Two-week joint mobilization intervention improves self-reported function, range of motion, and dynamic balance in those with chronic ankle instability. Rehabilitation for Chronic Ankle Instability With or Without Destabilization Devices: A Randomized Controlled Trial. Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability. Effects of joint mobilization on chronic ankle instability: a randomized controlled trial The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. Strength-training protocols to improve deficits in participants with chronic ankle instability: a randomized controlled trial. Balance training improves function and postural control in those with chronic ankle instability. Joint mobilization improves spatiotemporal postural control and range of motion in those with chronic ankle instability. The effectiveness of strain counterstrain in the treatment of patients with chronic ankle instability: A randomized clinical trial Altered visual focus on sensorimotor control in people with chronic ankle instability Six weeks of balance training improves sensorimotor function in individuals with chronic ankle instability. Plantar Cutaneous Sensitivity With and Without Cognitive Loading in People With Chronic Ankle Instability, Copers, and Uninjured Controls. Effects of 6 Weeks of Balance Training on Chronic Ankle Instability in Athletes: A Randomized Controlled Trial. Motoneuron Function Does not Change Following Whole-Body Vibration in Individuals With Chronic Ankle Instability. A comparison of electromyography of gluteus medius and maximus in subjects with and without chronic ankle instability during two functional exercises. The effect of two mobilization techniques on dorsiflexion in people with chronic ankle instability. A Randomized Controlled Trial Comparing Rehabilitation Efficacy in Chronic Ankle Instability. Localized Ankle Fatigue Development and Fatigue Perception in Adults With or Without Chronic Ankle Instability. Effects of a 4-week exercise program on balance using elastic tubing as a perturbation force for individuals with a history of ankle sprains. Gait termination control strategies are altered in chronic ankle instability subjects. Effects of a 4-week dynamic-balance-training program supplemented with Graston instrument-assisted soft-tissue mobilization for chronic ankle instability. Effects of circumferential ankle pressure on ankle proprioception, stiffness, and postural stability: a preliminary investigation. Cognitive loading-induced sway alterations are similar in those with chronic ankle instability and uninjured controls.
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 prospect i ve cohort study , subjects received six Maitl and 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 assessment s 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 CONTEXT Individuals with chronic ankle instability ( CAI ) have deficits in neuromuscular control and altered movement patterns . Ankle-destabilization devices have been shown to increase lower extremity muscle activity during functional tasks and may be useful tools for improving common deficits and self-reported function . OBJECTIVE To determine whether a 4-week rehabilitation program that includes destabilization devices has greater effects on self-reported function , range of motion ( ROM ) , strength , and balance than rehabilitation without devices in patients with CAI . DESIGN R and omized controlled clinical trial . SETTING Laboratory . PATIENTS OR OTHER PARTICIPANTS A total of 26 patients with CAI ( 7 men , 19 women ; age = 21.34 ± 3.06 years , height = 168.96 ± 8.77 cm , mass = 70.73 ± 13.86 kg ) . INTERVENTION(S ) Patients completed baseline measures and were r and omized into no-device and device groups . Both groups completed 4 weeks of supervised , impairment-based progressive rehabilitation with or without devices and then repeated baseline measures . MAIN OUTCOME MEASURE(S ) We assessed self-reported function using the Foot and Ankle Ability Measure . Ankle ROM was measured with an inclinometer . Ankle strength was assessed using a h and held dynamometer during maximal voluntary isometric contractions . Balance was measured using a composite score of 3 reach directions from the Star Excursion Balance Test and a force plate to calculate center of pressure during eyes-open and eyes-closed single-limb balance . We compared each dependent variable using a 2 × 2 ( group × time ) analysis of variance and post hoc tests as appropriate and set an a priori α level at .05 . The Hedges g effect sizes and associated 95 % confidence intervals were calculated . RESULTS We observed no differences between the no-device and device groups for any measure . However , both groups had large improvements in self-reported function and ankle strength . CONCLUSIONS Incorporating destabilization devices into rehabilitation did not improve ankle function more effectively than traditional rehabilitation tools because both interventions result ed in similar improvements . Impairment-based progressive rehabilitation improved clinical outcomes associated with CAI INTRODUCTION Deficient sensory input from damaged ankle ligament receptors is thought to contribute to sensorimotor deficits in those with chronic ankle instability ( CAI ) . Targeting other viable sensory receptors may then enhance sensorimotor control in these patients . The purpose of this r and omized controlled trial was to evaluate the effects of 2 wk of sensory-targeted ankle rehabilitation strategies ( STARS ) on patient- and clinician-oriented outcomes in those with CAI . METHODS Eighty patients with self-reported CAI participated . All patients completed patient-oriented question naires capturing self-reported function as well as the weight-bearing lunge test and an eyes-closed single-limb balance test . After baseline testing , patients were r and omly allocated to four STARS groups : joint mobilization , plantar massage , triceps surae stretching , or control . Each patient in the intervention groups received six 5-min treatments of their respective STARS over 2 wk . All subjects were reassessed on patient- and clinician-oriented measures immediately after the intervention and completed a 1-month follow-up that consisted of patient-oriented measures . Change scores of the three STARS groups were compared with the control using independent t-tests and Hedges ' g effect sizes with 95 % confidence intervals . RESULTS The joint mobilization group had the greatest weight-bearing lunge test improvement . Plantar massage  had the most meaningful single-limb balance improvement . All STARS groups improved patient-oriented outcomes with joint mobilization having the most meaningful effect immediately after the intervention and plantar massage at the 1-month follow-up . CONCLUSION Each STARS treatment offers unique contributions to the patient- and clinician-oriented rehabilitation outcomes of those with CAI . Both joint mobilization and plantar massage appear to demonstrate the greatest potential to improve sensorimotor function in those with CAI Abstract Purpose : To evaluate the effects of joint mobilization , in which movement is applied to the ankle 's dorsiflexion range of motion , on dynamic postural control and on the self-reported instability of patients with chronic ankle instability ( CAI ) . Methods : A double-blind , placebo-controlled , r and omized trial with repeated measures and a follow-up period . Ninety patients with a history of recurrent ankle sprain , self-reported instability , and a limited dorsiflexion range of motion , were r and omly assigned to either the intervention group ( Joint Mobilizations , 3 weeks , two sessions per week ) the placebo group ( Sham Mobilizations , same duration as joint mobilization ) or the control group , with a 6 months follow-up . Dorsiflexion Range of Motion ( DFROM ) , Star Excursion Balance Test ( SEBT ) and CAI Tool ( CAIT ) were outcome measures . A separate 3 × 4 mixed model analysis of variance was performed to examine the effect of treatment conditions and time , and intention-to-treat ( ITT ) analysis was applied to evaluate the effect of the independent variable . Results : The application of joint mobilization result ed in better scores of DFROM , CAIT , and SEBTs in the intervention group when compared with the placebo or the control groups ( p < 0.001 ) . The effect sizes of group-by-time interaction , measured with eta-squared , oscillated between 0.954 for DFROM and 0.288 for SEBT posteromedial distance . In within-group analysis , the manipulation group showed an improvement at 6 months follow-up in CAIT [ mean = 5.23 , CI 95 % ( 4.63–5.84 ) ] , DFROM [ mean = 6.77 , CI 95 % ( 6.45–7.08 ) ] , anterior SEBT [ mean = 7.35 , CI 95 % ( 6.59–8.12 ) ] , posteromedial SEBT [ mean = 3.32 , CI 95 % ( 0.95–5.69 ) ] , and posterolateral SEBT [ mean = 2.55 , CI 95 % ( 2.20–2.89 ) ] . Conclusion : Joint mobilization techniques applied to subjects suffering from CAI were able to improve ankle DFROM , postural control , and self-reported instability . These results suggest that joint mobilization could be applied to patients with recurrent ankle sprain to help restore their functional stability . Implication s for Rehabilitation Functional instability is a very common sequela in patients with CAI , result ing in reduced quality of living due to the limitations it imposes on daily life activities . The mobilization with movement technique presented by Mulligan , and based on the joint mobilization accompanied by active movement , appears as a valuable tool to be employed by physical therapists to restore ankle function after a recurrent ankle sprain history . ROM restriction , subjective feeling of instability and dynamic postural control are benefiting from the joint mobilization application STUDY DESIGN Prospect i ve , r and omized controlled trial . OBJECTIVE To examine the effects of a 4-week rehabilitation program for chronic ankle instability ( CAI ) on postural control and lower extremity function . BACKGROUND CAI is associated with residual symptoms , performance deficits , and reinjury . Managing CAI is challenging and more evidence is needed to guide effective treatment . METHODS AND MEASURES Subjects with unilateral CAI were r and omly assigned to the rehabilitation ( CAI-rehab , n=16 ) or control ( CAI-control , n=13 ) group . Subjects without CAI were assigned to a healthy group ( n=19 ) . Baseline testing included the ( 1 ) center of pressure velocity ( COPV ) , ( 2 ) star excursion balance test ( SEBT ) , and ( 3 ) Foot and Ankle Disability index ( FADI ) and FADI-Sports Subscale ( FADI-Sport ) . The CAI-rehab group completed 4 weeks of rehabilitation that addressed range of motion , strength , neuromuscular control , and functional tasks . After 4 weeks , all subjects were retested . Nonparametric analyses for group differences and between-group comparisons were performed . RESULTS Subjects with CAI demonstrated deficits in postural control and SEBT reach tasks of the involved limb compared to the uninvolved limb and reported functional deficits of the involved limb compared to healthy subjects . Following rehabilitation , the CAI-rehab group had greater SEBT reach improvements on the involved limb than the other groups and greater improvements in FADi and FADI-Sport scores . CONCLUSIONS These results demonstrate postural control and functional limitations exist in individuals with CAl . In addition , rehabilitation appears to improve these functional limitations . Finally , there is evidence to suggest the SEBT may be a good functional measure to monitor change after rehabilitation for CAI CONTEXT Although lateral ankle sprains are common in athletes and can lead to chronic ankle instability ( CAI ) , strength-training rehabilitation protocol s may improve the deficits often associated with CAI . OBJECTIVE To determine whether strength-training protocol s affect strength , dynamic balance , functional performance , and perceived instability in individuals with CAI . DESIGN R and omized controlled trial . SETTING Athletic training research laboratory . PATIENTS OR OTHER PARTICIPANTS A total of 39 individuals with CAI ( 17 men [ 44 % ] , 22 women [ 56 % ] ) participated in this study . Chronic ankle instability was determined by the Identification of Functional Ankle Instability Question naire , and participants were r and omly assigned to a resistance-b and - protocol group ( n = 13 [ 33 % ] age = 19.7 ± 2.2 years , height = 172.9 ± 12.8 cm , weight = 69.1 ± 13.5 kg ) , a proprioceptive neuromuscular facilitation strength- protocol group  ( n = 13 [ 33 % ] , age = 18.9 ± 1.3 years , height = 172.5 ± 5.9 cm , weight = 72.7 ± 14.6 kg ) , or a control group  ( n = 13 [ 33 % ] , age = 20.5 ± 2.1 years , height = 175.2 ± 8.1 cm , weight = 70.2 ± 11.1 kg ) . INTERVENTION(S ) Both rehabilitation groups completed their protocol s 3 times/wk for 6 weeks . The control group did not attend rehabilitation sessions . MAIN OUTCOME MEASURE(S ) Before the interventions , participants were pretested by completing the figure-8 hop test for time , the triple-crossover hop test for distance , isometric strength tests ( dorsiflexion , plantar flexion , inversion , and eversion ) , the Y-Balance test , and the visual analog scale for perceived ankle instability . Participants were again tested 6 weeks later . We conducted 2 separate , multivariate , repeated- measures analyses of variance , followed by univariate analyses on any significant findings . RESULTS The resistance-b and protocol group improved in strength ( dorsiflexion , inversion , and eversion ) and on the visual analog scale ( P < .05 ) ; the proprioceptive neuromuscular facilitation group improved in strength ( inversion and eversion ) and on the visual analog scale ( P < .05 ) as well . No improvements were seen in the triple-crossover hop or the Y-Balance tests for either intervention group or in the control group for any dependent variable ( P > .05 ) . CONCLUSIONS Although the resistance-b and protocol is common in rehabilitation , the proprioceptive neuromuscular facilitation strength protocol is also an effective treatment to improve strength in individuals with CAI . Both protocol s showed clinical benefits in strength and perceived instability . To improve functional outcomes , clinicians should consider using additional multiplanar and multijoint exercises PURPOSE The purpose of this r and omized controlled trial was to determine the effect of a 4-wk balance training program on static and dynamic postural control and self-reported functional outcomes in those with chronic ankle instability ( CAI ) . METHODS Thirty-one young adults with self-reported CAI were r and omly assigned to an intervention group ( six males and 10 females ) or a control group ( six males and nine females ) . The intervention consisted of a 4-wk supervised balance training program that emphasized dynamic stabilization in single-limb stance . Main outcome measures included the following : self-reported disability on the Foot and Ankle Disability Index ( FADI ) and the FADI Sport scales ; summary center of pressure ( COP ) excursion measures including area of a 95 % confidence ellipse , velocity , range , and SD ; time-to-boundary ( TTB ) measures of postural control in single-limb stance including the absolute minimum TTB , mean of TTB minima , and SD of TTB minima in the anteroposterior and mediolateral directions with eyes open and closed ; and reach distance in the anterior , posteromedial , and posterolateral directions of the Star Excursion Balance Test ( SEBT ) . RESULTS The balance training group had significant improvements in the FADI and the FADI Sport scores , in the magnitude and the variability of TTB measures with eyes closed , and in reach distances with the posteromedial and the posterolateral directions of the SEBT . Only one of the summary COP-based measures significantly changed after balance training . CONCLUSIONS Four weeks of balance training significantly improved self-reported function , static postural control as detected by TTB measures , and dynamic postural control as assessed with the SEBT . TTB measures were more sensitive at detecting improvements in static postural control compared with summary COP-based measures 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 r and omized cross-over study , subjects received a  Maitl and 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 st and ard 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 Abstract Study Design : R and omized clinical trial . Objective : To determine the effect of strain counterstrain ( SCS ) on dynamic balance and subjective sense of instability in individuals with chronic ankle instability ( CAI ) . Although many studies have been published on CAI , the cause for this common clinical dysfunction remains inconclusive . No studies have assessed the effectiveness of SCS on CAI . Methods : At baseline all participants completed a demographic question naire , the star excursion balance test ( SEBT ) , and the foot and ankle ability measure ( FAAM ) . Following the baseline evaluation , participants were r and omized into the SCS experimental group ( EG ) ( n = 13 ) or the sham SCS group ( SG ) ( n = 14 ) . All participants received the assigned treatment once a week for 4 weeks and participated in a prescribed exercise program . At week 4 , all participants repeated the outcome measures and completed a global rating of change ( GROC ) form . The primary aim was examined with a two-way analysis of variance ( ANOVA ) . Results : A significant group-by-time interaction was found for seven directions in the SEBT ( P<0·031 ) . For subjective measures , no significant group-by-time interaction was found for the FAAM ( P>0·548 ) , but the GROC revealed a significant difference ( P = 0·014 ) in the mean score for the EG ( 3·92±1·66 ) when compared to the SG ( 2·43±1·66 ) . Discussion : Although SCS may not have an effect on subjective ankle function in individuals with CAI , preliminary evidence suggests that SCS may lead to an improvement in dynamic ankle stability and the subjective sense of ankle instability . Level of Evidence : Therapy , Level 1b Abstract The purpose of this investigation was to examine the effects of the combination of  chronic ankle instability ( CAI ) and altered visual focus on strategies for dynamic stability during a drop-jump task . Nineteen participants with self-reported CAI and 19 healthy participants performed a drop-jump task  in looking-up and looking-down conditions . For the looking-up condition , participants looked up and read a r and om number that flashed on a computer monitor . For the looking-down condition , participants focused their vision on the force plate . Sagittal- and frontal-plane kinematics in the hip , knee and ankle were calculated at the time points of 100 ms pre-initial foot contact to ground and at IC . The result ant vector time to stabilisation was calculated with ground reaction force data . The CAI group demonstrated less hip flexion at the point of 100 ms pre-initial contact ( P < 0.01 ) , and less hip flexion ( P = 0.03 ) and knee flexion at initial contact ( P = 0.047 ) compared to controls . No differences in kinematics or dynamic stability were observed in either looking-up or looking-down conditions ( P > 0.05 ) . Altered visual focus did not influence movement patterns during the drop-jump task , but the presence of CAI did . The current data suggests that central ly mediated changes associated with CAI may lead to global alterations in the sensorimotor control STUDY DESIGN Prospect i ve cohort study . OBJECTIVE To assess the effect of 6 weeks of balance training on sensorimotor measures previously found to be deficient in participants with chronic ankle instability ( CAI ) . BACKGROUND CAI is the tendency toward repeated ankle sprains and recurring symptoms , occurring in 40 % to 70 % of individuals who have previously sustained a lateral ankle sprain . Recent studies have found deficits in sensorimotor measures in individuals with CAI . As balance training is a common component of ankle rehabilitation , underst and ing its effect on the sensorimotorsystem in individuals with CAI may enable us to optimize protocol s to better utilize this rehabilitation method . METHODS Twelve participants with CAI and 9 healthy volunteers participated . Independent variables were group ( CAI , control ) and time ( pretraining , posttraining ) . Participants with CAI who completed a 6-week balance training program and healthy controls who did not get any training were pretested and posttested at the beginning and at the end of 6 weeks . RESULTS The individuals in the CAI group who performed balance training demonstrated better performance than control participants on baseline adjusted posttraining measures of dynamic balance in the anterior medial ( P = .021 ) , medial ( P = .048 ) , and posterior medial directions ( P = .030 ) ; motoneuron pool excitability Hmax/Mmax ratio ( P = .044 ) and single-limb presynaptic inhibition ( P = .012 ) ; and joint position sense inversion variable error ( P = .017 ) . It may be of note that no systematic differences were detected for static balance or plantar flexion joint position sense tasks . CONCLUSIONS After 6 weeks of balance training , individuals with CAI demonstrated enhanced dynamic balance , inversion joint position sense , and changes in motoneuron pool excitability compared to healthy controls who did not train . LEVEL OF EVIDENCE Therapy , level 2b STUDY DESIGN Controlled laboratory study . BACKGROUND Deficits in light touch have recently been identified on the plantar surface of the foot in those with chronic ankle instability ( CAI ) but not in uninjured controls . It is unknown whether copers display similar deficits . Similarly , cognitive loading has been shown to impact postural control in different population s , but it is unclear how it may impact sensory perception . OBJECTIVES To evaluate the difference in cutaneous sensation thresholds at rest and under cognitive loading , using Semmes-Weinstein monofilaments ( SWMs ) , among uninjured controls , copers , and those with CAI . METHODS A total of 45 participants ( mean ± SD age , 20.2 ± 2.8 years ; height , 167.6 ± 9.9 cm ; mass , 66.3 ± 14.7 kg ) were recruited and categorized to a  CAI , coper , or control group  , based on Ankle Instability Instrument scores . Participants were assessed with SWMs for cutaneous thresholds using a 4 - 2 - 1 stepping algorithm at the head of the first metatarsal , base of the fifth metatarsal , calcaneus , and sinus tarsi . Each participant was then retested while generating r and om digits to the beat of a metronome in order to simulate cognitive loading . RESULTS Participants with CAI displayed significantly higher SWM thresholds at the head of the first metatarsal , base of the fifth metatarsal , and sinus tarsi than those of the control participants , and significantly higher thresholds at the base of the fifth metatarsal and calcaneus than those of copers ( all , P<.05 ) . Copers showed higher thresholds than those of controls at the sinus tarsi only ( P<.05 ) . A main effect of cognitive loading was identified at all 4 sites ( P<.05 ) . CONCLUSION People with CAI have deficits in plantar sensation relative to controls and copers . Cognitive loading increases plantar cutaneous sensation thresholds irrespective of CAI status The objective of the present study was to determine the effectiveness of a 6-week balance training program on patients with Chronic Ankle Instability ( CAI ) in relation to the results obtained in Dynamic Balance , subjective feeling of instability and pain using a single-blind r and omized controlled trial . 70 athletes were r and omly assigned to control or intervention group . The control group performed their usual training , and the intervention group was administered the same usual activity in addition to a balance program . The paired t-test was performed to evaluate the change scores in each group . The t-test for independent sample s was performed to evaluate between-group differences in change scores . Significance level was assigned for p-values less than 0.05 for all analyses . There were significant differences between groups in change scores in CAIT and all of the SEBTs reach distances ( p<0.001 ) but not in Pain ( p=0.586 ) . The effect sizes were larger for the outcomes measures that showed significant differences . In the within-group change , the experimental groups showed larger effect sizes in CAIT , SEBT posteromedial and SEBT posterolateral , and moderate effect sizes in SEBT anterior .  Exercise therapy training based on multi-station balance tasks led to significant improvements in dynamic balance and self-reported sensation of instability in patients with CAI CONTEXT Following a lateral ankle sprain , ∼40 % of individuals develop chronic ankle instability ( CAI ) , characterized by recurrent injury and sensations of giving way . Deafferentation due to mechanoreceptor damage postinjury is suggested to contribute to arthrogenic muscle inhibition ( AMI ) . Whole-body vibration ( WBV ) has the potential to address the neurophysiologic deficits accompanied by CAI and , therefore , possibly prevent reinjury . OBJECTIVE To determine if an acute bout of WBV can improve AMI and proprioception in individuals with CAI . DESIGN AND PARTICIPANTS The authors examined if an acute bout of WBV can improve AMI and proprioception in individuals with CAI with a repeated- measures design . A total of 10 young adults with CAI and 10 age-matched healthy controls underwent a control , sham , and WBV condition in r and omized order . SETTING Biomechanics laboratory . INTERVENTION WBV . MAIN OUTCOME MEASURES Motoneuron pool recruitment was assessed via Hoffmann reflex ( H-reflex ) in the soleus . Proprioception was evaluated using ankle joint position sense at 15 ° and 20 ° of inversion . Both were assessed prior to , immediately following , and 30 minutes after the intervention ( pretest , posttest , and 30mPost , respectively ) . RESULTS Soleus maximum H-reflex : M-response ( H : M ) ratios were 25 % lower in the CAI group compared with the control group ( P = .03 ) . Joint position sense mean constant error did not differ between groups ( P = .45 ) . Error at 15 ° in the CAI ( pretest 0.8 [ 1.6 ] , posttest 2.0 [ 2.8 ] , 30mPost 2.0 [ 1.9 ] ) and control group ( pretest 0.8 [ 2.0 ] , posttest 0.6 [ 2.9 ] , 30mPost 0.5 [ 2.1 ] ) did not improve post-WBV . Error at 20 ° did not change post-WBV in the CAI ( pretest 1.3 [ 1.7 ] , posttest 1.0 [ 2.4 ] , 30mPost 1.5 [ 2.2 ] ) or control group ( pretest -0.3 [ 3.0 ] , posttest 0.8 [ 2.1 ] , 30mPost 0.6 [ 1.8 ] ) . CONCLUSION AMI is present in the involved limb of individuals with CAI . The acute response following a single bout of WBV did not ameliorate the presence of AMI nor improve proprioception in those with CAI OBJECTIVE To determine how gluteus medius ( Gmed ) and maximus ( Gmax ) activate during closed-chain functional rehabilitative exercises in those with and without chronic ankle instability ( CAI ) . DESIGN Cohort study . Subjects performed ten repetitions of a rotational lunge and single-leg rotational squat while surface electromyography was used to collect mean muscle activity  of the Gmed and Gmax . MAIN OUTCOME MEASURES Mean electromyography activity of the Gmed and Gmax at maximum excursion was compared between Groups and Exercises using a separate 2-way repeated measures analysis of variance design for each muscle . SETTING University biomechanics lab . PARTICIPANTS Nine healthy ( 8F , 1 M ) and nine CAI subjects ( 8F , 1 M ) RESULTS : For Gmax activation , there was a statistically significant Group by Exercise interaction ( F(3,48 ) = 4.84 , p = 0.043 ) . A Scheffe 's post-hoc test revealed that during the rotational squat , the CAI group had significantly lower Gmax activation ( 51.1 ± 31.0 % ) than the healthy group ( 78.6 ± 44.8 % ) . There were no statistically significant findings for the Gmed . In the healthy group , the Gmax produced significantly higher activation during rotational squat ( 78.6 ± 44.8 % ) compared to the rotational lunge ( 57.6 ± 31.9 % ) . CONCLUSION Because the CAI group had significantly less Gmax activation than the healthy group during the rotational squat at the point of maximum excursion , and because the rotational squat showed significantly higher Gmax activation compared to the rotational lunge , it may be important for clinicians to implement the rotational squat during rehabilitation for those with CAI . Future prospect i ve and intervention research involving hip musculature in those with CAI is recommended OBJECTIVE To compare the effect of two manual therapy techniques , mobilization with movement ( WB-MWM ) and talocrural manipulation ( HVLA ) , for the improvement of ankle dorsiflexion in people with chronic ankle instability ( CAI ) over 48 h. DESIGN R and omized controlled clinical trial . SETTING University research laboratory . PARTICIPANTS Fifty-two participants ( mean ± SD age , 20.7 ± 3.4 years ) with CAI were r and omized  to WB-MWM ( n = 18 ) , HVLA ( n = 19 ) or placebo group ( n = 15 ) . MAIN OUTCOME MEASURES Weight-bearing ankle dorsiflexion measured with the weight-bearing lunge . Measurements were obtained prior to intervention , immediately after intervention , and 10 min , 24 h and 48 h post-intervention . RESULTS There was a significant effect × time ( F4,192 = 20.65 ; P < 0.001 ) and a significant time × group interactions ( F8,192 = 6.34 ; P < 0.001 ) . Post hoc analysis showed a significant increase of ankle dorsiflexion in  both WB-MWM and HVLA groups with respect to the placebo group with no differences between both active treatment groups . CONCLUSION A single application of WB-MWM or HVLA manual technique improves ankle dorsiflexion in people with CAI , and the effects persist for at least two days . Both techniques have similar effectiveness for improving ankle dorsiflexion  although WB-MWM demonstrated greater effect sizes CONTEXT There is minimal patient-oriented evidence regarding the effectiveness of interventions targeted to reduce symptoms associated with chronic ankle instability ( CAI ) . In addition , clinicians aim ing to prioritize care by implementing only the most effective components of a rehabilitative program have very little evidence on comparative efficacy . OBJECTIVE To assess the comparative efficacy of 2 common ankle rehabilitation techniques ( wobble-board [ WB ] balance training and ankle strengthening using resistance tubing [ RT ] ) using patient-oriented outcomes . DESIGN R and omized controlled trial . SETTING Laboratory . PATIENTS 40 patients with CAI r and omized into 2 treatment groups :  RT and WB .  CAI inclusion criteria included a history of an ankle sprain , recurrent " giving way , " and a Cumberl and Ankle Instability Tool ( CAIT ) score ≤25 . INTERVENTIONS Participants completed 5 clinician-oriented tests  ( foot-lift test , time-in-balance , Star Excursion Balance Test , figure-of-8 hop , and side-hop ) and 5  patient-oriented question naires ( CAIT , Foot and Ankle Ability Measure [ FAAM ] , Activities of Daily Living [ ADL ] and FAAM Sport scale , Short-Form 36 [ SF-36 ] , and Global Rating of Function [ GRF ] ) . After baseline testing , participants completed 12 sessions over 4 wk of graduated WB or RT exercise , then repeated baseline tests . MAIN OUTCOME MEASURES For each patient- and clinician-oriented test , separate 2 × 2 RMANOVAs analyzed differences between groups over time ( alpha set at P = .05 ) . RESULTS There was a significant interaction between group and time for the FAAM-ADL ( P = .04 ) . Specifically , the WB group improved postintervention ( P < .001 ) whereas the RT group remained the same ( P = .29 ) . There were no other significant interactions or significant differences between groups ( all P > .05 ) . There were significant improvements postintervention for the CAIT , FAAM-Sport , GRF , SF-36 , and all 5 clinician-oriented tests ( all P < .001 ) . CONCLUSIONS A single-exercise 4-wk intervention can improve patient- and clinician-oriented outcomes in individuals with CAI . Limited evidence indicates that WB training was more effective than RT . LEVEL OF EVIDENCE Therapy , level 1b CONTEXT Fatigue could contribute to ankle-sprain injuries during sport , particularly for individuals with chronic ankle instability ( CAI ) . OBJECTIVE To examine whether adults with or without CAI develop fatigue at similar rates when performing ankle exercises at the same relative effort level and whether these groups differ in their subjective perceptions of fatigue . DESIGN Controlled laboratory study . SETTING Biomechanics research laboratory . PATIENTS OR OTHER PARTICIPANTS A total of 11 volunteers with CAI ( 1 man , 10 women ; age = 23.5 ± 3.0 years , height = 168.0 ± 11.2 cm , mass = 64.3 ± 13.5 kg ) were recruited for the unstable-ankle group , and 11 volunteers matched for age , height , mass , and sex ( 1 man , 10 women ; age = 24.1 ± 2.1 years , height = 169.5 ± 9.7 cm , mass = 62.3 ± 9.7 kg ) were recruited as control participants . INTERVENTION(S ) Localized muscle fatigue ( LMF ) was induced in the ankle of the dominant limb using a custom fatigue protocol . Plantar-flexion and dorsiflexion exertions were completed at a rate of 12 cycles per minute at isotonic loads equal to 70 % and 30 % , respectively , of individual maximal voluntary isometric strength . Intermittent measures of maximal voluntary isometric strength and ratings of perceived exertion ( RPEs ) were obtained . MAIN OUTCOME MEASURE(S ) We compared isometric-strength measures and RPE scores at each observation time ( prefatigue and at 4 , 8 , 12 , and 16 minutes into the fatigue protocol ) and the group correlations between changes in strength and changes in RPE scores . RESULTS Based on ankle-strength measures , the 2 test groups developed LMF at similar rates when exercising at equivalent levels of relative effort . The 2 groups also reported similar levels of discomfort as fatigue progressed . CONCLUSIONS The rate of LMF development at the ankle and the associated perception of fatigue did not differ between adults with or without CAI STUDY DESIGN R and omized controlled trial with pretraining , posttraining , and follow-up repeated measures . OBJECTIVE To determine the effectiveness of a 4-week elastic resistance exercise program on  balance  in subjects with and without a history of sprained ankles . BACKGROUND Several research ers have suggested that improving balance may help alleviate the symptoms of functional ankle instability and reduce the rate of recurrent ankle sprains . METHODS AND MEASURES Forty subjects ( 20 males , 20 females ; 20 subjects with chronic ankle instability [ CAI ] , 20 healthy ) participated in the study . Ten subjects ( 5 males , 5 females ) from each CAI and healthy group were r and omly assigned to either the exercise or control group , result ing in a total of 4 groups . Total travel distance of the center of pressure , monitored using a force platform , was measured before training , after 4 weeks of training , and at a 4-week follow-up . RESULTS There were no interactions between gender , ankle sprain history , or training groups . Balance significantly improved in subjects with and without a history of ankle sprains following 4 weeks of elastic resistance exercises . Mean improvement in balance for the exercise group following training , reflected through a decrease in total travel distance , was -11.1 cm ( 95 % confidence interval : -14.0 to -8.2 cm ) . These improvements in balance were retained 4 weeks after training . CONCLUSIONS Balance was improved after 4 weeks of elastic resistance exercise in subjects with and without a history of lateral ankle sprains . Balance improvements persisted 4 weeks following the treatment cessation UNLABELLED Despite the high incidence of chronic ankle instability ( CAI ) , the underlying neurophysiologic mechanism is unknown . Evidence suggests that both feed-forward and feedback mechanisms may play a role . However , no investigation has examined both control mechanisms during the same movement task in the same cohort of CAI patients . PURPOSE To determine the neuromuscular and biomechanical control alterations present in CAI patients during planned ( feed-forward ) and unplanned ( feedback ) gait termination . METHODS Twenty subjects with CAI and 20 uninjured controls completed planned and unplanned gait termination protocol s. Both tasks began with subjects walking at a self-selected speed across a 12-m walkway . Unplanned gait termination required subjects to stop during r and omly selected trials on two adjacent force plates when cued . Planned gait termination required purpose ful stopping on the force places . Propulsive and braking force magnitude and the dynamic postural stability index were calculated from the result ing ground reaction forces . In addition , muscle activity from the soleus , tibialis anterior , and gluteus medius was collected bilaterally . RESULTS Both maximum propulsive ( CAI = 99.8 + /- 40.8 N , control = 88.6 + /- 33.6 N ) and braking ( CAI = 207.1 + /- 80.9 N , control = 161.6 + /- 62.2 N ) forces were significantly higher in the CAI group . The dynamic postural stability index revealed higher scores in the CAI group ( 0.24 + /- 0.03 ) compared with the control group ( 0.22 + /- 0.03 ) . Muscle activation of the soleus and tibialis anterior differed during unplanned and planned gait termination between groups ( P < 0.05 ) and between the limbs of the CAI group ( P < 0.05 ) . CONCLUSIONS Altered biomechanical strategies during both planned and unplanned gait termination indicate that patients with CAI have alterations in feed-forward neuromuscular control and suggest the presence of feedback neuromuscular control deficits CONTEXT A dynamic-balance-training ( DBT ) program supplemented with the Graston instrument-assisted soft-tissue mobilization ( GISTM ) technique has not been evaluated collectively as a treatment in subjects with chronic ankle instability ( CAI ) . OBJECTIVE To examine the effects of GISTM in conjunction with a DBT program on outcomes associated with CAI , including pain and disability , range of motion ( ROM ) , and dynamic postural control . DESIGN Pretest/posttest , repeated measures . SETTING High school and a Division I mid-Atlantic university . PARTICIPANTS Thirty-six healthy , physically active individuals ( 5 female , 31 male ; age 17.7 ± 1.9 y ; height 175.3 ± 14.6 cm ) with a history of CAI as determined by an ankle-instability question naire volunteered to be in this study . INTERVENTIONS Subjects were r and omly assigned to 1 of 3 intervention groups : both treatments ( DBT/GISTM , n = 13 ) , DBT and a sham GISTM treatment ( DBT/GISTM-S , n = 12 ) , or DBT and control-no GISTM ( DBT/C , n = 11 ) . All groups participated in a 4-wk DBT program consisting of low-impact and dynamic activities that was progressed from week to week . The DBT/GISTM and DBT/GISTM-S groups received the GISTM treatment or sham treatment twice a week for 8 min before performing the DBT program . Pretest and posttest measurements included the Foot and Ankle Ability Measure ( FAAM ) , FAAM Sport , the visual analog scale ( VAS ) , ankle ROM in 4 directions , and the Star Excursion Balance Test ( SEBT ) in 3 directions . MAIN OUTCOME MEASURES FAAM and FAAM-Sport scores , VAS , goniometric ROM ( plantar flexion , dorsiflexion , inversion , eversion ) , and SEBT ( anterior , posteromedial , posterolateral ) . RESULTS Subjects in all groups posttest demonstrated an increase in FAAM , FAAM Sport , ROM , and SEBT in all directions but not in VAS , which decreased . No other results were significant . CONCLUSION For subjects with  CAI , dynamic postural control , ROM , pain and disability improved pretest to posttest regardless of group membership , with the largest effects found in most measures in the DBT/GISTM group STUDY DESIGN Cross-sectional repeated- measures design . OBJECTIVE Determine the effects of circumferential ankle pressure ( CAP ) intervention on  proprioceptive acuity , ankle stiffness , and postural stability . BACKGROUND The application of CAP using braces , taping , and adaptive shoes or military boots is widely used to address chronic ankle instability ( CAI ) . An underlying assumption is that the CAP intervention might improve ankle stability through increased proprioceptive acuity and stiffness in the ankle . METHOD AND MEASURES : A convenience sample of 10 subjects was recruited from the local university community and categorized according to proprioceptive acuity ( high , low ) and ankle stability ( normal , CAI ) .  Proprioceptive acuity was measured when blindfolded subjects were asked to accurately reproduce a self-selected target ankle position before and after the application of CAP .  Proprioceptive acuity was determined in 5 different ankle joint position sense tests : neutral , inversion , eversion , plantar flexion , and dorsiflexion . Joint position angles were recorded electromechanically using a potentiometer . Passive ankle stiffness was computed from the ratio of applied static moment versus angular displacement . Active ankle stiffness was determined from biomechanical analyses of ankle motion following a mediolateral perturbation . Postural stability was quantified from the center of pressure displacement in the mediolateral and the anteroposterior directions in unipedal stance . All measurements were recorded with and without CAP applied by a pediatric blood pressure cuff . Data were analyzed using a separate mixed-model analysis of variance ( ANOVA ) for each dependent variable . Post hoc comparison using Tukey 's honestly significant difference ( HSD ) test was performed if significant interactions were obtained . Significance level was set at P<.05 for all analyses . RESULTS Significant group ( high versus low proprioceptive acuity ) x CAP interactions were identified for postural stability . Passive ankle stiffness was not increased by an application of CAP .  Active ankle stiffness was significantly different between the high and low proprioceptive acuity groups and was not affected by an application of CAP . Significant group ( normal versus CAI ) x CAP interactions were observed for mediolateral center-of-pressure displacement with a main effect of group on neutral joint position sense . CONCLUSIONS Application of CAP increased proprioceptive acuity and demonstrated trends toward increased active stiffness in the ankle , hence improved postural stability . The effects tend to be limited to individuals with low proprioceptive acuity Performing a cognitive task while balancing can result in either increased or decreased sway depending on the nature of the cognitive task , and is commonly used in pathologic population s to evaluate postural performance . A total of 39 participants were recruited into two groups : uninjured controls ( n=20 , age : 21.9±2.1 years , height : 175.0±11.2 cm , mass : 71.3±14.9 kg ) and chronic ankle instability ( n=19 , age : 22.1±5.6 years , height : 169.7±7.7 cm , mass : 72.9±17.3 kg ) . Participants were asked to perform one of three cognitive tasks while maintaining single limb balance . Cognitive tasks included backwards counting by 3 ( BC ) , the manikin test ( MAN ) , and r and om number generation ( RNG ) . Time-to-boundary minima , mean , and st and ard deviations were calculated and compared between groups as pre to post change scores . Effect sizes and 95 % confidence intervals were also calculated to test for group differences and the effect of task performance on sway . No significant main effects of Group or Group by Task interactions were identified ( p>0.05 ) . However , a significant multivariate main effect of Task was identified in BC ( p=0.001 , F(6 , 32)=4.804 ) and RNG ( p<0.001 , F(6 , 32)=6.233 ) but not for MAN ( p=0.117 ) . The results suggest that those with chronic ankle instability and uninjured controls have similar postural-suprapostural interactions across multiple cognitive task domains . Both the BC and RNG tasks result ed in less sway for all participants . Our results suggest that dual-task interference in the CAI population may not be present as previous research would suggest
Conclusions The main findings from this systematic review were balance training provided the most consistent improvements in self-reported function for patients with CAI
Objective To identify which therapeutic intervention may be most effective for improving self-reported function in patients with chronic ankle instability ( CAI ) .