Tag: health

Impact of Electrical Stimulation with Balance Training in those with CAI

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Blog Post Author Biography: Alan Needle is a Professor at Appalachian State University in the Department of Public Health and Exercise Science and the Department of Rehabilitation Sciences. He has been a certified and licensed athletic trainer since 2007, and conducts research related to assessing and treating neurological impairments in individuals with ankle sprains and chronic ankle instability.

Citation: Gottlieb U, Hayek R, Hoffman JR, Springer S. Exercise combined with electrical stimulation for the treatment of chronic ankle instability – A randomized controlled trial. J Electromyogr Kines. 2024; 74: 102856. https://doi.org/10.1016/j.jelekin.2023.102856.

Take-to-the-clinic message: Combining neuromuscular electrical stimulation with balance exercises improved long-term ankle function in individuals with chronic ankle instability better than therapeutic exercise combined with transcutaneous electrical nerve stimulation. These effects were observed with 12 total treatment sessions over 4-6 weeks, with improvements seen at 6 and 12 months following the intervention.

Background: While therapeutic exercises are a common method for treating individuals with chronic ankle instability (CAI), continued high rates of re-injury and many required treatment sessions creates a need for manners to augment CAI rehabilitation. In individuals with ACL injury, forms of electrical stimulation, including transcutaneous electrical nerve stimulation (TENS) and neuromuscular electrical stimulation (NMES) are often implemented to address neurological changes following injury. TENS and NMES have shown limited efficacy in individuals with CAI; however, it is unclear how they would affect function when combined with therapeutic exercise.

Purpose: This study aimed to assess the short, medium, and long-term effects of balance training in conjunction with NMES or TENS on dynamic postural control and patient-reported outcome measures.

Methods: This study implemented a double-blind randomized controlled trial design conducted in 34 young adults with CAI, following International Ankle Consortium guidelines. Participants were randomized into groups receiving NMES or TENS over the peroneal (fibularis) muscles, while all individuals conducted ankle rehabilitation exercises emphasizing static and dynamic balance. Outcome measures included dynamic balance conducted through a Y-balance test and time-to-stabilization from a single-leg drop jump. Patient function was quantified through the Foot and Ankle Ability Measure (FAAM) activities of daily living (FAAM-ADL) and sport subscales (FAAM-Sport), as well as the Cumberland Ankle Instability Tool (CAIT) and Identification of Functional Ankle Instability (IdFAI) instrument. Participants were instructed on performing the balance exercises and operation of a portable electrical stimulation device, with exercises being conducted during active stimulation. Participants performed 12 total treatment sessions over a period of 4 to 6 weeks, with follow-up immediately, 6-months, and 12-months following the intervention.

Results: Of the 34 individuals who enrolled in the study, 10 out of 14 participants in the NMES group completed the study, while 14 out of 15 participants in the TENS group completed the study. Patient-reported outcome measures improved across both groups at the 12-month follow-up. The NMES group showed improvements beyond the TENS group at 6 and 12 months for the IdFAI and FAAM-Sport measures. Large, but non-significant effects were observed in dynamic balance measures following the intervention.

Rolling the field forward: The researchers in this study explored how augmenting rehabilitation with treatments designed to be neuromodulatory (i.e. improve muscle reflexive actions) may improve clinician- and patient-oriented measures of function. The results showed improved long-term improvements in perceived disease-oriented function in individuals that received exercise and NMES, compared to those receiving exercise and TENS, with these improvements being in disease-oriented outcomes (IdFAI) and those reflecting more challenging function (FAAM-Sport). Importantly, these outcomes were achieved with a program carried out at home.

Question for the researchers: Do the authors feel that balance exercises were the ideal therapeutic exercise to pair with the NMES and TENS interventions? Given the programming needed on the stimulators, what steps would be needed to make this treatment more accessible to the average practicing clinician?

Chronic Ankle Instability, Kinesiophobia, and Postural Control

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Blog Post Author Biography: Ji Yeon Choi is a PhD student in the Department of Biomechanics and Kinesiology at The University of Nebraska at Omaha and certified AT. She has extensive background working with ankle injury extending from her education, research, and clinical experience.

The effects of kinesiophobia on postural controls with chronic ankle instability

Seunguk Han, Minsub Oh, Hyunwook Lee, Jon Tyson Hopkins

Take-to-the-clinic message: CAI patients with kinesiophobia rely more on visual feedback for static balance and show reduced performance in dynamic balance compared to those without kinesiophobia and controls. Clinicians should address both psychological and physical factors in rehab programs.

Background: Following ankle injuries, patients with chronic ankle instability (CAI) may develop kinesiophobia, which is characterized as an injury-related fear that occurs during physical activity and movement.1 Although the influence of kinsiophobia in patients with CAI is unknown.2 

Purpose: The purpose of this study was to examine the impact of kinesiophobia on static and dynamic balance within a CAI population.

Methods: Seventy patients were recruited for this study, 25 with kinesiophobia (CAI-K), 25 without kinesiophobia (CAI-N), and 20 controls. Inclusion criteria for CAI are consistent with the guidelines of the International Ankle Consortium.3 Kinesiophobia was assessed using the Tampa Scale for Kinesiophobia (TSK-17), with a score of 37 or higher indicating the presence of kinesiophobia.4 Static balance was measured using force plate. All participants performed a single-leg balance test with eyes open (EO) and eyes closed (EC). Participants performed the Y-balance test (YBT) for dynamic balance with EO. Romberg ratios were calculated as EC/EO and used for statistical analysis.

Results: There were no significant differences on the static balance among three groups. However, the CAI-K group showed a greater Romberg ratio in the mediolateral direction during static balance compared to CAI-N and control groups. On dynamic balance, the CAI-K group demonstrated less reaching distance in the anterior direction compared to CAI-N and control groups during YBT.

Rolling the field forward: This study found that CAI patients with kinesiophobia demonstrated increased visual reliance during static postural control in the ML direction and reduced reaching distance in the anterior direction during YBT compared to CAI patients without kinesiophobia and control groups. This study provides an approach for preventing further lateral ankle sprain for the CAI population by integrating both psychological and physical elements into rehabilitation programs.

Question for the researchers: What interventions would be beneficial for CAI patients with kinesiophobia? Given that kinesiophobia can occur in individuals with various musculoskeletal injuries, are there specific interventions that would be particularly effective for addressing patients with ankle injuries?

References

  1. Larsson C, Ekvall Hansson E, Sundquist K, Jakobsson U. Kinesiophobia and its relation to pain characteristics and cognitive affective variables in older adults with chronic pain. BMC Geriatr. 2016;16:128. Published 2016 Jul 7. doi:10.1186/s12877-016-0302-6
  2. Devecchi V, Alalawi A, Liew B, Falla D. A network analysis reveals the interaction between fear and physical features in people with neck pain. Sci Rep. 2022;12(1):11304. Published 2022 Jul 4. doi:10.1038/s41598-022-14696-8
  3. Gribble PA, Delahunt E, Bleakley C, et al. Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium. J Orthop Sports Phys Ther. 2013;43(8):585-591. doi:10.2519/jospt.2013.0303
  4. Luque-Suarez A, Martinez-Calderon J, Falla D. Role of kinesiophobia on pain, disability and quality of life in people suffering from chronic musculoskeletal pain: a systematic review. Br J Sports Med. 2019;53(9):554-559. doi:10.1136/bjsports-2017-098673

Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries

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Blog Post Author Biography:  Alexandra DeJong Lempke is an Assistant Professor in the Department of Physical Medicine & Rehabilitation at Virginia Commonwealth University, and has a clinical background as a certified athletic trainer. Dr. DeJong Lempke’s research focuses on biomechanical gait assessments of lower limb and ankle injuries through wearable technologies.

Citation: Kenneth C. Lam, Ashley N. Marshall, R. Curtis Bay, Erik A. Wikstrom; Patient-Reported Outcomes at Return to Sport After Lateral Ankle Sprain Injuries: A Report From the Athletic Training Practice-Based Research Network. J Athl Train. 2023; 58 (7-8): 627–634. doi: https://doi.org/10.4085/1062-6050-0111.22

Take-to-the-clinic message: Athletes across the United States self-reported residual pain, dysfunction, and disability at the time of return to sport after a lateral ankle sprain. Clinicians should implement patient-reported outcomes to catch lingering deficits post-ankle sprain to help guide return to sport decision-making.

Background: Lateral ankle sprains (LAS) are extremely common in sport and are often viewed as insignificant injuries with quick recoveries. Most patients return to sport within 10 days of injury, yet it is not clear if athletes may have lingering symptoms that may affect their long-term health. Understanding how patients with ankle sprains feel at the time of return to sport is important to catch residual problems post-injury and help with clinical decision-making.

Purpose: The purpose of this study was to evaluate self-reports of improvement, pain, function, and disability at return to sport after an LAS injury using single-item patient-reported outcome measures.

Methods: This was a retrospective study of 637 patients with LAS who returned to sport within 60 days of injury. The researchers identified LAS cases from electronic medical records within the 2010-2021 Athletic Training Practice-Based Research Network database (AT-PBRN; 69 clinical practice sites with athletic trainers). The research team assessed pertinent patient details, such as school level, gender, and sport. They also assessed patient-reported outcome measures relevant to LAS at initial injury evaluation and at the time of return to sport:

  • Improvement – Global Rating of Change
  • Pain – Numeric Pain Rating Scale
  • Function – Global Rating of Function
  • Disability – Global Rating of Disability

Results: The LAS patients assessed in this study were about equal genders (53.2% males), were primarily secondary school aged (79.1% of the sample) and participated in field or court sports (78% played in either basketball, football, soccer, or volleyball). Most patients returned to sport within 8 days after LAS. About 2 in every 3 patients reported a meaningful improvement at return to sport, or feeling at least “quite a bit better” on the Global Rating of Change scale. Most patients also still felt they had lingering deficits at return to sport, particularly for lingering pain (~65%), reduced function (~86%), and residual disability (~36%).

Rolling the field forward: This research shows that although LAS patients improve after their injury, many patients still feel like they have not fully recovered when they return to their sport. Clinicians should incorporate objective measures like patient-reported outcomes into return-to-sport decisions to best understand deficits related to LAS and advocate for athlete well-being.

Question for the researchers: Do you think that incorporating patient-reported outcome measures specific to the ankle would have uncovered more lingering deficits at return to sport? How do you think external pressures, such as competition timepoints, may have influenced the findings? Would it be possible to determine if repeat injuries occurred among those with lingering deficits, signaling Chronic Ankle Instability?