Emily A. Hall

Strength-Training Protocols to Improve Deficits in Participants With Chronic Ankle Instability: A Randomized Controlled Trial

CONTEXT Although lateral ankle sprains are common in athletes and can lead to chronic ankle instability (CAI), strength-training rehabilitation protocols may improve the deficits often associated with CAI. OBJECTIVE To determine whether strength-training protocols affect strength, dynamic balance, functional performance, and perceived instability in individuals with CAI. DESIGN Randomized controlled trial. SETTING Athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 39 individuals with CAI (17 men [44%], 22 women [56%]) participated in this study. Chronic ankle instability was determined by the Identification of Functional Ankle Instability Questionnaire, and participants were randomly assigned to a resistance-band-protocol group (n = 13 [33%] age = 19.7 ± 2.2 years, height = 172.9 ± 12.8 cm, weight = 69.1 ± 13.5 kg), a proprioceptive neuromuscular facilitation strength-protocol group (n = 13 [33%], age = 18.9 ± 1.3 years, height = 172.5 ± 5.9 cm, weight = 72.7 ± 14.6 kg), or a control group (n = 13 [33%], age = 20.5 ± 2.1 years, height = 175.2 ± 8.1 cm, weight = 70.2 ± 11.1 kg). INTERVENTION(S) Both rehabilitation groups completed their protocols 3 times/wk for 6 weeks. The control group did not attend rehabilitation sessions. MAIN OUTCOME MEASURE(S) Before the interventions, participants were pretested by completing the figure-8 hop test for time, the triple-crossover hop test for distance, isometric strength tests (dorsiflexion, plantar flexion, inversion, and eversion), the Y-Balance test, and the visual analog scale for perceived ankle instability. Participants were again tested 6 weeks later. We conducted 2 separate, multivariate, repeated-measures analyses of variance, followed by univariate analyses on any significant findings. RESULTS The resistance-band protocol group improved in strength (dorsiflexion, inversion, and eversion) and on the visual analog scale (P < .05); the proprioceptive neuromuscular facilitation group improved in strength (inversion and eversion) and on the visual analog scale (P < .05) as well. No improvements were seen in the triple-crossover hop or the Y-Balance tests for either intervention group or in the control group for any dependent variable (P > .05). CONCLUSIONS Although the resistance-band protocol is common in rehabilitation, the proprioceptive neuromuscular facilitation strength protocol is also an effective treatment to improve strength in individuals with CAI. Both protocols showed clinical benefits in strength and perceived instability. To improve functional outcomes, clinicians should consider using additional multiplanar and multijoint exercises.

Validity of clinical outcome measures to evaluate ankle range of motion during the weight-bearing lunge test

OBJECTIVES To determine the concurrent validity of standard clinical outcome measures compared to laboratory outcome measure while performing the weight-bearing lunge test (WBLT). DESIGN Cross-sectional study. METHODS Fifty participants performed the WBLT to determine dorsiflexion ROM using four different measurement techniques: dorsiflexion angle with digital inclinometer at 15cm distal to the tibial tuberosity (°), dorsiflexion angle with inclinometer at tibial tuberosity (°), maximum lunge distance (cm), and dorsiflexion angle using a 2D motion capture system (°). Outcome measures were recorded concurrently during each trial. To establish concurrent validity, Pearson product-moment correlation coefficients (r) were conducted, comparing each dependent variable to the 2D motion capture analysis (identified as the reference standard). A higher correlation indicates strong concurrent validity. RESULTS There was a high correlation between each measurement technique and the reference standard. Specifically the correlation between the inclinometer placement at 15cm below the tibial tuberosity (44.9°±5.5°) and the motion capture angle (27.0°±6.0°) was r=0.76 (p=0.001), between the inclinometer placement at the tibial tuberosity angle (39.0°±4.6°) and the motion capture angle was r=0.71 (p=0.001), and between the distance from the wall clinical measure (10.3±3.0cm) to the motion capture angle was r=0.74 (p=0.001). CONCLUSIONS This study determined that the clinical measures used during the WBLT have a high correlation with the reference standard for assessing dorsiflexion range of motion. Therefore, obtaining maximum lunge distance and inclinometer angles are both valid assessments during the weight-bearing lunge test.

Using Ankle Bracing and Taping to Decrease Range of Motion and Velocity During Inversion Perturbation While Walking.

CONTEXT Prophylactic ankle supports are commonly used. However, the effectiveness of external supports in preventing an inversion stress has been debated. OBJECTIVE To evaluate how ankle bracing and taping affect inversion range of motion, time to maximum inversion, inversion velocity, and perceived ankle stability compared with a control condition during a dynamic inversion perturbation while walking. DESIGN Crossover study. SETTING Research laboratory. PATIENTS OR OTHER PARTICIPANTS A total of 42 physically active participants (16 men, 26 women; age = 21.2 ± 3.3 years, height = 168.9 ± 8.9 cm, mass = 66.1 ± 11.4 kg) volunteered. INTERVENTION(S) Participants walked on a custom-built walkway that suddenly inverted their ankles to 30° in 3 conditions: brace, tape, and control (no external support). We used an ASO ankle brace for the brace condition and a closed basketweave technique for the tape condition. Three trials were completed for each condition. Main Outcome Measure(s) Maximum inversion (degrees), time to maximum inversion (milliseconds), and inversion velocity (degrees per second) were measured using an electrogoniometer, and perceived stability (centimeters) was measured using a visual analog scale. RESULTS Maximum inversion decreased more in the brace condition (20.1°) than in the control (25.3°) or tape (22.3°) conditions (both P values = .001), and the tape condition restricted inversion more than the control condition (P = .001). Time to maximum inversion was greater in the brace condition (143.5 milliseconds) than in the control (123.7 milliseconds; P = .001) or tape (130.7 milliseconds; P = .009) conditions and greater in the tape than in the control condition (P = .02). Inversion velocity was slower in the brace condition (142.6°/s) than in the control (209.1°/s) or tape (174.3°/s) conditions (both P values = .001) and slower in the tape than in the control condition (P = .001). Both the brace and tape conditions provided more perceived stability (0.98 cm and 0.94 cm, respectively) than the control condition (2.38 cm; both P values = .001). CONCLUSIONS Both prophylactic conditions affected inversion range of motion, time to maximum inversion, inversion velocity, and perceived ankle stability. However, bracing provided more restriction at a slower rate than taping.

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

&NA; • 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.

37 The differences in rate of inversion and perceived instability during a dynamic perturbation in those with and without cai

Background Following a lateral ankle sprain, residual symptoms such as pain, weakness, and perceived instability can occur. Objective To determine differences in rate of inversion and perceived ankle instability during a dynamic perturbation in individuals with and without chronic ankle instability (CAI). Design Crossover study. Setting Laboratory. Patients (or participants) Thirty-six participants volunteered and were divided into two groups: CAI (n = 16, age = 19.8 ± 0.9 years, height = 165.7 ± 7.0 cm, body mass = 65.5 ± 11.7 kg) and control (n = 20, age = 21.7 ± 3.6 years, height = 170.4 ± 10.6 cm, body mass = 65.3 ± 11.8 kg). The CAI group had a history of ankle sprains and scored ≥11 or higher on the IdFAI. The control group had no history of ankle sprains in either limb and scored zero on the IdFAI. Interventions Participants walked down a custom-built 7.3 m walkway, which was designed with sections that suddenly inverted the subjects’ ankles to 30° while wearing a standardised shoe. Main outcome measurements Rate of inversion (°/s) was calculated by dividing maximum range of motion by the time to maximum inversion. Data were captured using an electrogoniometer (SG110/A, Biometrics, Ltd, UK) placed on the lateral aspect of the ankle. The average of three trials was used for statistical analysis. Perceived ankle instability was measured using a visual analogue scale. Participants marked a dash on a vertical 10-cm line to rate how unstable their ankle felt on the walkway. One-way ANOVA was performed on each dependent variable. The a priori alpha level was set at p < 0.05. Results No significant difference in rate of inversion was observed between the groups (p = 0.70). There was a significant difference in perceived instability (p = 0.01, CAI group = 4.14 ± 2.48 cm, control group = 0.99 ± 1.3 cm). Conclusions These results indicate that despite the similarities between groups in rate of inversion, participants in the CAI group still felt less stable than the control group during the dynamic inversion task.

Balance- and Strength-Training Protocols to Improve Chronic Ankle Instability Deficits, Part I: Assessing Clinical Outcome Measures

CONTEXT   Functional rehabilitation may improve the deficits associated with chronic ankle instability (CAI). OBJECTIVE   To determine if balance- and strength-training protocols improve the balance, strength, and functional performance deficits associated with CAI. DESIGN   Randomized controlled clinical trial. SETTING   Athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS   Participants were 39 volunteers with CAI, which was determined using the Identification of Functional Ankle Instability Questionnaire. They were randomly assigned to 1 of 3 groups: balance-training protocol (7 males, 6 females; age = 23.5 ± 6.5 years, height = 175.0 ± 8.5 cm, mass = 72.8 ± 10.9 kg), strength-training protocol (8 males, 5 females; age = 24.6 ± 7.7 years, height = 173.2 ± 9.0 cm, mass = 76.0 ± 16.2 kg), or control (6 males, 7 females; age = 24.8 ± 9.0 years, height = 175.5 ± 8.4 cm, mass = 79.1 ± 16.8 kg). INTERVENTION(S)   Each group participated in a 20-minute session, 3 times per week, for 6 weeks. The control group completed a mild to moderately strenuous bicycle workout. MAIN OUTCOME MEASURE(S)   Participants completed baseline testing of eccentric and concentric isokinetic strength in each ankle direction (inversion, eversion, plantar flexion, and dorsiflexion) and the Balance Error Scoring System (BESS), Star Excursion Balance Test (SEBT), and side-hop functional performance test. The same variables were tested again at 6 weeks after the intervention. Two multivariate repeated-measures analyses of variance with follow-up univariate analyses were conducted. The α level was set a priori at .05. RESULTS   We observed time-by-group interactions in concentric ( P = .02) and eccentric ( P = .01) inversion, eccentric eversion ( P = .01), concentric ( P = .001) and eccentric ( P = .03) plantar flexion, BESS ( P = .01), SEBT ( P = .02), and side hop ( P = .004). With pairwise comparisons, we found improvements in the balance- and strength-training protocol groups in concentric and eccentric inversion and concentric and eccentric plantar flexion and the BESS, SEBT, and side hop (all P values = .001). Only the strength-training protocol group improved in eccentric eversion. The control group did not improve in any dependent variable. CONCLUSIONS   Both training protocols improved strength, balance, and functional performance. More clinicians should incorporate hop-to-stabilization exercises into their rehabilitation protocols to improve the deficits associated with CAI.

Balance- and Strength-Training Protocols to Improve Chronic Ankle Instability Deficits, Part II: Assessing Patient-Reported Outcome Measures

CONTEXT   Assessing global, regional, and fear-of-reinjury outcomes in individuals with chronic ankle instability (CAI) is critical to understanding the effectiveness of clinical interventions. OBJECTIVE   To determine the improvement of patient-reported outcomes after balance- and strength-training and control protocols among participants with CAI. DESIGN   Randomized controlled clinical trial. SETTING   Athletic training research laboratory. PATIENTS OR OTHER PARTICIPANTS   Thirty-nine volunteers with CAI who scored 11 or greater on the Identification of Functional Ankle Instability questionnaire were randomly assigned to 1 of 3 groups: balance-training protocol (7 males, 6 females; age = 23.5 ± 6.5 years, height = 175.0 ± 8.5 cm, mass = 72.8 ± 10.9 kg), strength-training protocol (8 males, 5 females; age = 24.6 ± 7.7 years, height = 173.2 ± 9.0 cm, mass = 76.0 ± 16.2 kg), or control (6 males, 7 females; age = 24.8 ± 9.0 years, height = 175.5 ± 8.4 cm, mass = 79.1 ± 16.8 kg). INTERVENTION(S)   Each group met for 20 minutes, 3 times each week, for 6 weeks. The control group completed a mild to moderately strenuous bicycle workout. MAIN OUTCOME MEASURE(S)   Global patient-reported outcomes, regional ankle function, and perceived instability were measured using the Disablement in the Physically Active Scale, the Fear-Avoidance Beliefs Questionnaire, the Foot and Ankle Ability Measure, and a visual analog scale for perceived instability. Participants completed the questionnaires at pretest and 6 weeks posttest. A multivariate repeated-measures analysis of variance with follow-up univariate analysis was conducted. The α level was set a priori at .05. RESULTS   No time-by-group interaction was found ( P = .78, η2 = 0.09). However, we observed a main effect for time ( P = .001, η2 = 0.49). Follow-up univariate analyses revealed differences between the pretest and posttest for the Disablement in the Physically Active Scale ( P = .02, η2 = 0.15), Fear-Avoidance Beliefs Questionnaire ( P = .001, η2 = 0.27), Foot and Ankle Ability Measure-Activities of Daily Living subscale ( P = .003, η2 = 0.22), Foot and Ankle Ability Measure-Sport subscale ( P = .001, η2 = 0.36), and visual analog scale ( P = .008, η2 = 0.18). CONCLUSIONS   Statistically, after the 6-week intervention, all groups improved in global and regional health-related quality of life. Clinicians should compare patient-reported outcomes with clinical measures to have a better understanding of progression during rehabilitation.

Prophylactic Bracing Has No Effect on Lower Extremity Alignment or Functional Performance

Prophylactic ankle bracing is commonly used during physical activity. Understanding how bracing affects body mechanics is critically important when discussing both injury prevention and sport performance. The purpose is to determine if ankle bracing affects lower extremity mechanics during the Landing Error Scoring System test (LESS) and Sage Sway Index (SSI). Thirty physically active participants volunteered for this study. Participants completed the LESS and SSI in both a braced and unsupported conditions. Total errors were recorded for the LESS. Total errors and time (seconds) were recorded for the SSI. The Wilcoxon signed-rank test was utilized to evaluate any differences between the brace conditions for each dependent variable. A priori alpha level was set at p<0.05. The Wilcoxon signed-rank test yielded no significant difference between the braced and unsupported conditions for the LESS (Z=-0.35, p=0.72), SSI time (Z=-0.36, p=0.72), or SSI Errors (Z=-0.37, p=0.71). Ankle braces had no effect on subjective clinical assessments of lower extremity alignment or postural stability. Utilization of a prophylactic support at the ankle did not substantially alter the proximal components of the lower kinetic chain.