Erik Anders Wikstrom

Clinical Scenario: Although chronic ankle instability (CAI) and ankle sprains are highly prevalent, there has been little advancement in treatment strategies. A challenging aspect of CAI rehabilitation is the multifaceted nature of CAI. Sensorimotor deficits particularly dynamic postural control impairments, are well documented in those with CAI relative to uninjured controls and likely contribute to the high prevalence of CAI. Because CAI is associated with deficits in sensory pathways, mind–body interventions may help enhance a patient’s awareness and processing of sensory information (ie, proprioception). Improved proprioception may subsequently result in more confidence in bodily movements, which we hypothesize would manifest as improved dynamic postural control. Focused Clinical Question: Do mind–body interventions, relative to a control condition, improve dynamic postural control in patients with CAI? Summary of Key Findings: Two studies found that a 12-week Yang style Tai Chi resulted in significantly greater improvements in all Star Excursion Balance Test reach directions compared with the respective control groups. One study found that a 4-week walking meditation program (which entails the participant slowly walking back and forth while keeping their concentration on movements of the body) resulted in significant improvements on some Star Excursion Balance Test reach directions, but these changes were not different from the changes observed in the control group. Clinical Bottom Line: The results indicate that mind–body interventions, especially Tai Chi, can improve dynamic postural control in those with CAI. Strength of Recommendation: Overall consistent high-quality evidence was present in the 3 studies, suggesting grade A evidence for the use of mind–body interventions in the rehabilitation of patients with CAI.

Context : Chronic ankle instability is associated with persistent biomechanical changes including a lateral center of pressure (COP) location during stance. Gait retraining studies generally show COP location improvements. Multiple COP processing techniques are available which may impact results. Therefore, the purpose of this study is to identify the impact of processing technique on the COP location during baseline walking and in response to intervention in people with chronic ankle instability. Design : Cohort Study. Methods : Participants with chronic ankle instability walked on an instrumented treadmill for 2 minutes (baseline), completed a vibration feedback gait retraining session, and then completed a posttest treadmill trial with no feedback. The COP location was filtered using a fourth-order Butterworth filter with a 10-Hz low-pass cutoff. Processing techniques included bounding COP data within the foot: (1) relative to the border of the lateral foot in the medial–lateral plane (Straight-Plane Technique) and (2) relative to the midline of the foot which changes with foot progression angle (Foot-Progression-Angle Technique). 1D statistical parametric mapping paired t tests were completed on absolute change scores at baseline between techniques and between baseline and posttest for each of the techniques. Results : Absolute COP change scores at baseline between processing techniques were statistically different from 5% to 44% of stance phase while walking. Baseline to posttest COP locations were statistically different from 4% to 62% of stance phase ( P ≤ .01) when processed with the Straight-Plane Technique. No statistically significant difference was identified using the Foot-Progression-Angle Technique. Conclusions : Interpretations of COP location and COP location changes could be impacted by processing techniques with differing reference coordinate systems. New insights into processing techniques could impact interpretations of previously published work and should be considered before comparing across studies to make broad generalizations related to the COP location.

Introduction/Clinical Scenario : Chronic ankle instability (CAI) is characterized by repeated ankle sprains, frequent episodes of giving way, and sensorimotor impairments including poor balance, and gait alterations. Foot morphology differences particularly loading induced changes in arch height (e.g., navicular drop), have been suggested to be a contributing factor to CAI and its associated impairments. However, the evidence is mixed, and no comprehensive evaluation of the literature has been completed. Focused Clinical Question : Does loading induced changes in arch height differ between those with and without CAI? Summary of Key Findings : A comprehensive search yielded three cross-sectional studies comparing loading induced changes in arch height between those with and without CAI. No significant differences in the magnitude of arch height change were noted between groups in the original investigations. Clinical Bottom Line : Based on the limited existing evidence, loading induced changes in arch height do not differ between those with and without CAI. Strength of Recommendation : Consistent findings in moderate to high quality studies suggest a level B strength of recommendation regarding the clinical bottom line.

Context : Chronic ankle instability (CAI) is associated with altered gait mechanics and impaired sensorimotor function (eg, postural control). While corrective exercise programs are known to improve sensorimotor function in those with CAI, their impact on gait-related outcomes remains unclear. Design: A randomized controlled trial was conducted to investigate the effects of a corrective exercise program on gait kinetics and postural control in individuals with CAI. Methods : Seventy recreational and collegiate athletes with CAI (aged 18−35) completed the randomized controlled trial. Participants were recruited from the local sports community and randomly assigned to either a control group (n = 34) or an intervention group (n = 36). The intervention group participated in an 8-week National Academy of Sports Medicine (NASM) corrective exercise program, while the control group received no intervention. The NASM program targets muscle relaxation, lengthening, and activation, and finally, integration into functional movements. Gait kinetics, such as contact time, foot progression angle, and peak plantar forces, as well as postural control, were assessed at baseline and postintervention and submitted to 2-way repeated-measure analysis of variance to evaluate the effects of the intervention. Results : Significant interaction effects were observed for postural control ( P < .01) and gait contact time ( P = .001), indicating greater improvements in the NASM group compared to the control group. No significant group or interaction effects were observed for specific plantar force distribution regions or other gait outcomes ( P > .05). Conclusion : The findings suggest that an 8-week NASM corrective exercise program improves postural control but has limited effects on gait kinetics in individuals with CAI.

Context : Chronic ankle instability (CAI) is a common consequence of a lateral ankle sprain. Sex differences in functional outcomes exist, but there is a lack of female-specific intervention studies. Hop stabilization training is effective in male athletes with CAI but has not been investigated in female athletes. Therefore, the purpose of this investigation was to describe the effect of hop stabilization exercises on functional movement patterns and patient-reported outcomes in female athletes with CAI. We also compared the current effect sizes with those observed in an all-male cohort following an identical intervention. Design : Randomized controlled trial. Methods : Fourteen female CAI participants completed hop stabilization training (age = 25.29 [5.86] y), and 14 female CAI participants were in the control group (age = 24.73 [6.97] y). Inclusion criteria were consistent with the International Ankle Consortium recommendations. The hop stabilization program consisted of three 20-minute sessions per week for 6 weeks. Sessions consisted of increasing foot-to-ground contacts each week until a taper in the final week. Exercise difficulty was also modified throughout the program. Functional movement patterns via the Functional Movement Screen and Fusionetics Scores, dorsiflexion range of motion, and select region-specific patient-reported outcomes were captured. Results : The hop training group (pre: 12.68 [1.32] cm, post: 13.42 [1.35] cm) had a significant improvement (P< .001) in dorsiflexion range of motion relative to the control group (pre: 13.62 [1.22] cm, post: 13.68 [1.16] cm). Hop training also significantly improved (P, Conclusions : A 6-week hop training program significantly improves patient-reported outcomes, dorsiflexion range of motion, and functional movement patterns in female athletes with CAI .

Context : Those with chronic ankle instability (CAI) rely more on visual information to maintain postural control. Plantar massage and ankle joint mobilization are moderately successful at improving CAI-associated postural control impairments. Manual therapies may have a larger influence on the underlying sensory strategy used to maintain postural control, but their effect on these strategies remains unknown. Objective: To evaluate the effects of separate 2-week plantar massage and ankle joint mobilization interventions on estimates of visual reliance during single-limb stance in those with CAI and determine whether changes in visual reliance estimates were driven by concurrent changes in peripheral- or spinal-level sensorimotor function. Design : Randomized controlled clinical trial. Setting : Research laboratory. Patients : Sixty participants with CAI. Interventions : Participants were equally randomized into plantar massage, ankle joint mobilization, and control (no intervention) groups. The manual therapy groups received six 5-minute treatments of their respective interventions over a 2-week period. Main Outcome Measure : A percentage modulation outcome quantified an individual’s reliance on visual information by estimating the weight given to visual information during eyes-open stance based on the magnitude of postural instability that occurs with vision removed. Secondary measures included joint position sense, plantar light-touch thresholds, and the H-reflex. Outcomes were captured before (baseline), immediately after (post), and 1-month (follow-up) after the 2-week intervention. Results : Plantar massage resulted in significant percentage modulation changes in sagittal ( P ≤ .046) but not frontal plane outcomes ( P ≥ .069) relative to the control group. Joint mobilization did not alter percentage modulation changes ( P ≥ .413). Significant correlations between percentage modulation changes and peripheral sensorimotor function were noted primarily at the 1-month follow-up. Conclusions : A 2-week plantar massage but not an ankle joint mobilization intervention alters sagittal plane percentage modulation values during single-limb stance in those with CAI. These changes may be driven by changes in peripheral sensorimotor function.

Introduction/objectives Chronic ankle instability (CAI) is a significant contributor to articular degeneration at the ankle. Identifying early pathogenic articular changes is limited to compositional MRI techniques which are not clinically feasible. Ultrasound is cost-effective, and echo-intensity (EI) measures may be an indicator of cartilage health. Therefore, we aimed to (i) quantify changes in ultrasound measures of talar cross-sectional area (CSA) and EI following standardized loading protocols and recovery periods and (ii) quantify the associations between ultrasound measures and talar and subtalar cartilage composition in those with CAI. Method Thirty-seven individuals with CAI (22.6 ± 4.2 years, 3.8 ± 2.7 sprains) completed a T1ρ MRI and two ultrasound assessments. The talar cartilage was imaged with US before, immediately after, 15-min after, and 30-min after separate static and dynamic loading protocols. Results Ultrasound outcomes acutely changed in response to load (p < 0.05). The CSA and EI means remained altered throughout the recovery period (p < 0.05) while the EI standard deviation recovered to baseline levels. Greater subtalar T1ρ relaxation times (i.e., worse composition) were significantly (p ≤ 0.05) associated with lower thickness (r = −0.409) and EI variability (r = 0.419) baseline values, greater EI mean responses to load (r = −0.558), and smaller EI mean recoveries (r ≥ −0.360) which all suggest worse cartilage health. Conclusions In those with CAI, ultrasound-based outcomes acutely respond to load but have unique recovery patterns. Ultrasound may serve as a valid clinically accessible tool to evaluate ankle cartilage composition, particularly Subtalar cartilage. Key Points • In those with CAI, talar cartilage CSA and EI, measured via ultrasound, are acutely sensitive to load but recovery patterns are outcome specific. • Ultrasound measures of thickness and EI may serve as valid clinically accessible surrogates of subtalar cartilage composition.

Individuals with chronic ankle instability (CAI) have postural control deficits and appear to be more reliant on visual information to maintain balance. The underlying cause of this visual reliance remains unknown. Our purpose was to determine how sensory integration and visual performance influence postural control under different visual occlusion levels in those with CAI. Sensory integration ability, as measured by the Sensory Organization Test, was not associated with postural control in those with CAI. Visual performance variables, such as perception span, depth perception, and target capture explained between 13% and 45% of postural control variance across visual occlusion levels. The results suggest that improving visual performance in those with CAI may improve postural control across levels of visual occlusion.

Clinical Scenario: Ankle sprains are highly common and can lead to chronic ankle instability (CAI). Individuals with CAI have a variety of sensorimotor impairments including poor postural control and altered sensory organization strategies. Visual occlusion modalities, if worn during neuromuscular control exercises, may facilitate greater postural control gains and a more appropriate sensory organization strategy. However, a cumulative review of the ability of visual occlusion modalities (e.g., stroboscopic goggles) to impair postural control and thus demonstrate the potential to facilitate greater postural gains has not yet been completed. Clinical Question: Does stroboscopic vision impair postural control in those with and without CAI, and if so, is the impairment comparable between the groups? Summary of Key Findings: Regardless of how postural control was assessed, stroboscopic vision impaired postural control relative to an eyes open (i.e., no goggles) condition. All studies demonstrated that those with and without CAI were impacted equally. Stroboscopic vision resulted in postural control impairments comparable to an eyes closed in some but not all studies. Clinical Bottom Line: Stroboscopic vision impairs postural control in both those with CAI and uninjured controls. Strength of Recommendation: There is moderate-quality evidence (Grade B) that stroboscopic vision impairs postural control in those with CAI and uninjured controls.

Objective To analyse the association between Ankle-GO score during the return to sport process and the probability of becoming a coper 1 year after lateral ankle sprain (LAS). Copers were defined as patients returning to their preinjury sport without loss of function and reporting no episodes of reinjury or giving-way. Methods Two months after a LAS, patients performed the Ankle-GO assessment which includes a cluster of four functional tests and two self-reported questionnaires for a maximum score of 25 points. One year after injury, participants were classified as copers or non-copers. Eight potential predictive variables associated with coper status were compared between the groups. Receiver operating characteristic curves (area under the curve (AUC)) and multivariable logistic regression models with OR and 95% CIs were used to determine the association of potential factors, including the Ankle-GO score, with copers. Results 64 patients (56% females; age 33.7±13.2 years) completed the Ankle-GO-GO at 2 months postinjury. At 1 year postinjury, 10 patients (15%) were lost to follow-up, and only 17 of 54 patients (31%) became copers. Two-month Ankle-GO score was higher among copers (9.9±4.9 points vs 6.9±3.7, p=0.015) and was associated with future coper status at 1 year (AUC=0.70). Patients with an Ankle-GO score above 11 points and male patients were more likely to become copers (OR=12.1; 95% CI 2.5 to 59, p=0.002 and OR=5.2; 95% CI 1.2 to 22.4, p=0.026, respectively). Conclusion The Ankle-GO may help identify patients more likely to become copers within a year of injury. Those with low Ankle-GO scores and female patients should receive additional rehabilitation to increase the odds of becoming a coper.