Effect of Mindfulness Training in Chronic Ankle Instability Among Collegiate Athletes
Phase: NA
Conditions: Musculoskeletal Pain, Ankle Injuries, Joint Instability
Sponsor: Universiti Tunku Abdul Rahman

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FULL STUDY PROTOCOL, 
STATISTICAL ANALYSIS PLAN (SAP) 
& INFORMED CONSENT FORMS (ICF) 
 
 
 
 
 
 
“Effect of Mindfulness Training in Chronic Ankle Instability among  
Collegiate Athletes” 
 
 
 
 
Ethical approval: FHLS 15/2017 
 
 
 
 
 
 
 
 
 
 
 
 
 15th January 2018 

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Table of Contents 
1. Personnel ................................................................................................................................ 3 
2. Introduction ............................................................................................................................ 4 
2.1 Background & Aims......................................................................................................... 4 
2.2 Background Literature Review ........................................................................................ 5 
3. Study Protocol ........................................................................................................................ 7 
3.1 Research Design Outline .................................................................................................. 7 
3.2 Participants ....................................................................................................................... 8 
3.3 Recruitment ...................................................................................................................... 8 
3.4 Randomization ............................................................................................................... 10 
3.5 Administration ................................................................................................................ 10 
3.6 Assessment & Outcomes Measures ............................................................................... 11 
3.7 Sample Size .................................................................................................................... 14 
4. Statistical Analysis Plan (SAP) ............................................................................................ 15 
4.1 Primary Outcomes .......................................................................................................... 15 
4.2. Secondary Outcomes ..................................................................................................... 17 
4.3 Missing Data................................................................................................................... 18 
5. Informed Consent Forms (ICF) ........................................................................................... 19 
5.1 Risks to participants ....................................................................................................... 19 
5.2 Privacy and Confidentiality ............................................................................................ 20 
6. References ............................................................................................................................ 21 

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1. Personnel 
 
 
 
 
 
Principal Investigator 
Dr. Lee Poh Foong 
Investigators 
Mr.Vinodhkumar 
Ramalingam 
 
Prof Dr. Soon Keng Cheong 
 
Ms.Swii Yitt Ho 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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2. Introduction 
 
2.1 Background & Aims 
 
Chronic ankle instability (CAI) is the most common musculoskeletal injury in sports and the 
rate of CAI accounts for 85% of ankle injuries. It has been estimated that 23,000 ankle 
sprains occur each day in the United States, representing approximately 1 sprain per 10,000 
people per day and nearly one in five ankle injuries result in chronic symptoms. Numerous 
researchers applied mindfulness for improving the performance of various sports such as 
table tennis, shooting, cricket, archery, golf, swimming, and cycling. Since many of the 
players do not possess effective pain coping skills, they are at risk for lifelong impairment of 
their emotional, social, and physical functioning. Mindfulness-centered interventions may 
well serve to mitigate pain-related disability. Training in mindfulness meditation improves 
anxiety, depression, stress, and cognition. Mindfulness-related health benefits are associated 
with enhancements in cognitive control, emotion regulation, positive mood, and acceptance, 
each of which have been associated with pain modulation. Since mindfulness has been 
proven effective in managing various health disorders and in enhancing sports performance, 
our study aims to apply the mindfulness approach in rehabilitating the most common sports 
injury, CAI. The improvement in CAI due to the mindfulness approach will be assessed by 
the improvement in pain response through the Cumberland ankle instability tool, Functional 
ankle disability index (FADI), Visual analog scale (VAS), Brief Pain Inventory (BPI), Y-
balance test, Mindfulness attention awareness score (MAAS), Oxford Happiness 
Questionnaire (OHQ) quantitative electroencephalography (Q-EEG). This study finding will 
be useful in assessing the effectiveness of mindfulness in rehabilitating CAI and identify the 
correlation of CAI pain response with VAS & BPI, quantitative electroencephalography - Q-
EEG. In this clinical trial, we wish to use noninvasive methods such as quantitative EEG 
(electroencephalogram) to find the brainwave patterns during the different stages of 

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mindfulness intervention (pre and post). The outcome of this study will eventually lead to the 
identification of a better assessment method to indicate the pain response for the appropriate 
physiotherapy management. The application of mindfulness technique in CAI management 
and the usage of Q- EEG to assess the pain response in chronic ankle injury athletes are the 
novel approaches of this research study. 
 
 
2.2 Background Literature Review 
 
Chronic ankle pain can affect all age groups, ranging from young athletes to elderly patients 
with degenerative joint and soft-tissue disorders. As nearly one in five ankle injuries result in 
chronic symptoms1. Approximately 60 percent of the injuries occurred in players younger 
than 20 years of age. The majority of injuries (91.5 percent) were categorized as mild 
overuse injury and mostly involved the knee and ankle. The majority of the injuries were 
diagnosed in younger players and occurred during training/practice sessions2. Athletes who 
sustained an injury are potentially at the risk of developing major depressive and 
posttraumatic stress disorders. The injured athletes suffer from depression 6 times more in 
chances as compared to the non-injured athletes3. Besides, the injured athletes also exhibit 
greater anxiety and lower self-esteem. In chronic sports injuries, the athletes are more likely 
to become depressed than the counterpart.  Practicing in elite level sports offers an entirely 
different set of circumstances, representing a high-pressure career replicate with stressors 
and constraints that tend to cause injuries to the athletes4. 

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In accordance to Putukian, (2016) stress is an important antecedent to injuries and can play a 
role in the response to, rehabilitation and return to play after injury5. The psychological 
response to injury can trigger and/or unmask mental health issues including depression and 
suicidal ideation, anxiety, disordered eating, and substance use/abuse. There are barriers to 
mental health treatment in athletes. They often consider seeking help as a sign of weakness, 
feeling that they should be able to ‘push through’ psychological obstacles as they do physical 
activities. Athletes may not have developed healthy coping behaviors making response to 
injury. Shivarathre et al., (2014) showed a significant association of anxiety, depression, and 
neuroticism in patients presenting with chronic foot and ankle pain6. 
 
Mindfulness meditation has been found to improve a wide spectrum of cognitive and health 
outcomes. Training in mindfulness meditation improves anxiety, depression, stress, and 
cognition. Mindfulness-related health benefits are associated with enhancements in cognitive 
control, emotion regulation, positive mood, and acceptance, each of which have been 
associated with pain modulation. A pilot study by Schmidt et al., (2015) using 8-week 
mindfulness-based stress reduction (MBSR) program on a sample of low back pain patients 
was conducted in order to assess the feasibility and effectiveness of the intervention as well 
as changes in an EEG pattern called thalamocortical dysrhythmia which is associated with 
chronic pain7. For a full MBSR course, it can take up to eight weeks, with weekly meetings 
that last for about three hours and daily practice of about an hour8. This can be difficult to 
adhere to especially in the current fast-paced lifestyle of young people9.  With due 
consideration with participants’ compliance, the mindfulness intervention practice of the 
present study has been modified to 3- min video assisted mindfulness deep breathing.  
Furthermore, the follow up of participants’ home practices will be monitored with the use of 
a smartphone app which has the facility to send reminders as text messages to fill in the 

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practice diaries or online portals to record the frequency of home practice of our intervention. 
We wish to apply the video assisted mindful deep breathing combined with standard 
physiotherapy to find the effectiveness of the interventions in attention process to reduce the 
incidence of reoccurrence of chronic ankle instability. 

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3 Study Protocol 
 
3.1 Research Design Outline 
 
The study aims to perform a randomized control trial on CAI participants in INTI 
physiotherapy centre and compare with healthy controls as a casual comparative study 
 
Study 1 (Formerly titled “Effect of short duration video assisted mindful deep breathing 
among collegiate athletes with chronic ankle instability– a Randomised Control Trial”) 
involves participants with chronic ankle instability by using the Cumberland Ankle 
Instability Tool (CAIT)10,  if the score was ≤27 in the CAIT tool over 30 by fulfilling the 
inclusion criteria.  
 
 
Study 2 is a causal comparative study, which involves age matched healthy collegiate athlete 
from local university and compared them with the baseline parameters of Study 1. 
 
 
 
The proposed study designs are all investigator blinded in the randomized control trials 
(Study 1). Participants    only be involved in Study 1 and baseline measurements are compared 
with Study 2. 
 
 
 
3.2 Participants 
 
Study 1 and 2 
 
University students those who involved in collegial sports with chronic ankle instability and 
without chronic ankle instability/musculoskeletal injuries from INTI International 
University at Malaysia will be eligible to participate in this   study. 

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Study investigators will not be eligible to participate. 
 
Participants randomized to experimental group in the study 1 will require a personal android 
support hand phone to the install the VAMDB from the google app store to participate. 
 
 
3.3Recruitment 
 
Study 1 
 
All participants with chronic ankle instability (CAI) attending the INTI physiotherapy centre  
will be enrolled in the study at  Phase 1. The participation information and consent sheet will 
be distributed which details including inclusion and exclusion criteria. Interested CAI 
participants will be invited to undergo baseline assessments (pain – Visual analog score 
(VAS), Brief pain inventory (BPI); Balance – Cumberland ankle instability tool (CAIT), 
functional ankle disability index (FADI) and Y-balance test; psychology – mindfulness 
attention awareness score (MAAS) and oxford happiness questionnaire (OHQ); quantitative 
EEG) with scheduled appointments.  
All participants will have to return a signed consent form to the physiotherapy centre officer 
to  random allocation to a study group. 
 
 
Study 2 
 
 
All participants without chronic ankle instability (CAI)/ musculoskeletal injuries will be 
invited by flyers and sending an invitation to University sports club. The participation 
information and consent sheet will be distributed which details including inclusion and 
exclusion criteria. Interested CAI participants will be invited to undergo baseline 

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assessments (Balance – Cumberland ankle instability tool, functional ankle disability index; 
psychology – mindfulness attention awareness score and oxford happiness questionnaire; 
quantitative EEG) with scheduled appointments. All participants will have to return a signed 
consent form to physiotherapy centre officer for allocation to a study group 
 
3.4 Randomization 
 
Collegiate athletes with CAI who consent to participate will be randomly allocated (within 
their study) to one of two groups (at a ratio of 1:1): the intervention, the standard 
physiotherapy, and short duration video assisted mindful deep breathing + standard 
physiotherapy. Whereas the participants without CAI (healthy age matched control) will be 
allocated to group 3 as healthy controls.  
 
Computer randomisation (http://www.graphpad.com/quickcalcs/index.cfm) and concealed 
envelopes will be used for CAI participants. 
Participants will be allocated a unique identification number, and this  will be recorded 
against their identification number allocation in an electronic database. This will be done 
by the INTI physiotherapy centre maintenance officer to ensure the investigators remain 
blinded. 
 
 
3.5 Administration 
 
Study 1 
 
Participants allocated to experimental and experimental control group will be given the 
appropriate access for 12 weeks (instructions provided in the study envelope). Participants 
will be encouraged to attend the regular appointments for 5 times a week for 6 weeks 
intervention and follow up (week12) in INTI international university physiotherapy centre. At 

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the end of week 3, end of week 6 and end of week 12 instructed to participate in post 
intervention assessments the duration of waiting time and assessment time will be clearly 
stated under the guidelines.  
 
Study 2 
 
Participants allocated to healthy control group will be given the appropriate access for 
baseline assessment (instructions provided in the study envelope) 
3.6 Assessment & Outcomes Measures 
 
Study 1 
Chronic ankle Instability (CAI) participants will be assessed for: 
 
1. Primary outcomes 
 
 Cumberland Ankle Instability Tool (CAIT) 
 
o Ankle stability will be assessed by validated 9-item Questionnaire, to find the 
chronic ankle disability score among participants and to recruit in the study if 
the score was ≤27 in the CAIT tool over 30. 
 
 Y-balance test (YBT) 
o The dynamic balance of the participants will be assessed using reliable and 
validated the Y balance test (YBT) by measuring the distance in anterior, 
posterolateral, and posteromedial directions.  
 Visual analog scale (VAS) 
o CAI participants pain intensity will be record by self-reported pain intensity 
on a 10 cm line to point out the pain level. The point at 0 cm represents "no 
pain" and 10 cm represents "worst pain".  
 Brief Pain Inventory (BPI) 

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o Besides VAS, pain intensity and pain interference will be recorded using 4- 
items (worst pain, least pain, average pain, and pain right now) to measure the 
pain intensity, and 7 -items (general activity, mood, walking, normal work, 
relations, sleep, enjoyment of life) to assess the pain interference. The 
participants will be instructed to report the pain intensity from 0 (no pain) to 
10 (as pain bad as you can imagine). Similarly, the pain interference is 
recorded from 0 (does not interfere) to 10 (completely interferes) 
 Mindful Attention Awareness Scale (MAAS) 
o  CAI participants will be assessed by 15-item questionnaire to identify the 
participants' mindfulness level during the ankle instability. 
 Oxford Happiness Questionnaire (OHQ) 
o Happiness level of CAI participants will be assessed using the Oxford 
Happiness Questionnaire (OHQ), which consists of a 29-item questionnaire. 
 Functional ankle disability index (FADI) 
 
o CAI participants will be asked to complete 34-item questionnaire used to 
check the participant's general daily activity and sports specific functions 
for physical function and disability. 
 
 
2. Secondary outcomes 
 
 
 Non-invasive wireless electroencephalogram (EEG) 
o EEG will be used at 14 positions: AF3, AF4, F3, F4, F7, F8, FC5, FC6, P7, 
P8, T7, T8, O1, and O2. The EEG recordings of the CAI participants will be 
collected between 9 and 12 hours in the morning to reduce participants 
sleeping artifacts and to exclude the EEG from the influence of circadian 
variables. The EEG recordings will be  recorded in eyes closed and eyes 

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open for 2mins. 
 
The time commitment required of participants for assessment will be approximately 60 mins. 
 
 
 
 
Study 2 
 
Healthy control participants will be assessed for: 
 
1. Primary outcomes 
 
 Cumberland Ankle Instability Tool (CAIT) 
 
o Ankle stability will be assessed by validated 9-item Questionnaire, among 
participants and to recruit in the study if the score was >27 in the CAIT tool 
over 30. 
 
 Functional ankle disability index (FADI) 
 
o Participants will be asked to complete 34-item questionnaire used to 
check the participant's general daily activity and sports specific functions 
for physical function. 
 Mindful Attention Awareness Scale (MAAS) 
o Participants will be assessed by 15-item questionnaire to know the 
mindfulness attention level. 
 Oxford Happiness Questionnaire (OHQ) 
o Happiness level of participants will be assessed using the Oxford Happiness 
Questionnaire (OHQ), which consists of a 29-item questionnaire.  
 
2. Secondary outcomes 
 
 Non-invasive wireless electroencephalogram (EEG) 

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o EEG will be used at 14 positions: AF3, AF4, F3, F4, F7, F8, FC5, FC6, P7, 
P8, T7, T8, O1, and O2. The EEG recordings of the participants will be 
collected between 9 and 12 hours in the morning to reduce participants 
sleeping artifacts and to exclude the EEG from the influence of circadian 
variables. The EEG recordings will berecorded in eyes closed and eyes open 
for 2mins. 
 
The time commitment required of participants for assessment will be approximately 45 
mins. 
 
 
 
3.7 Sample Size 
 
 
Study 1 
 
G*power was utilized for sample size calculation with equal group sizes (i.e ratio of groups 
1:1). A total of 36 participants with CAI (i.e. 18 in each group) to be able to reject the null 
hypothesis that the population means of the experimental and control groups are equal with 
probability (power) 0.95. The Type I error probability associated with this test of this  null 
hypothesis is 0.0511. 
 Assuming a total drop-out rate of 10%, we will recruit 20 subjects for each group, i.e. 
20 experimental and 20 experimental control group. 
Study 2 
 
A total of 20 participants without CAI will be recruited and compared with the age matched 
CAI participants in the study 1.   
 

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4. Statistical Analysis Plan (SAP) 
 
 
All Studies 
 
Descriptive and inferential statistics will be used. Normally distributed data will be presented 
by mean and standard deviation (SD) and non-normally distributed data will be presented by 
median and interquartile range. Categorical data will be presented using percentages. SPSS 
(version 22.0) will be used for all statistical analyses. 
 
 
4.1 Primary Outcomes 
 
 
Study 1 
 
The primary analyses will compare: (1) experimental vs experimental control group 
guidelines on their mean and standard deviation: (i) pain score (VAS & BPI), (ii) balance 
scores (CAIT &FADI), (iii) mindful attention (MAAS), and (iv) happiness scores (OHQ). 
Comparisons will be  made using an unpaired t-test or a Mann-Whitney test for parametric 
and non-parametric data, respectively. P-values <0.05 will be considered statistically 
significant. 
2*4-Repeated measures analysis of variance (ANOVA) will be performed to test the 
significant difference in the intervention effects between the time intervals (baseline, mid-
intervention, post-intervention, and follow-up) and also between the two groups 
(Experimental control group and Experimental Group).  
The post–hoc analysis will be conducted to investigate significant effect within the time 
intervals. Condition on if the sphericity violated (p-value < 0.05), the Greenhouse- Geisser 
estimated correction will be applied. 

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Effect sizes for will be calculated using Cohen’s d (d) with 95% confidence intervals 
(95%CI) using the ‘effsize’ package12. Effect sizes will be considered small if 0.2 ≤ d < 0.5, 
medium if 0.5 ≤ d < 0.8, and large if d ≥ 0.8. 
 
Study 2 
The primary analyses will compare: (1) CAI participants vs healthy control group guidelines 
on their mean and standard deviation: (i) balance scores (CAIT &FADI) (ii), mindful 
attention (MAAS) and (iii) happiness scores (OHQ). Comparisons will be  made using an 
unpaired t-test or a Mann-Whitney test for parametric and non-parametric data, respectively. 
P-values <0.05 will be considered statistically significant. 
Effect sizes for will be calculated using Cohen’s d (d) with 95% confidence intervals 
(95%CI) using the ‘effsize’ package12. Effect sizes will be considered small if 0.2 ≤ d < 0.5, 
medium if 0.5 ≤ d < 0.8, and large if d ≥ 0.8. 

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4.2. Secondary Outcomes 
 
 
Study 1 
 
The primary analyses will compare: (1) experimental vs experimental control guidelines on 
their mean and standard deviation of brain waves (alpha, beta, theta, gamma and delta). 
Comparisons will be  made using an unpaired t-test or a Mann-Whitney test for parametric 
and non-parametric data, respectively. P-values <0.05 will be considered statistically 
significant. 
2×4-Repeated measures analysis of variance (ANOVA) will be performed to test the 
significant difference in the intervention effects between the time intervals (baseline, mid-
intervention, post-intervention, and follow-up) and also between the two groups 
(Experimental control group and Experimental Group).  
The post–hoc analysis will be conducted to investigate significant effect within the time 
intervals. Condition on if the sphericity violated (p-value < 0.05), the Greenhouse- Geisser 
estimated correction will be applied. 
Effect sizes for will be calculated using Cohen’s d (d) with 95% confidence intervals 
(95%CI) using the ‘effsize’ package. Effect sizes will be considered small if 0.2 ≤ d < 0.5, 
medium if 0.5 ≤ d < 0.8, and large if d ≥ 0.8. 
 
Study 2 
The primary analyses will compare: (1) CAI participants vs healthy control group guidelines 
on their mean and standard deviation brain waves (alpha, beta, theta, gamma and delta). 
Comparisons will be  made using an unpaired t-test or a Mann-Whitney test for parametric 
and non-parametric data, respectively. P-values <0.05 will be considered statistically 

18 
 
significant. 
Effect sizes for will be calculated using Cohen’s d (d) with 95% confidence intervals 
(95%CI) using the ‘effsize’ package. Effect sizes will be considered small if 0.2 ≤ d < 0.5, 
medium if 0.5 ≤ d < 0.8, and large if d ≥ 0.8. 
Pearson’s correlation or a spearman’s correlation for parametric and non-parametric data, 
respectively will be used to report the association of EEG with the primary outcomes pain 
intensity (VAS &BPI) and pain interference (BPI). 
 
 
4.3 Missing Data 
 
 
For participants who are randomized and do not attend for assessment, a mean imputation of 
the   assessment scores from their allocation group will used. 

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5. Informed Consent Forms (ICF) 
 
 
Study 1 
 
Written consent will be gained from the study participants with CAI using the consent forms 
attached to  the application. 
 
 
Study 2 
 
Written consent will be gained from the study participants without CAI using the consent 
forms   attached to the application. 
 
 
 
5.1 Rights and Risks to participants 
 
Rights  
The participants may decide to stop being a part of this research study at any time without 
explanation. The participants have the right to omit or refuse to answer or respond to any 
question that is asked.  In addition, they have the right to ask any questions about the 
procedures practiced (unless answering these questions would interfere with the study 
outcome). If  they having any questions on this information sheet/test/training, they may 
ask the investigator or research in-charge person  before the study begins or during the 
course of assessment and interventions. Participation in this study is voluntary and it does 
not carry any remuneration or reimbursement. 
Risks  
Researcher does not anticipate any risk from this research study. However, researchers have 
to touch at the head, injured ankle joint and neighboring muscles during the primary, 
secondary outcomes and during the intervention procedures.  Also will have to fix the 
surface electrodes of 14-channel EEG headset to record the brain waves. The intervention 

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may reduce the occurrence of pain and provide an insight about the risk factors associate 
with injuries among collegiate athletes. 
 
 
5.2 Privacy and Confidentiality 
 
 
All study participants will be de-identified and given a unique ID number at the time of 
enrolment; this will be recorded by the front desk officer in the physiotherapy centre (INTI 
international university) and emailed or WhatsApp to the participant. The key linking study 
participants to their unique ID number will only be accessed by the front desk officer and will 
be stored in the password protected folder on the secure physiotherapy centre (INTI 
international university) hard drive. This will be destroyed after the 7-year retention period. 
Participants will  not be able to be identified from any results published. 

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6. References 
 
1.  Wukich DK, Tuason DA. Diagnosis and treatment of chronic ankle pain. Instr Course 
Lect. 2011;60:335-350. 
 
2.  Shariff AH, George J, Ramlan AA. Musculoskeletal injuries among Malaysian badminton 
players. Singapore Med J. 2009;50(11):1095-1097. 
 
3.  O´Connell S, Manschreck TC. Playing through the pain : Curr Psychiatr. 2012;11(7):16-
20. 
 
4.  Schaal K, Tafflet M, Nassif H, et al. Psychological balance in high level athletes: Gender-
Based differences and sport-specific patterns. PLoS One. 2011;6(5). 
doi:10.1371/journal.pone.0019007 
 
5.  Putukian M. The psychological response to injury in student athletes: a narrative review 
with a focus on mental health. Br J Sports Med. 2016;50(3):145-148. 
doi:10.1136/bjsports-2015-095586 
 
6.  Shivarathre DG, Howard N, Krishna S, Cowan C, Platt SR. Psychological Factors and 
Personality Traits Associated With Patients in Chronic Foot and Ankle Pain. Foot Ankle 
Int. 2014;35(11):1103-1107. doi:10.1177/1071100714550648 
 
7.  Schmidt S, Gmeiner S, Schultz C, et al. Mindfulness-based Stress Reduction (MBSR) as 
treatment for chronic back pain-an observational study with assessment of thalamocortical 
dysrhythmia. Complement Med Res. 2015;22(5):298-303. 
 
8.  Bernier M, Thienot E, Codron R, Fournier JF. Mindfulness and Acceptance Approaches 
in Sport Performance. J Clin Sport Psychol. 2009;3(4):320-333. doi:10.1123/jcsp.3.4.320 
 
9.  Cheng KS, Chang YF, Han RPS, Lee PF. Enhanced conflict monitoring via a short-
duration, video-assisted deep breathing in healthy young adults: an event-related potential 
approach through the Go/NoGo paradigm. PeerJ. 2017;5:e3857. 
 
10.  Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for patients with chronic 
ankle instability in controlled research: a position statement of the International Ankle 
Consortium. J Orthop Sports Phys Ther. 2013;43(8):585-591. 
doi:10.2519/jospt.2013.0303 
 
11.  Faul F, Erdfelder E, Lang A-G, Buchner A. G* Power 3: A flexible statistical power 
analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 
2007;39(2):175-191. 
 
12.  Cohen, 1988 (Statistical Power, 273-406).pdf.