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Christopher J. Burcal, Alejandra Y. Trier, and Erik A. Wikstrom

Context:

Both balance training and selected interventions meant to target sensory structures (STARS) have been shown to be effective at restoring deficits associated with chronic ankle instability (CAI). Clinicians often use multiple treatment modalities in patients with CAI. However, evidence for combined intervention effectiveness in CAI patients remains limited.

Objective:

To determine if augmenting a balance-training protocol with STARS (BTS) results in greater improvements than balance training (BT) alone in those with CAI.

Design:

Randomized-controlled trial.

Setting:

Research laboratory.

Patients:

24 CAI participants (age 21.3 ± 2.0 y; height 169.8 ± 12.9 cm; mass 72.5 ± 22.2 kg) were randomized into 2 groups: BT and BTS.

Interventions:

Participants completed a 4-week progression-based balance-training protocol consisting of 3 20-min sessions per week. The experimental group also received a 5-min set of STARS treatments consisting of calf stretching, plantar massage, ankle joint mobilizations, and ankle joint traction before each balance-training session.

Main Outcome Measures:

Outcomes included self-assessed disability, Star Excursion Balance Test reach distance, and time-to-boundary calculated from static balance trials. All outcomes were assessed before, and 24-hours and 1-week after protocol completion. Self-assessed disability was also captured 1-month after the intervention.

Results:

No significant group differences were identified (P > .10). Both groups demonstrated improvements in all outcome categories after the interventions (P < .10), many of which were retained at 1-week posttest (P < .10). Although 90% CIs include zero, effect sizes favor BTS. Similarly, only the BTS group exceeded the minimal detectable change for time-to-boundary outcomes.

Conclusions:

While statistically no more effective, exceeding minimal detectable change scores and favorable effect sizes suggest that a 4-week progressive BTS program may be more effective at improving self-assessed disability and postural control in CAI patients than balance training in isolation.

Open access

Christopher J. Burcal, Sunghoon Chung, Madison L. Johnston, and Adam B. Rosen

Background: Region-specific patient-reported outcomes (PROs) are commonly used in rehabilitation medicine. Digital versions of PROs may be implemented into electronic medical records and are also commonly used in research, but the validity of this method of administration (MOA) must be established. Purpose: To determine the agreement between and compare the test–retest reliability of a paper version (FAAM-P) and digital version (FAAM-D) of the Foot and Ankle Ability Measure (FAAM). Study Design: Randomized, nonblinded, crossover observational study. Methods: A total of 90 adults were randomized to complete the FAAM-P or FAAM-D first, and then completed the second MOA (first day [D1]). The FAAM-D was a digital adaptation of both FAAM-P subscales on Qualtrics. Identical test procedures were completed 1 week later (D2). Data were removed if a participant scored 100% on both MOA, reported injury between D1 and D2, or did not complete both MOA. Agreement was assessed on 46 participants between the 2 MOA using intraclass correlation coefficients (ICC) at D1. There was good-to-excellent test–retest reliability for the FAAM activities of daily living. Results: The authors observed good agreement between the FAAM-P and FAAM-D for the activities of daily living (ICC = .88) and sport scales (ICC = .87). Test–retest reliability was good-to-excellent for the FAAM activities of daily living (FAAM-P: ICC = .87; FAAM-D: ICC = .89) and sport (FAAM-P: ICC = .71; FAAM-D: ICC = .91). Conclusions: The MOA does not appear to affect the responses on the FAAM; however, the authors observed slightly higher reliability on the FAAM-D. The FAAM-D is sufficient to be used for generating practice-based evidence in rehabilitation medicine.

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Christopher J. Burcal and Erik A. Wikstrom

Dual-task interference is a phenomenon that often results in performance tradeoffs when simultaneously completing tasks. Inconsistent results in the literature suggest an individualistic response to dual-tasking among chronic ankle instability (CAI) patients. We aim to examine the relationship between dual-task balance outcomes and patient- and clinician-oriented outcomes as well as injury characteristics in CAI patients. We identified moderate correlations between a higher number of ankle rolling instances in the past 3 months and worse balance while dual-tasking. Our results highlight the potential individualistic nature of dual-task impairments that may be masked within larger group comparisons.

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Adam B. Rosen, Abbis Jaffri, Andrew Mitchell, Rachel M. Koldenhoven, Cameron J. Powden, John J. Fraser, Janet E. Simon, Matthew Hoch, and Christopher J. Burcal

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.

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Cameron J. Powden, Rachel M. Koldenhoven, Janet E. Simon, John J. Fraser, Adam B. Rosen, Abbis Jaffri, Andrew B. Mitchell, and Christopher J. Burcal

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.