The 2BFit study: is an unsupervised proprioceptive balance board training programme, given in addition to usual care, effective in preventing ankle sprain recurrences? Design of a randomized controlled trial

Effects of combination of strength and balance training on postural control and functionality in people with chronic ankle instability: a systematic review and meta analysis

AIM

To identify the effects of strength and balance training on dynamic balance and patient reported outcomes in people with chronic ankle instability(CAI).

METHOD

Five databases(CNKI, WanFang, Web of Science, EBSCO-SPORTD and PubMed were searched in September 2022. The search was conducted on randomized controlled trials(RCTs) that the effects of strength training, balance training and combination of strength and balance training in people with chronic ankle instability compared to a control group. Using Review Manager 5.3 and Stata-SE 15 to conduct Meta-analysis on the included literature. methodological quality and risk of bias were assessed by using the PEDro scale.

RESULTS

A total of 33 Chinese and English RCTs document were screened and 1154 patients with CAI were included in the study. Compared with control group, strength training, balance training and combination of strength and balance training demonstrated to be more effective in terms of improving patient reported outcomes(strength training: SMD = 0.80, 95%CI = 0.39-1.22; balance training: SMD = 0.79, 95%CI = 0.41-1.17; combination of strength and balance training: SMD = 1.28, 95%CI = 0.57, 1.99). Subgroup analysis: Intervention for 6 weeks, more than 3 times a week and more than 30 min each time were the best rehabilitation programs to improve CAI patientreported outcomes. Compared with control group, balance training demonstrated to be more effective in terms of improving Star Excursion Balance Test (SEBT)((anterior: SMD = 0.71, 95%CI = 0.03-1.40; posterolateral: SMD = 0.84, 95%CI = 0.22-1.46; posteromedial: SMD = 0.88, 95%CI = 0.45-1.32). However, strength training and combination of strength and balance training had no improvement effects on SEBT.

CONCLUSIONS

Available evidence showed that, results of the comparison between balance training versus strength training suggest that the combination of strength and balance training achieves greater benefits for patient reported outcomes and balance training could bring greater benefits to dynamic balance. Strength training should be used cautiously in clinic to improve the dynamic balance in individuals with CAI.

TRIAL REGISTRATION

( http://www.crd.york.ac.uk/PROSPERO , Registration No. CRD42022371396).

Effectiveness of Mobilization of the Talus and Distal Fibula in the Management of Acute Lateral Ankle Sprain

OBJECTIVE

Distal fibular mobilization with movement (MWM), with and without a posterior gliding fibular tape, and anteroposterior mobilization of the talus (MOB) are widely used to treat acute lateral ankle sprains. The purpose of this study was to investigate the short-term and long-term relative effectiveness of these techniques.

METHODS

In this double-blind randomized controlled trial, 45 amateur soccer players with acute (<72 hours) lateral ankle sprain were randomly allocated to 6 sessions (3/wk within the first 2 weeks) of either MWM, MWM with tape (MWMtape), or MOB. All participants also received general advice, transcutaneous electrical nerve stimulation, edema draining massage, and a program of proprioception exercises. Participant ratings of function on the Foot and Ankle Ability Measure and Patient Global Impression of Improvement Scale were the primary outcomes measured over 52 weeks. Secondary outcomes were ankle pain, pressure pain threshold, range of motion, volume, and strength.

RESULTS

MWM and MWMtape were equally effective and participants demonstrated greater function on the Foot and Ankle Ability Measure at 12 and 52 weeks when compared with those receiving MOB; however, the latter demonstrated superior function at 2 weeks. No differences between groups were observed for Patient Global Impression of Improvement Scale or any of the secondary outcomes.

CONCLUSION

There are limited differences in the short term among techniques, with the exception of better sport function with MOB. Over the longer term, the distal fibular MWM is most effective to achieve activities of daily living and sport function when added to usual physical therapy care. The addition of a posterior gliding fibular tape provides no additional benefit.

IMPACT

Distal fibular mobilization with movement may be the most appropriate choice of treatment for acute lateral ankle sprain to achieve long-term activities of daily living and sport function. In the short term, anteroposterior mobilization of the talus offers greater improvement in sport function. The use of fibular tape provides no added benefit as an adjunct to a treatment that includes distal fibular mobilization with movement.

Rehabilitation Exercises Reduce Reinjury Post Ankle Sprain, But the Content and Parameters of an Optimal Exercise Program Have Yet to Be Established: A Systematic Review and Meta-analysis

OBJECTIVES

To determine if exercise-based rehabilitation reduces reinjury following acute ankle sprain. Our secondary objective was to assess if rehabilitation efficacy varies according to exercise content and training volume.

DATA SOURCES

The following electronic databases were searched: EMBASE, MEDLINE, the Cochrane Central Register of Controlled Trials, and Physiotherapy Evidence Database (PEDro).

STUDY SELECTION

Randomized controlled trials investigating the effect of exercise-based rehabilitation programs on reinjury and patient-reported outcomes (perceived instability, function, pain) in people with an acute ankle sprain. No restrictions were made on the exercise type, duration, or frequency. Exercise-based programs could have been administered in isolation or as an adjunct to usual care. Comparisons were made to usual care consisting of 1 or all components of PRICE (protection, rest, ice, compression, elevation).

DATA EXTRACTION

Effect sizes with 95% CIs were calculated in the form of mean differences for continuous outcomes and odds ratios (ORs) for dichotomous outcomes. Pooled effects were calculated for reinjury prevalence with meta-analysis undertaken using RevMan software.

DATA SYNTHESIS

Seven trials (n=1417) were included (median PEDro score, 8/10). Pooled data found trends toward a reduction in reinjury in favor of the exercise-based rehabilitation compared with usual care at 3-6 months (OR, 0.87; 95% CI, 0.48-1.58) with significant reductions reported at 7-12 months (OR, 0.53; 95% CI, 0.38-0.73). Sensitivity analysis based on pooled reinjury data from 2 high quality studies (n=629) also found effects in favor of exercise-based rehabilitation at 12 months (OR, 0.60; 95% CI, 0.49-0.89). Training volume differed substantially across rehabilitation programs with total rehabilitation time ranging from 3.5-21 hours. The majority of rehabilitation programs focused primarily on postural balance or strength training.

CONCLUSIONS

Exercise-based rehabilitation reduces the risk of reinjury following acute ankle sprain when compared with usual care alone. There is no consensus on optimal exercise content and training volume in this field. Future research must explicitly report all details of administered exercise-based rehabilitation programs.

Preventive lateral ligament tester (PLLT): a novel method to evaluate mechanical properties of lateral ankle joint ligaments in the intact ankle

PURPOSE

To construct and evaluate an ankle arthrometer that registers inversion joint deflection at standardized inversion loads and that, moreover, allows conclusions about the mechanical strain of intact ankle joint ligaments at these loads.

METHODS

Twelve healthy ankles and 12 lower limb cadaver specimens were tested in a self-developed measuring device monitoring passive ankle inversion movement (Inv-ROM) at standardized application of inversion loads of 5, 10 and 15 N. To adjust in vivo and in vitro conditions, the muscular inactivity of the evertor muscles was assured by EMG in vivo. Preliminary, test-retest and trial-to-trial reliabilities were tested in vivo. To detect lateral ligament strain, the cadaveric calcaneofibular ligament was instrumented with a buckle transducer. After post-test harvesting of the ligament with its bony attachments, previously obtained resistance strain gauge results were then transferred to tensile loads, mounting the specimens with their buckle transducers into a hydraulic material testing machine.

RESULTS

ICC reliability considering the Inv-ROM and torsional stiffness varied between 0.80 and 0.90. Inv-ROM ranged from 15.3° (±7.3°) at 5 N to 28.3° (±7.6) at 15 N. The different tests revealed a CFL tensile load of 31.9 (±14.0) N at 5 N, 51.0 (±15.8) at 10 N and 75.4 (±21.3) N at 15 N inversion load.

CONCLUSIONS

A highly reliable arthrometer was constructed allowing not only the accurate detection of passive joint deflections at standardized inversion loads but also reveals some objective conclusions of the intact CFL properties in correlation with the individual inversion deflections. The detection of individual joint deflections at predefined loads in correlation with the knowledge of tensile ligament loads in the future could enable more individual preventive measures, e.g., in high-level athletes.

HOW DOES THE BRAZILIAN ORTHOPEDIC SURGEONS TREAT ACUTE LATERAL ANKLE SPRAIN?

Acute lateral ankle sprain (ALAS) is a common injury, but its treatment has yet to be firmly established. The purpose of this study was to investigate how Brazilian Orthopedists (including residents) manage the diagnosis, classification, treatment and complications of ALAS.

METHODS

A multiple-choice questionnaire was developed with the aim of addressing the main aspects of the treatment of ALAS. The questionnaire was made available on the official website of the Brazilian Society of Orthopedics and Traumatology between June 15 and August 1, 2004.

RESULTS

444 questionnaires were included in the analysis. The results showed agreement among most of the interviewees in the following regards: 90.8% used a classification method to guide treatment of the sprain; 59% classified the ankle sprain with certainty; 63.7% used rigid immobilization in cases of totally torn ligaments; 60.6% used anti-inflammatory medication in cases of partial ligament tears; and 75.9% reported that residual pain was the most frequent complication. There was no consensus regarding the immobilization method for partial ALAS, given that immobilization and functional treatment were chosen with the same frequency (47%). There was no significant difference between the responses from residents and from orthopedists (p = 0.81).

CONCLUSIONS

Orthopedists and orthopedic residents in Brazil have difficulty classifying ALAS and there is no consensus about the best therapeutic option for partial ALAS.

Muscle activity of leg muscles during unipedal stance on therapy devices with different stability properties

OBJECTIVES

To test the hypotheses that less stable therapy devices require greater muscle activity and that lower leg muscles will have greater increases in muscle activity with less stable therapy devices than upper leg muscles.

DESIGN

Cross-sectional laboratory study.

SETTING

Laboratory setting.

PARTICIPANTS

Twenty-five healthy subjects.

MAIN OUTCOME MEASURES

Electromyographic activity of four lower (gastrocnemius medialis, soleus, tibialis anterior, peroneus longus) and four upper leg muscles (vastus medialis and lateralis, biceps femoris, semitendinosus) during unipedal quiet barefoot stance on the dominant leg on a flat rigid surface and on five therapy devices with varying stability properties.

RESULTS

Muscle activity during unipedal stance differed significantly between therapy devices (P < 0.001). The order from lowest to highest relative muscle activity matched the order from most to least stable therapy device. There was no significant interaction between muscle location (lower versus upper leg) and therapy device (P = 0.985). Magnitudes of additional relative muscle activity for the respective therapy devices differed substantially among lower extremity muscles.

CONCLUSIONS

The therapy devices offer a progressive increase in training intensity, and thus may be useful for incremental training programs in physiotherapeutic practice and sports training programs.

Effects of ankle strengthening exercises combined with motor imagery training on the timed up and go test score and weight bearing ratio in stroke patients

[Purpose] The purpose of the present study was to compare the effects of ankle strengthening exercises combined with motor imagery training and those of ankle strengthening exercises alone in stroke patients. [Subjects and Methods] Thirty stroke patients were randomly assigned to one of the following two groups: experimental group (15 patients) and control group (15 patients). The experimental group underwent motor imagery training for 15 minutes and ankle joint strengthening exercises for 15 minutes, while the control group underwent only ankle joint strengthening exercises for 30 minutes. Each session and training program was implemented four times a week for 4 weeks. The timed up and go (TUG) test score, affected-side weight bearing ratio, and affected-side front/rear weight bearing ratio were assessed. [Results] Both groups demonstrated improvement on the TUG test, and in the affected-side weight bearing ratios, affected-side front/rear weight bearing ratios, and balance errors. The experimental group demonstrated greater improvement than the control group in all variables. [Conclusion] Motor imagery training is an effective treatment method for improving static balance ability in stroke patients.

The trAPP-study: cost-effectiveness of an unsupervised e-health supported neuromuscular training program for the treatment of acute ankle sprains in general practice: design of a randomized controlled trial

BACKGROUND

Ankle sprains are one of the most frequent injuries of the musculoskeletal system, with yearly around 680.000 new sprains in The Netherlands. Of these, about 130.000 people will visit the general practitioner (GP) each year. In addition, patients have an increased risk of a recurrent ankle sprain and about a third report at least one re-sprain. No optimal treatment strategy has proven to be effective in general practice, however promising results were achieved in a preventive trial among athletes. Therefore, the objective is to examine the (cost)-effectiveness of an unsupervised e-health supported neuromuscular training program in combination with usual care in general practice compared to usual care alone in patients with acute ankle sprains in general practice.

METHOD/DESIGN

This study is a multi-center, open-label randomized controlled trial, with a one-year follow-up. Patients with an acute lateral ankle sprain, aged between 14 and 65 years and visiting the GP within three weeks of injury are eligible for inclusion. Patients will be randomized in two study groups. The intervention group will receive, in addition to usual care, a standardized eight-week neuromuscular training program guided by an App. The control group will receive usual care in general practice alone. The primary outcome of this study is the total number of ankle sprain recurrences reported during one year follow-up. Secondary outcomes are subjective recovery after one year follow-up, pain at rest and during activity, function, return to sport, cost-effectiveness and compliance of the intervention. Measurements will take place monthly for the study period of 12 months after baseline measurement.

DISCUSSION

For general practitioners the treatment of acute ankle sprains is a challenge. A neuromuscular training program that has proven to be effective for athletes might be a direct treatment tool for acute ankle sprains in general practice. Positive results of this randomized controlled trial can lead to changes in practice guidelines for general practitioners. In addition, since this training program is e-health supported, positive results can also lead to a novel way of injury prevention.

TRIAL REGISTRATION

Dutch Trial Registration: NTR4765.

Implementation of an app-based neuromuscular training programme to prevent ankle sprains: a process evaluation using the RE-AIM Framework

BACKGROUND/AIM

The contemporary electronic media is regarded as a practical tool in the dissemination of preventive measures and interventions. For this purpose an App (free of charge) was developed including an efficacious programme for the prevention of ankle sprain recurrences. This study evaluated the implementation effectiveness of this 'Versterk je Enkel' App.

METHODS

The App was evaluated within its practical context using the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) Framework. The launch of the App was accompanied by a press release, website banners, as well as online and offline advertisements. Data for the evaluation of the App were objectively registered through Google analytics. Data were obtained in February 2013 based on 25,781 users resulting in follow-ups of 18 months (iOS version) and 15 months (Android version), respectively. Users questionnaires provided a qualitative view of the objectively assessed measures (n=82) to gain insight into the demographics of users, reasons to download, user experience and how the information was used.

RESULTS

The App reached only 2.6% of the projected target population. User ratings for the App's relevancy, clarity, usefulness, appeal, information and reliability were high. App usage indicates that compliance with the embedded programme was low.

CONCLUSIONS

Although the App was well received by the users, targeted efforts are required to ensure proper uptake and usage of the App by the target population. This also holds true for eHealth and mHealth efforts aimed at athlete care and injury prevention in general.

Foot orientation affects muscle activation levels of ankle stabilizers in a single-legged balance board protocol

CONTEXT

The main goal of balance training is regaining a normal neuromuscular control to a functional level. Although uniaxial balance boards are commonly used, no research has been done on the effect of foot orientation on muscle activation levels.

OBJECTIVE

To investigate the effect of foot orientation on muscle activation levels and modulation of the ankle stabilizing muscles in a single-legged balance protocol on a uniaxial balance board.

METHODS

Sixty-nine healthy subjects (age: 21.8±1.7years; mass: 67.5±11.9kg; body height: 174.7±8.6cm; BMI: 21.5±3.0) participated in this study. Subjects were asked to keep their balance during a single leg stance on a uniaxial balance board for four different foot orientations, aligning the board's rotation axis with frontal, sagittal, diagonal and subtalar axes of the foot, respectively. Surface electromyography registered muscle activity of peroneus longus, tibialis anterior, medial and lateral gastrocnemius muscles.

RESULTS

Highest muscle activation levels and modulation for the peroneus longus were registered exercising along the frontal axis; for the tibialis anterior along the diagonal axis; for the medial gastrocnemius along the sagittal axis; and for the lateral gastrocnemius along the diagonal axis.

CONCLUSION

Foot orientation modifications on a uniaxial balance board allows to differentially target specific ankle stabilizing muscles during balance training.

The implementation effectiveness of the 'Strengthen your ankle' smartphone application for the prevention of ankle sprains: design of a randomized controlled trial

BACKGROUND

Ankle sprains continue to pose a significant burden to the individual athlete, as well as to society as a whole. However, despite ankle sprains being the single most common sports injury and despite an active approach by various Dutch organisations in implementing preventive measures, large-scale community uptake of these preventive measures, and thus actual prevention of ankle sprains, is lagging well behind. In an attempt to bridge this implementation gap, the Dutch Consumer Safety Institute VeiligheidNL developed a freely available interactive App ('Strenghten your ankle' translated in Dutch as: 'Versterk je enkel; available for iOS and Android) that contains - next to general advice on bracing and taping - a proven cost-effective neuromuscular program. The 'Strengthen your ankle' App has not been evaluated against the 'regular' prevention approach in which the neuromuscular program is advocated through written material. The aim of the current project is to evaluate the implementation value of the 'Strengthen your ankle' App as compared to the usual practice of providing injured athletes with written materials. In addition, as a secondary outcome measure, the cost-effectiveness will be assessed against usual practice.

METHODS/DESIGN

The proposed study will be a randomised controlled trial. After stratification for medical caregiver, athletes will be randomised to two study groups. One group will receive a standardized eight-week proprioceptive training program that has proven to be cost-effective to prevent recurrent ankle injuries, consisting of a balance board (machU/ MSG Europe BVBA), and a traditional instructional booklet. The other group will receive the same exercise program and balance board. However, for this group the instructional booklet is exchanged by the interactive 'Strengthen your ankle' App.

DISCUSSION

This trial is the first randomized controlled trial to study the implementation effectiveness of an App for proprioceptive balance board training program in comparison to a traditional printed instruction booklet, with the recurrence of ankle sprains among athletes as study outcome. Results of this study could possibly lead to changes in practical guidelines on the treatment of ankle sprains and in the use of mobile applications for injury prevention. Results will become available in 2014.

TRIAL REGISTRATION

The Netherlands National Trial Register NTR4027. The NTR is part of the WHO Primary Registries.

Comparison of effects of a proprioceptive exercise program in water and on land the balance of chronic stroke patients

[Purpose] The purpose of this study was to compare changes in balance ability of land exercise and underwater exercise on chronic stroke patients. [Subjects] A total of 60 patients received exercise for 40 minutes, three times a week, for 6 weeks. [Methods] Subjects from both groups performed general conventional treatment during the experimental period. In addition, all subjects engaged in extra treatment sessions. This extra treatment consisted of unstable surface exercise. The underwater exercise group used wonder boards in a pool (depth 1.1m, water temperature 33.5 °C, air temperature 27 °C) dedicated to underwater exercise, and the land exercise group used balance mats. [Result] The joint position sense, sway area, Berg Balance Scale showed significant improvements in both groups. However, the joint position sense test, sway area, and Berg Balance Scale showed there was more improvement in the underwater exercise group than in the land exercise group. [Conclusion] The results suggest that underwater exercise is more effective than land exercise at improving the joint position sense and balance of stroke patients.

The impact of adherence on sports injury prevention effect estimates in randomised controlled trials: looking beyond the CONSORT statement

OBJECTIVE

To investigate estimated outcome effects of a sports injury prevention intervention when analysed by means of a per protocol (PP) analysis approach.

DESIGN

Randomised controlled trial (RCT) involving 522 athletes who sustained a lateral ankle sprain allocated to either an intervention (received a preventive programme in addition to usual care) or control group who were followed prospectively for one year.

METHODS

Secondary analysis of data relating to registered ankle sprain recurrences, exposure and adherence to the allocated intervention using a PP analysis approach.

RESULTS

Twenty-three percent of the RCT intervention group indicated to have fully adhered with the neuromuscular training programme. A per protocol analysis only considering fully adherent athletes and control athletes, showed a Hazard Ratio of 0.18 (95% CI: 0.07-0.43). Significantly fewer recurrent ankle sprains were found in the fully adherent group compared to the group that was not adherent (relative risk = 0.63; 95% CI: 0.43-0.99).

CONCLUSIONS

A PP analysis on fully adherent athletes versus control group athletes showed that the established intervention effect was over threefold higher compared to an earlier intention-to-treat based analysis approach. This shows that outcomes of intervention studies are heavily biased by adherence to the allocated intervention.

Potential savings of a program to prevent ankle sprain recurrence: economic evaluation of a randomized controlled trial

BACKGROUND

The most common ankle injury is the lateral ankle sprain. Dutch annual sports-related ankle sprain costs can roughly be estimated at €187,200,000. Research has shown that proprioceptive training accounts for an approximated overall 50% reduction in ankle sprain recurrence rate.

HYPOTHESIS

An unsupervised proprioceptive training program to reduce the recurrence of lateral ankle sprains will reduce overall health care costs.

DESIGN

Cohort study (economic analysis); Level of evidence, 2.

METHODS

The study included 522 male and female athletes: 256 athletes (120 female and 136 male) in the intervention group, and 266 athletes (128 female and 138 male) in the control group. Both groups received treatment according to usual care. Athletes allocated to the intervention group received an 8-week proprioceptive training program in addition to usual care. Costs per athlete and costs per injured athlete were calculated. Costs related to ankle sprain recurrences were measured from a societal perspective using cost diaries. Bootstrapping was used to analyze the cost-effectiveness data. Follow-up was 1 year.

RESULTS

Mean total costs in the intervention group were €81 (standard deviation, €134) per athlete and €114 (€325) per injured athlete. Mean overall costs in the control group were €149 (€836) per athlete and €447 (€1403) per injured athlete. Statistically significant differences in total costs were found per athlete (mean difference, -€69; 95% confidence interval, -€200 to -€2) and per injured athlete (-€332; -€741 to -€62) in favor of the intervention group. A cost-effectiveness plane showed the effect of the intervention was larger and the costs were lower in the intervention group than the control group.

CONCLUSION

The use of a proprioceptive training program after usual care of an ankle sprain is cost-effective for the prevention of ankle sprain recurrences in comparison with usual care alone. In the Netherlands, an estimated annual €35.9 million in medical and lost productivity costs can be saved solely by advocating a proprioceptive training program as in the present study.

Effect of unsupervised home based proprioceptive training on recurrences of ankle sprain: randomised controlled trial

OBJECTIVE

To evaluate the effectiveness of an unsupervised proprioceptive training programme on recurrences of ankle sprain after usual care in athletes who had sustained an acute sports related injury to the lateral ankle ligament.

DESIGN

Randomised controlled trial, with one year follow-up.

SETTING

Primary care.

PARTICIPANTS

522 athletes, aged 12-70, who had sustained a lateral ankle sprain up to two months before inclusion; 256 (120 female and 136 male) in the intervention group; 266 (128 female and 138 male) in the control group.

INTERVENTION

Both groups received treatment according to usual care. Athletes allocated to the intervention group additionally received an eight week home based proprioceptive training programme.

MAIN OUTCOME MEASURE

Self reported recurrence of ankle sprain.

RESULTS

During the one year follow-up, 145 athletes reported a recurrent ankle sprain: 56 (22%) in the intervention group and 89 (33%) in the control group. Nine athletes needed to be treated to prevent one recurrence (number needed to treat). The intervention programme was associated with a 35% reduction in risk of recurrence. Cox regression analysis showed significantly fewer recurrent ankle sprains in the intervention than in the control group. This effect was found for self reported recurrent ankle sprains (relative risk 0.63, 95% confidence interval 0.45 to 0.88), recurrent ankle sprains leading to loss of sports time (0.53, 0.32 to 0.88), and recurrent ankle sprains resulting in healthcare costs or lost productivity costs (0.25, 0.12 to 0.50). No significant differences were found between medically treated athletes in the intervention group and medically treated controls. Athletes in the intervention group who were not medically treated had a significantly lower risk of recurrence than controls who were not medically treated.

CONCLUSIONS

The use of a proprioceptive training programme after usual care of an ankle sprain is effective for the prevention of self reported recurrences. This proprioceptive training was specifically beneficial in athletes whose original sprain was not medically treated.

TRIAL REGISTRATION

ISTRCN34177180.