Matthew C. Hoch

Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability.

The purpose of this study was to examine the effects of a single joint mobilization treatment on dorsiflexion range of motion (DF ROM), posterior talar glide, and dynamic and static postural control in individuals with self‐reported chronic ankle instability (CAI). In this randomized cross‐over study, subjects received a Maitland Grade III anterior‐to‐posterior joint mobilization treatment and a control treatment of rest for 5 min. Weight‐bearing DF ROM, instrumented posterior talar displacement and posterior stiffness, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and time‐to‐boundary (TTB) single‐limb stance static postural control were assessed on both treatment days in 9 males and 11 females with CAI. The results indicated that the joint mobilization treatment was associated with significantly greater DF ROM (p = 0.01) and TTB in the anterior–posterior direction with eyes‐open (p < 0.05). Although not significant, trends were identified in posterior talar displacement (p = 0.08) and the mean of TTB in the medial‐lateral (ML) direction (p = 0.07). No significant differences were observed in the standard deviation of TTB in the ML direction, the SEBT, or posterior stiffness (p > 0.05). This indicates that a single joint mobilization treatment has mechanical and functional benefits for addressing impairments in sensorimotor function and arthrokinematic restrictions commonly experienced by individuals with CAI.

Dorsiflexion range of motion significantly influences dynamic balance

The purpose of this study was to examine the relationships between dorsiflexion range of motion on the weight-bearing lunge test (WBLT) and normalized reach distance in three directions on the Star Excursion Balance Test (SEBT). Thirty-five healthy adults (14 males, 21 females, age: 25.9±6.7 years, height: 166.7±22.9 cm, weight: 76.7±22.8 kg) participated. All subjects performed three trials of maximum lower extremity reach in the anterior, posteromedial, and posterolateral directions of the SEBT on each limb to assess dynamic balance. Subjects performed three trials of the WBLT to measure maximum dorsiflexion range of motion. Dependent variables included the means of the SEBT normalized reach distances in the anterior, posteromedial, and posterolateral directions and the mean of the WBLT. Only the anterior direction (mean: 79.0±5.8%) of the SEBT was significantly related to the WBLT (mean: 11.9±2.7 cm), r=0.53 (p=0.001). The r² for this simple linear regression was 0.28, indicating that the WBLT explained 28% of the variance in the anterior normalized reach distance. The WBLT explained a significant proportion of the variance within the anterior reach distance signifying this direction of the SEBT may be a good clinical test to assess the effects of dorsiflexion range of motion restrictions on dynamic balance.

Dorsiflexion and Dynamic Postural Control Deficits are Present in Those with Chronic Ankle Instability

OBJECTIVES To determine if differences in weight-bearing ankle dorsiflexion range of motion (DFROM) and Star Excursion Balance Test (SEBT) reach distances were present between participants with chronic ankle instability (CAI) and healthy individuals. A secondary objective was to re-examine the relationship between these measures in participants with and without CAI. DESIGN Case-control. METHODS Thirty participants with CAI were matched to 30 healthy participants. All participants performed maximum reach in the anterior, posteromedial and posterolateral directions of the SEBT; as well as, the Weight-Bearing Lunge Test (WBLT) to measure DFROM. Dependent variables included maximal DFROM (cm) and normalized SEBT reach distances (%). Independent t-tests were used for group comparisons (a priori p ≤ 0.05). Simple-linear regression examined the relationship between the WBLT and each SEBT direction. RESULTS Significant differences were detected between groups for the WBLT (CAI: 10.73 ± 3.44 cm, healthy: 12.47 ± 2.51 cm; p=0.03) and anterior reach distance (CAI: 76.05 ± 6.25%, healthy: 80.12 ± 5.88%; p=0.01). No differences were identified in posteromedial or posterolateral (ps>0.70) reach. The WBLT had a significant moderate correlation to anterior reach in both groups (ps<0.05) but was not significantly correlated to posteromedial or posterolateral reach distance (ps>0.70). CONCLUSIONS The results indicate that participants with CAI demonstrated less DFROM and anterior SEBT reach distance compared to health controls. Additionally, both groups demonstrated similar correlations between WBLT and SEBT performance. These findings suggest that participants with CAI have alterations in ankle motion which may negatively influence dynamic postural control; however, the relationship between WBLT and SEBT performance is consistent in those with and without CAI.

Two-Week Joint Mobilization Intervention Improves Self-Reported Function, Range of Motion, and Dynamic Balance in Those with Chronic Ankle Instability

We examined the effect of a 2‐week anterior‐to‐posterior ankle joint mobilization intervention on weight‐bearing dorsiflexion range of motion (ROM), dynamic balance, and self‐reported function in subjects with chronic ankle instability (CAI). In this prospective cohort study, subjects received six Maitland Grade III anterior‐to‐posterior joint mobilization treatments over 2 weeks. Weight‐bearing dorsiflexion ROM, the anterior, posteromedial, and posterolateral reach directions of the Star Excursion Balance Test (SEBT), and self‐reported function on the Foot and Ankle Ability Measure (FAAM) were assessed 1 week before the intervention (baseline), prior to the first treatment (pre‐intervention), 24–48 h following the final treatment (post‐intervention), and 1 week later (1‐week follow‐up) in 12 adults (6 males and 6 females) with CAI. The results indicate that dorsiflexion ROM, reach distance in all directions of the SEBT, and the FAAM improved (p < 0.05 for all) in all measures following the intervention compared to those prior to the intervention. No differences were observed in any assessments between the baseline and pre‐intervention measures or between the post‐intervention and 1‐week follow‐up measures (p > 0.05). These results indicate that the joint mobilization intervention that targeted posterior talar glide was able to improve measures of function in adults with CAI for at least 1 week.

Normative range of weight-bearing lunge test performance asymmetry in healthy adults.

Reduced dorsiflexion is a clinical consideration during the management and rehabilitation of several lower extremity injuries (Landrum et al., 2008;Youdas et al., 2009). Decreases in dorsiflexion are often the result of triceps surae muscle tightness (You et al., 2009) or local arthrokinematic restrictions in posterior talar glide in reference to the ankle mortise (Denegar et al., 2002). Additionally, reduced dorsiflexion has been and identified as a risk factor for sustaining lower extremity injury in military recruits (Pope et al., 1998), male physical education students (Willems et al., 2005), and adult volleyball players (Hadzic et al., 2009). Reduced dorsiflexionmay bemodifiable risk factor for lower extremity injury that can be easily identified during clinical examination. The weight-bearing lunge test (WBLT) is a functional and reliable method to indirectly assess dorsiflexion by measuring the maximal advancement of the tibia over the rearfoot in a weightbearing position (Bennell et al., 1998). Previous investigators (Bennell et al., 1998;Jones et al., 2005;Vicenzino et al., 2006) have reported robust inter-tester and intersession reliability associated with the assessment of WBLT performance in healthy adults along with a robust correlation(r 1⁄4 0.95) between degrees of dorsiflexion range of motion and maximal lunge distance. Furthermore, there is a significant positive correlation between WBLT performance and peak ankle sagittal plane kinematics during walking and running (Barrett & Caulfield, 2009); as well as, reach distance on the Star Excursion Balance Test (Hoch et al., 2010b). Lunge distance asymmetries on the WBLT have been used to identifyweight-bearingdorsiflexion impairments in individualswith

Plantar vibrotactile detection deficits in adults with chronic ankle instability.

PURPOSE The purpose of this study was to investigate the vibrotactile detection thresholds of the plantar cutaneous afferents in subjects with chronic ankle instability compared with healthy control subjects. METHODS Eight adults with chronic ankle instability and eight adults with no ankle sprain history participated. Vibrotactile detection thresholds were assessed using a mechanical stimulus generator system, mounted onto an articulated microscope arm, which delivered sinusoidal vibrotactile inputs to the foot sole at three different sites: head of the first metatarsal, base of the fifth metatarsal, and the heel. Vibrotactile stimulation was delivered at a range of test frequencies that corresponded to the known responsiveness of cutaneous mechanoreceptors in the glabrous skin of the foot sole (10, 25, and 50 Hz). Probe displacement measures (dB) from the last eight displacement trials that contained 50% positive detection responses were averaged to obtain a single threshold estimate for each test frequency and site combination. RESULTS The results of this study indicate that no significant group-by-site interactions were found for any test frequencies (P > 0.29). However, group main effects were present at the 10-Hz (P < 0.0001), 25-Hz (P = 0.03), and 50-Hz (P = 0.04) test frequencies, indicating that subjects with chronic ankle instability had significantly higher detection thresholds or less sensitivity when stimulation sites were pooled. CONCLUSIONS The results of this study indicate that subjects with chronic ankle instability may demonstrate decreased sensitivity on the plantar surface of the foot. These alterations in plantar cutaneous somatosensation may help explain the underlying mechanisms associated with the prolonged sensorimotor system impairments in postural control and gait commonly exhibited by people with chronic ankle instability.

Health-Related Quality of Life in Individuals With Chronic Ankle Instability

CONTEXT Individuals with chronic ankle instability (CAI) have reported decreased global and regional function. Despite the identification of functional deficits in those with CAI, more research is required to determine the extent to which CAI influences the multidimensional profile of health-related quality of life. OBJECTIVE To determine whether global, regional, and psychological health-related outcomes differ between individuals with and without CAI. DESIGN Case-control study. SETTING Laboratory. PATIENTS OR OTHER PARTICIPANTS Twenty-five participants with CAI (age = 21.9 ± 2.5 years, height = 170.8 ± 8.6 cm, mass = 69.8.0 ± 11.7 kg) were sex- and limb-matched to 25 healthy participants (age = 22.0 ± 2.1 years, height = 167.4 ± 9.1 cm, mass = 64.8 ± 11.2 kg). MAIN OUTCOME MEASURE(S) Both groups completed the Disablement in the Physically Active Scale, the Foot and Ankle Ability Measure (FAAM), the FAAM-Sport, the Tampa Scale of Kinesiophobia-11, and the Fear-Avoidance Beliefs Questionnaire. Dependent variables were scores on these instruments, and the independent variable was group. RESULTS Compared with healthy individuals, those with CAI reported decreased function on the Disablement in the Physically Active Scale, FAAM, and FAAM-Sport (P < .001) and increased fear of reinjury on the Tampa Scale of Kinesiophobia-11 and Fear-Avoidance Beliefs Questionnaire (P < .001). In the CAI group, the FAAM and FAAM-Sport demonstrated a significant relationship (r = 0.774, P < .01). CONCLUSIONS Individuals with CAI reported decreased function and increased fear of reinjury compared with healthy control participants. Also, within the CAI group, there was a strong relationship between FAAM and FAAM-Sport scores but not between any other instruments. These findings suggest that health-related quality of life should be examined during the rehabilitation process of individuals with CAI.

Patient-Reported Outcome Measures in Individuals With Chronic Ankle Instability: A Systematic Review

CONTEXT A comprehensive systematic literature review of the health-related quality-of-life (HRQOL) differences among individuals with chronic ankle instability (CAI), ankle-sprain copers, and healthy control participants has not been conducted. It could provide a better indication of the self-reported deficits that may be present in individuals with CAI. OBJECTIVE To systematically summarize the extent to which HRQOL deficits are present in individuals with CAI. DATA SOURCES We searched for articles in the electronic databases of EBSCO Host and PubMed Central using key words chronic, functional, mechanical, coper, instability, sprains, and patient-assessed. We also performed a hand search of reference lists, authors, and patient-reported outcomes (PROs) of the articles screened for inclusion. STUDY SELECTION Studies were included if they (1) incorporated a PRO as a participant descriptor or as a study outcome to compare adults with CAI to ankle-sprain copers or healthy controls, (2) were written in English, and (3) were published in peer-reviewed journals. DATA EXTRACTION Two authors independently assessed methodologic quality using the modified Downs and Black Index. Articles were filtered into 3 categories based on between-groups comparisons: CAI and copers, CAI and healthy control participants, copers and healthy participants. We calculated Hedges g effect sizes and 95% confidence intervals to examine PRO group differences. DATA SYNTHESIS Of the 124 studies assessed for eligibility, 27 were included. A total of 24 articles compared PROs in individuals with CAI and healthy controls, 7 compared individuals with CAI and copers, and 4 compared copers and healthy controls. Quality scores on the modified Downs and Black Index ranged from 52.9% to 88.2%, with 8 high-, 16 moderate-, and 3 low-quality studies. Overall, we observed moderate to strong evidence that individuals with CAI displayed deficits on generic and region-specific PROs compared with copers and healthy controls. However, evidence that differences exist between copers and healthy controls was conflicting. In addition, for dimension-specific outcomes, evidence to suggest that fear of reinjury is heightened in individuals with CAI was limited. CONCLUSIONS The evidence suggested that CAI is associated with functional and HRQOL deficits, particularly when examined with region-specific PROs. However, PROs do not appear to differ between copers and healthy controls.

Plantar cutaneous sensitivity and balance in individuals with and without chronic ankle instability.

Objective:To determine if plantar cutaneous sensation and postural control differ between individuals with and without chronic ankle instability (CAI). Design:Case–control. Setting:Laboratory. Participants:Ten subjects with CAI and 10 subjects with no ankle sprain history participated. Interventions:Light touch was evaluated at 3 sites (heel, base of fifth metatarsal, and head of first metatarsal) on the plantar aspect of the foot using Semmes–Weinstein Monofilaments (SWMs). Postural control was assessed using the single leg firm and foam conditions of the Balance Error Scoring System (BESS) and during eyes open and eyes closed static postural control on a force plate. Main Outcome Measures:Semmes–Weinstein Monofilament detection thresholds, BESS errors, and the mean of time-to-boundary (TTB) minima (TTB-mean) and the SD of TTB minima (TTB-SD) in the anterior–posterior (AP) and medial–lateral directions were evaluated for each subject. Results:Subjects with CAI demonstrated increased SWM detection thresholds at the heel (P = 0.009), head of the first (P = 0.01), and base of the fifth metatarsal (P < 0.001) and postural control deficits on the BESS firm (P = 0.04) and foam (P = 0.001) conditions and with eyes open TTB-mean AP (P = 0.007) and TTB-SD AP (P = 0.02). When combining groups, a negative moderate correlation was observed between the base of the fifth metatarsal detection threshold and eyes open TTB-mean AP (r = −0.50; P = 0.03). Conclusions:Light touch and postural control deficits were observed in individuals with CAI. The correlation between light touch over the base of the fifth metatarsal and eyes open TTB-mean AP suggests that there may be a relevant relationship between these measures. Clinical Relevance:Individuals with CAI demonstrated deficits in light touch over the plantar aspect of the foot. The relationship between base of the fifth metatarsal sensation and TTB-mean AP may provide a starting point to link plantar cutaneous sensory deficits to changes in other aspects of sensorimotor function.

Reliability and minimal detectable change of the weight-bearing lunge test: A systematic review

Ankle dorsiflexion range of motion (DROM) is often a point of emphasis during the rehabilitation of lower extremity pathologies. With the growing popularity of weight-bearing DROM assessments, several versions of the weight-bearing lunge (WBLT) test have been developed and numerous reliability studies have been conducted. The purpose of this systematic review was to critically appraise and synthesize the studies which examined the reliability and responsiveness of the WBLT to assess DROM. A systematic search of PubMed and EBSCO Host databases from inception to September 2014 was conducted to identify studies whose primary aim was assessing the reliability of the WBLT. The Quality Appraisal of Reliability Studies assessment tool was utilized to determine the quality of included studies. Relative reliability was examined through intraclass correlation coefficients (ICC) and responsiveness was evaluated through minimal detectable change (MDC). A total of 12 studies met the eligibility criteria and were included. Nine included studies assessed inter-clinician reliability and 12 included studies assessed intra-clinician reliability. There was strong evidence that inter-clinician reliability (ICC = 0.80-0.99) as well as intra-clinician reliability (ICC = 0.65-0.99) of the WBLT is good. Additionally, average MDC scores of 4.6° or 1.6 cm for inter-clinician and 4.7° or 1.9 cm for intra-clinician were found, indicating the minimal change in DROM needed to be outside the error of the WBLT. This systematic review determined that the WBLT, regardless of method, can be used clinically to assess DROM as it provides consistent results between one or more clinicians and demonstrates reasonable responsiveness.