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Kathryn A. Webster and Phillip A. Gribble

Context:

Functional rehabilitation is often employed for ankle instability, but there is little evidence to support its efficacy, especially in those with chronic ankle instability (CAI).

Objective:

To review studies using both functional rehabilitation interventions and functional measurements to establish the effectiveness of functional rehabilitation for both postural control and self-reported outcomes in those with CAI.

Evidence Acquisition:

The databases of Medline, SPORTDiscus, and PubMed were searched between the years 1988 and 2008. Inclusion criteria required articles to have used a clinical research trial involving at least 1 functional rehabilitation intervention, have at least 1 outcome measure of function and/or functional performance, and to have used at least 1 group of subjects who reported either repeated lateral ankle sprains or episodes of “giving way.” The term functional was operationally defined as dynamic, closed-kinetic-chain activity other than quiet standing.

Evidence Synthesis:

Six articles met the inclusion criteria. The articles reviewed used multiple functional means for assessment and training, with a wobble board or similar device being the most common. Despite effect sizes being inconsistent for measures of dynamic postural control, all interventions resulted in improvements. Significant improvements and strong effect sizes were demonstrated for self-reported outcomes.

Conclusions:

The reviewed studies using functional rehabilitation interventions and functional assessment tools were associated with improved ankle stability for both postural control and self-reported function, but more studies may be needed with more consistent effect sizes and confidence intervals to make a definitive conclusion.

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Shiho Goto, Naoko Aminaka and Phillip A. Gribble

Context : Altered lower-extremity muscle activity has been associated with lower-extremity kinematics in individuals with patellofemoral pain (PFP). However, few studies have examined these relationships, and the results are inconsistent. Objective: To compare the lower-extremity muscle activity, kinematics, pain level, and reach distance during the anterior reach of the star excursion balance test (SEBT) between participants with PFP and healthy individuals (control [CON] group). Design: Case control. Setting: Research laboratory. Participants: Twenty-eight (PFP = 14 and CON = 14) participants volunteered. Intervention: Each participant performed 3 maximal voluntary isometric contractions of the gluteus maximus, gluteus medius (GMED), adductor longus (AL), and vastus medialis, and 5 anterior reaches of the SEBT. Main Outcome Measures: Three-dimensional joint kinematics of the hip and knee at the time of touchdown of the SEBT and integrated electromyography of each muscle were recorded during the descent phase of the SEBT. Coactivation ratios between the GMED and AL were calculated (GMED/AL). Pain level was assessed at the baseline and during performance of the SEBT, using a visual analog scale. Results: Participants with PFP demonstrated decreased GMED/AL coactivation ratio (P = .01) and shorter reach distance (P = .01) during anterior reach of the SEBT compared with the CON group. Participants with PFP demonstrated higher pain levels at baseline (P = .03) and during test performance (P < .001) compared with the CON group and increased pain level during the test performance compared with the baseline (P < .001). No other significant differences were observed. Conclusions: There were alterations in muscle activity during SEBT performance, suggesting that overactivity of AL relative to GMED is a unique neural recruitment pattern in those with PFP. However, hip and knee joint kinematics did not seem to contribute to deficits in the anterior reach distance, suggesting a need for continued assessment of these deficiencies.

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Kyle B. Kosik and Phillip A. Gribble

Clinical Scenario: Dorsiflexion range of motion is an important factor in the performance of the Star Excursion Balance Test (SEBT). While patients with chronic ankle instability (CAI) commonly experience decreased reach distances on the SEBT, ankle joint mobilization has been suggested to be an effective therapeutic intervention for targeting dorsiflexion range of motion. Clinical Question: What is the evidence to support ankle joint mobilization for improving performance on the SEBT in patients with CAI? Summary of Key Findings: The literature was searched for articles examining the effects of ankle joint mobilization on scores of the SEBT. A total of 3 peer-reviewed articles were retrieved, 2 prospective individual cohort studies and 1 randomized controlled trial. Only 2 articles demonstrated favorable results following 6 sessions of ankle joint mobilization. Clinical Bottom Line: Despite the mixed results, the majority of the available evidence suggests that ankle joint mobilization improves dynamic postural control. Strength of Recommendation: In accordance with the Centre of Evidence Based Medicine, the inconsistent results and the limited high-quality studies indicate that there is level C evidence to support the use of ankle joint mobilization to improve performance on the SEBT in patients with CAI.

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Megan Q. Beard, Samantha A. Boland and Phillip A. Gribble

Decreased hip strength is often present in patients with chronic overuse lower extremity injuries. The hand-held dynamometer (HHD) can be used in a clinical setting to quantify hip strength; however, reliability of the device remains unclear. The purpose of this study was to determine the interexaminer and intersession reliability of a HHD when measuring isometric hip abduction (HABD) and external rotation (HER) strength, both with and without a fixed strap. The HHD had good to high reliability regardless of examiner, session, or stabilization when measuring HABD (ICC = 0.885–0.977) and HER (ICC = 0.879–0.958) isometric strength. HHD is an appropriate instrument for measuring isometric hip strength.

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Bridget M. Walsh, Katherine A. Bain, Phillip A. Gribble and Matthew C. Hoch

Clinical Scenario: Patients with chronic ankle instability (CAI) commonly display lower levels of self-reported function and health-related quality of life. Several rehabilitation interventions, including manual therapy, have been investigated to help CAI patients overcome these deficits. However, it is unclear if the addition of manual therapy to exercise-based rehabilitation is more effective than exercise-based rehabilitation alone. Clinical Question: Does incorporating manual therapy with exercise-based rehabilitation improve patient-reported outcomes when compared with exercise-based rehabilitation alone? Summary of Key Findings: The literature was searched for articles that examined the difference in outcomes for patients with CAI between manual therapy with exercise-based rehabilitation and exercise-based rehabilitation alone. A total of 3 peer-reviewed randomized controlled trials were identified. Two articles demonstrated improved patient-reported outcome scores following the incorporation of manual therapy with exercise-based rehabilitation, whereas one study found no statistically significant differences between interventions. Clinical Bottom Line: The current evidence suggests that incorporating manual therapy in addition to exercised-based rehabilitation may improve patient-reported outcome scores in patients with CAI. Strength of Recommendation: In accordance with the Strength of Recommendation Taxonomy, the grade of A is recommended due to consistent evidence from high-quality studies.

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Katherine L. Helly, Katherine A. Bain, Phillip A. Gribble and Matthew C. Hoch

Clinical Scenario: Patients with chronic ankle instability (CAI) demonstrate deficits in both sensory and motor function, which can be objectively evaluated through static postural control testing. One intervention that has been suggested to improve somatosensation and, in turn, static postural control is plantar massage. Clinical Question: Does plantar massage improve static postural control during single-limb stance in patients with CAI relative to baseline? Summary of Key Findings: A search was performed for articles exploring the effect of plantar massage on static postural control in individuals with CAI. Three articles were included in this critically appraised topic including 1 randomized controlled trial and 2 crossover studies. All studies supported the use of plantar massage to improve static postural control in patients with CAI. Clinical Bottom Line: There is currently good-quality and consistent evidence that supports the use of plantar massage as an intervention that targets the somatosensory system to improve static postural control in patients with CAI. Future research should focus on incorporating plantar massage as a treatment intervention during long-term rehabilitation protocols for individuals with CAI. Strength of Recommendation: In agreement with the Center of Evidence-Based Medicine, the consistent results from 2 crossover studies and 1 randomized controlled trial designate that there is level B evidence due to consistent, moderate- to high-quality evidence.

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Matthew Harkey, Michelle M. McLeod, Masafumi Terada, Phillip A. Gribble and Brian G. Pietrosimone

Context:

Spinal-reflexive and corticomotor excitability may have a critical role in altering muscle function needed to stabilize the ankle in people with chronic ankle instability (CAI).

Objective:

To determine the association between self-reported disability and both spinal-reflexive and corticomotor excitability in people with CAI.

Design:

Descriptive laboratory study.

Setting:

Research laboratory.

Participants:

30 participants with CAI.

Main Outcome Measures:

Soleus spinal-reflexive excitability was measured with normalized Hoffmann reflexes (H:M ratio), and corticomotor excitability was measured with transcranial magnetic stimulation and quantified by normalized motor-evoked-potential (MEP) amplitudes at 120% of active motor threshold (120%MEP). Self-reported disability was quantified with the activities-of-daily-living and sport subscales of the Foot and Ankle Ability Measure (FAAM-ADL and FAAM-S). Separate linear Pearson product–moment correlations and nonlinear quadratic correlations were used to determine associations between the neural-excitability and disability variables.

Results:

Thirty participants were included in the spinal-reflexive-excitability analysis, while only 19 were included in the corticomotor analysis. There was a significant, weak linear association between H:M ratio and FAAM-ADL (R = .39, P = .03) and a nonsignificant, weak linear association between H:M ratio and FAAM-S (R = .36, P = .06). There were significant, moderate quadratic associations between H:M ratio and both FAAM-ADL (R = .48, P = .03) and FAAM-S (R = .50, P = .02). There was a significant, moderate linear association between 120%MEP and FAAM-ADL (R = –.48, P = .04) and a nonsignificant, moderate negative linear association between FAAM-S (R = –.42, P = .07). There was a significant, moderate quadratic association between 120%MEP and FAAM-ADL (R = .57, P = .046) and a significant, strong quadratic correlation between 120%MEP and FAAM-S (R = .71, P = .004).

Conclusions:

There are significant quadratic associations between self-reported disability and both spinal-reflexive and corticomotor excitability of the soleus. CAI participants with low or high neural excitability present with lower function.

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Phillip A. Gribble, Richard H. Robinson, Jay Hertel and Craig R. Denegar

Context:

Deficits in static postural control related to fatigue have been investigated previously, but there is little evidence to link fatigue to performance measures of dynamic postural control.

Objective:

To investigate the effects of fatigue and gender on performance measures of the Star Excursion Balance Test (SEBT).

Design:

Mixed-model design.

Setting:

Research laboratory.

Participants:

16 healthy young adults.

Intervention:

Subjects performed the SEBT before and after 4 different fatiguing conditions.

Main Outcome Measures:

The normalized reach distances and sagittal-plane kinematics of the knee and hip were recorded.

Results:

Fatigue produced deficits in normalized reach distances and decreased knee flexion in all 3 reaching directions. Overall, women were able to reach farther than men while simultaneously demonstrating a greater amount of knee flexion.

Conclusions:

Gender differences were observed during performance of the SEBT, with women demonstrating greater reach distances and knee flexion, and fatigue amplified these differences.

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Hayley M. Ericksen, Brian Pietrosimone, Phillip A. Gribble and Abbey C. Thomas

Context: Feedback is an important factor in interventions designed to reduce anterior cruciate ligament injury risk. Self-analysis feedback requires participants to self-critique their jump-landing mechanics; however, it is unknown if individuals can effectively self-analyze their own biomechanics and if this self-analysis agrees with observed biomechanical changes by an expert. Objective: To determine agreement between an expert and participants on biomechanical errors committed during 3 of 12 sessions, which were part of an intervention to change jump-landing biomechanics in healthy females. Design: Descriptive analysis. Setting: Research laboratory. Patients or Other Participants: Healthy recreationally active females with no history of lower-extremity fracture or surgery. Interventions: Participants completed a 4-week, 12-session feedback intervention. Each intervention session lasted approximately 15 minutes and included asking participants to perform 6 sets of 6 jumps off a 30-cm-high box placed 50% of their height away from the target landing area. Participants performed self-analysis feedback and received expert feedback on 7 different jump-landing criteria following each set of jumps. Main Outcome Measures: Data were coded, and agreement between the expert and the participant was assessed using Cohen’s unweighted kappa for sessions 1, 6, and 12. Results: There was agreement between the expert and participants for 0/7 criteria for session 1, 3/7 criteria for session 6, and 4/7 criteria for session 12. Conclusions: Participants demonstrated some agreement with the expert when evaluating their jump-landing biomechanics. Self-analysis feedback may not replace what an expert can provide; both types of feedback may be better used in conjunction to produce significant biomechanical changes. Changes made by the participant may not translate into biomechanical changes during a real-life game or practice situation. Future research should continue to investigate effective interventions to reduce injury risk.

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Kate R. Pfile, Phillip A. Gribble, Gretchen E. Buskirk, Sara M. Meserth and Brian G. Pietrosimone

Context:

Epidemiological data demonstrate the need for lower-extremity injury-prevention training. Neuromuscularcontrol (NMC) programs are immediately effective at minimizing lower-extremity injury risk and improving sport-related performance measures. Research investigating lasting effects after an injury-prevention program is limited.

Objective:

To determine whether dynamic balance, landing mechanics, and hamstring and quadriceps strength could be improved after a 6-wk NMC intervention and maintained for a season.

Design:

Prospective case series.

Setting:

Controlled laboratory.

Participants:

11 Division I women’s basketball players (age 19.40 ± 1.35 y, height 178.05 ± 7.52 cm, mass 72.86 ± 10.70 kg).

Interventions:

Subjects underwent testing 3 times, completing the Star Excursion Balance Test (SEBT), Landing Error Scoring System (LESS), and isometric strength testing for the hamstrings and quadriceps muscles. Pretest and posttest 1 occurred immediately before and after the intervention, respectively, and posttest 2 at the end of the competitive season, 9 mo after posttest 1. Subjects participated in eighteen 30-min plyometric and NMC-training sessions over a 6-wk period.

Main Outcome Measures:

The normalized SEBT composite score, normalized peak isometric hamstrings:quadriceps (H:Q) ratio, and the LESS total score.

Results:

The mean composite reach significantly improved over time (F 2,10 = 6.96, P = .005) where both posttest scores were significantly higher than pretest (70.41% ± 4.08%) (posttest 1 73.48% ± 4.19%, t 10 = –3.11, P = .011) and posttest 2 (74.2% ± 4.77%, t 10 = –3.78, P = .004). LESS scores significantly improved over time (F 2,10 = 6.29, P = .009). The pretest LESS score (7.30 ± 3.40) was higher than posttest 1 (4.9 ± 1.20, t 10 = 2.71, P = .024) and posttest 2 (5.44 ± 1.83, t 10 = 2.58, P = .030). There were no statistically significant differences (P > .05) over time for the H:Q ratio when averaging both legs (F 2,10 = 0.83, P = .45).

Conclusions:

A 6-wk NMC program improved landing mechanics and dynamic balance over a 9-mo period in women’s basketball players. NMC adaptations can be retained without an in-season maintenance program.