Response Shift and Functional Outcomes in Individuals with Chronic Ankle Instability

Ankle sprains are one of the most common injuries sustained by those who are physically active. One in three individuals will develop a condition known as chronic ankle instability (CAI) after suffering a single ankle sprain. These individuals suffer from recurrent bouts of ankle instability, residual symptoms, and a myriad of other mechanical and functional impairments as well as health-related quality of life (HRQL) deficits. Due to the abundance of health consequences associated with this condition it is imperative to establish evidence based interventions that are focused on restoring function and HRQL to pre-injury statuses. The overarching purpose of this dissertation was to add to the available treatment paradigms for those with CAI. To achieve this overarching goal multiple sub-purposes were employed. The first purpose of this dissertation was to perform a systematic review of the available literature to examine the efficacy of current CAI interventions to enhance HRQL (Project IA). The second purpose was to systematically review the literature to evaluate response shift in patients with various orthopedic conditions following rehabilitation (Project IB). The third purpose was to investigate the effects of a 4-week comprehensive evidence-based intervention on disease-oriented measures in those with CAI. Lastly, the final purpose was to evaluate the effect of a 4-week comprehensive evidence-based intervention on patient-oriented outcomes in those with CAI and to determine if those with CAI who undergo this intervention experience response shift. The systematic reviews (Project IA, IB) determined that the available evidence-based interventions are effective at enhancing HRQL in those with CAI and that those who undergo care for orthopedic conditions may experience a response shift that can confound assessment of HRQL changes. Project II found that robust improvements in disease-oriented measures were obtained immediately following a 4-week intervention and were maintained for 2-weeks after its completion. In Project III, evidence of response shift was not identified in those with CAI following a 4-week intervention. This finding indicates that traditional pre-to-post methods for assessing HRQL changes are accurate in these patients. Furthermore, significant improvements in ankle- and dimension-specific self-reported function as well as global well-being were identified following a 4-week comprehensive intervention for those with CAI. The results of these investigations demonstrate the clinical efficacy of the investigated 4-week comprehensive intervention to enhance a diverse array of detriments associated with CAI

Lower Extremity Musculoskeletal Screening Tool Practices Among Athletic Trainers in Secondary School and Collegiate Settings

Purpose: Musculoskeletal (MSK) screening tools can allow athletic trainers (AT) to focus prevention efforts by providing patient risk information. The purpose of this study is to examine lower extremity MSK screening tool practices and perceptions of ATs in traditional settings. Methods: A cross-sectional online survey was distributed to 4,937 full- and part-time collegiate and secondary school ATs randomly selected by the NATA. MSK screening tools were grouped into 7 categories: Range of Motion (ROM), Strength, Balance, Drop and Jump Landing (D/J Land), Double- and Single-Leg Hopping (D/S Hop), Movement Quality (MQual), and Injury History (History). For each screening tool category, questions assessed MSK screening tool usage, the perceived effectiveness of MSK screening tools to provide relevant injury risk and return to play (RTP) information, and MSK screening tools effect on decisions to implement prevention programs. Results: A total of 372 participants (female=215(48.4%), male=152(34.2%), age=35±10 years, experience=12±10 years, secondary school=194(52.2%), collegiate=178(47.8%)) completed the survey. Participants within our study indicated the used of the following screening tools categories in clinical practice: ROM=339(91.1%), Strength=342(91.9%), Balance=238(64.0%), D/J-Landing=134(36.0%), D/S-Hopping=233(62.6%), MQual=212(57.0%), History=316(85.0%), and None=18(4.8%). Conclusions: ATs in traditional settings indicate that they primarily use ROM, Strength, and History screening tools to gather information concerning LE injury risk and RTP. Implementation of screening tools most frequently occurred post-injury. Lastly, it seemed that intervention prescriptions were consistent regardless of screening tool used, suggesting blanket interventions prescription. This may have been do feelings of moderate effectiveness of these tools to determine injury risk

A 4-Week Multimodal Intervention for Individuals With Chronic Ankle Instability: Examination of Disease-Oriented and Patient-Oriented Outcomes

Context Individuals with chronic ankle instability (CAI) experience disease- and patient-oriented impairments that contribute to both immediate and long-term health detriments. Investigators have demonstrated the ability of targeted interventions to improve these impairments. However, the combined effects of a multimodal intervention have not been evaluated for their effects on a multidimensional profile of health. Objective To examine the effects of a 4-week rehabilitation program on disease- and patient-oriented impairments associated with CAI. Design Controlled laboratory study. Setting Laboratory. Patients or Other Participants Twenty adults (5 males, 15 females; age = 24.35 ± 6.95 years, height = 169.29 ± 10.10 cm, mass = 70.58 ± 12.90 kg) with self-reported CAI participated. Inclusion criteria were at least 1 previous ankle sprain, at least 2 episodes of giving way in the 3 months before the study, and a Cumberland Ankle Instability Tool score ≤24. Intervention(s) Individuals participated in 12 sessions over 4 weeks that consisted of balance training, ankle strengthening, and joint mobilizations. They also completed home ankle-strengthening and -stretching exercises daily. Main Outcome Measure(s) Dorsiflexion range of motion (weight-bearing–lunge test), isometric ankle strength (inversion, eversion, dorsiflexion, plantar flexion), isometric hip strength (abduction, adduction, flexion, extension), dynamic postural control (Y-Balance test), static postural control (eyes-open and -closed time to boundary in the anterior-posterior and medial-lateral directions), and patient-reported outcomes (Foot and Ankle Ability Measure–Activities of Daily Living and Foot and Ankle Ability Measure–Sport, modified Disablement in the Physically Active scale physical and mental summary components, and Fear-Avoidance Belief Questionnaire–Physical Activity and Fear-Avoidance Belief Questionnaire–Work) were assessed at 4 times (baseline, preintervention, postintervention, 2-week follow-up). Results Dorsiflexion range of motion, each direction of the Y-Balance test, 4-way ankle strength, hip-adduction and -extension strength, the Foot and Ankle Ability Measure–Activities of Daily Living score, the modified Disablement in the Physically Active scale–physical summary component score, and the Fear-Avoidance Belief Questionnaire–Physical Activity score were improved at postintervention (P \u3c .001; effect-size range = 0.72–1.73) and at the 2-week follow-up (P \u3c .001; effect-size range = 0.73–1.72) compared with preintervention. Hip-flexion strength was improved at postintervention compared with preintervention (P = .03; effect size = 0.61). Hip-abduction strength was improved at the 2-week follow-up compared with preintervention (P = .001, effect size = 0.96). Time to boundary in the anterior-posterior direction was increased at the 2-week follow-up compared with preintervention (P \u3c .04; effect-size range = 0.61–0.78) and postintervention (P \u3c .04) during the eyes-open condition. Conclusion A 4-week rehabilitation program improved a multidimensional profile of health in participants with CAI

Response Shift After a 4-Week Multimodal Intervention for Chronic Ankle Instability

Context The accurate evaluation of self-reported changes in function throughout the rehabilitation process is important for determining patient progression. Currently, how a response shift (RS) may affect the accuracy of self-reported functional assessment in a population with chronic ankle instability (CAI) is unknown. Objective To examine the RS in individuals with CAI after a 4-week multimodal rehabilitation program. Design Controlled laboratory study. Setting Laboratory. Patients or Other Participants Twenty adults (5 men, 15 women; age = 24.35 ± 6.95 years, height = 169.29 ± 10.10 cm, mass = 70.58 ± 12.90 kg) with self-reported CAI participated. Inclusion criteria were at least 1 previous ankle sprain, at least 2 episodes of the ankle giving way in the 3 months before the study, and a score ≤24 on the Cumberland Ankle Instability Tool. Intervention(s) Individuals participated in 12 intervention sessions over 4 weeks and daily home ankle strengthening and stretching. Main Outcome Measure(s) Patient-reported outcomes (PROs) were assessed at 4 times (baseline, preintervention, postintervention, and 2-week follow-up). At the postintervention and 2-week follow-up, participants completed then-test assessments to measure RS. Then-test assessments are retrospective evaluations of perceived baseline function completed after an intervention. The PROs consisted of the Foot and Ankle Ability Measure-Activities of Daily Living and Sport subscales, the modified Disablement in the Physically Active scale physical and mental summary components, and the Fear-Avoidance Beliefs Questionnaire Physical Activity and Work subscales. We used repeated-measures analyses of variance to compare preintervention with then-test measurements. Individual-level RSs were examined by determining the number of participants who experienced preintervention to then-test differences that exceeded the calculated minimal detectable change. Results We did not identify an RS for any PRO (F \u3e 2.338, P \u3e .12), indicating no group-level differences between the preintervention and retrospective then-test assessments. Individual- level RS was most prominent in the Foot and Ankle Ability Measure-Sport subscale (n = 6, 30%) and the Fear-Avoidance Beliefs Questionnaire Physical Activity subscale (n = 9, 45%). Conclusions No group-level RS was identified for any PRO after a 4-week multimodal rehabilitation program in individuals with CAI. This finding indicates that traditional assessment of self-reported function was accurate for evaluating the short-term effects of rehabilitation in those with CAI. Low levels of individual-level RS were identified

The Effectiveness of Prophylactic Ankle Braces in Reducing the Incidence of Acute Ankle Injuries in Adolescent Athletes: A Critically Appraised Topic

Clinical Scenario: Ankle injuries constitute a large number of injuries sustained by adolescent athletes participating in high school athletics. Prophylactic ankle bracing may be an effective and efficient method to reduce the incidence of ankle injuries in adolescent athletes in the secondary-school setting. Clinical Question: Do prophylactic ankle braces reduce the incidence of acute ankle injuries in adolescent athletes? Summary of Key Findings: Two of the three included studies reported that prophylactic ankle braces reduced the incidence of ankle injuries compared with no ankle bracing. Clinical Bottom Line: There is moderate evidence to support the use of prophylactic ankle braces in adolescent athletes, particularly those who participate in football and basketball, to reduce the incidence of acute ankle injuries. Strength of Recommendation: Grade B evidence exists that prophylactic ankle braces reduce the incidence of acute ankle injuries in adolescent athletes

Rehabilitation and Improvement of Health-Related Quality-of-Life Detriments in Individuals With Chronic Ankle Instability: A Meta-Analysis

OBJECTIVE: To conduct a systematic review with meta-analysis assessing the effectiveness of conservative rehabilitation programs for improving health-related quality of life (HRQL) in individuals with chronic ankle instability (CAI). DATA SOURCES: PubMed, MEDLINE, CINAHL, and SPORTDiscus were searched from inception to January 2016. STUDY SELECTION: Studies were included if the researchers examined the effects of a conservative rehabilitation protocol in individuals with CAI, used validated patient-reported outcomes (PROs) to quantify participant-perceived HRQL, and provided adequate data to calculate the effect sizes (ESs) and 95% confidence intervals (CIs). Studies were excluded if the authors evaluated surgical interventions, prophylactic taping, or bracing applications or examined only the immediate effects of 1 treatment session. DATA EXTRACTION: Two investigators independently assessed methodologic quality using the Physiotherapy Evidence Database (PEDro) Scale. Studies were considered low quality if fewer than 60% of the criteria were met. Level of evidence was assessed using the Strength of Recommendation Taxonomy. Preintervention and postintervention sample sizes, means, and standard deviations of PROs were extracted. DATA SYNTHESIS: A total of 15 studies provided 24 participant groups that were included in the analysis. Seven high-quality studies with a median PEDro score of 50% (range = 10%-80%) and a median level of evidence of 2 (range = 1-2) were identified. The magnitudes of preintervention to postintervention PRO differences were examined using bias-corrected Hedges g ESs. Random-effects meta-analysis was performed to synthesize PRO changes across all participant groups. Positive ES values indicated better PRO scores at postintervention than at preintervention. The α level was set at .05. Meta-analysis revealed a strong ES with a nonoverlapping 95% CI (ES = 1.20, CI = 0.80, 1.60; P \u3c .001), indicating HRQL improved after conservative rehabilitation. CONCLUSIONS: Based on the quality of the evidence and the results of the meta-analysis, grade A evidence showed that conservative rehabilitation produces large improvements in HRQL for people with CAI