Tag: Balance

Proprioception and Postural Control: Clinical Insights from Recent Research

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Blog Post Author Biography: Dr. Brice Picot currently works at the Sciences et Technologies des Activités Physique et Sportives (STAPS), Université Savoie Mont Blanc and in the French association of Sports Physical Therapy. Brice does research in Traumatology, Rehabilitation Medicine and Physiotherapy. His current projects are focused on injury rehabilitation and prevention of Chronic Ankle Instability and ACL among athletes.

Citation: Sagnard T, Picot B, Forestier N. Proprioceptive acuity, proprioceptive weighting and balance in individuals with chronic ankle instability. Gait Posture. Published online March 15, 2025. doi:10.1016/j.gaitpost.2025.03.006

Take-to-the-Clinic Message:

  • Not all patients suffering from CAI exhibits postural impairments or proprioceptive acuity and reweighting deficits.
  • Poorer proprioceptive acuity is associated with increases postural sway, only in CAI patients.
  • Higher proprioceptive reweighting is observed when proprioception is disrupted in healthy individuals only.

Background: Chronic ankle instability (CAI) is a common consequence of repeated ankle sprains, often leading to impaired postural control and proprioception. Understanding the impact of these deficits is crucial for improving rehabilitation strategies.

Purpose: The purposes of this study were to evaluate proprioceptive and postural control deficits among CAI and healthy control individuals, and to assess whether these parameters were correlated among those two groups.

Methods: The study assessed 13 participants with chronic ankle instability (CAI) and 15 healthy controls to examine proprioception and balance deficits. Joint position sense (JPS) was evaluated in dorsiflexion and plantarflexion by calculating absolute and constant repositioning errors. Unipedal balance was measured using center of pressure (CoP) ellipse area and velocity to assess postural stability. Relative proprioceptive weighting (RPW) was determined by analyzing postural responses to triceps surae and lumbar multifidus tendinous vibrations.

Results: This study found nodifferences in proprioception or balance between CAI patients and healthy controls. However, within the CAI group, poorer accuracy in proprioceptive acuity was linked to greater difficulty maintaining balance, as shown by increased body sway. In contrast, for the control group, a different relationship emerged—those with greater proprioceptive errors tended to rely more on other sensory inputs for balance.

Rolling the field forward: Contrary to previous belief, not all CAI patients exhibited poor postural control or impaired proprioception. However, results from the present study suggests that contrary to healthy individuals, people with CAI still maintain an ankle steered strategy when proprioceptive signals are inaccurate. This could explain why CAI patients with unreliable acuity (i.e. high errors in JPS) exhibit poorer postural control while healthy control individuals do not. These findings highlight the importance of assessing both proprioception and balance in CAI patients to better address potential deficits in rehabilitation programs.

Question for the researchers:

  • How can we easily evaluate postural control deficits in CAI patients?
  • What are the normative values in errors of repositioning among healthy individuals?

Do ankle braces affect functional performance?

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Blog Post Author Biography: Dr. Tomas Megalaa is a researcher and clinician, with expertise in sports injury prevention and rehabilitation. He has recently completed his PhD degree at the University of Sydney. Tomas has published multiple peer-reviewed articles and has extensive clinical and academic experience in Allied Health in Australia.

Citation: Megalaa T, Le PL, Fong Yan A, Beckenkamp PR, Hiller CE. Do ankle braces affect functional performance? A randomised double-blinded cross-over trial. JSAMS Plus. 2024;4:100061. DOI: 10.1016/j.jsampl.2024.100061.

Take-to-the-clinic message: Clinicians and sports practitioners can confidently prescribe ankle braces without concern of having a negative impact on functional performance. This study demonstrated that neither the KISS® nor Aircast ankle brace negatively affected objective measures of functional performance or balance in individuals with and without chronic ankle instability (CAI). Further, participants perceived greater stability and reassurance when they were wearing the KISS® ankle brace compared to no brace during the functional tasks.

Background: Ankle braces are effective in managing and preventing lateral ankle sprains. A new ankle brace, the Kinetic Impulse Suppression System® (KISS®), was developed to allow unrestricted ankle and foot movement within normal ranges while preserving subtalar joint motion in the frontal plane (inversion/eversion) and restricting only end-range joint motion. Despite the known protective benefits of ankle braces, concerns persist regarding their potential impact on functional performance.

Purpose: We aimed to compare the effects of two different ankle braces (KISS® and Aircast) with a no-brace condition on functional performance and perceptions of stability, confidence, and reassurance in individuals with and without CAI. The primary hypothesis was that wearing the KISS® brace would not impair functional performance compared to the no brace condition and participants would present a superior performance compared to the Aircast brace.

Methods: A randomised double-blinded cross-over trial was conducted in people (18-65 years) with and without CAI (determined using the International Ankle Consortium criteria). Participants completed an array of functional performance tests under three conditions: wearing the KISS® ankle brace, the Aircast A60 ankle brace, and no brace (control). The order of condition was randomly allocated, a researcher not involved in data collection applied the braces and the ankle was covered with a black sleeve to keep the assessor blinded to condition. Tests included the side hop test, Star Excursion Balance Test (SEBT), triple hop test, modified T-agility test, and vertical jump test. Perceptions of stability, confidence, and reassurance were also recorded on a 10-point numerical rating scale. Statistical analyses included linear mixed models to assess performance and subjective measures across conditions.

Results: A total of 42 participants were included (21 with and 21 without CAI), 24 females and18 males, with mean (SD) age of 25.4 (7.8) years. No significant differences were found between the three conditions for any objective functional performance measure, including the side hop test (p=0.96), SEBT (p>0.92), triple hop test (p=0.97), agility test (p=0.21), or vertical jump tests (p>0.97). However, subjective measures showed that participants felt significantly more stable and reassured while wearing the KISS brace compared to no brace (p=0.03 and p=0.046, respectively) after performing the side hop test.

Rolling the field forward: This study provides strong evidence that ankle braces do not impair functional performance, addressing a common concern among clinicians, trainers, and athletes. Future research should explore the long-term effects on perception of brace use and evaluate whether different brace designs influence injury prevention strategies and athletic performance. Studies involving elite athletes may help determine if subtle biomechanical effects of bracing emerge in high-performance settings.

Question for the researchers: Given the subjective preference for the KISS brace over the no-brace condition, do you anticipate that different brace designs could have a greater perceived impact on confidence and injury prevention? Would further testing in high-performance athletes reveal different functional outcomes?

Use of Functional Tests to Predict Ankle Instability Development

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Blog Post Author Biography: Luke Donovan is an Associate Professor at the University of North Carolina at Charlotte in the Department of Applied Physiology, Health, and Clinical Sciences and a certified athletic trainer. Dr. Donovan’s research aims to develop clinical measurement techniques for assessing gait and rehabilitation strategies among patients with chronic ankle instability.

Citation: Shein Lumbroso D, Gottlieb U, Zimmerman DR, Springer S. Functional tests as predictors of ankle instability six months after an acute lateral ankle sprain. J Sports Med Phys Fitness. 2023 Apr;63(4):570-579. doi: 10.23736/S0022-4707.22.14395-1.

Take-to-the-clinic message: Following an acute lateral ankle sprain, balance performance on foam in tandem stance, willingness to perform a single-limb drop landing task, and limb-dominance of the injured ankle were associated with the development of ankle instability 6-months after the initial injury. Clinicians can use these functional tasks and descriptive information to identify patients that may be at a greater risk of experiencing residual symptoms following a lateral ankle sprain. 

Background: Lateral ankle sprains (LAS) are one of the most common musculoskeletal injuries among individuals who are physically activity. It has been estimated that as high as 2 out of 3 individuals who experience a LAS develop a long-term condition characterized by repetitive ankle sprains and/or feelings of instability known as chronic ankle instability (CAI). Identifying individuals at risk of developing CAI as close to the initial injury as possible may help clinicians implement rehabilitative strategies to mitigate the development of the chronic condition. Given the sensorimotor disruption affiliated with CAI, the authors hypothesized that functional tasks that require attention and cognitive demand would be capable of discriminating between individuals who recover from the LAS (copers) vs individuals who do not (ankle instability).

Purpose: The purpose of this study was to prospectively determine whether performance on various functional tasks within 3-weeks of an acute LAS, as well as other demographic information could predict ankle instability outcomes 6-months after the initial injury. Specifically, the authors evaluated performance on the balance error scoring system (BESS) with a dual-cognitive task (Modified-BESS), a single-limb drop landing (SLDL) task and drop-vertical jump (DVJ) task.

Methods: The authors completed a prospective study of individuals who experienced a LAS within 3-weeks of data collection. To be included in the study, participants were required to be between the ages of 18 and 35. In addition, the LAS must have been associated with inflammatory symptoms and caused at least 1-day of interruption in their physical activity. 

Participants who enrolled in the study completed a one-hour data collection session. During this session, participants provided demographic information (age, gender, weight, height, injured leg, dominant leg, and physical activity). Next, participants completed the Modified-BESS, the SLDL, and the DVJ tasks. The Modified-BESS task reflected the previously reported BESS procedures (eyes closed balancing on firm/foam surfaces during double-limb, single-limb and tandem stance), but also included a dual-task component (Backward Digits Span Task). A 40-cm box was used for both the SLDL and DVJ tasks. After completing the data collection sessions, participants were contacted every month to determine whether they re-injured the involved ankle. After 6-months, participants completed the Cumberland Ankle Instability Tool (CAIT) to determine their status as either potential ankle instability or potential copers. Since a patient is not considered to be diagnosed with CAI until 12-months post-injury, the authors found the term ‘potential’ to be most appropriate.  Individuals who scored lower than a 24 on the CAIT and/or experienced any re-sprain during the follow-up period were classified as ‘potential ankle instability’. Participants who scored 24 or greater on the CAIT and did not experience any re-sprains were classified as ‘potential copers’. 

Results: Thirty-three individuals completed the study where 21 of the individuals met the potential ankle instability criteria 6-months following their initial injury. Specific to the main outcome measures, the authors found that for every 1-point increase observed on the Foam-Tandem stance task (part of the Modified BESS) increased the odds of developing ankle instability by 1.5. In addition, participants who were unwilling to complete the SLDL increased their odds of developing ankle instability by 10. Finally, individuals who sustained a LAS to their non-dominant limb had a 6 times greater odds of developing ankle instability when compared to individuals who sprained the ankle on the dominant limb. 

Rolling the field forward: The authors report that various functional tests, as well as demographic information may help clinicians prospectively identify individuals at a heightened risk of developing ankle instability 6-months after the initial injury. Clinicians can incorporate functional tasks as an evaluation tool to help guide the return to activity process.

Question for the researchers: The criteria required participants to be within 3-weeks of the LAS at the time of data collection; however, the time since injury was not reported. Did the authors observe differences in time since ankle sprain among participants? Do the authors have a recommendation as to when clinicians should incorporate these functional tasks as part of their evaluation?

Dual-Task Postural Control Assessment in Individuals with Chronic Ankle Instability

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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?