Blog Post Author Biography: Dr. Matthew Hoch is a Professor in the Department of Athletic Training and Clinical Nutrition and the Senior Associate Director for the Sports Medicine Research Institute at the University of Kentucky. Dr. Hoch’s interests include the investigation of rehabilitation interventions for patients with chronic ankle instability.

Citation: Choi JY, Yoo T, Burcal CJ, Rosen AB. Dual-task differences in individuals with chronic ankle instability: A systematic review with meta-analysis. Gait Posture. 2023; 106(28-33). DOI: 10.1016/j.gaitpost.2023.08.013

Take-to-the-clinic message: The clinical utility of dual-task assessments is continually evolving for an array of sports medicine applications. This meta-analysis sought to examine the ability of dual-task balance and gait assessments to identify performance deficits in people with chronic ankle instability. The literature to date is unable to consistently identify balance or gait deficits using dual-task testing paradigms. However, trends in the data suggest that further examining dual-task assessments utilizing more challenging tasks may yield different insights.

Background: Ligamentous injuries, such as lateral ankle sprains, create complex sensorimotor alterations which often manifest clinically as impairments in postural control and gait. Understanding the interaction of cognitive and sensorimotor function using dual-task assessments has emerged as a potential area to advance care for musculoskeletal conditions. Several studies have applied dual-task balance and gait assessments to assess performance in people with chronic ankle instability. However, the conclusiveness of these studies is difficult to determine without more advanced analysis.

Purpose: The purpose of this systematic review and meta-analysis was to determine differences in dual-tasking assessing gait and postural control in individuals with chronic ankle instability compared to healthy controls.

Methods: This systematic review and meta-analysis searched for articles using multiple relevant databases from inception through 2022. Peer-reviewed observational studies which incorporated single- and dual-task assessments to study motor performance related to gait, balance, or other functional performance outcomes in patients with a history of ankle sprain or chronic ankle instability along with either a healthy reference group or limb were included. Two reviewers applied the 22-item Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to assess risk of bias and methodological quality of the included studies. Separate, random effect meta-analyses were used to evaluate mediolateral and anteroposterior directions of balance-related outcomes. Additional supporting analyses were applied to evaluate heterogeneity and potential bias from unpublished studies.

Results: A total of nine studies were included in the systematic review. Five studies met the requirements to be included in the meta-analysis. The average STROBE score was 13.3±3.8 indicating a moderate level of study quality. Six the included studies examined dual-task balance while three focused on dual-task gait. The results of the meta-analyses determined that dual-tasking affected postural control outcomes in the control group. However, no differences were identified in the chronic ankle instability group or when comparing healthy and chronic ankle instability groups.

Rolling the field forward: The primary finding of this study was that dual-tasking did not significantly impact postural control outcomes in individuals with chronic ankle instability. However, trends within the available data indicated that studies applying more challenging balance tasks demonstrated trends towards poorer postural control under the dual-task condition. This indicates that future studies and clinical investigations should explore coupling dual-task balance assessments or exercises with more challenging and potentially dynamic balance tasks. This systematic review was only able to identify three studies which examined dual-task gait in chronic ankle instability patients and identified mixed results. The application of dual-task gait requires additional study before strong recommendations can be made. Cumulatively, this study suggests that the field may need to explore different mechanisms to effectively integrate dual-task paradigms into the clinical management for patients with a history of ankle sprain.

Question for the researchers: Many of the included studies used an approach to dual-tasking by adding cognitive load through tasks such as serial subtraction. Do you think utilizing cognitive challenges associated with greater demand on sensory integration or decision making could produce different results in patients with a history of ankle sprain or instability?