Sports Medicine Research: In the Lab & In the Field: Correcting Chronic Ankle Instability with Exercises (Sports Med Res)


Friday, November 17, 2017

Correcting Chronic Ankle Instability with Exercises

Corrective Exercises Improve Movement Efficiency and Sensorimotor Function but Not Fatigue Sensitivity in Chronic Ankle Instability Patients: A Randomized Controlled Trial

Bagherian S, Rahnama N, Wikstrom E. Clin J Sport Med. 2017;0:1-10.

Take Home Message: Eight weeks of corrective exercises enhanced movement efficiency, dynamic and static postural control, joint position sense, and self-reported function in a non-fatigued state; however, the protocol did little to mitigate the effects of fatigue on these measures.

Chronic ankle instability (CAI) is associated with feelings of “giving way” or bouts of instability, decreased self-reported quality of life, and lower levels of physical activity. Thus, clinicians need treatments, like the National Academy of Sports Medicine (NASM) corrective exercise protocol, that target sensory and motor components of ankle function. The authors examined the efficacy of the corrective exercise protocol on self-reported function (Foot and Ankle Ability Measure (FAAM) and FAAM-Sport Subscale), movement efficiency (double-limb squat (DLS), DLS with heel lift, single-limb squat), dynamic postural control (Star Excursion Balance Test), static postural control (eyes open and eyes closed balance), joint position sense, and fatigue sensitivity compared with a non-treatment control condition among males with CAI. At baseline, participants completed an assessment protocol following a short warm up. Next, they underwent a progressive fatiguing protocol on a treadmill, and were retested in a fatigued state. After the baseline assessment, an investigator randomized a participant into the control or intervention group. The intervention group received 8-weeks of supervised corrective exercises 3 times per week. The follow-up visit mirrored the baseline testing procedures. The authors found that the intervention group improved more than the control group in movement efficiency, sensorimotor function, and self-reported outcomes during a non-fatigued state. In a fatigued state, the intervention group only improved in the anterior-posterior center of pressure during static balance compared with control group.

The authors found that an individual with CAI can improve sensorimotor function with a corrective exercise protocol, but improvements may not be sustained following activity. These results are consistent with the current literature regarding rehabilitation outcomes. A combination of exercises to target sensory and motor impairments effectively improves a variety of outcomes better than a single intervention strategy alone. In addition to overall improvements in function, the corrective exercises improved self-reported function, which is a common goal of rehabilitation. Unfortunately, the exercises failed to target fatigue sensitivity. Even after 8-weeks of increasing the difficulty of the corrective exercises, the participants failed to sustain the improvements when fatigued. This may be problematic as fatigue sensitivity may play a role in increasing a person’s risk for subsequent ankle injury in CAI. The authors suggest administering the interventions in a fatigued state may mitigate the effects of fatigue; but, this is understudied in those with CAI. Clinicians should be aware that using the NASM corrective exercises may successfully address sensory and motor deficits in those with ankle sprains, however, alternative strategies may be necessary to address the effects of fatigue.  

Questions for Discussion: Would you consider using the NASM corrective exercises as your rehabilitation approach for individuals with CAI? Should we expect to see changes in fatigue sensitivity if we do not put patients through fatiguing exercises during treatment?

Reviewed by: Jeffrey Driban

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Kevin said...

Hi Rachel,

Thanks for sharing. Although the results of the NASM corrective exercise protocol had promising results, I think it would be difficult to implement this into clinical practice.
As you mentioned, fatigue plays a great role in subsequent ankle injury. When you begin to think of the concept of impairment-based rehab, where we are treating the impairments rather than the diagnosis, it would seem unwise to not address the fatiguability of the ankle. Then again, the NASM protocol did help improve self-reported level of function in CAI patients which is arguably more important.

What are your thoughts?

Rachel said...

Hi Kevin,

Thank you for your response. I agree that for certain clinicians the protocol may be difficult to implement. I think the timing of when we provide rehabilitation exercises may play a role. So, while impairment based rehabilitation is important, it may be useful to do this rehab once they've been fatigued (ex. after practice) if you want to make changes when they are in a fatigued state. I think taking the patient's goals into account and addressing the deficits where they lie (could be during fatigued state) may be the best course of action. This would also hopefully improve the self-reported level of function for these patients.

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