Effectiveness of Balance Training and Dynamic Neuromuscular Stabilization Training in Amateur Athletes with Chronic Ankle Instability

The goal of this clinical trial is to determine and compare the effects of balance and dynamic neuromuscular stabilization training on ankle function ability, functional instability severity, physical activity level, muscle strength, proprioception, stabilization, balance, reaction time and performance of amateur athletes with chronic ankle instability. The main questions it aims to answer are:

* Do balance and dynamic neuromuscular stabilization training positively affect functionality, balance, stabilization, proprioception and performance in amateur athletes with chronic ankle sprains?
* Does balance training or dynamic neuromuscular stabilization training have a more positive effect on functionality, balance, stabilization, proprioception and performance in amateur athletes with chronic ankle sprains?

Participants will apply:

* a dynamic neuromuscular stabilization training program consisting of a series of special exercises based on the developmental kinesiology steps of a healthy baby.
* balance training which consist of an effective postural stability program.
* conventional training program which consist of stretching, joint range of motion, strengthening and postural control exercises.

Researchers will compare balance and dynamic neuromuscular stabilization training to see if effectiveness of ankle function ability, functional instability severity, physical activity level, muscle strength, proprioception, stabilization, balance, reaction time and performance.

Chronic ankle instability is a repetitive chronic ankle imbalance that leads to a high rate of ankle sprains. Ankle sprains remain the most common foot-ankle and sports injury for which individuals require medical care, including emergency room visits. It is known that 58.5% of professional basketball and football athletes experience ankle sprains. Approximately three-quarters of patients who sustain an ankle sprain have persistent symptoms 1.5 to 4 years after the injury.

The hallmark symptoms of chronic ankle instability are a history of recurrent sprains and/or repeated episodes of giving-way and/or a feeling of instability. Additionally, many permanent symptoms such as pain, structural changes, and adaptations in the sensorimotor and vestibular systems have also been reported. Both acute trauma and residual neuromuscular adaptations lead to biomechanical changes, resulting in chronic ankle instability. Chronic ankle instability generally occurs as a result of 2 deficiencies: functional instability caused by proprioceptive and neuromuscular deficiencies and mechanical instability caused by changes in joint structure and function.

Lateral ankle sprains and chronic ankle instability cause changes in feedback control, which regulates motor control through reflex loops, and in feedforward control, which plans the movement pattern based on especially past experience. Due to changes in neuromuscular control, kinematic and kinetic adaptations are also common in individuals with chronic ankle instability compared to uninjured individuals, and these adaptations may result in abnormal tension on the talar joint cartilage. Therefore, there is a need to identify therapeutic interventions that can restore appropriate neuromuscular control strategies.

Surgical and conservative treatment methods that assist in ankle-foot deformity recovery, return to social life activities and return to sports can provide even better results with in-depth knowledge of ankle anatomy, biomechanics and pathology. Anatomical repair, tendon augmentation, or both are the basic methods of surgical intervention, and today, arthroscopy treatment is becoming more and more common in the treatment of chronic ankle instability. Conservative treatments include the use of orthoses in the acute period and physical therapy modalities that can be applied in the acute/chronic period . Exercise therapy in physiotherapy is one of the most supported interventions in treating chronic ankle instability and significantly reduces the risk of re-injury. Strength training, balance and dual task training, and isokinetic exercises are effective in ankle instability. It has been reported that 6 weeks of dynamic neuromuscular exercise training leads to improvements in sensorimotor control of the ankle joint in athletes with chronic ankle instability. Moreover, balance training exercises based on multi-station tasks have been observed to significantly improve self-reported sense of instability and dynamic balance in individuals with chronic ankle instability. It has been reported that rehabilitation protocols focusing on balance training effectively improve health-related quality of life in individuals with chronic ankle instability. However, it is recommended that interventions include more open chain joint position sense training, multi-plane single limb challenges, and jumping and landing exercises. In addition, during rehabilitation, the focus should not only be on exercising the muscles in their dynamic anatomical functions, but their stabilizing functions should also be addressed. Therefore, dynamic neuromuscular stabilization (DNS) training has been developed, which optimizes the movement system based on the scientific principles of developmental kinesiology. DNS training aims to stimulate the natural movement control system in the brain to activate the body's stabilization system. In the literature, studies on the effects of DNS training on ankle sensorimotor control and ankle joint position are limited. Our aim in this study is to determine and compare the effects of balance and DNS training on ankle function adequacy, functional instability severity, physical activity level, muscle strength, proprioception, stabilization, balance, reaction time and performance of amateur athletes with chronic ankle instability.

Our hypothesis in this study:

H0: Balance and DNS training does not positively affect functionality, balance, stabilization, proprioception and performance in amateur athletes with chronic ankle sprains.

H1: Balance and DNS training positively affects functionality, balance, stabilization, proprioception and performance in amateur athletes with chronic ankle sprains. The effect of balance training is superior to DNS training.

H2: Balance and DNS training positively affects functionality, balance, stabilization, proprioception and performance in amateur athletes with chronic ankle sprains. The effect of DNS training is superior to balance training.

Eligibility Criteria:
Inclusion Criteria:

* Being between the ages of 18-25
* Being a non-smoker
* Being an athlete at amateur level
* Score 25 or less on the Cumberland Ankle Instability Questionnaire
* At least 1 acute ankle inversion sprain resulting in swelling, pain, and dysfunction that occurred at least 12 months before the study
* Feeling of giving way in the ankle at least 2 times in the last 6 months

Exclusion Criteria:

* If the patient has any mental problems
* Neurological diseases
* Cerebellar, vestibular, cochlear and inner ear dysfunction
* Surgeries on musculoskeletal structures, chronic musculoskeletal disorders, severe acute lower extremity injuries or head trauma in the last 6 months