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Three Part Question

In [adults with chronic ankle instability] does [exercise rehabilitation help decrease or prevent recurrence of ankle sprains], and if so [is strengthening or proprioception] more effective?

Clinical Scenario

A 29 year old female presents to the physiotherapy department for treatment of recurrent giving way of her right ankle, present since a severe ankle sprain in her late teens. The ankle gives way into the inversion direction when walking on uneven surfaces such as cobble stones; this occurs approximately twice per week.
Any possible underlying structural cause for the instability has been ruled out by a Consultant Orthopaedic Foot and Ankle Surgeon assessment, X-rays and a MRI. A diagnosis of “Functional Instability” has been made and she has been referred to physiotherapy for rehabilitation.

Search Strategy

Medline 1966-2011 using the PubMed Clinical queries database was searched using the following terms:

Therapy/Broad[filter] AND (chronic[All Fields] AND ("ankle"[MeSH Terms] OR "ankle"[All Fields] OR "ankle joint"[MeSH Terms] OR ("ankle"[All Fields] AND "joint"[All Fields]) OR "ankle joint"[All Fields]) AND instability[All Fields])
In addition the Best BETS and PEDrO databases were searched using similar terms.
PEDrO (Physiotherapy best evidence database): http://www.pedro.org.au/
Pub Med: http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml
Best BETS http://www.bestbets.org

Search Outcome

Altogether 66 titles were identified from the combined searches, after duplicates had been removed 6 abstracts were identified as being possibly relevant and the full articles were retrieved. Reference lists were then checked and a further 3 articles were identified as being relevant with the full text articles obtained and added to the search results.

Nine articles were then divided up between members of the team and screened to identify if they answered, or potentially answered the three part search question. These papers were rated for quality and risk of bias using the CASP website critical appraisal proformas (http://www.phru.nhs.uk/pages/PHD/resources.htm).
This process resulted in 5 papers being rated as good quality and relevant to directly answering the PICO question. These papers were included in our Best BETS analysis.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
De Vries et al 2009 Netherlands	Adults with chronic ankle instability. Surgical Treatment and Conservative Treatment subject groups. 7 studies.	Systematic Review	Assessment of methodological quality using the Cochrane bone, joint and muscle group trauma evaluation tool	Insufficient evidence to determine the relative effectiveness of surgical and conservative treatment for CAI.	Pooling of data was not possible due to clinical and methodological diversity of the studies.
Hale S, Hertel J, Olmsted-Kramer 2007 USA	48 recreationally active individuals from the university community.	Prospective RCT	Postural control using AMTI Accusway force plate.	Subjects with CAI demonstrated deficits in postural control and SEBT reach tasks.	Subjects needed only to have had 1 previous ankle sprain and the presence of giving way in the last 6 months Failed trials or “touch-downs” were discarded and repeated in this study
Hughes & Rochester 2008 UK	Subjects of any age, classified as suffering from FAI or chronic, recurrent lateral ankle sprains with subjective feeling of instability/giving way. 13 studies.	Systematic Review	Proprioceptive outcome measures including joint position sense, kinaesthesia, muscle response time and postural control.	The exercise literature was limited due to poor methodological quality.	Only used peer reviewed journals and trials written in English. All studies classed as carrying a high risk of bias. Meta-analysis unable due to poor quality of studies.
Mc Keon 2008 USA	11 studies including a mixed population: 1)Volleyball players with and without previous ankle sprains 2) patients with acute lateral ankle sprain and no history of previous injury, Male soccer players with history of lateral ankle sprain and functional instability of 1 or both ankles, patients with grade 2 ankle sprain who previously had participated in 2 h of physical activity/wk 3) Patients with recurrent lateral ankle sprains with functional or mechanical instability	Systematic Review to answer 3 key questions: (1) Can prophylactic balance & coordination training reduce the risk of lateral ankle sprain? (2) Can balance & coordination training improve treatment outcomes associated with acute ankle sprains? (3) Can balance and coordination training improve treatment outcomes in patients with CAI?	Quality of papers checked for	Balance training can be used prophylactically	There was a lack of detail into the optimum treatment dose (length, volume and intensity) used in studies.
Webster KA, Gribble PA 2010 USA	1988-2008-6 studies. Clinical Studies that have at least one functional rehabilitation intervention and at least one outcome measure of function and or functional performance. At least one group of CAI subjects who reported lateral ankle sprains or episodes of giving way	Systematic Review	Dynamic postural Control measured by- Star excursion Balance Test and Biodex Stability System.	3 studies included FADI, FADI-Sport and AJFAT with Functional rehabilitation. All 3 showed significant improvement in self reported outcomes in those with CAI with 2 studies Rozzi (Balance training on Biodex 3x.wk 4 wk) and Hale et al (stretching, theraband strengthening in multiple directions, neuromuscular control, jumping and running drills 3-5 x week/ 4 weeks) with appropriate effect sizes with 95% confidence intervals.	Only used trials written in English, didn’t contact professionals in the field or look at reference lists from articles Meta-analysis unable due to quality of studies. Poor detailing in 2 of the studies who used rate of reoccurrence of ankle injury as outcome measure. No means or standard deviations recorded, just percentage of reoccurrence.

Comment(s)

Very few articles passed the appraisal stage. Many studies had flaws in their methodology and did not separate or clearly define acute and chronic ankle instability patient groups. Treatment interventions including programme administered, frequency and timeframes were poorly detailed in most studies. Mc Keon et al (2008), in their systematic review found evidence in the literature to support balance training as being be effective if used prophylactically after an acute ankle sprain in an effort to reduce future ankle sprains. However, there was insufficient evidence to assess its effect on recurrence rates in patients with chronic ankle instability. There is some evidence (Hale et al, 2007) to suggest that Functional Rehabilitation including stretching, theraband strengthening and proprioception rehabilitation improves self reported outcomes in those with Chronic Ankle Instability. This review highlights the need for further study in this area with clearly defined chronic instability patient groups, detailed treatment interventions and long-term (at least >2 years) follow up data which examines the recurrence rates of injury. Currently our practice is to follow the Dutch guidelines for Chronic Ankle Instability (KNGF 2003). And also, at a level 4 and 5 of evidence, we have found from our own clinical experience that physiotherapy seems to work.

Clinical Bottom Line

There is some evidence to suggest that Functional Rehabilitation including stretching, theraband strengthening and proprioception rehabilitation improves self reported outcomes in those with Chronic Ankle Instability. However, there is a lack of research looking at longer term follow-up and the recurrence rates of injury.

References

1. de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN Interventions for treating chronic ankle instability (Review) WILEY, The Cochrane Collaboration 2009; 1-44
2. Hale S, Hertel J, Olmsted-Kramer. The Effect of a 4-Week Comprehensive Rehabilitation Program on Postural Control and Lower Extremity Function in Individuals With Chronic Ankle Instability Journal of Orthopaedic & Sports Physical Therapy 2007; 303-311
3. Hughes T, Rochester P The effects of proprioceptive exercise and taping on proprioception in subjects with functional ankle instability: A review of the literature Elsevier 2008; 136-147
4. Mc Keon P, Hertel J Systematic Review of Postural Control and Lateral Ankle Instability, Part II: Is balance training clinically effective? Journal of Athletic Training 2008; 305-315
5. Webster KA, Gribble PA Functional Rehabilitation Interventions for Chronic Ankle Instability: A Systematic Review Human Kinetics, Inc 2010; 98-114