for Chronic Ankle Instability.

CONTEXT: The accurate evaluation of self-reported changes in function throughout the rehabilitation process is important for determining patient progression. Currently, how a response shift (RS) may affect the accuracy of self-reported functional assessment in a population with chronic ankle instability (CAI) is unknown. OBJECTIVE: To examine the RS in individuals with CAI after a 4-week multimodal rehabilitation program. DESIGN: Controlled laboratory study. SETTING: Laboratory. PATIENTS OR OTHER PARTICIPANTS: Twenty adults (5 men, 15 women; 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 the ankle "giving way" in the 3 months before the study, and a score ≤24 on the Cumberland Ankle Instability Tool. INTERVENTION(S): Individuals participated in 12 intervention sessions over 4 weeks and daily home ankle strengthening and stretching. MAIN OUTCOME MEASURE(S): Patient-reported outcomes (PROs) were assessed at 4 times (baseline, preintervention, postintervention, and 2-week follow-up). At the postintervention and 2-week follow-up, participants completed then-test assessments to measure RS. Then-test assessments are retrospective evaluations of perceived baseline function completed after an intervention. The PROs consisted of the Foot and Ankle Ability Measure-Activities of Daily Living and Sport subscales, the modified Disablement in the Physically Active scale physical and mental summary components, and the Fear-Avoidance Beliefs Questionnaire Physical Activity and Work subscales. We used repeated-measures analyses of variance to compare preintervention with then-test measurements. Individual-level RSs were examined by determining the number of participants who experienced preintervention to then-test differences that exceeded the calculated minimal detectable change. RESULTS: We did not identify an RS for any PRO (F > 2.338, P > .12), indicating no group-level differences between the preintervention and retrospective then-test assessments. Individual-level RS was most prominent in the Foot and Ankle Ability Measure-Sport subscale (n = 6, 30%) and the Fear-Avoidance Beliefs Questionnaire Physical Activity subscale (n = 9, 45%). CONCLUSIONS: No group-level RS was identified for any PRO after a 4-week multimodal rehabilitation program in individuals with CAI. This finding indicates that traditional assessment of self-reported function was accurate for evaluating the short-term effects of rehabilitation in those with CAI. Low levels of individual-level RS were identified.

Changes in Dorsiflexion and Dynamic Postural Control After Mobilizations in Individuals With Chronic Ankle Instability: A Systematic Review and Meta-Analysis.

OBJECTIVE: To conduct a systematic review with meta-analysis assessing the effectiveness of joint mobilizations for improving dorsiflexion range of motion (DFROM) and dynamic postural control in individuals with chronic ankle instability. DATA SOURCES: Electronic databases (PubMed, MEDLINE, CINAHL, and SPORTDiscus) were searched from inception to January 2017. STUDY SELECTION: Included studies examined the isolated effects of joint mobilizations to enhance DFROM and dynamic postural control in individuals with chronic ankle instability and provided adequate data to calculate effect sizes (ESs) and 95% confidence intervals (CIs). DATA EXTRACTION: Two investigators independently assessed the methodologic quality, level of evidence, and strength of recommendation using the Physiotherapy Evidence Database scale and the Strength of Recommendation Taxonomy. We extracted the sample sizes, means, and standard deviations for DFROM and dynamic postural control and filtered the data based on control-to-intervention and preintervention-to-postintervention (pre-post) comparisons. DATA SYNTHESIS: We included 7 level 1 and 3 level 2 studies that had a median Physiotherapy Evidence Database score of 60% (range = 40%-80%). The magnitudes of control-to-intervention and pre-post differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analyses were conducted for each outcome measure and comparison. Positive ESs indicated better outcome scores in the intervention group than in the control group and at postintervention than at preintervention. The α level was set at .05. Meta-analysis revealed weak and moderate ESs for overall control-to-intervention (ES = 0.41; 95% CI = 0.14, 0.68; P = .003) and pre-post (ES = 0.34; 95% CI = 0.20, 0.48; P < .001) DFROM analyses. Overall, dynamic postural control meta-analysis revealed moderate control-to-intervention (ES = 0.42; 95% CI = -0.14, 0.98; P = .14) and weak and moderate ESs for pre-post (ES = 0.37; 95% CI = -0.12, 0.87; P = .14) analyses. CONCLUSIONS: We observed grade A evidence that joint mobilizations can mildly improve DFROM among individuals with chronic ankle instability compared with controls and preintervention. We observed grade B evidence that indicated conflicting effects of joint mobilizations on dynamic postural control compared with controls and preintervention.

Joint mobilization and static stretching for individuals with chronic ankle instability - A pilot study.

OBJECTIVE: To complete preliminary analysis regarding the effects joint mobilization timing during a 4-week calf stretching intervention on clinician-oriented and patient-oriented outcomes in individuals with chronic ankle instability (CAI). Additionally, a secondary objective was to examine the combined effect of joint mobilization and calf stretching. DESIGN: Randomized two-group pretest posttest design. SETTING: Laboratory. PARTICIPANTS: Ten adults (age = 24.4 ±â€¯4.7years; height = 172.1 ±â€¯11.3 cm; weight = 76.2 ±â€¯17.1 kg) with self-reported CAI participated. INTERVENTIONS: Participants completed outcome measures at three collection sessions (baseline, pre-intervention, and post-intervention). Participants were randomized into either into an early-mobilization or late-mobilization group in which they completed a joint mobilization intervention during the first or last 2 weeks of a 4-week calf stretching intervention. MAIN OUTCOME MEASURES: Outcome measures included: dorsiflexion ROM, dynamic postural control, single-limb postural control, Disablement in the Physically Active Scale (DPA), Foot and Ankle Ability Measure (FAAM), and Fear-Avoidance Beliefs Questionnaire (FABQ). Wilcoxon Sign Rank Tests examined pre-intervention to post-intervention differences for each dependent variable. Mann-Whitney U tests examined differences between early-mobilization and late-mobilization groups. Alpha was set a priori at p < .05. RESULTS: No significant differences were identified between early-mobilization and late-mobilization groups at post intervention (p > .095). FAAM-Activities of Daily Living, DPA, FABQ-Physical Activity, and dorsiflexion ROM were significantly improved at post-intervention compared to pre-intervention (p < .047). No other significant differences were identified between pre-intervention and post-intervention (p > .057). CONCLUSION: Preliminarily results suggest the timing of joint mobilization when used in conjunction with calf stretching does not effect treatment efficacy. However, the combination of joint mobilization and calf stretching can improve dorsiflexion ROM and self-reported function in individuals with CAI. Improvements from the combined intervention are similar to previously reported effects of isolated joint mobilization or stretching.

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.

Reliability, minimal detectable change, and responsiveness of the Quick-FAAM.

OBJECTIVE: To determine the test-retest reliability, minimal detectable change (MDC) and responsiveness of the Quick-FAAM in people with chronic ankle instability (CAI). DESIGN: 10-week controlled laboratory study. SETTING: Laboratory. PARTICIPANTS: A total of 20 adults with self-reported CAI. MAIN OUTCOME MEASURES: Participants completed a supervised 4-week intervention. The Quick-FAAM was assessed 4-weeks before the intervention (T1), prior to the first intervention (T2), 24-h post-intervention (T3), and 2-weeks after the intervention (T4). The Quick-FAAM is a 12-item region specific PRO scored on 5-point Likert scale, often reported as a percentage, and a lower percentage indicates decreased ankle function. Test-retest reliability was determined using Intraclass-correlation coefficients (ICC2,1) and standard error of measure (SEM). The MDC was calculated using the equation: SEM*√2. Hedges g effect sizes and associated 95% confidence intervals (95%CI) were calculated as a measure of group responsiveness. RESULTS: The test-retest reliability was clinically acceptable (ICC2,1 = 0.82, SEM = 4.56). The MDC was 6.5% and pre-post intervention effect sizes were large between T2-T3 (ES = 1.27, 95%CI:0.59-1.95) and T2-T4 (ES = 1.49, 95%CI:0.79-2.19). CONCLUSION: The Quick-FAAM demonstrated clinically acceptable reliability and was responsive to treatment. Future research should examine these properties in patients with acute ankle and foot conditions, determine patient acceptability, and clinician feasibility.

Examination of Response Shift After Rehabilitation for Orthopedic Conditions: A Systematic Review.

CONTEXT: There is an increased emphasis on the need to capture and incorporate self-reported function to make clinical decisions when providing patient-centered care. Response shift (RS), or a change in an individual's self-evaluation of a construct, may affect the accurate assessment of change in self-reported function throughout the course of rehabilitation. A systematic review of this phenomenon may provide valuable information regarding the accuracy of self-reported function. OBJECTIVES: To systematically locate and synthesize the existing evidence regarding RS during care for various orthopedic conditions. EVIDENCE ACQUISITION: Electronic databases (PubMed, MEDLINE, CINAHL, SPORTDiscus, and Psychology & Behavioral Sciences Collection) were searched from inception to November 2016. Two investigators independently assessed methodological quality using the modified Downs and Black Quality Index. The quality of evidence was assessed using the Strength-of-Recommendation Taxonomy. The magnitude of RS was examined through effect sizes. EVIDENCE SYNTHESIS: Nine studies were included (7 high quality and 2 low quality) with a median Downs and Black Quality Index score of 81.25% (range = 56.25%-93.75%). Overall, the studies demonstrated weak to strong effect sizes (range = -1.58-0.33), indicating the potential for RS. Of the 36 point estimates calculated, 22 (61.11%), 2 (5.56%), and 12 (33.33%) were associated with weak, moderate negative, and strong negative effect sizes, respectively. CONCLUSIONS: There is grade B evidence that a weak RS, in which individuals initially underestimate their disability, may occur in people undergoing rehabilitation for an orthopedic condition. It is important for clinicians to be aware of the potential shift in their patients' internal standards, as it can affect the evaluation of health-related quality of life changes during the care of orthopedic conditions. A shift in the internal standards of the patient can lead to subsequent misclassification of health-related quality of life changes that can adversely affect clinical decision making.

Proprioceptive Training for the Prevention of Ankle Sprains: An Evidence-Based Review.

Reference: Schiftan GS, Ross LA, Hahne AJ. The effectiveness of proprioceptive training in preventing ankle sprains in sporting populations: a systematic review and meta-analysis. J Sci Med Sport. 2015;18(3):238-244. CLINICAL QUESTION: Does the use of proprioceptive training as a sole intervention decrease the incidence of initial or recurrent ankle sprains in the athletic population? DATA SOURCES: The authors completed a comprehensive literature search of MEDLINE, CINAHL, SPORTDiscus, and Physiotherapy Evidence Database (PEDro) from inception to October 2013. The reference lists of all identified articles were manually screened to obtain additional studies. The following key words were used. Phase 1 population terms were sport*, athlet*, and a combination of the two. Phase 2 intervention terms were propriocept*, balance, neuromusc* adj5 train*, and combinations thereof. Phase 3 condition terms were ankle adj5 sprain*, sprain* adj5 ankle, and combinations thereof. STUDY SELECTION: Studies were included according to the following criteria: (1) the design was a moderate- to high-level randomized controlled trial (>4/10 on the PEDro scale), (2) the participants were physically active (regardless of previous ankle injury), (3) the intervention group received proprioceptive training only, compared with a control group that received no proprioceptive training, and (4) the rate of ankle sprains was reported as a main outcome. Search results were limited to the English language. No restrictions were placed on publication dates. DATA EXTRACTION: Two authors independently reviewed the studies for eligibility. The quality of the pertinent articles was assessed using the PEDro scale, and data were extracted to calculate the relative risk. Data extracted were number of participants, intervention, frequency, duration, follow-up period, and injury rate. MAIN RESULTS: Of the initial 345 studies screened, 7 were included in this review for a total of 3726 participants. Three analyses were conducted for proprioceptive training used (1) to prevent ankle sprains regardless of history (n = 3654), (2) to prevent recurrent ankle sprains (n = 1542), or (3) as the primary preventive measure for those without a history of ankle sprain (n = 946). Regardless of a history of ankle sprain, participants had a reduction in ankle-sprain rates (relative risk [RR] = 0.65, 95% confidence interval [CI] = 0.55, 0.77; numbers needed to treat [NNT] = 17, 95% CI = 11, 33). For individuals with a history of ankle sprains, proprioceptive training demonstrated a reduction in repeat ankle sprains (RR = 0.64, 95% CI = 0.51, 0.81; NNT = 13, 95% CI = 7, 100). Proprioceptive training as a primary preventive measure demonstrated significant results (RR = 0.57, 95% CI = 0.34, 0.97; NNT = 33, 95% CI = 16, 1000). CONCLUSIONS: Proprioceptive training programs were effective in reducing the incidence rates of ankle sprains in the athletic population, including those with and those without a history of ankle sprains.

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.

Y-Balance Test Performance Following a Competitive Field Hockey Season: A Pretest-Posttest Study.

CONTEXT: The Y-Balance Test (YBT) is a dynamic balance assessment used as a preseason musculoskeletal screen to determine injury risk. While the YBT has demonstrated excellent test-retest reliability, it is unknown if YBT performance changes following participation in a competitive athletic season. OBJECTIVE: Determine if a competitive athletic season affects YBT performance in field hockey players. DESIGN: Pretest-posttest. SETTING: Laboratory. PARTICIPANTS: 20 NCAA Division I women's field hockey players (age = 19.55 ± 1.30 y; height = 165.10 ± 5.277 cm; mass = 62.62 ± 4.64 kg) from a single team volunteered. Participants had to be free from injury throughout the entire study and participate in all athletic activities. INTERVENTIONS: Participants completed data collection sessions prior to (preseason) and following the athletic season (postseason). Between data collections, participants competed in the fall competitive field hockey season, which was ~3 months in duration. During data collection, participants completed the YBT bilaterally. MAIN OUTCOME MEASURES: The independent variable was time (preseason, postseason) and the dependent variables were normalized reach distances (anterior, posteromedial, posterolateral, composite) and between-limb symmetry for each reach direction. Differences between preseason and postseason were examined using paired t tests (P ≤ .05) as well as Bland-Altman limits of agreement. RESULTS: 4 players sustained a lower extremity injury during the season and were excluded from analysis. There were no significant differences between preseason and postseason reach distances for any reach directions on either limb (P ≥ .31) or in the between-limb symmetries (P ≥ .52). The limits of agreement analyses determined there was a low mean bias across measurements (≤1.67%); however, the 95% confidence intervals indicated there was high variability within the posterior reach directions over time (±4.75 to ± 14.83%). CONCLUSION: No changes in YBT performance were identified following a competitive field hockey season in Division I female athletes. However, the variability within the posterior reach directions over time may contribute to the limited use of these directions for injury risk stratification.

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.

The influence of foot posture on dorsiflexion range of motion and postural control in those with chronic ankle instability.

BACKGROUND: To investigate the effect of foot posture on postural control and dorsiflexion range of motion in individuals with chronic ankle instability. METHODS: The study employed a cross-sectional, single-blinded design. Twenty-one individuals with self-reported chronic ankle instability (male=5; age=23.76(4.18)years; height=169.27(11.46)cm; weight=73.65(13.37)kg; number of past ankle sprains=4.71(4.10); episode of giving way=17.00(18.20); Cumberland Ankle Instability Score=18.24(4.52); Ankle Instability Index=5.86(1.39)) participated. The foot posture index was used to categorize subjects into pronated (n=8; Foot Posture Index=7.50(0.93)) and neutral (n=13; Foot Posture Index=3.08(1.93)) groups. The dependent variables of dorsiflexion ROM and dynamic and static postural control were collected for both groups at a single session. FINDINGS: There were no significant differences in dorsiflexion range of motion between groups (p=0.22) or any of the eyes open time-to-boundary variables (p>0.13). The pronated group had significantly less dynamic postural control than the neutral group as assessed by the anterior direction of the Star Excursion Balance Test (p<0.04). However, the pronated group had significantly higher time-to-boundary values than the neutral group for all eyes closed time-to-boundary variables (p≤0.05), which indicates better eyes closed static postural control. INTERPRETATION: Foot posture had a significant effect on dynamic postural control and eyes closed static postural control in individuals with chronic ankle instability. These findings suggest that foot posture may influence postural control in those with chronic ankle instability.