Sports Medicine Research: In the Lab & In the Field: Aiming for the STARS for Chronic Ankle Instability (Sports Med Res)
Wednesday, February 3, 2016

Aiming for the STARS for Chronic Ankle Instability

Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability

McKeon PO & Wikstrom EA. Med Sci Sports Exerc. Published Online First: December 10, 2015; DOI: 10.1249/MSS.0000000000000859

Take Home Message: Sensory-targeted rehabilitation strategies (STARS) result in improvements in patient-reported and clinical outcomes.  Certain deficits may be specifically targeted by different techniques.

Chronic ankle instability (CAI) with recurrent episodes of giving way and functional limitations can cause long-term complications.  Sensorimotor deficits may play a significant role in those with CAI.  Therefore, the authors of this randomized control study compared the effects of 3 sensory-targeted ankle rehabilitation strategies (STARS; i.e., ankle joint mobilization, plantar massage, or triceps surae stretching) on improvements in clinician- and patient-reported outcomes among individuals with CAI.  The authors randomized 80 participants to 4 groups (3 STARS interventions and a control group). 75 participants completed the entire duration of the study at the 1-month follow-up.  STARS programs consisted of six total treatment sessions over the course of 2 weeks.  Joint mobilization participants received 2 two-minute sets of grade III (one-second large amplitude) oscillations.  Participants within the plantar massage group received 2 two-minute sets of effleurage and petrissage on the plantar aspect of the foot.  Trcieps surae stretching participants performed 2 sets of three 30-second stretches with their knee flexed.  Control participants received no treatments. Participants were assessed at baseline, within 72 hours of their last treatment, and at a 1-month follow-up.  Patient reported outcomes included self-reported disability (Foot and Ankle Ability Measure; FAAM) and self-reported physical activities levels (NASA Physical activity status scale).  Clinician measures of interest were dorsiflexion range of motion (weight-bearing lunge test) and single-limb balance.  Overall, the plantar massage and calf stretching groups had the best improvements in patient and clinician reported outcomes.  After 2 weeks, all 3 STARS programs had improvements compared with the control group. The plantar massage and calf stretching groups had the largest improvements in patient-reported disability and number of episodes of giving way.  The calf stretching and joint mobilization groups had improvements in range of motion, while all 3 groups had improvements in single leg balance. The plantar massage group had the most pronounced improvement in balance after two weeks. 

Each STARS group had unique improvements.  For example, joint mobilization offered the most meaningful benefit for improving dorsiflexion, plantar massage led to the most meaningful change in balance, and stretching offered benefits in various outcomes. Amazingly, these benefits were achieved with just six 5-minute treatment sessions during a 2-week period.  Clinicians could carefully add a specific treatment to their rehabilitation protocol based on deficits found during assessment.  It would have been interesting to see if any of the clinical findings (i.e., single limb balance & range of motion) had lasting effects at the 1-month follow-up.  It would also be interesting to see if a combination of these techniques resulted in better short and long-term outcomes.  For example, the joint mobilizations showed the best outcomes immediately post-treatments, while plantar massage showed better outcomes at the 1-month follow-up.  The findings of this study help to confirm that clinicians should consider STARS to target improvements in certain areas for patients with CAI. 

Questions for Discussion:  Are there any other therapy decisions that you have used with individuals with CAI?  What has your experience been with trying to improve patient and clinical outcomes in patients with CAI?

Written by: Nicole Cattano
Reviewed by: Jeffrey Driban

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McKeon, P., & Wikstrom, E. (2015). Sensory-Targeted Ankle Rehabilitation Strategies for Chronic Ankle Instability Medicine & Science in Sports & Exercise DOI: 10.1249/MSS.0000000000000859

3 comments:

Anonymous said...

I agree that it would be interesting to see what happens to the patients with CAI going forward long term. As we know, CAI does not always go away, and people can suffer from that giving away sensation at any point in their life. So it would be interesting to see how the patients feel, one-three years follow up. I also wonder if any of those patients have becoming copers.

Kyle Hernden said...

I found this article interesting mostly because it goes into depth about how the different interventions affected the patients differently. At times it can be easy to use a treatment for ankle instability because it's "what everybody does", but this article reinforces the idea that every treatment should be used for a specific goal depending on the patient's deficits. Although all components of STARS are commonly useful for CAI patients, it's very important to look into exactly what effects each intervention may have.

Nicole Cattano said...

Thanks Kyle and other commenter. I think you both make great points. We are ultimately trying to mitigate these giving way episodes and using various interventions to help make people better copers.

You also wonder how long do improvements last? For example, we have seen in previous posts that some injury prevention programs have neuromuscular effects that last as long as 6 months. It may be that this principle can be applied to our CAI folks.

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